The use of the NEJM knowledge + online platform to supplement traditional pulmonary didactic: a resident-led educational quality improvement project at a community hospital IM GME program.

Introduction: Many internal medicine residents struggle to prepare for both the ITE and board test. Most existing resources are simply test question banks that are not linked to existing supporting literature from which they can study. Additionally, program directors are unable to track how much time residents are spending or performing on test preparation. We looked to evaluate the benefit of using this online platform to augment our pulmonary didactics and track time and performance on the pulmonary module and ITE pulmonary section. Method: During the month-long live didactic sessions, residents had free access to the pulmonology NEJM K+ platform. A platform-generated post-test was administered with new questions covering the same key elements, including the level of confidence meta-metric. An anonymous feedback survey was collected to assess the residents' feelings regarding using the NEJM Knowledge+ platform as compared to other prep resources. Results: 44 of 52 residents completed the pre-test. 51/52 completed the month-long didactic sessions and the post-test. Residents' score improvement from % correct pre-test (M = 46.90, SD = 15.31) to % correct post-test (M = 76.29, SD = 18.49) correlated with levels of mastery (t = 9.60, df = 41, p < .001). The % passing improved from 1/44 (2.3%) pre-test to 35/51 (68.6%) post-test, also correlating with levels of mastery. Accurate confidence correlated with improvement from pre to post test score (r = -51, p = .001). Survey feedback was favorable.

LA inhalers for COPD: perceptions/reality of ABCD GOLD tool use.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Recurrent Rhabdomyolysis Induced by Severe Hypothyroidism.

Hypothyroidism is frequently associated with myalgias, muscle stiffness, easy fatigability, and occasionally some degree of myopathy with mildly elevated muscle enzymes. Rarely, hypothyroidism may be complicated by rhabdomyolysis, the rapid destruction of skeletal muscle with myoglobin, creatine kinase, urate, and electrolytes release into the circulation. Recurrent cases of rhabdomyolysis are uncommon as most patients experience only one episode of rhabdomyolysis in their lifetime. Most common causes of such episodes are trauma, epileptic seizures, or medication. We describe a case of a 49-year-old male with a history of hypothyroidism, who repeatedly developed severe rhabdomyolysis precipitated by deep muscle injury, seizure, and poor medication compliance. Interestingly, he never developed any of the complications of rhabdomyolysis despite high levels of serum creatine kinase. The most common and feared complication of rhabdomyolysis is acute kidney injury which can occur in 15 to 50% of patients with rhabdomyolysis. Timely and appropriate fluid resuscitation is the mainstay therapy for acute kidney injury (AKI) prevention. Recurrent rhabdomyolysis in a patient should prompt further investigation if there is a family history of a neuromuscular disorder or exercise intolerance. In a case of refractory hypothyroidism, a patient should be counseled on proper regimen and medication compliance.