On the fence: Combining multimodal imaging and laparoscopy for diagnosing tuberculous peritonitis.

Tuberculous peritonitis (TB peritonitis) is one of the most challenging forms of extrapulmonary TB to diagnose. While tumor markers can be elevated in patients with TB peritonitis, FDG-PET/CT can aid in distinguishing TB peritonitis from malignancies, if an apron-like omentum pattern is seen. Laparoscopy is crucial for accurate and early diagnosis.

Hospitalists' COVID-19 management roles in hospitals without infectious disease specialists.

BACKGROUND: Hospitalists may work in a variety of clinical settings to manage COVID-19 cases. However, the extent of their involvement in COVID-19 care is unknown, particularly in hospitals without infectious disease (ID) specialists. METHODS: This study aimed to confirm whether hospitalists provided COVID-19 management in various clinical settings when ID specialists were unavailable. We conducted a multicenter cross-sectional study using a web-based questionnaire. The participants were full-time hospitalists working in Japanese academic community-based hospitals. The study period was from 15 January 2021 to 15 February 2021, during Japan's third wave of the COVID-19 pandemic. The primary outcome was the rate of hospitalists participating in COVID-19 inpatient management in hospitals with or without ID specialists. RESULTS: ID specialists were absent in 31% of small hospitals (those with fewer than 249 registered beds), but only 4% of large hospitals (p < 0.001). Hospitalists were more likely to manage both COVID-19 inpatient care and emergency department care in hospitals without than with hospitals with ID specialists (76 versus 56% (p = 0.01) and 90 versus 73% (p = 0.01), respectively). After adjusting for confounders by multivariate analysis, hospitalists who worked in hospitals without ID specialists had higher odds of participating in COVID-19 inpatient care than those who worked in hospitals with such specialists (adjusted odds ratio: 3.0, 95% CI: 1.2-7.4). CONCLUSION: Hospitalists were more likely to provide COVID-19 inpatient care in various clinical settings in hospitals without ID specialists.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

Elements Influencing Recruitment and Retention of Millennial Hospitalists Born in or after 1982: a Survey-Based Study.

BACKGROUND: Hospitalist turnover is exceedingly high, placing financial burdens on hospital medicine groups (HMGs). Following training, many begin their employment in medicine as early-career hospitalists, the majority being millennials. OBJECTIVE: To understand what elements influence millennial hospitalists' recruitment and retention. DESIGN: We developed a survey that asked participants to rate the level of importance of 18 elements (4-point Likert scale) in their decision to choose or remain at an HMG. PARTICIPANTS: The survey was electronically distributed to hospitalists born in or after 1982 across 7 HMGs in the USA. MAIN MEASURES: Elements were grouped into four major categories: culture of practice, work-life balance, financial considerations, and career advancement. We calculated the means for all 18 elements reported as important across the sample. We then calculated means by averaging elements within each category. We used unpaired t-tests to compare differences in means for categories for choosing vs. remaining at an HMG. KEY RESULTS: One hundred forty-four of 235 hospitalists (61%) responded to the survey. 49.6% were females. Culture of practice category was the most frequently rated as important for choosing (mean 96%, SD 12%) and remaining (mean 96%, SD 13%) at an HMG. The category least frequently rated as important for both choosing (mean 69%, SD 35%) and remaining (mean 76%, SD 32%) at an HMG was career advancement. There were no significant differences between respondent gender, race, or parental status and ratings of elements for choosing or remaining with HMGs. CONCLUSION: Culture of practice at an HMG may be highly important in influencing millennial hospitalists' decision to choose and stay at an HMG. HMGs can implement strategies to create a millennial-friendly culture which may help improve recruitment and retention.

HTLV-1 associated acute adult T-cell lymphoma/leukemia presenting as acute liver failure in Micronesian: A case report.

RATIONALE: Malignant infiltration accounts for 0.5% of acute liver failure cases, with non-Hodgkin's lymphoma the predominant cause. Adult T-cell lymphoma/leukemia (ATLL) is a rarer source of acute hepatitis, with only 3 cases reported and all resulting in immediate deterioration with death. ATLL rises from human T-lymphocytic virus-1 (HTLV-1), commonly found in Japan (southern and northern islands), the Caribbean, Central and South America, intertropical Africa, Romania, and northern Iran. In Micronesia, HTLV-1 infection amongst native-born is absent or exceedingly rare. PATIENT CONCERNS: A 77-year-old Marshallese man presented to the emergency department with a 1-week history of generalized weakness, fatigue, and nausea. The physical exam revealed a cervical papulonodular exanthem and scleral icterus. DIAGNOSIS: Laboratory studies were remarkable for aspartate-aminotransferase of 230 IU/L (reference range [RR]: 0-40), alanine-aminotransferase of 227 IU/L (RR: 0-41), alkaline phosphatase of 133 IU/L (RR: 35-129), and total bilirubin of 4.7 mg/dL (RR: 0-1.2), supporting acute liver injury. Platelet count was 11.6x104/µL (RR: 15.1-42.4 × 104), hemoglobin was 13.8 g/dL (RR: 13.7-17.5), and white blood cell count was 7570/µL (RR: 3800-10,800) with 81.8% neutrophils (RR: 34.0-72.0) and 10.4% lymphocytes (RR: 12.0-44.0). The peripheral blood smear demonstrated abnormal lymphocytes with occasional flower cell morphology. HTLV-1/2 antibody tested positive. The skin and liver biopsies confirmed atypical T-cell infiltrate. The diagnosis of ATLL was established. INTERVENTIONS: The patient elected for palliative chemotherapy with cyclophosphamide, vincristine, and prednisone (CVP). He began antiviral treatment with zidovudine 250 mg bis in die (BID) indefinitely. Ursodiol and cholestyramine were added for his hyperbilirubinemia. OUTCOMES: Four weeks from admission, the patient returned to near baseline functional status and was discharged home. LESSONS: This case highlights that ATLL can initially present as isolated acute hepatitis, and how careful examination of peripheral blood-smear may elucidate hepatitis etiology. We also present support for utilizing ursodiol with cholestyramine for treating a hyperbilirubinemia. Moreover, unlike prior reports of ATLL presenting as liver dysfunction, combined antiviral and CVP chemotherapy was effective in this case. Lastly, there are seldom demographic reports of HTLV-1 infection from the Micronesian area, and our case represents the first indexed case of HTLV-1-associated-ATLL presenting as acute liver failure in a Marshallese patient.

Wanted and Unwanted Care: The Double-Edged Sword of Partial Do-Not-Resuscitate Orders.

BACKGROUND: The interpretation of do-not-resuscitate orders (DNRs) may vary in nonarrest situations. To reduce ambiguity, many hospitals allow patients to elect partial DNRs. OBJECTIVE: To investigate the effect of partial DNRs on physicians' willingness to perform cardiopulmonary resuscitation (CPR) and nonarrest procedures. DESIGN: Cross-sectional study using scenario-based questionnaires between October 2015 and March 2016. A partial DNR was identified as a DNR with Adult Emergency Protocols (AEP) order. Each survey presented 3 patient scenarios followed by 10 interventions. SETTING/SUBJECTS: Preclerkship and clerkship medical students, and internal medicine residents at a single medical school, and hospitalists at a tertiary-care academic medical center. RESULTS: Responses from 275 of 366 (75.1%) eligible subjects were collected. Compared to the case with a full DNR, the presence of a partial DNR was positively associated with subjects' willingness to provide both nonarrest procedures and CPR (p < 0.05). The number of training or practice years was positively associated with a decision not to perform CPR: case 1 (odds ratio [OR], 1.09; confidence interval [CI], 1.04-1.16; p = 0.003); case 2 (OR, 1.07; CI, 1.01-1.14; p = 0.03); and case 3 (OR, 1.09; CI, 1.04-1.16; p < 0.001). CONCLUSIONS: A partial DNR made our respondents more willing to provide nonarrest procedures, but also CPR. These findings suggest an ongoing need to develop better means of incorporating patients' goals of care into orders that more faithfully guide care for both nonarrest and arrest situations.

Cardiovascular consequences of hypophosphatemia.

INTRODUCTION: Few studies have been conducted to evaluate the effect of hypophosphatemia on cardiovascular consequences. The goal of this review was to determine whether hypophosphatemia is associated with cardiovascular consequences and to increase its awareness as a new clinical entity and a reversible cause of cardiovascular consequences. EVIDENCE ACQUISITION: We searched MEDLINE and PubMed through September 2016 for primary studies that reported the relationship between hypophosphatemia and cardiovascular consequences including cardiomyopathy and arrhythmia. EVIDENCE SYNTHESIS: A total of 937 articles were initially obtained. Of these articles, 921 publications were excluded according to the inclusion and exclusion criteria. Sixteen articles were included in this review. These articles included 3 prospective cohort studies, 1 retrospective cohort study, 7 case series or case reports, 2 case-control studies, 1 pre- vs. post-test in a single group, and 2 animal studies. CONCLUSIONS: The mechanisms of hypophosphatemia in cardiomyopathy and arrhythmia have been reported to be a depletion of adenosine triphosphate in myocardial cells and decreased 2,3-diphosphoglycerate in erythrocytes. Left ventricular performance seems to improve when severe hypophosphatemia is corrected, but not in those with mild to moderate hypophosphatemia. However, analyses of the relationship between cardiac function and hypophosphatemia using clinical end points have not been conducted. The association between hypophosphatemia and arrhythmia remains unclear, but anecdotal reports exist in the literature.

Hypophosphatemia-induced Cardiomyopathy.

Relatively few studies have been conducted to evaluate the effect of hypophosphatemia on cardiac function. The goal of this review was to determine whether there is an association between hypophosphatemia and cardiac function and to increase awareness of hypophosphatemia-induced cardiomyopathy as a new clinical entity and a reversible cause of heart failure. We searched MEDLINE and PubMed from 1971 until March 2015 for primary studies, which reported the relationship between hypophosphatemia and cardiac function. A total of 837 articles were initially obtained. Of these articles, 826 publications were excluded according to the inclusion and exclusion criteria. In all, 11 articles were included in this review. These articles included 7 case series or case reports, 1 case-control study, 1 pretest versus posttest in a single group and 2 animal studies. In conclusion, the mechanisms of hypophosphatemia in cardiomyopathy have been reported to be a depletion of adenosine triphosphate in myocardial cells and decreased 2,3-diphosphoglycerate in erythrocytes. After correction of hypophosphatemia, left ventricular performance seems to improve in patients with severe hypophosphatemia, but not in those with mild-to-moderate hypophosphatemia. However, analyses of the relationship between cardiac function and hypophosphatemia using clinical end points have not been conducted.

Bordetella trematum sepsis with shock in a diabetic patient with rapidly developing soft tissue infection.

Bordetella is a gram-negative, glucose non-fermenting bacillus, consisting of many host-associated species. B. trematum has previously been identified in wound infections, but rarely known to be a source of bacteremia. Currently, 16S rRNA sequencing represents the reference standard method by which identification is made. Herein, we present a case of fatal B. trematum bacteremia with septic shock. The presumed primary site of the infection was a rapidly developing left leg deep soft tissue infection without necrotizing fasciitis. B. trematum should now be considered as a significant pathogen in sepsis.

Septic arthritis and osteomyelitis due to Bordetella petrii.

A case of Bordetella petrii septic arthritis and osteomyelitis in an elbow resulted from a dirt bike accident in Hawaii. Two months of intravenous antibiotics and repeated surgeries were required to cure this infection. Our case, and literature review, suggests that extended-spectrum penicillins, tetracycline, and trimethoprim-sulfamethoxazole are good treatment options.

Mid-ventricular variant takotsubo cardiomyopathy associated with Cannabinoid Hyperemesis Syndrome: a case report.

A case of the mid-ventricular variant of takotsubo cardiomyopathy is reported, occurring in a patient with Cannabinoid Hyperemesis Syndrome (CHS), and presented with a review of the relevant literature. The patient is a 32-year-old woman who presented with epigastric pain, nausea and vomiting. Her EKG showed dynamic T-wave changes associated with a modest cardiac biomarker elevation. Ventricular wall motion abnormalities suggestive of the mid-ventricular variant of takotsubo cardiomyopathy were demonstrated by echocardiography, ventriculography and cardiac angiography, the latter showing normal coronary arteries. The patient was a previous marijuana user who had recently ingested marijuana after a period of abstinence. Severe epigastric pain, nausea and cyclic vomiting followed this. She had previously experienced similar gastrointestinal symptoms, relieved by compulsive hot water bathing, and resolving after marijuana cessation. Recent resumption of marijuana use was followed by a recurrence of these symptoms, a pattern characteristic of CHS. The association of cardiomyopathy with CHS has been described only once in the literature, and if this is a true relationship, its mechanism is not clearly defined. Animal models have suggested that endocannabinoid receptors are expressed in the myocardium, which could be a pathway for developing cardiac manifestations with cannabinoid use.