The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools.

BACKGROUND: While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists. OBJECTIVE: To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA. DESIGN: Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022. PARTICIPANTS: Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. MAIN MEASURES: Clinical load, productivity expectations, cross-coverage, and team-based care models. KEY RESULTS: Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices. CONCLUSIONS: In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

Importance of Hemoglobin SC (HbSC) Screening: Diagnosis of Sickle Cell HbSC Disease Following Hemolytic Crisis and Pulmonary Embolism Due to Peripherally Inserted Central Catheter (PICC Line) Thrombosis.

Sickle cell disease includes various inherited hemoglobinopathies due to the production of abnormal hemoglobin molecules. This can lead to significant clinical complications and sequelae. Hemoglobin SC (HbSC) is a notable variant of SCD, requiring early diagnosis and management to prevent severe outcomes. This case report highlights the critical need for SCD screening, particularly among immigrant populations where current U.S. guidelines do not mandate arrival screening. We present the case of a West African male, age 45, with chronic osteomyelitis, who developed a life-threatening pulmonary embolism (PE) due to peripherally inserted central catheter (PICC line) thrombosis, triggering a hemolytic crisis and thereby revealing HbSC disease. The authors of this report advocate for routine SCD screening in high-risk populations through targeted screening programs. Through multidisciplinary management and public health initiatives, we can address the gap in screening and ensure early detection and treatment of SCD in vulnerable populations.

Systemic Lupus Erythematosus (SLE)-Associated Jaccoud's Arthropathy.

Jaccoud's arthropathy (JA) is a chronic deforming arthropathy, initially linked to rheumatic fever, now more commonly associated with systemic lupus erythematosus (SLE). We report a case of a 27-year-old male presenting with a four-month history of joint pain in the bilateral hands and feet, accompanied by stiffness but no swelling, erythema, or fever. Physical examination revealed flexion deformities, ulnar deviation at the metacarpophalangeal joints, and hyperextension at the proximal interphalangeal joints, without tenderness. Laboratory findings showed elevated anti-double stranded DNA (anti-dsDNA) antibodies and positive antinuclear antibodies (ANA), and imaging confirmed non-erosive arthropathy. Diagnosed with SLE-associated JA, the patient was treated with prednisone, diclofenac, and hydroxychloroquine, leading to significant symptom improvement and decreased anti-dsDNA antibody levels. Even though non-erosive and non-deforming arthropathy is more commonly seen in SLE, timely identification of JA as a non-erosive but deforming arthritis is crucial in differentiating SLE from rheumatoid arthritis. This case underscores the need for comprehensive evaluation and tailored therapy in complex autoimmune conditions to prevent long-term joint damage and improve patient outcomes.

Early-Onset Atrial Fibrillation Complicated by Substance Use Disorder and Psychiatric Comorbidities: A Case Report.

Atrial fibrillation (AFib) is predominantly diagnosed in older adults, with early-onset AFib being relatively rare and often associated with preexisting heart conditions or due to hereditary familial AFib. This case report highlights the unusual diagnosis of AFib in an adolescent and the subsequent management complexities exacerbated by drug dependence and severe psychiatric comorbidities. The case shows the challenges in recognizing and treating AFib masked by psychiatric symptoms and substance abuse. A 33-year-old male with a history of AFib, diagnosed at 18, presented to the emergency department with symptoms suggestive of cardiac arrhythmia exacerbated by acute psychological stress and drug use. Despite a history devoid of classic cardiovascular risk factors, the patient developed drug dependence and psychiatric conditions over 15 years, potentially complicating and delaying effective AFib management. The patient's treatment was further complicated by self-medication with illicit drugs, initially aimed at managing palpitations and anxiety, which may have masked or mimicked cardiac symptoms, thereby delaying appropriate AFib diagnosis and management. His recent hospitalization provided multidisciplinary interventions, including cardiology and psychiatric care, aiming to stabilize his cardiac and psychological conditions. This case illustrates the critical importance of considering early-onset AFib in differential diagnoses regardless of patient age and highlights the need for integrated care approaches in patients with complex comorbidities such as illicit drug use and severe mental health disorders. Moreover, it emphasizes the necessity of educating patients on the interactions between illicit drugs, psychiatric symptoms, and cardiac health. Early and accurate diagnosis, alongside comprehensive management, is crucial for improving outcomes in young patients with AFib complicated by noncardiac conditions. This report encourages further discussion and research into the management strategies for AFib in the context of psychiatric and substance abuse disorders.

Linking Diabetic Retinopathy Severity to Coronary Artery Disease Risk Factors in Type 2 Diabetic Patients.

BACKGROUND: Diabetes mellitus (DM) is a common metabolic disorder characterized by hyperglycemia, leading to chronic complications, notably cardiovascular diseases such as coronary artery disease (CAD). Diabetic retinopathy (DR), a leading cause of blindness, may serve as a non-invasive marker for CAD. This study investigates the correlation between DR and CAD to explore its diagnostic potential in diabetic populations. METHODS: A cross-sectional study was conducted over one year in a general hospital, involving 100 type 2 DM patients with retinopathy. DR was classified as mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, or proliferative retinopathy, based on fundus examinations. Data on age, duration of diabetes, cholesterol levels, glycated hemoglobin (HbA1C), and ECG (electrocardiography) findings were collected. Statistical analysis included frequency analysis, chi-square tests for association between categorical variables, and significance testing with p-values. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States). Descriptive statistics were characterized by categorical and continuous variables. The chi-square test determined associations between qualitative variables, with significance set at p<0.05. RESULTS: The mean age of patients was 57.13 ± 8.51 years. Age and duration of diabetes were significant predictors of retinopathy severity (p<0.001). Proliferative retinopathy was found exclusively in patients over 70 years. Lower cholesterol levels (<200 mg/dL) were significantly associated with less severe retinopathy (p=0.033), whereas higher cholesterol levels (>200 mg/dL) did not show a statistically significant association with retinopathy severity (p=0.772). Patients with HbA1C levels between 6.5% and 8.5% predominantly had milder forms of retinopathy, as indicated by the significant p-value (<0.001). In contrast, patients with HbA1C levels above 8.5% are more likely to have severe NPDR or proliferative diabetic retinopathy (PDR), but this association was not statistically significant (p=0.582). ECG abnormalities increased with retinopathy severity (p=0.002). Hypertension was significantly linked to cardiac changes in retinopathy patients (p<0.001), while smoking and family history of CAD were not significant factors. This study's cross-sectional design limits causality inference. The single-center sample of 100 patients may not be broadly generalizable. Reliance on self-reported data introduces potential recall bias, and confounding factors such as diet, physical activity, and additional comorbidities were not accounted for. The lack of a control group further limits comparative analysis. Future longitudinal studies with larger, diverse samples are needed. CONCLUSION: Retinopathy in DM patients is significantly associated with cardiac changes and other risk factors such as hypertension, dyslipidemia, and poor glycemic control. Aggressive management of these factors is essential. Retinopathy can serve as a predictor of CAD in diabetic patients.

Internal Medicine and Internal Medicine-Pediatrics Residency Program Website Traffic Patterns Across Two Institutions and Five Electronic Residency Application Service (ERAS) Cycles.

Background Since the start of the COVID-19 pandemic in Spring 2020, medical residency program recruitment has become increasingly web-based due to the transition to virtual interviews. Although social media use by residency programs has soared during this time, applicant surveys show that official program websites remain the most used online resource. According to survey-based studies, the content that applicants favor on program websites tends to mirror their priorities in choosing programs. However, it is unclear whether applicant-reported priorities in program choice and website content truly drive program website traffic. In this analysis, we will elucidate website traffic patterns from two Internal Medicine residency programs and two Internal Medicine-Pediatrics programs, both in terms of the thematic content of high-traffic pages and changes in traffic patterns throughout the Electronic Residency Application Service (ERAS) application cycle. We will provide novel, data-driven guidance to residency program leadership regarding website content. Methodology For each of the four programs included in the analysis, total pageviews on a monthly basis were obtained for the annual ERAS application cycles taking place from 2017 through 2022. For one Internal Medicine program, data was only available for its current website from 2020 to 2022. The mean monthly pageviews were calculated for each page within each website. The total site traffic trends across each year and within high-traffic months were totaled as well. Results As expected, the highest traffic period for all programs in all years was the days before the application deadline, with a secondary, smaller spike in traffic around Match Day. In general, the most popular pages for all four programs were thematically in line with the top five applicant priorities in the 2022 National Resident Matching Program applicant survey, namely, geographic location, goodness of fit, program reputation, work/life balance, and current program residents. Three of the websites featured unique content that unexpectedly proved to be as popular as the top survey-reported topics, such as pages related to a new major clinical site, a new integrated subspecialty pathway, and, most profoundly, a pipeline program for certain applicants from groups that are underrepresented in medicine. Alumni career content was also heavily trafficked across all four programs. Conclusions Program directors should plan twice-yearly updates to residency program websites, timed to be finished by the start of the ERAS cycle in the fall, and again just before Match Day in March. Program directors should include specific, up-to-date information about unique program features. Future research should incorporate a more diverse variety of programs, software-based page content analysis, and traffic source data.

Fever, Leukocytosis, and Ulcerated Vulvar Lesions: An Atypical Presentation Concerning Behcet's Disease.

Behcet's disease (BD) is a variable-vessel vasculitis commonly presenting in early adulthood with painful oral aphthous ulcers, genital ulcers, uveitis, pathergy, and skin lesions. The diagnosis of BD is made clinically based on criteria from the International Study Group (ISG) and the International Criteria for Behcet's Disease (ICBD). Due to the wide constellation of symptoms BD can cause, it can be challenging to diagnose in an acute setting. Here, we discuss a patient who presented with a clinical picture of sepsis, with profound ulcerated vulvar and herpetiform oral mucosal lesions, that led us to a presumptive diagnosis of Behcet's disease.

An Atypical Presentation of Fabry Disease in a Patient With Nephrotic Syndrome: A Case Report.

Fabry disease is a rare X-linked lysosomal storage disorder that leads to the accumulation of globotriaosylceramide (Gb3) across various tissues, stemming from a deficiency in alpha-galactosidase A (GLA). This condition is characterized by a spectrum of clinical manifestations that can significantly complicate diagnosis. Classical symptoms typically include neuropathic pain, angiokeratomas, and significant involvement of the renal and cardiac systems. However, atypical presentations may obscure the underlying diagnosis, emphasizing the importance of maintaining a high level of clinical suspicion. This case report details the diagnostic journey of a 24-year-old female who initially presented with nephrotic syndrome, a presentation not commonly associated with Fabry disease. Subsequent genetic testing revealed a pathogenic variant in the GLA gene, confirming Fabry disease and highlighting the critical need for genetic analysis in cases of unexplained renal pathology. This case underscores the variability of Fabry disease presentations and the pivotal role of comprehensive diagnostic strategies in uncovering this complex disorder.

Enhancing Clinical Diagnosis With Convolutional Neural Networks: Developing High-Accuracy Deep Learning Models for Differentiating Thoracic Pathologies.

Background The use of computational technology in medicine has allowed for an increase in the accuracy of clinical diagnosis, reducing errors through additional layers of oversight. Artificial intelligence technologies present the potential to further augment and expedite the accuracy, quality, and efficiency at which diagnosis can be made when used as an adjunctive tool. Such techniques, if found to be accurate and reliable in their diagnostic acuity, can be implemented to foster better clinical decision-making, improving patient quality of care while reducing healthcare costs. Methodology This study implemented convolution neural networks to develop a deep learning model capable of differentiating normal chest X-rays from those indicating pneumonia, tuberculosis, cardiomegaly, and COVID-19. There were 3,063 normal chest X-rays, 3,098 pneumonia chest X-rays, 2,920 COVID-19 chest X-rays, 2,214 chest X-rays, and 554 tuberculosis chest X-rays from Kaggle that were used for training and validation. The model was trained to recognize patterns within the chest X-rays to efficiently recognize these diseases within patients to be treated on time. Results The results indicated a success rate of 98.34% incorrect detections, exemplifying a high degree of accuracy. There are limitations to this study. Training models require hundreds to thousands of samples, and due to potential variability in image scanning equipment and techniques from which the images are sourced, the model could have learned to interpret external noise and unintended details which can adversely impact accuracy. Conclusions Further studies that implement more universal database-sourced images with similar image scanning techniques, assess diverse but related medical conditions, and the utilization of repeat trials can help assess the reliability of the model. These results highlight the potential of machine learning algorithms for disease detection with chest X-rays.

Risk Factors for Falls Among Hospitalized Medical Patients - A Systematic Review and Meta-analysis.

OBJECTIVE: To identify and quantify risk factors for in-hospital falls in medical patients. DATA SOURCES: Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles. STUDY SELECTION: All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded. DATA EXTRACTION: Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting. DATA SYNTHESIS: The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small. CONCLUSIONS: The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

Diagnostic errors and characteristics of patients seen at a general internal medicine outpatient clinic with a referral for diagnosis.

OBJECTIVES: Patients referred to general internal medicine (GIM) outpatient clinics may face a higher risk of diagnostic errors than non-referred patients. This difference in risk is assumed to be due to the differences in diseases and clinical presentations between referred and non-referred patients; however, clinical data regarding this issue are scarce. This study aimed to determine the frequency of diagnostic errors and compare the characteristics of referred and non-referred patients visit GIM outpatient clinics. METHODS: This study included consecutive outpatients who visited the GIM outpatient clinic at a university hospital, with or without referral. Data on age, sex, chief complaints, referral origin, and final diagnosis were collected from medical records. The Revised Safer Dx Instrument was used to detect diagnostic errors. RESULTS: Data from 534 referred and 599 non-referred patients were analyzed. The diagnostic error rate was higher in the referral group than that in the non-referral group (2.2 % vs. 0.5 %, p=0.01). The prevalence of abnormal test results and sensory disturbances was higher in the chief complaints, and the prevalence of musculoskeletal system disorders, connective tissue diseases, and neoplasms was higher in the final diagnoses of referred patients compared with non-referred patients. Among referred patients with diagnostic errors, abnormal test results and sensory disturbances were the two most common chief complaints, whereas neoplasia was the most common final diagnosis. Problems with data integration and interpretation were found to be the most common factors contributing to diagnostic errors. CONCLUSIONS: Paying more attention to patients with abnormal test results and sensory disturbances and considering a higher pre-test probability for neoplasms may prevent diagnostic errors in patients referred to GIM outpatient clinics.

Disconnected Pancreatic Duct Syndrome: A Rare Complication of Pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is a rare complication of a common disease. Typically, DPDS occurs in acute necrotizing pancreatitis (ANP), chronic pancreatitis, abdominal surgery, or trauma. We present a case of DPDS from acute non-necrotizing pancreatitis (ANNP). A 41-year-old male with a history of alcohol use and prior AP presented with progressive, severe left-sided abdominal pain that was worse with movement. Labs revealed a lipase of 95 U/L (normal range 11-82 U/L). Computed tomography (CT) of the abdomen/pelvis (A/P) with IV contrast demonstrated a large left-sided pleural effusion, non-necrotic pancreatic pseudocysts, and a large subdiaphragmatic fluid collection. Thoracentesis of the pleural effusion revealed an amylase of 601 U/L confirming pancreatic etiology. A subsequent magnetic resonance cholangiopancreatography (MRCP) confirmed complex peripancreatic ascites, rapid subdiaphragmatic fluid accumulation, and a fistula from the pancreatic tail to retroperitoneum concerning for a rapidly dissecting pancreatic pseudocyst. He ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the main pancreatic duct. His left-sided abdominal pain rapidly improved, and the patient was discharged. CT A/P one week after discharge showed a reduced size of subdiaphragmatic fluid collection. DPDS is usually seen in patients with a history of ANP. Our case demonstrates that it can also occur in ANNP, which has not previously been described in the literature. Therefore, a high index of clinical suspicion must be maintained for DPDS even in ANNP given its potential for severe complications.

Battlefield Acupuncture for the Treatment of Chronic Migraines.

A 70-year-old man presented with worsening migraines and was referred to a neurologist by their primary care doctor for further workup. Imaging and lab work were benign. The patient then underwent several trials of various first and second-line medications and anti-migraine devices to no avail. It was not until one session of battlefield acupuncture, where five needles were placed in the patient's ear for a few days, that the patient had a resolution of his symptoms.

Uncommon Association Between Gastrointestinal Stromal Tumors (GIST) and Pheochromocytoma With Abdominal Wall Relapse: Case Report and Literature Review.

Gastrointestinal stromal tumors (GISTs) represent a rare form of gastrointestinal neoplasm. This report details a medical case involving a 44-year-old woman who underwent bilateral pheochromocytoma resection, GIST gastrectomy, and laparoscopic adrenalectomy with intestinal resection. Despite an initially positive response to oral imatinib, treatment was delayed due to economic constraints. This delay resulted in a critical event marked by abdominal GIST metastasis to the abdominal wall, subsequent rupture leading to hemoperitoneum, and emergency surgery. Following an adequate postsurgical recovery, she was successfully discharged prior to medication adjustments.

Primary Care: Its Pokemon Moment.

Primary care in the United States is undergoing bursts of evolution in response to health system stresses, changing demographics, and expansion of risk and value-based reimbursement structures. The impact of primary care remains substantive and associated with improved population health. However, the spectrum of services, the nature of the physicians involved and new ways of including the patient in her, or his own care suggests that a new definition of primary care be considered, and patient expectations be heeded and understood. Evolutionary bursts yield new traits and in primary care, they are spawning new care models with significant implications for general internal medicine, internal medicine/pediatrics trained individuals and medicine subspecialties given the focus of these models on Medicare Advantage. Ultimately, changes in reimbursement and creative incentives will be two factors among many that will solidify the next stage of primary care in the United States.

Generative Artificial Intelligence in Patient Education: ChatGPT Takes on Hypertension Questions.

Introduction Uncontrolled hypertension significantly contributes to the development and deterioration of various medical conditions, such as myocardial infarction, chronic kidney disease, and cerebrovascular events. Despite being the most common preventable risk factor for all-cause mortality, only a fraction of affected individuals maintain their blood pressure in the desired range. In recent times, there has been a growing reliance on online platforms for medical information. While providing a convenient source of information, differentiating reliable from unreliable information can be daunting for the layperson, and false information can potentially hinder timely diagnosis and management of medical conditions. The surge in accessibility of generative artificial intelligence (GeAI) technology has led to increased use in obtaining health-related information. This has sparked debates among healthcare providers about the potential for misuse and misinformation while recognizing the role of GeAI in improving health literacy. This study aims to investigate the accuracy of AI-generated information specifically related to hypertension. Additionally, it seeks to explore the reproducibility of information provided by GeAI. Method A nonhuman-subject qualitative study was devised to evaluate the accuracy of information provided by ChatGPT regarding hypertension and its secondary complications. Frequently asked questions on hypertension were compiled by three study staff, internal medicine residents at an ACGME-accredited program, and then reviewed by a physician experienced in treating hypertension, resulting in a final set of 100 questions. Each question was posed to ChatGPT three times, once by each study staff, and the majority response was then assessed against the recommended guidelines. A board-certified internal medicine physician with over eight years of experience further reviewed the responses and categorized them into two classes based on their clinical appropriateness: appropriate (in line with clinical recommendations) and inappropriate (containing errors). Descriptive statistical analysis was employed to assess ChatGPT responses for accuracy and reproducibility. Result Initially, a pool of 130 questions was gathered, of which a final set of 100 questions was selected for the purpose of this study. When assessed against acceptable standard responses, ChatGPT responses were found to be appropriate in 92.5% of cases and inappropriate in 7.5%. Furthermore, ChatGPT had a reproducibility score of 93%, meaning that it could consistently reproduce answers that conveyed similar meanings across multiple runs. Conclusion ChatGPT showcased commendable accuracy in addressing commonly asked questions about hypertension. These results underscore the potential of GeAI in providing valuable information to patients. However, continued research and refinement are essential to evaluate further the reliability and broader applicability of ChatGPT within the medical field.

Asthma Prevalence Among Adults in Qassim Region, Saudi Arabia.

BACKGROUND: Asthma is a major non-communicable disease affecting both children and adults and is the most common chronic disease among children. It has a significant effect on patient's daily lives, as well as a big economic impact on society, as it affects 262 million people of the population globally. According to the previous research conducted in the Aseer region in southwestern Saudi Arabia, the prevalence rate of bronchial asthma was found to be 19.2%. Also, a number of studies revealed a significant prevalence of asthma in Saudi Arabia. Therefore, it is simple and effective to measure specific asthma symptoms among the adult population by utilizing the European Community Respiratory Health Survey (ECRHS) criteria. OBJECTIVES: To investigate asthma prevalence and measure asthma symptoms among Saudi adults in Qassim, Saudi Arabia using the ECRHS. METHODS: This cross-sectional study targets the males and females living in the Qassim region of Saudi Arabia. The study was conducted by handing out a validated, self-administered questionnaire among adult male and female patients in the Qassim region of Saudi Arabia. Both descriptive and inferential statistics analyses were conducted. To test the association, both chi-square and Fisher's exact tests were carried out. For the test, a p-value less than 0.05 was considered statistically significant. RESULTS: The study involved 461 participants who met the inclusion criteria. The study found that 137 (29.9%) participants reported having tightness in their chests when they woke up. Among the respondents who reported these symptoms were 83 (60.1%) female and 55 (39.9%) male respondents. This shows a statistically significant difference between the gender and severity of chest tightness upon waking up (p = 0.008) with more females experiencing it than the male gender. More so, there was a statistically significant difference between the gender and severity of shortness of breath (p = 0.008), with more females (81, 60.4%) having the symptoms than the male gender (53, 39.6%). In addition, the study results reveal statistically significant gender differences among the patients who were diagnosed with asthma by the physician (p = 0.003), with more males (51, 65.4%) having been diagnosed than the female gender (27, 34.6%). Asthma attacks in the 12 months (p = 0.047) and the use of tobacco products (p = 0.001) were also found to have a statistically significant difference across the genders. This was shown by most males (26, 65.0%) who had asthma attacks in the 12 months and 70 (98.6%) who smoked any tobacco products than the few females (14, 35.0%) who reported to have had asthma attacks in the 12 months and one (1.4%) who reported smoking any tobacco products. CONCLUSION: This study noted that the prevalence of asthma symptoms varied based on the gender of the participants. Therefore, the study suggests that gender should be taken as an important factor while evaluating the severity and how asthma-related symptoms manifest.

Hashimoto Thyroiditis Coexisting With Breast Fibroadenoma.

A 34-year-old female with co-existing multiple breast nodules being treated simultaneously presented to the outpatient clinic with fatigue as the chief complaint which had progressively worsened over one year. Ultrasound showed a heterogeneous parenchymal ectopic pattern suggestive of thyroiditis, with no suspicion of nodules and cysts. Laboratory results showed raised levels of thyroid-stimulating hormone (TSH), serum anti-thyroglobulin antibody, and serum thyroid peroxidase antibody. Levothyroxine sodium at a dosage of 50 µg/day was prescribed to the patient, following which the patient had normal TSH levels on follow-up after two months. Simultaneously the patient was under investigation for the breast nodules that were seen as the patient's medical history when she presented to the endocrinology clinic. She was diagnosed with fibroadenoma with a canalicular pattern, without ductal atypia in both breasts and malignancy.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2023.

The expansive scope of internal medicine can make it challenging for clinicians to stay informed about new literature that changes practice. Guideline updates and synthesis of relevant evidence can facilitate incorporation of advancements into clinical practice. The titles and abstracts from the seven general medicine journals with highest impact factors and relevance to outpatient internal medicine were reviewed by six internal medicine physicians. Coronavirus disease 19 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Mayo Clinic Proceedings were reviewed. Additionally, article synopsis collections and databases were evaluated: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, seven practice-changing articles were included.