Monoarticular Arthritis.

Monoarticular arthritis is inflammation characterized by joint pain, swelling, and sometimes periarticular erythema. Although chronic causes are seen, the onset is often acute. An infected joint can quickly lead to permanent damage, making it a medical emergency. However, acute gout presenting as monoarticular arthritis is often so uncomfortable it requires urgent attention. Monoarticular crystalline arthritis is common and a septic joint is a medical emergency so it is no surprise that these diagnoses come to mind with complaint of inflammation in 1 joint. However, there are many causes of monoarticular arthritis that clinicians must consider.

Hydralazine associated pauci-immune glomerulonephritis.

Hydralazine is a medication that has been used to manage hypertension and heart failure. In this case series, we report 4 patients who presented to a large, Midwestern academic medical center on chronic hydralazine therapy with acute kidney injury, nephritic urine sediment on urine microscopy, and the simultaneous presence of autoantibodies suggesting both drug-induced lupus and drug-induced vasculitis. All of them had evidence of pauci-immune glomerulonephritis on kidney biopsy. All the patients reported in our series are white women older than 60 years who were receiving hydralazine for more than 12 months at a dose of 150 mg or more. On initial presentation, all had evidence of acute kidney injury with nephritic sediment. These patients also had high titers of serum anti-neutrophil cytoplasmic antibodies of the antimyeloperoxidase subtype and simultaneous presence of multiple autoantibodies. All of them subsequently underwent a kidney biopsy, which revealed pauci-immune glomerulonephritis. This case series draws rheumatologists' attention to the possibility of pauci-immune glomerulonephritis in patients taking hydralazine, highlights the presence of multiple antibodies in these cases, and questions the long-term use of hydralazine especially in an elderly female population.

Developing future faculty: a program targeting internal medicine fellows' teaching skills.

INTRODUCTION: The increased demand for clinician-educators in academic medicine necessitates additional training in educational skills to prepare potential candidates for these positions. Although many teaching skills training programs for residents exist, there is a lack of reports in the literature evaluating similar programs during fellowship training. AIM: To describe the implementation and evaluation of a unique program aimed at enhancing educational knowledge and teaching skills for subspecialty medicine fellows and chief residents. SETTING: Fellows as Clinician-Educators (FACE) program is a 1-year program open to fellows (and chief residents) in the Department of Internal Medicine at the University of Iowa. PROGRAM DESCRIPTION: The course involves interactive monthly meetings held throughout the academic year and has provided training to 48 participants across 11 different subspecialty fellowships between 2004 and 2009. PROGRAM EVALUATION: FACE participants completed a 3-station Objective Structured Teaching Examination using standardized learners, which assessed participants' skills in giving feedback, outpatient precepting, and giving a mini-lecture. Based on reviews of station performance by 2 independent raters, fellows demonstrated statistically significant improvement on overall scores for 2 of the 3 cases. Participants self-assessed their knowledge and teaching skills prior to starting and after completing the program. Analyses of participants' retrospective preassessments and postassessments showed improved perceptions of competence after training. CONCLUSION: The FACE program is a well-received intervention that objectively demonstrates improvement in participants' teaching skills. It offers a model approach to meeting important training skills needs of subspecialty medicine fellows and chief residents in a resource-effective manner.

A randomized controlled study comparing educational outcomes of examination room versus conference room staffing.

BACKGROUND: This prospective randomized controlled study examined outpatient clinical teaching in the presence of the patient. METHODS: In 2006, patients in ambulatory internal medicine clinics at the University of Iowa were randomized to have faculty-learner presentations either in their presence or in the conference room. Staffing encounters were timed and faculty, learners and patients completed postencounter surveys. RESULTS: Participation included 254 patients and 12 faculty. Comparison of patient encounters randomized to exam room (n = 120) or conference room (n = 134) staffing demonstrated increased time spent with the patient in exam room staffing (91% vs. 54% of total staffing time; p < .0001) but no significant differences in mean total staffing time. Patients, learners, and faculty preferred exam room staffing. CONCLUSIONS: Concerns about time efficiency and patient and learner satisfaction during exam room staffing were not supported. This approach may allow attending physicians to maximize billing levels while increasing learner/patient involvement.

An instructional program to facilitate teaching joint/soft-tissue injection and aspiration.

OBJECTIVE: We developed an instructional program to teach aspiration and injection techniques of the knee and shoulder to medical students and residents. METHODS: Residents and fourth-year medical students participating in a rheumatology elective were assigned by deterministic allocation into 3 groups: the Traditional group received no specific instruction in arthrocentesis but simply rotated through rheumatology, learning injection techniques only if they saw patients who required them; the Lecture-only group received only the didactic lecture and did not have the opportunity to practice on the models; the Program group participated in the newly developed program of instruction that combined a didactic lecture and a hands-on workshop using the anatomic models to practice arthrocentesis techniques. RESULTS: The scores on the written examination for those in the Program group (mean score 37.46 out of 40 possible) and the Lecture-only group (mean 37.75) were significantly higher than those of the Traditional group (mean 33.15) (P <.05). The scores on the practical examination for those in the Program group (mean score 24.08 out of 26 possible) were significantly higher than those of the Lecture-only (mean 20.50) and Traditional (mean 17.33) (P <.05) CONCLUSION: The addition of this type of instruction to supplement a traditional internal medicine rotation can enhance a learner's ability to perform joint/soft-tissue injection and aspiration.

The many guises of amyloidosis.

Preview Amyloidosis can present in myriad ways and is often confused with other diseases. To help physicians avoid diagnostic pitfalls, Drs Vogelgesang and Klipple describe the various clinical amyloid syndromes, tell what differentiates them, and summarize the effects of amyloid infiltration on various organ systems. They also assess the effectiveness of diagnostic techniques and note the relative ineffectiveness of medications that have been used to treat amyloidosis.