The Internal Medicine Subinternship--Now More Important than Ever: A Joint CDIM-APDIM Position Paper.

For decades, the internal medicine (IM) subinternship has served as a critical interface between undergraduate and graduate medical education. As such, the vast majority of U.S. medical schools offer this rotation to help students prepare for post-graduate training. Historically an experiential rotation, a formal curriculum with specific learning objectives was eventually developed for this course in 2002. Since then, graduate medical education (GME) has changed significantly with the regulation of duty hours, adoption of competency-based education, and development of training milestones and entrustable professional activities. In response to these and many other changes to residency training and medical practice, in 2010, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members-with input from the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force-to determine which core skills program directors expected from new medical school graduates. The results of that survey helped to inform a joint CDIM-APDIM committee's decision to re-evaluate the goals of the IM subinternship in an effort to enhance the transition from medical school to residency. This joint committee defined the minimum expectations of what constitutes an IM subinternship rotation, proposed recommended skills for IM subinterns, and discussed challenges and future directions for this crucial course.

Subdural actinomycoma presenting as recurrent chronic subdural hematoma.

Actimomycosis is a rare chronic bacterial infection of the central nervous system, and subdural actinomycoma is extremely rare. This case report brings to bear an uncommon association between subdural actinomycosis with chronic subdural hematoma. Subdural actinomycoma may present as a diagnostic conundrum and could be mistaken radiologically for either a subdural hematoma or an empyaema.

Using the head as a mould for cranioplasty with methylmethacrylate.

Methacrylate is a valuable tool to the neurosurgeon, even though it is currently being replaced by custom bone. During cranioplasty in the absence of custom bone, which is preformed based on the patients imaging, one has to make a cast to cover the cranial defect with or without the use of a mould. A good artificial skull outline is necessary for prevention of implant extrusion and acceptable cosmetic outcome. Using the patients head as a mould is a simple, cheap, and useful technique. An incision is made, and either a craniectomy or an attempt at skull elevation or separation of the scalp from dura is done based on the indication for the cranioplasty. The methacrylate monomer is mixed with its solvent. It is placed in between a sliced glove and then thinned out. Several layers of drapes are placed on the patients head, the acrylate which is in between the gloves is then placed on the drapes. As soon as it starts setting and the required shape obtained, it is removed and place on the sterile tray. It is then anchored and the wound closed. This technique produces good cosmetic outcome. However, the head must be properly protected from the risk of burns from the exothermic reaction. The technique is described in a 40-year-old driver who had a compound depressed skull fracture. He had a methylmethacrylate cranioplasty in the 9(th) week post trauma after allowing for wound healing. We recommend that this technique may be used in centers where custom bone is either too expensive or not available during cranioplasty in order to obtain a good outcome.

Fetal head injury from intentional penetrating abdominal trauma in pregnancy.

A male fetus was extruded from the uterus following multiple lower abdominal stab wounds to the mother. He was brought to the emergency room at 8 hours of age. He had sustained a compound skull fracture with brain contusion. There was no neurological deficit. Debridement and primary wound closure were undertaken. His mother had multiple lacerations to the uterus and a laceration of the fundus of the bladder. Following resuscitation, she had repair of the uterus and bladder and made an uneventful recovery. At 3 years of age, the boy is developing normally.

Solitary giant neurofibroma of the scalp with calvarial defect in a child.

Neurofibroma of the scalp are mostly multiple as part of neurofibromatosis or other phakomatosis. De novo solitary types are less common and rarely erode the skull, unlike the intracranial counterpart. Skull erosion has been reported in adults with longstanding plexiform neurofibromas. We report a giant neurofibroma on the scalp of a five-year-old boy, managed in our center. Although this condition is a rare entity, it should be anticipated and the treatment strategy should include repair of the skull defect.

Management of pneumocephalus in a resource limited environment: review from sub-Saharan Africa.

BACKGROUND: Although pneumocephalus is not uncommon, most reports from Africa are of single or few cases. METHODS: A retrospective review of 20 patients with pneumocephalus managed in 4 years was done. There were 19 males and one female aged 22-45 years (median 35 years). The cause of pneumocephalus was head trauma in 18 patients and spontaneous in 2. The commonest symptoms were headache 19 and CSF rhinorrhoea 11. Skull radiographs and brain CT scan were used to confirm the diagnosis in all the patients. Eight patients had surgery while 12 were managed non-operatively. RESULTS: Of the eight that had surgery; six recovered fully, one had residual neurologic deficit and one died from meningitis. Nine patients that were managed non-operatively recovered fully; one died also from meningitis and one refused treatment and left the hospital against advice. CONCLUSIONS: Air in the cranial cavity behaves like any space-occupying lesion; a high index of suspicion is needed to make a diagnosis, prompt treatment and control of infection will prevent unwanted morbidity and mortality.

Acute ileus following ventriculoperitoneal shunt: case report.

A three month old girl with progressive hydrocephalus from birth had a ventriculoperitoneal (VP) shunt, during which the cerebrospinal fluid (CSF) was found to be xanthochromic. She developed acute ileus four hours post-operatively and continued to deteriorate. The shunt was exteriorised as an external ventricular drain. She did well and another VP shunt was inserted later. Acute ileus following VP shunt is not common, but can occur in the presence of xanthochromic CSF. It is advisable that when such CSF is encountered during VP shunt, the initial management should be external ventricular drainage, followed later by VP shunt when the CSF becomes clear. This can be life saving.

Spina bifida cystica: selective management in Zaria, Nigeria.

Management of spina bifida cystica in Zaria, Nigeria is selective. Over a period of 11 years, 77 children with this defect, 54 meningocoeles and 23 myelomeningocoeles, 66 (86%) situated in the lumbosacral region, were treated operatively. Forty-two (55%) had surgery in the neonatal period and 91% within 6 months of birth. Postoperative complications occurred in 19 of 68 patients (28%), including mild hydrocephalus, which resolved spontaneously (six, 9%), wound infection (six, 9%), leakage of cerebrospinal fluid (four, 6%) and meningitis (three, 4%). Mortality was 3% from both meningitis and cardiac arrest. Of 32 patients followed up for 3-5 years, 20 with meningocoeles were normal. Of 12 with myelomeningocoele, four had varying degrees of lower limb weakness, three double incontinence, two faecal incontinence, two had progressive hydrocephalus plus paralysis and double incontinence, and one had urinary incontinence. Therefore, 38% were functionally disabled and could not be adequately rehabilitated owing to poor facilities. While management of spina bifida cystica is more aggressive now in most developed countries, ours remains selective due to difficulty with multidisciplinary care and rehabilitation. Even with our selective management, the care of patients with functional handicap remains a challenge.