Caring for the Forcibly Displaced.

Immigration, and health issues surrounding the immigration status of patients, remains much in the media forefront and will likely remain so in the future due to ongoing political challenges. Although precise definitions of immigrants, refugees, and asylum seekers remain vitally important when framing discussions around immigration, all newcomers face health challenges. By educating themselves about these issues, health care professionals can better care for their patients, no matter their specialty.

Immigrant and Refugee Health in North Carolina.

The demographic composition of North Carolina has changed dramatically in the past three decades. Because of trends in immigration and refugee resettlement, our state is more diverse than ever before. Immigrants and refugees in North Carolina face unique challenges within the health care system, as well as increasing political and social pressures. Although often discussed as a homogenous group, newcomers comprise a varied mix of peoples from many cultures. The ability to connect across cultural barriers remains a key point when working with these populations. Despite myriad backgrounds, practice recommendations do exist when working with refugees and immigrants, and clinicians and other health care providers should adhere to these standards when working with these underserved individuals.

Photo Rounds: Painless penile ulcer and tender inguinal lymphadenopathy.

Our patient had previously been treated for syphilis. But when his symptoms persisted, further testing revealed that he was being treated for the wrong STD.

Same Content, Different Methods: Comparing Lecture, Engaged Classroom, and Simulation.

BACKGROUND AND OBJECTIVES: There is a push to use classroom technology and active teaching methods to replace didactic lectures as the most prevalent format for resident education. This multisite collaborative cohort study involving nine residency programs across the United States compared a standard slide-based didactic lecture, a facilitated group discussion via an engaged classroom, and a high-fidelity, hands-on simulation scenario for teaching the topic of acute dyspnea. The primary outcome was knowledge retention at 2 to 4 weeks. METHODS: Each teaching method was assigned to three different residency programs in the collaborative according to local resources. Learning objectives were determined by faculty. Pre- and posttest questions were validated and utilized as a measurement of knowledge retention. Each site administered the pretest, taught the topic of acute dyspnea utilizing their assigned method, and administered a posttest 2 to 4 weeks later. Differences between the groups were compared using paired t-tests. RESULTS: A total of 146 residents completed the posttest, and scores increased from baseline across all groups. The average score increased 6% in the standard lecture group (n=47), 11% in the engaged classroom (n=53), and 9% in the simulation group (n=56). The differences in improvement between engaged classroom and simulation were not statistically significant. CONCLUSIONS: Compared to standard lecture, both engaged classroom and high-fidelity simulation were associated with a statistically significant improvement in knowledge retention. Knowledge retention after engaged classroom and high-fidelity simulation did not significantly differ. More research is necessary to determine if different teaching methods result in different levels of comfort and skill with actual patient care.

Pott's Disease Resulting in Complete Cervical Vertebral Destruction.

Skeletal tuberculosis, otherwise known as Pott's disease, has been recognized for centuries. Although typically diagnosed in citizens from countries with endemic tuberculosis, long-term workers in these regions, such as military deployees, can also acquire the disease. We present a case report of a military veteran presenting with neck pain and initially diagnosed with cervical disc disease. The patient's pain progressed to the point of developing paresthesias in his bilateral upper extremities. Eventually, cervical spine radiographs were obtained that revealed complete cervical vertebral body destruction from spinal tuberculosis. Epidemiology, diagnosis, and treatment of the disorder are discussed.

(Almost) Lost at SEA: An Unusual Cause of Cortical Blindness.

A middle-aged man with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, prior cerebral vascular accident, and remote history of generalized seizure disorder presented with worsening right-sided visual deficits and focal seizures. On examination the patient had dense homonymous hemianopsia on the right side. He was initially diagnosed with a stroke and underwent further investigation for potential causes. However, upon further review, magnetic resonance imaging (MRI) findings and repeat examination were more consistent with seizure-related effects on cortical brain matter as the cause of his visual disturbances rather than stroke. An EEG confirmed focal seizures from the left posterior quadrant of the brain, and the diagnosis of status epilepticus amauroticus (SEA) was made. The hemianopsia resolved with antiepileptic treatment.

Impact of Academic Detailing and Same-Day Reminders on Monitoring for Iron Deficiency in Patients With Heart Failure in a Family Medicine Residency.

INTRODUCTION: As we move from a fee-for-service system to a value-based payment system, ongoing quality improvement projects have become the norm. We chose to evaluate whether academic detailing by a pharmacist is an effective means of increasing knowledge among family medicine residents of the need to monitor for iron deficiency in chronic heart failure (CHF) patients. METHODS: We identified the baseline number of iron levels obtained for CHF patients and surveyed all 24 residents to evaluate baseline knowledge of the association between iron deficiency and CHF. Residents met with a pharmacist on clinic days to discuss iron deficiency and CHF and received an educational handout and a list of their CHF patients. Periodic reminders were first sent electronically to residents followed by in-person reminders from the pharmacist for patients seen that day in clinic. RESULTS: At baseline, 16 (3%) of 488 CHF patients had an iron level collected within the past year. Initial survey results showed only one resident (4.2%) reported knowledge of monitoring iron in CHF patients. After academic detailing, residents ordered iron panels on 234 patients. Of these, 98 patients (42%) were found to be iron deficient. On postintervention analysis, all residents surveyed (20) reported that they would monitor iron in CHF patients (P<0.001). Residents were receptive to academic detailing and preferred it over EMR messages. CONCLUSION: Education from a pharmacist improved awareness of the necessity to evaluate for iron deficiency in CHF patients. Academic detailing with reminders is a viable option for improving quality and educating residents.

Puzzles in practice: splenic vein thrombosis.

This report details a 58-year-old gentleman who presented to his outpatient primary care physician's clinic several times over four weeks for ongoing epigastric pain radiating into his left flank, dry heaving, and constipation. He was presumed to have gastritis at each visit and prescribed escalating doses of proton pump inhibitors. Due to the unrelenting pain, he eventually was admitted to the hospital and diagnosed with splenic vein thrombosis after computed tomography imaging of the abdomen. Our literature search revealed that pancreatic pathology is overwhelmingly the contributing factor to splenic vein thrombosis. Our patient had prominent collateral vasculature, suggesting that his splenic vein thrombosis was chronic in nature and likely the cause of his ongoing abdominal pain. Splenic vein thrombosis is an uncommon cause of abdominal pain, but one that should be included in the treating physician's differential diagnoses when abdominal pain is ongoing despite medical therapy. Although he had no evidence of initial findings on radiography, our patient was eventually diagnosed with biopsy-proven pancreatic cancer. Our case report demonstrates how patients presenting with persistent or worsening abdominal pain despite the use of proton pump inhibitors or other acid reducing agents and potential 'red flag' findings such as decreased appetite and weight loss should be worked up for other potential sources of abdominal pathology.

Streptococcal pharyngitis: an uncommon cause of subdural empyema.

A 7-year-old girl with an unremarkable medical history presented to a local paediatric emergency department with a 7-day history of fever, sore throat and vomiting, and a 1-day history of rash. She was admitted to the hospital, with presumed Kawasaki disease. A few hours after admission, the patient had sudden onset of two witnessed tonic-clonic seizures and subsequent decreased mental status. She was transferred to the paediatric intensive care unit and started on broad-spectrum antibiotics. On hospital day 2, cerebral spinal fluid cultures and blood cultures grew Streptococcus pyogenes, and repeat physical examination was consistent with acute streptococcal pharyngitis. On hospital day 3, the patient developed left-sided hemiparesis and had another witnessed seizure. A CT scan was obtained and revealed a subdural abscess. She was transferred to a tertiary care centre and underwent craniotomy with evacuation of her subdural abscess. Surgical cultures eventually grew S. pyogenes.