Additional studies are needed to identify those patients at highest risk for autoimmune complications.Lymphangioleiomyomatosis (LAM) is a rare disease characterized by cystic lung lesions, lymphatic abnormalities, and angiomyolipomas. It can take a significant amount of time to diagnose LAM due to the vague symptoms of fatigue, progressive dyspnea, pneumothorax, and pleural effusion. We present a case of a 29-year-old woman with recurrent spontaneous pneumothorax and progressive dyspnea who was initially misdiagnosed with asthma and was later found to have LAM. As with all rare diagnoses, there needs to be a suspicion of the disease in order for a further workup to be initiated. In patients with a compatible High-resolution CT scan of the chest, a high vascular endothelial growth factor-D (VEGF-D) value is diagnostic for LAM, and no other confirmatory test is needed.

Leadless pacemakers (LPM) are introduced in cardiovascular market with a goal to avoid lead- and pocket-associated complications due to conventional artificial pacemakers (CPM). The comparison of LPM and CPM complications is not well studied at a case by case level.

Comprehensive literature was searched on multiple databases performed from inception to December 2019 and revealed 204 cases that received LPM with a comparison of CPM. The data of complications were extracted, screened by independent authors and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY IBM Corp.).

The complications of CPM were high in comparison to LPM in terms of electrode dislodgement (56% vs 7% of cases, p-value < .0001), pocket site infection rate (16% vs 3.4%, p-value=0.02), and a lead fracture rate (8% vs 0%, p-value=0.04). LPMs had a statistically non-significant two-times high risk of pericardial effusion (8%) compared to CPMs (4%) with a p-value=0.8.

LPMs appear to have a better safety profile than CPMs. There was a low pocket site and lead-related infections in LPM as compared to CPM. However, LPM can have twice the risk of pericardial effusion than CPMs, but this was not statistically significant.

LPMs appear to have a better safety profile than CPMs. There was a low pocket site and lead-related infections in LPM as compared to CPM. However, LPM can have twice the risk of pericardial effusion than CPMs, but this was not statistically significant.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) created an ABCD tool to assess staging and severity of COPD subgroups that respond to LAMA or LABA with improved quality of life and reduced exacerbations. Our study assesses perception of physicians at five community hospitals towards LAMA use for patients admitted with COPD exacerbations according to the GOLD guidelines and describes the experience at our hospital.

Electronic survey forms regarding LAMA use and the GOLD criteria ABCD for COPD treating physicians were sent to five hospitals. A one-year chart review at our hospital determined prevalent use of a maintenance LAMA or LABA inhaler in patients admitted with acute COPD exacerbation. Currently, our EMR does not require a field for the GOLD ABCD categorization.

We obtained a 33% (45/136) response rate. Of these, 63% felt a LAMA to be essential on formulary; 60% were neutral or unlikely to initiate LAMA on admission; 47.7% likely or very likely to start a LAMA during hospitalization; 82% were neutral to very likely to discharge a patient on a LAMA if deemed necessary for maintenance. Of those admitted for acute COPD exacerbations to our hospital, over a third of COPD patients were not on a maintenance LAMA or LABA.

Most physicians felt it important to prescribe a maintenance LAMA to COPD patients hospitalized for acute exacerbation. Our hospital’s use of LAMA or LABA demonstrates the need to incorporate strategies to encourage appropriate prescribing of these LA inhalers per GOLD guidelines.

Most physicians felt it important to prescribe a maintenance LAMA to COPD patients hospitalized for acute exacerbation. Our hospital’s use of LAMA or LABA demonstrates the need to incorporate strategies to encourage appropriate prescribing of these LA inhalers per GOLD guidelines.Spontaneous coronary artery dissection (SCAD) is a type of non-atherosclerotic coronary artery disease, initially thought to be uncommon but is now being increasingly recognized as a cause of acute coronary syndrome in females. The exact incidence of this remains unknown and most of these cases undergo emergent percutaneous intervention (PCI) due to concern for acute coronary syndrome (ACS). Prior studies have shown that PCI can be detrimental in these cases. It is important to recognize the possibility of SCAD in young female patients so that potentially harmful interventions, such as starting these patients immediately on heparin, use of thrombolytic therapy, and emergent PCI that can lead to worse outcomes, are avoided.Multiple myeloma (MM) is a hematological malignancy characterized by an abnormal clone of plasma cells in the bone marrow. MM and its therapy increase the risk of complications like anemia, osteolytic lesions, pain, infections, and renal abnormalities in MM patients. Supportive care for MM patients improves the quality of life. Treatment with bisphosphonates decreases skeletal-related events. Vertebroplasty and kyphoplasty are done in cases of vertebral compression fractures. Prophylactic antibiotics and antivirals can decrease infections related to morbidity. Plasmapheresis in patients with renal dysfunctions decreases dialysis dependency and improve quality of life.Avicenna, to the west, and Ibn Sina to the East, is more than a historical figure often overlooked beyond his contributions to the Golden Age of Islam. While a deeper image of this multi-faceted individual can be cultivated by exploring his extensive contributions to the fields of medicine, science, philosophy, and pharmacology, his impact on medicine is often forgotten. However, it is important to shed light on the role of the 'Prince of Physicians’ in the major advancements achieved in medicine today, especially with regards to the Western hemisphere. This report focuses on Avicenna’s advancements in the medical field, and how there is more to the history of medicine than Hippocrates and the western authorities that dominate our accounts.We present three patients with COVID-19 who developed acute renal failure during hospitalization and were seen to have an improvement in their kidney function after being started on therapeutic anticoagulation with heparin (Target PTT 58-93 seconds) for varying indications (atrial fibrillation, popliteal vein thrombosis and a pulmonary embolism). Their kidney functions improved significantly following anticoagulation with a clear temporal relationship between the former and latter. Anticoagulation was held for one patient due to concern of gastrointestinal bleeding and his kidney functions worsened a day after stopping anticoagulation. D-dimer levels also improved with anticoagulation but the trend of other inflammatory markers remained unpredictable.

Treating COVID-19 patients can affect anxiety.

To compare the anxiety of internal medicine residents treating COVID-19 patients at a level-3 hospital with a level-2 hospital.

A questionnaire related to COVID-19 and anxiety using the State-Trait Anxiety Inventory (STAI-S) was sent to internal medicine residents of a COVID-19 referral level-3 hospital and a level-2 hospital from which all diagnosed COVID-19 cases are transferred to the COVID-19 referral hospital.

Responses were received from 76.3% of the internal medicine residents. There was no difference in the anxiety scores between residents from the level-3 center (44.4) and the level-2 center (44.4), p =0.9. There was a significant difference between the number of residents from the level-3 center, 22/56 (63%) and the number of residents from the level-2 center, 1/10 (10%) who were concerned about better protective gear (p=0.003) and between residents from the level-3 center19/35 (54%) and those from the level-2 center, 1/10 (10%) who were concerned about infecting their families (p=0.01).

The internal medicine resident anxiety scores were not a function of hospital level, but safety was less of a concerns in the level-2 center with only emergency room COVID-19 services.

The internal medicine resident anxiety scores were not a function of hospital level, but safety was less of a concerns in the level-2 center with only emergency room COVID-19 services.In response to the COVID-19 pandemic, hospitals have adopted protocols geared to optimize the care of patients with COVID-19, while mitigating risk of exposure to other patients and to health care workers. These modifications can have un-intended consequences and impact the care of non-COVID patients. In the campaign against COVID-19, we must remain vigilant that patients with traditional disease processes also receive thoughtful and coordinated care.SARS-CoV-2 is a novel coronavirus that was initially described in Wuhan China in December 2019. In the USA (US), the person to be diagnosed with the novel Coronavirus infection (COVID) was on 19 January 2020. On 18 March 2020, a 31-year-old morbidly obese African American woman presented with severe dyspnea with associated hypoxemia, fever and bilateral interstitial pulmonary ground glass infiltrates consistent with viral pneumonitis. Nasopharyngeal PCR testing was positive for SARS-CoV-2. Despite initiation of hydroxychloroquine and azithromycin along with supplemental oxygen therapy, rapid disease progression consistent with cytokine release syndrome ensued, leading to initiation of mechanical ventilatory support. Anti-Interleukin (IL)-6 receptor monoclonal antibody (tocilizumab) was administered. Acute respiratory distress syndrome (ARDS) leads to refractory hypoxemia and demise. Severe morbid obesity as well as race may be unidentified risk factors for the development of severe Illness in patients with COVID-19.Rhabdomyosarcoma is an aggressive malignant soft-tissue sarcoma that develop from undifferentiated mesenchymal cells. Less than 1% of all adult solid malignant cancers are sarcomas, and RMSs represent less than 2-5% of adult sarcomas.   RMS is divided into three main subtypes Embryonal, alveolar and pleomorphic RMS (PRMS).   Most common subtype in adults is PRMS. Most common primary sites are extremities, trunk wall, and genitourinary organs. Metastasis are often found at diagnosis. 5-year overall survival rates were reported in the Surveillance, Epidemiology, and End Results database (SEER) to be 63% for pediatric patients and 27% for adults. Given the rarity of the adult PRMS, variation in its clinical presentation, characteristics of the tumor itself and the prognosis; there are very limited data available to guide the management of adults with PRMS. Herein we present a case report of pleomorphic rhabdomyosarcoma of the right thigh in a 60-year-old male who achieved a long-term survival (30 months) which was accomplished by multimodality treatment including surgery, radiotherapy, and chemotherapy.   .Ventricular stand still is an electrophysiologic phenomenon characterized by the absence of ventricular activity or contraction. It is the result of the lack of impulse formation in ventricles (absence of idioventricular automaticity) or the failure of impulse transmission to ventricles (conduction disturbance) [1]. It is an uncommon condition that can affect a wide range of age groups with life threatening consequences. There are no set guidelines on the treatment of ventricular standstill – swift and sound clinical judgment is required. The condition should be treated as a cardiac arrest, with resolution of precipitating factors. Here we present a case of a 59-year-old man with multiple comorbidities, who presented with massive gastrointestinal hemorrhage and recurrent episodes of ventricular standstill during hospitalization, with his immediate treatment and stabilization.Transcatheter aortic valve implantation (TAVR) constitutes an established treatment in inoperable or high perioperative risk patients with severe aortic stenosis. Prosthetic valve endocarditis after ΤΑVR occurs with an incidence of 0.3-1% per patient-year. Infective endocarditis may stem from hematogenous dissemination or contact with infected adherent tissue. Few cases of infective endocarditis after TAVR have been reported. We present an interesting case of a 79-year-old male with a history of severe aortic stenosis status post TAVR greater than one year ago, and pulmonary vein isolation for atrial fibrillation six weeks ago was found to have infective endocarditis with a vegetation on the prosthetic valve leading to multiple embolic strokes as a result of Enterococcus faecalis bacteremia. The patient was not a surgical candidate with his Society of Thoracic Surgery (STS) risk score being 18%; therefore, he was managed conservatively on intravenous antibiotics. Our case had endocarditis from enterococcus bacteremia; however, the patient never had any gastrointestinal or genitourinary procedure.

Gilteritinib is a FLT3 kinase inhibitor approved for FLT3-mutated acute myeloid leukemia (AML). We present a case of febrile neutropenia and neutrophilic dermatosis consistent with Sweet’s syndrome (SS).

A 55-year-old woman presented with fever and skin lesions after 4weeks of initiation of Gilteritinib for AML. She was febrile, pancytopenic and neutropenic with absolute neutrophil count (ANC) of 0.1x10E3/UI. Examination revealed reddish and violaceous rashes on her extremities. Pathology showed superficial dermal edema, widespread epidermal spongiosis and multiple neutrophils in the dermal infiltrate. Rash improved with prednisone 60 mg daily and started to flare with taper. She was still on Gilteritinib all this time. Gilteritinib was finally stopped due to non-response and possible contribution in flaring her SS. Shortly after, the patient succumbed to progressive disease and complications of sepsis.

There have been reports of SS in neutropenic patients although SS is typically a neutrophilic dermatosis. The pathogenesis of SS in neutropenia remains uncertain. Our study represents an additional medication-associated cutaneous complication of AML therapy. Clinicians need to be aware of potential neutrophilic dermatoses with FLT-3 inhibition, even with peripheral neutropenia.

There have been reports of SS in neutropenic patients although SS is typically a neutrophilic dermatosis. The pathogenesis of SS in neutropenia remains uncertain. Our study represents an additional medication-associated cutaneous complication of AML therapy. Clinicians need to be aware of potential neutrophilic dermatoses with FLT-3 inhibition, even with peripheral neutropenia.Hepatitis is a rare complication of herpes simplex virus (HSV) which can lead to acute liver failure, liver transplant, or death. This complication is more commonly seen in neonates, immunocompromised, or pregnant patients. Early recognition of disease facilitates prompt treatment with antiretrovirals and prevent its progression. To our knowledge, only 30 cases have been reported. Our patient presented with headaches and elevation of transaminases followed by vesicular rash. Culture tested positive for HSV1 and HSV2 and the patient was successfully treated with Acyclovir.Tumor lysis syndrome (TLS) is an oncological emergency characterized by a classic tetrad of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Risk assessment and prophylactic therapy is critical in preventing this oncological emergency. Treatment of established TLS involves aggressive hydration, electrolyte management, and the use of hypouricemic agents.Legionella pneumophilia remains an important cause of pneumonia that can cause substantial clinical morbidity and mortality. We describe a case involving a 67-year-old woman with legionella pneumonia who developed diffuse alveolar hemorrhage. We also highlight the pitfalls of commonly used legionella urine antigen testing. Furthermore, we explore the role of high-dose steroid therapy as a treatment option for patients with diffuse alveolar hemorrhage secondary to legionella pneumonia who continue to deteriorate in spite of adequate antimicrobial therapy.Takotsubo Cardiomyopathy (TCM) is characterized by a transient but reversible ventricular dysfunction in post-menopausal females following, but not always, a recent emotional or physical stress. Typically, chest pain is reported as a presenting symptom in the majority of patients. The severe diarrheal illness secondary to acute viral gastroenteritis is not commonly reported as the stressor event prior to TCM. We report a unique case of a middle-aged male presented with syncope shortly after loose bowel movements. He was diagnosed with TCM and was successfully managed with supportive care. The purpose of this case is to make clinicians aware of this rare association.Rhabdomyosarcoma (RMS) is a malignant soft tissue tumor of the pediatric population which is  rarely seen in adults. Metastatic rhabdomyosarcoma is even rarer. We present an unusual case of a 49 year old female presenting with palpitations and uterine bleeding. An Echo-cardiogram revealed a large oval mass on the posterior mitral leaflet and a Computerized Tomography (CT) scan of the abdomen revealed a uterine growth. Surgical excision of the cardiac mass was done and histological analysis of cardiac lesion confirmed it to be rhabdomyosarcoma with a primary source in the uterus. The patient became asymptomatic from a cardiac standpoint after excision of the mass and was scheduled for chemo/radiation therapy for the primary uterine malignancy. Metastatic cardiac rhabdomyosarcoma can be confused with a myxoma or any other primary or secondary cardiac tumors resulting in delayed diagnosis. However, its aggressive nature makes it a life-threatening tumor that requires an early diagnosis to prevent fatal consequences.is a rare fungal opportunistic infection originally isolated from the oral cavity of severely immunocompromised individuals. We present a case of a candidiasis infection in a patient with only decompensated liver cirrhosis and diabetes mellitus as his immunocompromising risk factors, resulting in severe fungemia and death within 5 days despite being on antifungal therapy.Thymomas are rare tumors of the thymic epithelium with an incidence of 1.5 cases in a million, with a wide spectrum of morphological, pathologic characteristics, and clinical presentations. Despite its benign histological appearance, it can invade nearby structures or metastasize hence clinicians need to have a high index of suspicion for early diagnosis. The natural history of the disease is seldom predictable and ranges anywhere from indolent to aggressive malignant course. In this review, we report a case of invasive thymoma in a patient whose presenting complaint was intermittent chest pain x 2 years that had gone undiagnosed. Complete surgical resection is the cornerstone of treatment in early presentation, but with the case of our patient who presented with a locally advanced thymoma treatment, her treatment options were challenging and had to be a multimodal approach with a combination of surgery, chemotherapy and radiation therapy to reduce the chances of recurrence and improve survival. Given the rarity of this presentation, the clinicopathological characteristics that influence the survival of patients with these tumors are still under debate, and guidelines for management for advanced disease are yet to be defined hence warranting our review on this discussion.Loperamide is a widely available, over-the-counter medication. The advent of the opioid epidemic has seen cases of loperamide overdose being reported. The common side effects of the medication can be relatively benign, but at high doses, loperamide can precipitate life-threatening arrhythmias. Our case highlights rare side effects of loperamide overdose inducing ventricular tachycardia, with unfavorable consequences. This case emphasizes that the distribution and availability of this medication should be restricted, to be a prescription drug, to prevent overdose and adverse outcomes.

The Brugada pattern is identified on the EKG by a coved ST-segment elevation accompanied by a negative T wave in the early precordial leads in the absence of a cardiac structural abnormality. Brugada pattern and Brugada syndrome should be differentiated, as the latter is associated with an increased risk of sudden cardiac death.

The literature was searched using multiple databases to identify all the articles on Brugada pattern. Data were screened and analyzed by independent authors.

Sixty articles, comprising 71 patients, were included in the study. The mean age of patients was 42.6years, with a higher prevalence of Brugada pattern in men (83%) than women (17%). The most frequent findings associated with Brugada pattern was fever (83%). Other less common presentations included cough (21%), sore throat (10%), syncope (18%), abdominal pain (8%), and chest pain (7%). Comorbidities included pneumonia (30%), upper respiratory tract infections (14%) and smoking (14%). Among treatment modalities, 39% of patients had ICD placement performed, 44% received antibiotics, while 14% had supportive care. Adenosine was given to 3% of patients, while other antiarrhythmics like milrinone, amiodarone, sotalol, procainamide, flecainide, and nitroglycerin were given to 1% of patients. Most patients with Brugada syndrome had a satisfactory outcome, with only 4% mortality rate(WHAT ABOUT THE OTHER 11%?). Out of the 71 patients, 3% had persistent Brugada patterns, while 86% of patients recovered completely. There was no significant effect of ICD on mortality or Brugada pattern resolution (p 0.37).

Our study shows that fever is the main reason for unmasking the Brugada pattern in patients with this channelopathy. ICD placement in such patients is not recommended as it has no mortality benefits.

Our study shows that fever is the main reason for unmasking the Brugada pattern in patients with this channelopathy. ICD placement in such patients is not recommended as it has no mortality benefits.

Electronic cigarettes (EC) remain a controversial topic with uncertainty about harm reduction in current smokers, their efficacy in smoking cessation, their potential for addiction, the need for regulation, and the type of information needed to educate the public about the benefits and hazards of EC. Multiple medical institutions and organizations have conducted surveys to investigate the demographics and perceptions of EC consumers in adult and youth populations. However, it is unknown whether these surveys use consistent, reliable, or accurate measures for EC use.

We analyzed 13 survey articles identified during a review of the use of EC during smoking cessation programs to determine the characteristic features of the surveys and to determine how frequently they satisfied the measurement of important core items suggested by recent articles.

Our analysis focused on 13 studies. These studies represented the work of 13 separate research groups and were published in 10 different biomedical journals with a study goals. Consequently, comparisons across studies become difficult and limit the external validity of survey studies on EC.Over the years, Takotsubo Cardiomyopathy (TCMP) has become increasingly apparent, now comprising a significant portion of patients presenting with suspected acute coronary syndrome. The most common presentation of TCMP is ST segment elevation on EKG, troponin elevation, and apical ballooning in the absence of significant coronary artery disease as seen via cardiac catheterization. Although this is the most common presentation, it is important to highlight the less common variants of TCMP. In this article, we present a case series of patients presenting with the different variants of TCMP, followed by a literature review.

Stool ova and parasite (O&P) examinations are routinely ordered initial tests in patients admitted to the hospital with acute diarrhea, despite low test positivity rates. We examined the diagnostic yield of inpatient stool O&P exams and identified risk factors associated with positive tests.

A retrospective, case-control analysis of inpatients admitted with diarrhea, who underwent O&P examination, was conducted. Clinical and demographic variables of cases were compared with age-and gender-matched controls via uni- and multivariate conditional logistic regression analyses.

The yield of inpatient O&P exams was 2.15% (37/1723).

spp. represented the most common parasites. All patients with positive tests, excluding

spp., had at least one of the following risk factors smoking, prior parasitic disease, HIV-positive status, travel to an endemic area, and institutionalization.

Superfluous inpatient stool O&P exams confer a financial and labor burden to hospital systems. Stool O&P exams should be restricted to individuals admitted to the hospital for <3days, having diarrhea >7days and possessing at least one of the following risk factors smoking, prior parasitic disease, HIV-positive status, travel to an endemic area, and institutionalization. Such selective testing can confer a 51% reduction in testing, costs, and labor.

7 days and possessing at least one of the following risk factors smoking, prior parasitic disease, HIV-positive status, travel to an endemic area, and institutionalization. Such selective testing can confer a 51% reduction in testing, costs, and labor.Acute decompensated heart failure is the leading cause of hospitalization in older adults. Clinical practice guidelines recommend patients should be euvolemic at hospital discharge – yet accurate assessment of volume status is recognized to be exceptionally challenging. This conundrum led us to investigate how hospitalists are assessing volume status and discharge- readiness of patients hospitalized with heart failure. We collected audience response data during a didactic heart failure presentation at the 2019 Society of Hospital Medicine annual meeting. Respondents (n = 216), 76% of whom were practicing physician hospitalists caring for more than 20 acute heart failure patients per year, were presented six questions. Eighteen percent of respondents reported not being able to determine the completeness of decongestion on discharge and 32% reported that complete decongestion was not a treatment target. These findings suggest important differences between guideline recommendations and how hospitalists treat heart failure in current clinical practice.Inadvertent removal of percutaneous endoscopic gastrostomy (PEG) tube shortly after placement creates the potential for gastric perforation and requires immediate attention. This problem has been addressed in the past with either observation or surgery. We describe our experience with the alternative approach of semi-urgent 're-PEGing’. Our results in seven patients were favorable.

Obstructive sleep apnea (OSA) is an established risk factor for poor cardiovascular outcomes and coronary artery disease, but its influence on the development of peripheral artery disease (PAD) is not well established. The aim of our study was to understand the mutual prevalence of OSA and PAD and any reported statistical association between the two conditions.

PubMed, Ovid Embase, Web of Science, Cochrane library and clinicaltrials.gov databases were systematically searched up to 29 November 2018. A total of 844 articles were identified and 744 articles were screened for relevance.

Eleven prospective cohorts qualified for inclusion with

=63,642 (

=28,062,

=35,494). All studies evaluated OSA severity primarily with apnea-hypopnea index (AHI) values. The overall prevalence of PAD was 20.5% (

=13,068). Except for two studies, all studies reported an increased prevalence of OSA in patients with PAD. OSA severity was not found to have an association with poor ankle brachial index values or increasing daytime sleepiness as measured by Epworth sleepiness scale. Further prospective clinical trials are required to further delineate this finding.

Eleven prospective cohorts qualified for inclusion with N = 63,642 (M = 28,062, F = 35,494). All studies evaluated OSA severity primarily with apnea-hypopnea index (AHI) values. The overall prevalence of PAD was 20.5% (N = 13,068). Except for two studies, all studies reported an increased prevalence of OSA in patients with PAD. OSA severity was not found to have an association with poor ankle brachial index values or increasing daytime sleepiness as measured by Epworth sleepiness scale. Further prospective clinical trials are required to further delineate this finding.Patients with atrial fibrillation are at an increased risk for stroke, and many benefits from anticoagulation. Despite the emergence of direct oral anticoagulants, many patients continue to rely on warfarin for their anticoagulation due to logistical, pharmacokinetic, clinical, or patient preference issues. Previous work has suggested that outcomes of warfarin therapy are related to patient education/knowledge. We assessed knowledge of indications, benefits, and complications of warfarin therapy in 99 randomly selected patients enrolled in the Warfarin Anticoagulation Clinic at the Mayo Clinic in Florida who were taking warfarin for non-valvular atrial fibrillation. Patients were labeled as 'knowledgeable’ or 'not knowledgeable’ regarding warfarin therapy according to the results of a cross-sectional questionnaire. The majority of patients in both the knowledgeable and not knowledgeable groups displayed understanding that they were taking warfarin for atrial fibrillation (valvular vs non-valvular atrial fibrillation was not an included answer choice). However, there was a clear lack of knowledge amongst patients with atrial fibrillation in both groups about their stroke risk while on and off warfarin, and their risk of major bleeding or adverse events related to their warfarin therapy. There was only a significant difference between the two groups regarding their knowledge of what increases or decreases the risk of bleeding while on warfarin. There was no major difference between the groups with regards to demographic and medical characteristics, except that 'not knowledgeable’ patients tended to have more peripheral vascular disease, ulcer disease, and moderate-severe renal disease compared to 'knowledgeable’ patients.A 48-year-old male presented to the emergency room for 2 weeks of joint pain and swelling of his four extremities. His symptoms started suddenly and were quite debilitating. His hands, fingers, knees, and ankles were so swollen and painful that he was unable to get out of bed and had to use crutches to ambulate. He also complained of anorexia, nausea, and lack of energy over the past few months, but denied any other complaints. His only medical history was a traumatic left tibia fracture 1 year ago. The patient had a 30-pack year history of smoking tobacco and used marijuana daily. The patient recently had an arthrocentesis at an outside hospital which was non-diagnostic and showed no infection. Given his symptoms, a thorough rheumatic workup was ordered. The ESR and CRP were elevated. ANA, rheumatoid factor, HLA B27, HIV, hepatitis panel, TSH, T4, Coombs antibodies, gonorrhea, chlamydia, CCP, alpha 1 antitrypsin, parvovirus, fungal antibodies, and myeloperoxidase antibodies were all within the normal range. unusual presentation of non-small-cell lung cancer and highlights the importance of maintaining malignancy on the differential diagnosis for sudden arthritis.With the advent of medical technology, coronary angiography is a common practice to evaluate patient for coronary artery disease. Normally, patients undergoing angiogram receive antiplatelets, anticoagulants, and platelet aggregation inhibitor agents. Glycoprotein IIb/IIIa receptor inhibitors are a type of platelets antiaggregant agents that can cause severe thrombocytopenia in very few cases. We present a case of a 69-year-old female who presented with chest pain, underwent an angiography and had two stents placed. She was administered tirofiban during angiogram that caused acute severe thrombocytopenia decreasing her platelets count from 224 to 2 k/mm3 within 1 day. Patients platelets gradually recovered after trial of steroid and platelets transfusion. Antiplatelets (Aspirin and Clopidogrel) were resumed; however, patient’s platelets remained stable.

Current evidence shows that telemetry monitoring is commonly overutilized for ’

diseases such as COPD exacerbation, pneumonia, pulmonary embolism and sepsis. This issue has not been addressed clearly in the recent American Heart Association (AHA) guidelines and no standard recommendations on the use of telemetry in non-cardiac conditions exist; therefore, clinicians continue to make such decisions based on personal preferences.As medical residency is an important phase during which young physicians develop clinical skills and habits for their future practice, the aim of this study was to understand the prevalent trends related to inappropriate telemetry use amongst the medical residents at a community hospital and the associated factors which influence the use of telemetry monitoring in non-cardiac patients.

All the residents undergoing internal medicine training at a community hospital were surveyed with the help of a questionnaire regarding the utility of telemetry in

patients admitted with

condl resources to the clinical staff at every level along with other system-based strategies.

Majority of the medical residents overutilize telemetry in non-cardiac conditions due to lack of knowledge, perceived sense of security and inappropriate trends set by their colleagues. In order to abolish these tendencies, we propose the provision of adequate educational resources to the clinical staff at every level along with other system-based strategies.Intravesical instillation of Bacillus-Calmette-Guerin (BCG), a live-attenuated-strain of Mycobacterium bovis, is an established treatment for superficial bladder carcinoma. Although generally well tolerated, 1/15,000 patients can develop life-threatening disseminated-BCG-infection typically soon after the procedure, a condition colloquially termed BCG-osis. Side-effects of intravesical BCG instillation including fever, chills, fatigue are common but BCG-osis is rare and severe, oftentimes requiring intensive care unit admission and triple anti-TB-therapy as in this case. It is therefore important for clinicians to recognize this possibility as the absence of specific signs and symptoms, coupled with the fastidious nature of the Mycobacteria, pose a diagnostic dilemma in the acute setting. Our case highlights this potential rare iatrogenic side effect of intravesical BCG treatment and the risk associated with non-treatment of BCG-osis.We report a case of an African American woman who presented with fatigue, generalized weakness, and hypophosphatemia in the setting of a recent hospitalization for severe, symptomatic iron deficiency anemia requiring ferric carboxymaltose infusions. Parental iron is indicated in numerous clinical settings including chronic kidney disease, inflammatory bowel disease, and iron deficiency anemia. Ferric carboxymaltose is one of the most common forms of parental iron infusions used due to administration procedure and minimal reported side effects. The most common side effect reported is a transient decrease in serum phosphate. This case highlights the necessity of monitoring serum phosphate in the setting of parental iron infusions, especially ferric carboxymaltose, and when severe hypophosphatemia occurs management includes intravenous phosphorous and calcitriol.is a gram-positive bacillus in the female genital tract believed to be a commensal organism that inhibits the growth of more virulent pathogens. Prevotella bivia is a gram-negative bacillus species also typically commensal in the female genital tract. Lactobacillus as the primary causative agent in perinephric abscesses and bacteremia has been documented, albeit very uncommon and opportunistic. Prevotella bivia is not classically associated with perinephric abscesses but has been implicated in rare cases of pelvic inflammatory disease and tubo-ovarian abscesses. In this report, we present a 26-year-old immunocompetent woman with a recent history of nephrolithiasis treated with lithotripsy, ureteral stent placement and removal, and antibiotics who was admitted for fever and severe right flank pain. Imaging showed a right-sided renal and perinephric abscesses colonized by Lactobacillus jensenii and Prevotella bivia. Blood cultures were also positive for Lactobacillus species. Per literature review, intravenous ceftriaxone and metronidazole were administered with successful resolution of abscesses and negative repeat blood cultures. To our knowledge, this is the first case of simultaneous renal system abscesses caused by Lactobacillus and Prevotella species. Nephrolithiasis and prior antibiotics likely contributed to the opportunistic pathogenesis in this otherwise immunocompetent patient.Kaposi sarcoma (KS) is caused by Human Herpesvirus 8 (HHV-8), and it affects 15 times more common in men than women. It has varied clinical presentation from classic, endemic, organ transplant-related, and acquired immunodeficiency syndrome (AIDS)-related. Clinical features of pulmonary KS might be challenging to distinguish from pneumonia in immunocompromised patients and could lead to diagnostic challenges. Hence Pulmonary KS should also be considered in the differential when HIV-infected patients develop rapidly progressive respiratory symptoms after the initiation of glucocorticoid therapy and immunocompromised not responding to antibiotic treatment for pneumonia, especially when CD4 10,000. Early diagnosis and treatment are essential for a better outcome and prevent morbidity and mortality. Highly active antiretroviral therapy (HAART) is the only proven therapy to prevent Kaposi sarcoma. We report the case of a young woman who presented with symptoms of pneumonia and was later found to have pulmonary KS (PKS).Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome, accounting for 40% of nephrotic syndrome in adults. FSGS has diverse clinical and morphological features and underlying pathogenesis. We present a case of a 33-year-old male presenting with acute systolic heart failure complicated with left ventricular thrombus with embolism to coronary circulation and bilateral deep vein thrombosis. He was found to have nephrotic range proteinuria with kidney biopsy showing FSGS. Association of FSGS with cardiomyopathy has been reported in children. However, in adults, according to our best knowledge, there have not been any report of FSGS and non-ischemic cardiomyopathy or it is at least underreported.

FSGS Focal segmental glomerulosclerosis; ESRD End-stage renal disease; NOS Not otherwise specified; LV Left ventricle.

FSGS Focal segmental glomerulosclerosis; ESRD End-stage renal disease; NOS Not otherwise specified; LV Left ventricle.Diphenhydramine is a widely available, over-the-counter medication used for allergies and as a sleeping aid. When used in prescription doses, it is generally safe. Overdose of the medication has been associated with dangerous and life-threatening outcomes. Our case describes diphenhydramine toxicity manifesting with two rare but potentially life-threatening complications, rhabdomyolysis, and QT prolongation. Laboratory testing for diphenhydramine levels are not widely available. We recommend a high degree of suspicion for these complications when evaluating patients with diphenhydramine overdose, to adequately manage and prevent untoward outcomes.Alien Hand Syndrome (AHS) is characterized by intermittent and involuntary movements of a single limb that is not associated with motor dysfunction. AHS may be the initial presentation of serious underlying pathology, such as stroke localized to the non-dominant parietal lobe, corpus callosum damage, or neurodegenerative disease. AHS occurs at a low prevalence in the general population yet represents significant underlying disease burden, necessitating early identification. In this case report, we present an 88-year-old right-handed male with involuntary movement of his left forearm and hand three hours prior to presentation. His symptom corresponded to findings on MRI of the brain, which showed acute infarcts of the right temporal lobe, right parietal cortex, and right parietal subcortex. Infarction of the right parietal cortex accounted for his AHS. The multifocal nature of the infarcts elevated the index of suspicion for an embolic source.Patients presenting with bacteremia and the presence of multiple infected emboli sites should be promptly investigated for heart valve endocarditis as the possible culprit. We present a case of Eustachian valve endocarditis secondary to multiple abdominal surgeries to highlight not only the importance of recognizing risks factors, other than intravenous drug use, in the pathogenesis of right sided endocarditis, but also to illustrate the significance of systematically interrogating all the heart valves, including the Eustachian valve during echocardiography.Gastric cancer is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. Signet-ring cell type is the most malicious subtype. We report a case of advanced stage gastric adenocarcinoma case post-radical gastrectomy who presented with nausea, vomiting, and diarrhea. Though there were no signs of bowel obstruction on abdominal CT and PET imagine studies, and the cytology of body fluid was initially negative, the patient had unilateral malignant pleural effusion, a moderate amount of ascites and bilateral hydronephrosis. After laparoscopic surgery, the patient was diagnosed with local cancer relapse causing jejunojejunal anastomosis obstruction and peritoneal carcinomatosis causing hydronephrosis. We urge broadening the indication of EGD in the evaluation of advanced stage gastric carcinoma to include mechanic bowel obstruction.Dieulafoy lesions are tortuous vascular malformations characterized by thick walled submucosal arteries/large caliber arterioles protruding through a small mucosal defect surrounded by normal mucosa. They can occur in the jejunum/ileum and can cause massive, life-threatening GI bleeding. We present an 80-year-old female with three weeks of black tarry stools, progressive dyspnea on exertion and generalized body weakness with no significant findings on Esophagogastroduodenoscopy (EGD). Push enteroscopy revealed a Dieulafoy lesion in the proximal jejunum and an overlying clot, with oozing of blood noted after clot removal. The lesion was treated with Argon plasma coagulation (APC) and a post-APC fleshy protuberance was clipped to secure hemostasis. It is therefore important to keep a high index of suspicion for jejunal/ileal Dieulafoy lesions in patients with massive GI bleeding of unclear etiology on EGD/colonoscopy.Neuroleptic malignant syndrome is a potentially fatal neurological condition secondary to antipsychotic medication. It is characterized by distinctive clinical findings and autonomic disturbances. NMS has not been associated with Takotsubo cardiomyopathy (TCM). TCM is an abnormal response to physiological stressors resulting from the autonomic abnormalities which at times can mimic myocardial infarction (MI). We present a unique case of a 54-year-old female with bipolar disease presenting with lithium and haloperidol-induced NMS complicated by TCM. The purpose of this case is to make clinicians aware of this rare association.

Atrial Fibrillation (AFib) is the most common cardiac arrhythmia, occurring in ≈1% of the general population. An increased risk of malignancy among patients with AFib would be of substantial public health importance, given the high prevalence and associated economic burden of both disorders.

To evaluate the relationship between atrial fibrillation (AFib) and cancer.

We conducted an extensive database search on PubMed, Google Scholar, ScienceDirect, and SEER Database from their inception to September 2019 for any study that evaluated the association between AFib and cancer.

In the first 3months of AFib diagnosis, Ostenfeld et al. reported an absolute cancer risk of 2.5% with a standardized incidence ratio of 7.02 and 3.53 for metastatic and localized cancer, respectively. Likewise, Saliba et al. detected an increase in the odds of cancer diagnosis in first 90days after AF diagnosis with OR of 1.85. Moreover, in another study new-onset breast and colorectal cancer was especially associated with AF in thestions for future search, they are not currently strong enough to justify initiating cancer screening for an occult cancer in a patient with AF. Regardless, measures to target modification of these shared risk factors remains an important consideration.Substance use disorder is a significant health concern. Hospitalists manage patient with various forms of substance use disorder on a daily basis. In this review, we have tried to synthesize evidence together to give a brief, yet succinct, review of commonly encounters disorders; alcohol intoxication and withdrawal, opioid intoxication and withdrawal, cocaine intoxication and methamphetamine intoxication. We describe clinical features, diagnosis and management, which would serve as a great resource for hospitalist when managing these complicated patients.

Despite the Clinical Learning Environment Review’s recommendations of their use, patient safety event reporting systems are underutilized by residents.

We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates.

A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents’ perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents’ event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting.

94/94 (100%) of IM residents had a sig Institute of Medicine I; ACGME CLER Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME Graduate Medical Education; IRB Institutional Review Board; PDSA Plan, Do, Study, Act.In a hospital setting, nurses and physicians are the two main caregivers for admitted patients. Their communication is an important driver of positive teamwork and ensures proper patient safety and a high level of patient care. In a hospital with a large internal medicine residency program, where the main communication between nurses and residents is by phone calls, the excess number of phone calls received, especially for non-urgent patient-related matters, can be disruptive and cause fatigue and burnout. Alternative means of communication have been reported, namely using the electronic medical records to try and create new means of communication and to decrease the burden of direct communication for non-urgent matters. This manuscript describes the results of a survey administered in an attempt to understand the communication between residents and nurses in the setting of a new communication tool created within the electronic medical records.

Despite its proven utility, integration of point-of-care ultrasound (POCUS) into internal medicine (IM) residency training has been inconsistent. Due to their unique constraints, community-based teaching hospitals may face particular challenges in providing POCUS training to IM residents.

To evaluate short-term educational outcomes of an academic center’s POCUS curriculum following its adaptation and delivery to IM residents at a community-based teaching hospital.

A needs assessment (NA) regarding POCUS training was distributed to PGY-2 and PGY-3 IM residents at a community-based teaching hospital in 2017. Based on the NA results, a POCUS curriculum from an academic center was modified and a revised course was offered to the same residents. Participants completed cognitive assessments before and after three of the four didactic sessions. Observed placement of an ultrasound-guided peripheral IV before and after the training program comprised the skills assessment.

17 of 28 (61%) residents completed the NA; eleven participated in the course. Of 33 possible quiz pairs, 15 (45%) were completed. Average quiz scores rose after the first and third sessions. Skills assessment scores increased after course completion.

Adaptation of POCUS curricula from academic centers may be a feasible instructional strategy for community-based IM residency programs.

Adaptation of POCUS curricula from academic centers may be a feasible instructional strategy for community-based IM residency programs.We have completed volume 9 of the Journal of Community Hospital Internal Medicine Perspectives — JCHIMP. In this perspective piece we discuss the many achievements of our journal, including our impact factor, the diversity of institutions publishing, our editorial board, and the importance of our reviewers.The pandemic outbreak of COVID-19 challenges medical care systems all around the world. We here describe our experiences during the treatment of COVID-19 patients (n = 42) treated from 2 March 2020 to 16 April 2020 at a German district hospital. Forty-two COVID-19 patients were hospitalized and five patients developed a severe disease, requiring intensive care. Overall, 11 out of 42 hospitalized patients died. COVID-19 caused lymphocytopenia, as well as increased d-dimer, c-reactive protein and creatine kinase, and lactate dehydrogenase levels. These changes were mostly pronounced in patients that developed a severe disease course. Radiologic findings included ground-glass opacity, bilateral/multilobular involvement, consolidation, and posterior involvement. We compared COVID-19 patients to an average population of 'non-COVID’ patients. Interestingly, no laboratory or radiologic finding was specific for COVID-19 when standing alone, as comorbidities of 'non-COVID’ patients certainly can mimic similar results. In common praxis, the diagnosis of COVID-19 is based on a positive PCR result. However, a false-negative result causes problems for the workflow of an entire hospital. In our clinic, the consequences of a false assumption of SARS-CoV-2 negativity in four cases had dramatic consequences, as contact persons had to be quarantined. To avoid this, a comprehensive view of lab-results, radiology, clinical symptoms and comorbidities is necessary for the correct diagnosis or exclusion of COVID-19.