Streptococcus pyogenes sternoclavicular septic arthritis in a healthy adult.

Sternoclavicular septic arthritis is a rare infection, accounting for approximately 1% of septic arthritis in the general population. Staphylococcus aureus is the predominant etiologic agent, and it usually occurs in relatively young adults with some type of predisposition to infection. We report, to the best of our knowledge, the first case of group A streptococcal, sternoclavicular arthritis in a previously healthy 62-year-old male patient. We present a detailed history and physical examination, with laboratory findings, imaging studies, cultures, and therapy.

Survey of internal medicine physicians trained in three different eras: reflections on duty-hour reform.

OBJECTIVES: To survey internal medicine physicians and residents who have completed residency in three different eras of medical training regarding their experiences during their intern year and their perceptions of duty-hour reform. METHODS: An online survey was administered to 268 residents, fellows, and staff physicians who had completed or were completing residency during one of three eras of training: before the 80-hour work week, after the 80-hour work week (instituted in 2003), and after the 16-hour limit on continuous shifts for interns (instituted in 2011). The survey assessed experiences during their intern year of residency and perceptions regarding resident duty-hour reform. RESULTS: The majority of respondents (n = 32; 54%) indicated that duty-hour restrictions would result in residents being less prepared for their future careers. In addition, 36% (n = 21) of respondents anticipated a decrease in the quality of patient care under the restricted duty hours. A total of 41% (n = 24) were undecided regarding the impact of duty-hour reform on patient care. Respondents reported time spent on independent study, research, and conference attendance did not increase following the institution of duty-hour restrictions. CONCLUSIONS: Survey responses indicated that after 18 months of experience with the Accreditation Council for Graduate Medical Education duty-hour restrictions, physician opinions were mixed and a substantial number remain undecided regarding the impact of duty-hour restrictions on resident career preparedness and the quality of patient care.

Rural-urban Differences in Long-term Mortality and Readmission Following COVID-19 Hospitalization, 2020 to 2023.

Background: We compared long-term mortality and readmission rates after COVID-19 hospitalization based on rural-urban status and assessed the impact of COVID-19 vaccination introduction on clinical outcomes by rurality. Methods: The study comprised adults hospitalized for COVID-19 at 17 hospitals in 4 US states between March 2020 and July 2022, followed until May 2023. The main analysis included all patients, whereas a sensitivity analysis focused on residents from 4 states containing 17 hospitals. Additional analyses compared the pre- and postvaccination periods. Results: The main analysis involved 9325 COVID-19 hospitalized patients: 31% were from 187 rural counties in 31 states; 69% from 234 urban counties in 44 states; the mean age was 65 years (rural, 66 years; urban, 64 years); 3894 women (rural, 41%; urban, 42%); 8007 Whites (rural, 87%; urban, 83%); 1738 deaths (rural, 21%; urban, 17%); and 2729 readmissions (rural, 30%; urban, 29%). During a median follow-up of 602 days, rural residence was associated with a 22% higher all-cause mortality (log-rank, P < .001; hazard ratio, 1.22; 95% confidence interval, 1.10-1.34, P < .001), and a trend toward a higher readmission rate (log-rank, P = .038; hazard ratio, 1.06; 95% confidence interval, .98-1.15; P = .130). The results remained consistent in the sensitivity analysis and in both pre- and postvaccination time periods. Conclusions and Relevance: Patients from rural counties experienced higher mortality and tended to be readmitted more frequently following COVID-19 hospitalization over the long term compared with those from urban counties, a difference that remained even after the introduction of COVID-19 vaccines.

Year 3 of COVID-19: Harsh Truths, Brutal Realities, and Glimmers of Hope.

Severe acute respiratory syndrome coronavirus 2, the virus causing coronavirus disease 2019 (COVID-19), has now killed 1 of every 303 Americans. Whereas 4 vaccines are approved in the United States and masks are widely available, too few are fully immunized and most of the population has stopped wearing protective masks. The ongoing consequences of this include continued excess morbidity and mortality and the generation of immune-evading variants and subvariants, which in toto are injurious and ultimately self-defeating. Herein we briefly update and review COVID-19 vaccines, waning immunity, and new variants.

Ultrasonographic Assessment of Extravascular Lung Water in Hospitalized Patients Requiring Hemodialysis: A Prospective Observational Study.

INTRODUCTION: Sonographic technologies can estimate extravascular lung water (EVLW) in hemodialysis (HD) patients. This study investigated the suitability of a handheld scanner in contrast to a portable scanner for quantifying EVLW in hospitalized patients requiring HD. METHODS: In this prospective study, 54 hospitalized HD patients were enrolled. Bedside lung ultrasound was performed within 30 min before and after dialysis using handheld (phased array transducer, 1.7-3.8 MHz) and portable (curved probe, 5-2 MHz) ultrasound devices. Eight lung zones were scanned for total B-lines number (TBLN). The maximum diameter of inferior vena cava (IVC) was measured. We performed Passing-Bablok regression, Deming regression, Bland-Altman, and logistic regression analysis. RESULTS: The 2 devices did not differ in measuring TBLN and IVC (p > 0.05), showing a high correlation (r = 0.92 and r = 0.51, respectively). Passing-Bablok regression had a slope of 1.11 and an intercept of 0 for TBLN, and the slope of Deming regression was 1.02 within the CI bands of 0.94 and 1.11 in the full cohort. TBLN was logarithmically transformed for Bland-Altman analysis, showing a bias of 0.06 (TBLN = 1.2) between devices. The slope and intercept of the Deming regression in IVC measurements were 0.77 and 0.46, respectively; Bland-Altman plot showed a bias of -0.07. Compared with predialysis, TBLN significantly (p < 0.001) decreased after dialysis, while IVC was unchanged (p = 0.16). Univariate analysis showed that cardiovascular disease (odds ratio [OR] 8.94 [2.13-61.96], p = 0.002), smoking history (OR 5.75 [1.8-20.46], p = 0.003), and right pleural effusion (OR 5.0 [1.2-25.99], p = 0.03) were strong predictors of EVLW indicated by TBLN ≥ 4. CONCLUSION: The lung and IVC findings obtained from handheld and portable ultrasound scanners are comparable and concordant. Cardiovascular disease and smoking history were strong predictors of EVLW. The use of TBLN to assess EVLW in hospitalized HD patients is feasible. Further studies are needed to determine if TBLN can help guide volume removal in HD patients.

Migratory Polyarthralgias and Skin Rash: Rat Bite Fever with a Positive Anti-Cyclic Citrullinated Peptide.

Rat bite fever is a rare, underdiagnosed disease caused by Streptobacillus moniliformis in the United States, and is typically characterized by leukocytosis, elevated C-reactive protein, migratory polyarthralgias, and pustular skin rash. Rat bite fever is frequently misdiagnosed as either a viral illness or a rheumatologic disease and carries a high mortality risk if untreated. We report the first case of rat bite fever associated with positive anti-cyclic citrullinated peptide. The patient initially presented with low back pain and developed a pustular rash as well as severe asymmetric polyarthralgias. Blood cultures turned positive for S. moniliformis and the patient completed a 4-week course of antibiotics for presumed septic arthritis.

Inpatient Care of Patients with COVID-19: A Guide for Hospitalists.

Since its emergence in December 2019, the virus known as severe acute respiratory syndrome coronavirus 2 has quickly caused a pandemic. This virus causes a disease now known as coronavirus disease 2019, or COVID-19. As an increasing proportion of the at-risk population becomes infected, and patients with severe illness are hospitalized, it is essential for hospitalists to remain current on how to best care for people with suspected or confirmed disease. Establishing a system for logistical planning, and accurate information sharing is strongly recommended. Infection control remains the ultimate goal. As such, health care workers should be educated on universal and isolation precautions, and the appropriate use of personal protective equipment. Social distancing should be encouraged to prevent the spread of infection, and creative and innovative ways to reduce contact may need to be considered. Moreover, it is imperative to prepare for contingencies as medical staff will inevitably get sick or become unavailable. Hospitalists have the difficult task of caring for patients while also adapting to the many logistical and social elements of a pandemic.

Characteristics and quality of rotation-specific resident learning goals: a prospective study.

Background: Residents are expected to develop the skills to set learning goals. Setting learning goals is part of self-regulated learning, setting the foundation for creating a learning plan, deploying learning strategies, and assessing their progress to those goals. While effective goal setting is essential to resident self-regulated learning, residents struggle with setting learning goals and desire faculty assistance with goal setting.Objective: We aimed to characterize the topics and quality of residents' rotation-specific learning goals.Design: We conducted a prospective study of 153 internal medicine residents, assessing 455 learning goals for general medicine inpatient rotations. We coded learning goal themes, competencies, and learning domains, and assessed quality using the validated Learning Goal Scoring Rubric. We compared topic categories, competencies, learning domains, and quality between the first and second months of postgraduate (PGY)-1 residents and between PGY-1 and PGY-3 residents. We assessed factors associated with learning goal completion.Results: The overall response rate was 80%. The top three learning goal categories were patient management, specific diseases related to general medicine, and teaching skills. There were no changes in learning goal characteristics between PGY-1 months (p ≥ 0.04). There were differences between PGY-1 and PGY-3 residents' learning goals in patient management (28% vs 6%; p < .001), specific disease conditions (19% vs 3%; p < .001), and teaching skills (2% vs 56%; p < .001). There was no difference in learning goal quality between PGY-1 months (1.63 vs. 1.67; p = 0.82). The PGY-3 learning goals were of higher quality than PGY-1 learning goals for the 'specific goal' item (1.38 vs. 0.98, p = 0.005), but not for other items or overall (all p ≥ 0.02). Residents reported 85% (297/347) learning goal completion.Conclusions: Resident rotation-specific learning goals reflect a broad array of topics. Residents' learning goal quality was low and residents may benefit from guidance to support residents' learning goals.

Unusual case of immune-related colitis.

The cancer immunotherapy field has had many promising developments in recent years. Checkpoint inhibitors are good examples of that. This new class of medications comes with a new constellation of side effects that require early recognition and management. Here we present a patient with metastatic adenocarcinoma on pembrolizumab who was admitted to the hospital for colitis. This was found to be an immune-related adverse event from pembrolizumab. We discuss our work-up and approach to the diagnosis, then highlight important treatment pearls for internal medicine physicians who are increasingly taking care of such patients.

Impact of QRS duration on survival benefit with prophylactic implantable cardioverter-defibrillators: a meta-analysis of randomized controlled trials.

BACKGROUND: QRS duration is an important risk factor for both sudden cardiac death and all-cause mortality in patients with moderate to severe left ventricular systolic dysfunction. However, it is unknown whether baseline QRS duration can help predict the mortality benefit from implantable cardioverter-defibrillators (ICDs) when used for primary prevention purposes. OBJECTIVE: Our objective was to examine the relationship between baseline QRS duration and mortality reduction with ICDs implanted for primary prevention by performing a meta-analysis of all available randomized clinical trials. METHODS: A systematic literature search of SCOPUS (covering MEDLINE and EMBASE) was conducted for randomized controlled clinical trials involving ICDs. Primary prevention trials of systolic dysfunction that reported all-cause mortality according to subgroups on the basis of baseline QRS duration were included. RESULTS: A total of four randomized controlled clinical trials enrolling 3561 patients were included. Patients with QRS durations less than 120 ms [n = 2002, hazard ratio 0.78, 95% confidence interval (CI) 0.63-0.96, P = 0.018] and at least 120 ms (n = 1559, hazard ratio 0.59, 95% CI 0.48-0.73, P = 0.0000009) had significant decreases in all-cause mortality. On heterogeneity analysis, a strong trend for greater magnitude of benefit in patients with QRS at least 120 ms was observed (22% risk reduction vs. 41% risk reduction, P = 0.066). CONCLUSION: For primary prevention purposes, ICDs are effective in reducing all-cause mortality in moderate to severe systolic dysfunction regardless of QRS duration. However, patients with a baseline QRS duration of at least 120 ms seem to derive a greater mortality benefit from ICDs.

Frequency and Appropriateness of Fasting Orders in the Hospital.

OBJECTIVE: To evaluate the frequency and appropriateness of nil per os (nothing by mouth) (NPO) orders and determine the number of meals missed because of these orders among hospitalized patients. PATIENTS AND METHODS: We retrospectively analyzed inpatient NPO orders at an academic institution in the United States. The frequency and duration of NPO orders and the number of meals missed because of these orders were assessed for adult patients admitted to the hospital medicine services from January 1, 2013, through December 31, 2013, with a hospital stay of 2 or more and 30 or fewer days. Two blinded reviewers assessed if the order could be avoided or the period shortened for a random sample of NPO orders of 120 or more minutes' duration that were written for patients on the general medicine ward. RESULTS: A total of 3641 NPO orders were identified. At least one NPO order was placed in 46.6% of the admissions (2211 of 4743). The median duration of NPO orders was 12.8 hours (interquartile range, 9.2-17.3 hours), resulting in 2 (interquartile range, 1-4) missed meals. Of 1130 NPO orders reviewed, 263 (23.3%; 95% CI, 20.9%-25.8%) were deemed avoidable (κ statistic, 0.68), and 482 (42.7%) were unavoidable but led to more missed meals than needed. Taken together, patients could have had 44.8% of the meals (1085 of 2424; 95% CI, 42.8%-46.7%) missed due to NPO orders. CONCLUSION: Approximately half of the patients admitted to the hospital medicine services experienced a period of fasting. One in 4 NPO orders and nearly half of missed meals could have been avoided. Further study is warranted to assess the generalizability of our findings.