Influenza Vaccination During COVID-19 in a Rural Community: A Cross-sectional Survey.

Vaccination behavior is an informative metric for assessing flu seasons and is especially important to understand for the 2020-2021 flu season, which coincided with the COVID-19 pandemic. This study aimed to estimate flu vaccine behavior and assess vaccine perceptions during the pandemic season. Using a cross-sectional descriptive study design, we conducted an online survey to assess vaccination behavior and perceptions of both COVID-19 and the flu. Patients were identified as recently seen by providers in an academic internal medicine practice (n = 827) and surveys were distributed as messages in the Epic electronic medical record system. We found that 88.3% of respondents (188/206) had received their flu vaccination for the season at the time of their survey response in December 2020-February 2021. Of those that had not yet received the flu vaccine, only 13.6% indicated they planned on getting one. 12.5% of respondents said they had changed their flu vaccine plans due to the COVID-19 pandemic. Looking at differences from past season's behavior, more individuals switched to getting the flu vaccine than those that switched to not getting the vaccine this season. The most frequently cited reasons for not receiving the flu vaccination were concerns about side effects and not being in a priority group. Changes in flu vaccination behavior from previous seasons represent a net positive in the direction of vaccine acceptance. Barriers to vaccination were identified and results from this study provide more information on vaccine perceptions, beliefs, and behavior, which can benefit future vaccination programs.

Evaluation of a points-based scholarly activity policy in internal medicine.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that scholarly activity be carried out in residency programs without numerical guidelines for publication of papers by residents. Until now, publication-to-resident ratios (PTRR) have not been reported in internal medicine (IM) programs. This article describes the 5-year resident publication record of an IM program with a points-based scholarly activity policy. METHODS: Articles published by residents in the said program from July 2007 to June 2012 were collated based on PubMed searches and author reports. A PTRR was calculated across the 5-year period. RESULTS: A total of 57 unique resident papers were identified. Over the 5 years, the publication-to-resident ratio was 0.88 for IM residents, the highest reported in any graduate medical education program to date. CONCLUSIONS: A PTRR was seen in an IM program with a points-based scholarly activity policy. Further studies are needed to determine whether points-based policies encourage publication of scholarly papers among residents.

Having found the unexpected, we should look again: in favor of lung cancer screening.

Lung cancer is a leading cause of morbidity and death in the United States. A 65-year-old female with a 30 pack-year smoking history who requested screening for lung cancer was initially turned down in the absence of screening guidelines. Computed tomography ordered a month later after review of current evidence revealed a 3.9-cm right lower lobe speculated mass proven to be adenocarcinoma on biopsy. Reflecting on this case, we concur with emerging national guidelines that patients who meet the selection criteria for the National Lung Screening Trial should be screened with annual Low Dose Computed Tomography.

Reversible stroke-like symptoms with severe hyponatremia.

A 65-year-old Caucasian female was brought to the Emergency Department by her husband for increasing generalized weakness, slurred speech and new-onset facial droop. A non-contrast computerized tomography scan of her brain was negative; however, she was found to have a sodium level of 99 mmol/L. Her daily medications included hydrochlorothiazide, omeprazole and irbesartan. On physical examination, she was found to have slight confusion, lethargy, slowed speech, generalized weakness and left-sided facial droop but no other focal deficits. Over the course of her hospital stay, the patient's sodium levels were corrected slowly On the fifth day of admission, the majority of the patient's neurologic symptoms had resolved, suggesting her stroke-like symptoms were correctable with sodium repletion.

Knowledge of addiction medicine among internal medicine residents and medical students.

OBJECTIVES: More than 22 million Americans are living with addiction, including nearly seven million who misuse prescription medications. However, most medical schools and residency programs provide little to no education addressing alcohol and drug addiction. Implementation of a new addiction medicine curriculum at a single internal medicine program provided an opportunity for knowledge assessment in a select population of health professionals. We hypothesized that knowledge of addiction medicine would not differ by training level or geographical location of medical school, but that knowledge would improve following a structured curriculum. METHODS: Study participants included internal medicine and transitional year residents, as well as a group of medical students who were enrolled in a single internal medicine program at the time of the didactic series. A pre-test was administered prior to a four-week structured curriculum. The topics addressed included but were not limited to: 1) an overview of addiction, 2) opioids and chronic pain, 3) benzodiazepines and illicit stimulants, and 4) alcohol. A panel discussion was convened at the end of the fourth session. Following participation in the symposium, participants completed an online post-test. ANOVA was used to compare means. Paired t-tests were used to compare pre-test and post-test scores. RESULTS: 36 of 44 eligible medical students and residents completed the pre-test. Mean pre-test percentage scores were 64 percent for fourth year medical students and 62.5 percent for all residents. For residents, U.S. medical school trainees answered 65 percent of the pre-test questions correctly, versus 58.6 percent correct responses among their international medical graduate peers. No inter-group differences were statistically significant. Of the 36 participants, 20 completed both pre-tests and post-tests. The mean post-test score of 68.75 percent was higher than the mean pre-test score of 61.75 percent, p = 0.009. CONCLUSIONS: Knowledge of addiction medicine can be improved for medical students and residents in an academic medicine department. Significant improvements were observed following completion of eight hours of interactive didactics.

Hiding in plain sight: H1N1 influenza presenting with respiratory failure and normal chest radiography.

Sepsis and respiratory failure are uncommon complications of infection with H1N1 influenza. In the majority of cases of H1N1-associated sepsis and respiratory failure found in the literature, evidence of pneumonia or the acute respiratory distress syndrome was seen on chest radiography. This case report describes the clinical characteristics of a patient who presented with septic shock and multi-system organ failure due to H1N1 influenza, but had normal chest radiography. Beyond describing a unique presentation of H1N1-related sepsis, this report highlights the need for clinicians to maintain a high index of suspicion for infection with H1N1 influenza in patients with sepsis and respiratory distress.

Improvement in ocular myasthenia gravis during CPAP therapy for sleep apnea.

We describe the case of a 73-year-old male with a history of ocular myasthenia gravis (OMG) who was followed through diagnosis and treatment of sleep-disordered breathing (SDB). Therapeutic use of continuous positive airway pressure (CPAP) led to improvement of not only SDB but also OMG. To our knowledge, this is the first paper describing this treatment benefit. This case report emphasizes the need to obtain a sleep history in patients with ocular myasthenia gravis in order to screen for SDB.

A deadly cold.

This narrative describes how non-execution of screening at an urgent care visit may have delayed the diagnosis of cervical cancer in a young woman.

A Rare Case of Metachronous Quadruple Primary Malignancies in a Single Patient: A Case Report and Comprehensive Literature Review.

Multiple primary malignancies (MPMs) in the same patient are rare. Over the past decade, the incidence of MPMs is increasing. The prevalence in the general population is 0.7-11.7%, with a higher incidence in the elderly. This increase in incidence can be attributed to advanced lifespan, environmental factors, early chronic disease/cancer screening, and advanced treatment leading to more metaplasia. The chances are higher in cancer patients due to the carcinogenic effect of chemoradiotherapy. Here, we present a 79-year-old female with a 27 pack-year smoking history without any significant genetic predisposition, who developed four different primary malignancies including (1) chronic lymphocytic leukemia in 2017 (stage I modified Rai), positive for CD23 and CD5, which did not require treatment; (2) melanoma in situ on the left cheek in 2019 status post excision; (3) lung adenocarcinoma with negative molecular study (epidermal growth factor receptor (EGFR)/ROS proto-oncogene, receptor tyrosine kinase (ROS)/v-Raf murine sarcoma viral oncogene homolog B1 (BRAF)/anaplastic lymphoma kinase (ALK)) and negative programmed cell death ligand 1 (PDL-1) in 2020 for which she received treatment with carboplatin, pemetrexed, and pembrolizumab; and (4) left lower pole renal mass on surveillance CT scan, which was highly suspicious for primary malignancy as opposed to metastasis, for which she underwent radical nephrectomy and biopsy positive for clear cell renal cancer. Regarding these multiple primary cancers, the thought of germline mutation was considered. But as she did not have a family history of malignancy, genetic testing was not needed as per the genetic counselor. Patients are being diagnosed with MPMs as there is more advancement in tumor detection and treatment. With the advancement in the treatment, cancer survivorship is improving. Given that there are no large studies, we believe that treatment modality for MPMs should be on a case-to-case basis and needs a multidisciplinary approach to tackle therapeutic challenges and provide radical treatment.

Mediastinal extragonadal seminoma presenting as severe back pain in a young male.

Back pain is a common complaint in the outpatient setting. The etiology is most often benign but it can be a serious, even life-threatening problem. This report describes a 33-year-old Caucasian male who presented with severe upper back pain for three weeks that did not respond to symptomatic outpatient treatment. Imaging studies revealed a mediastinal mass and lymphadenopathy with superior vena cava and tracheal compression. Pathology showed a poorly-differentiated malignant neoplasm consistent with seminoma. No evidence of primary testicular tumor was found. His atypical presentation of back pain was thus consistent with an extragonadal seminoma in the mediastinum.

Petechiae, as seen on TV.

This narrative describes how a patient facilitated a diagnosis of acute myeloid leukemia in a primary care visit because she recognized petechiae she had seen on television on her own skin.

Looking Back and Going Forward: Roles of Varenicline and Electronic Cigarettes in Smoking Cessation.

Tobacco use is the single largest preventable cause of death in the United States (US). The national goal of reducing the prevalence of adult cigarette smoking to 12% was retained for 20 years due to non-attainment. Meanwhile, varenicline and electronic cigarettes (ECs) became available in the US in 2006 and 2007, respectively, and have been used by many smokers wanting to quit. The purpose of this review is to compare varenicline and ECs in terms of efficacy for smoking cessation after over a decade of widespread use in the US. Data collection for systematic review and qualitative synthesis by a PubMed search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelinesand the Oxford Quality Scale, respectively, was performed in June 2018 and updated in June 2020. Articles were eligible if published in English as original research in the form of a randomized clinical trial (RCT), a systematic review and meta-analysis, a systematic review, or a cross-sectional study. Eighteen studies were included: nine RCTs, four cross-sectional studies, two meta-analyses, one systematic review, one systematic review and meta-analysis, and one cohort study. No head-to-head RCT compared varenicline to ECs. In four RCTs, varenicline was more effective than placebo for smoking cessation. In two RCTs, ECs were more effective than placebo but a meta-analysis of 20 studies reported a statistically significant decrease in the odds of quitting smoking using ECs as compared to placebo. To conclude, varenicline and ECs have data suggesting efficacy for smoking cessation; however, unlike varenicline, ECs were not effective in all studies.

Back pain and mental retardation.

UNLABELLED: A 25-year-old African-American male with mental retardation was brought to the hospital by his caregiver with a chief complaint of low back pain for four months, complicated by recent anorexia and weight loss. Lumbar spine x-ray showed spondylosis at L2-L3 with normal sacroiliac joints, hip and femur; MRI showed a fracture of the L2 vertebral body. Consequently he underwent L2 anterior corpectomy with bone graft replacement and fusion. Spinal surgical biopsy revealed large cell neuroendocrine carcinoma with immunostaining studies suggesting lung origin. A chest CT scan showed a large solid mass in the mediastinum. CONCLUSION: We are reporting a unique case of large cell neuroendocrine carcinoma (LCNEC) of the lung in a nonsmoking young male which presented as low back pain to emphasize the importance of taking symptoms of patients with mental retardation seriously to avoid diagnostic delay.

Catastrophic antiphospholipid antibody syndrome in a young woman in the postpartum period.

A 27-year-old Hispanic female was admitted to hospital with fever, a sudden marked decrease in vision, and multi-organ failure shortly after preterm delivery by cesarean section for eclampsia. Her past history was significant for a spontaneous first trimester abortion and one live birth complicated by intrauterine growth retardation. She was found to have several focal brain infarcts, exudative retinal detachment, bilateral adrenal hemorrhage, renal insufficiency, hypertension and subsequently hypotension. Positive anticardiolipin antibodies, lupus anticoagulant, and anti-B2 glycoprotein-I, as well as deranged coagulation profile and PTT mixing studies aided in the diagnosis of catastrophic antiphospholipid antibody syndrome. Anticoagulation and high-dose intravenous steroids led to significant improvement in the patient's condition, including her vision.