A new dawn in internal medicine education curriculum-a project by the residents, with the residents, for the residents.

The academic half-day (AHD) curriculum is an alternative to the noon conference (NC) approach. To date, there is little literature evaluating the transition from NC to AHD in internal medicine residency programs. We investigated the effectiveness of AHD by comparing in-training exam (ITE) and American Board of Internal Medicine (ABIM) certifying exam scores of residents before and after implementation of AHD. In 2019, we transitioned to the AHD curriculum. Averages of three consecutive years of NC (2016-2018) and AHD (2019-2021) were used for statistical testing to determine ITE and ABIM score changes. The class of 2018 experienced both approaches. Cohen's d effect sizes were calculated to assess the magnitude of change in ITE and ABIM scores between NC (2016-2018) and AHD (2019-2021) cohorts. Residents' performance significantly improved (P < 0.05) on ABIM scores (513.80 ± 48.34) on average from 2019 to 2021 compared to ABIM scores (452.42 ± 49.72) on average from 2016 to 2018 with a large effect size of 1.27. Similarly, a significant (P = 0.005) improvement in ITE scores was observed from 2019 to 2021 with implementation of AHD compared to preceding NC scores (2016-2018) with a moderate effect size of 0.52. Participating residents in AHD sessions had higher ITE and ABIM scores compared to those in hourly NC didactic sessions with significantly improved resident attendance and overall satisfaction.

Hemodynamic collapse following bilateral knee arthroplasty: a mysterious case.

Severe hemodynamic collapse after knee surgery from bilateral adrenal hemorrhages is rare. Even rarer is it occurring from adrenal hemorrhage as a complication of heparin induced thrombocytopenia. Due to lack of awareness of this rare complication and associated complex scenario in critically ill patients, diagnosis is often made post mortem. A diagnosis of bilateral adrenal hemorrhage should be considered in any patient presenting with non-specific symptoms of fever, abdominal pain, confusion and rapid hemodynamic collapse not responding to standard therapy. This is crucial especially in the setting of heparin induced thrombocytopenia as thrombosis and not hemorrhage is often the most feared complication of this syndrome.

Spontaneous rectus sheath hematoma.

Abdominal wall pathology is a frequently overlooked cause of acute abdomen. Increasing use of antiplatelet and anticoagulant therapies has led to an increase in the incidence of spontaneous rectus sheath hematoma (RSH). A high index of suspicion is needed for diagnosis as it can closely mimic other causes of acute abdomen. Herein, we report a case of RSH presenting with abdominal pain in which there was a significant delay in diagnosis. We wish to highlight the need to increase awareness among primary and emergency physicians about considering RSH in the initial differential diagnoses of abdominal pain.

Chilaiditi syndrome complicated by cecal perforation.

Chilaiditi sign is a radiological finding which describes the interposition of a part of the bowel between the diaphragm and the liver, a finding that can be misinterpreted as pneumoperitonium. Chilaiditi syndrome refers to a clinically symptomatic patient in the presence of the classical radiographic findings. It is a very rare syndrome which usually follows a benign course. Here we report the first documented case of Chiliaditi syndrome complicated by cecal perforation.

Rhabdomyolysis induced by simvastatin-fluconazole combination.

Rhabdomyolysis is a potential adverse consequence of statin therapy. Here, we report a patient with prostate cancer being treated with simvastatin who developed rhabdomyolysis after coadministration with fluconazole. The rhabdomyolysis promptly resolved after discontinuation of fluconazole, suggesting the possible role of drug interaction in the development of rhabdomyolysis with coadministration of the two medications. Both simvastatin and fluconazole were promptly discontinued, and the patient was admitted to the intensive care unit, where vigorous hydration along with urine alkalinization led to resolution of rhabdomyolysis. Since statins are commonly prescribed treatments for individuals with hyperlipidemia, caution is advised in coadministration with azoles such as fluconazole. Although supportive treatment remains the mainstay of therapy for patients with rhabdomyolysis, fatal consequences can arise from hyperkalemia, cardiac arrhythmia, renal failure and disseminated intravascular coagulation.

Preoperative evaluation of the gynecologic patient: considerations for improved outcomes.

The preoperative evaluation serves several purposes for the gynecologist. Patients with previously undiagnosed, or incompletely managed, medical concerns are identified and appropriate treatment initiated. In women with known medical concerns, the surgeon can anticipate problems and plan for appropriate postoperative care. In certain cases, the preoperative evaluation identifies medical conditions that are unstable enough to adversely affect the postoperative outcome, and appropriate referral for medical management can be made. One of the most important aspects of the evaluation is the identification of women at high risk for cardiovascular complications. A stepwise approach is useful to identify those women who may proceed to surgery and those who need further testing. Much of the preoperative evaluation of the woman with pulmonary disease can be done during the history and physical examination without additional testing. Deep venous thrombosis is a significant concern in gynecologic surgery; appropriate identification of the woman at risk is important, with initiation of prophylaxis occurring shortly after the surgery concludes. Many women undergoing gynecologic surgery have diabetes. Careful management of diabetes in the perioperative period has become more germane, with evidence of improved outcomes as tight control is achieved. Much of the preoperative evaluation falls easily into the purview of the gynecologist, with advice presented as to when medical consultation should be considered.

An acculturization curriculum: orienting international medical graduates to an internal medicine residency program.

BACKGROUND: The number of International Medical Graduate (IMG) applicants to residency programs has increased steadily over the past decade. Despite high motivation and significant medical knowledge, differences in training and cultural expectations can create knowledge gaps and influence how IMGs relate to patients and staff. This contributes to increased opportunities for medical errors, patient dissatisfaction, and frustration among colleagues. DESCRIPTION: To improve this transition we introduced a required, 2-week precourse for IMGs entering our program. The curriculum focused around the Accreditation Council for Graduate Medical Education core competencies. EVALUATION: Participants reported knowledge gains and rated favorably didactic sessions and small-group activities. Program directors and other key stakeholders reported positive experiences with the precourse, especially the reduction in transition stress and missed work time in July. CONCLUSION: An intensive precourse for IMGs can attenuate transition stress and increase knowledge of core medical skills and competencies.

A rare case of hemochromatosis and Wilson's disease coexisting in the same patient.

Wilson's disease and hereditary hemochromatosis are two inherited diseases with life-threatening complications. Early recognition and prompt treatment may be instrumental in reducing such complications associated with these disorders. Although both Wilson's disease and hereditary hemochromatosis are genetic in nature, the two conditions have distinct, unrelated genetic etiologies. Two distinct, separate mutations are required for simultaneous existence of the two diseases. As such, the likelihood of the two conditions coexisting is exceedingly rare. Here we report a case of a 23-year-old male with hereditary hemochromatosis with coexistent Wilson's disease. Only two reported cases exist in which this dual diagnosis was present simultaneously. In our patient, laboratory evaluation demonstrated elevated ferritin, transferrin saturation >90%, and subsequent liver biopsy demonstrated diffuse fibrotic changes. Confirmatory genetic analysis revealed the patient to be a compound heterozygous for C282Y and H63D gene mutations. Given the patient's young age and the improbability of hemochromatosis-induced hepatic damage at that age, an alternative diagnosis was sought. Further analysis revealed reduced serum ceruloplasmin along with elevated urinary copper excretion. Subsequent ophthalmologic exam revealed bilateral Kaiser Fleischer rings. In conclusion, Wilson's disease and genetic hemochromatosis both involve inherent flaws in the transportation of heavy metals and their accumulation in hepatocytes. Although both diseases arise from distinctly different genetic mutations, the coincidence of the two disorders can, in rare cases, occur.