Endocarditis due to Salmonella.

We present a case of endocarditis caused by Salmonella in a patient with newly diagnosed diabetes and preexisting rheumatic heart disease. Despite sterilization of the blood with a fluoroquinolone and a third-generation cephalosporin, the patient required surgical intervention.

Residency recruitment: postmatch survey says...

BACKGROUND: Information is limited regarding the most effective methods of recruitment in internal medicine residency programs. To address this deficiency, we conducted a 4-year survey of students who interviewed at our program addressing aspects of the application and interview process to maximize recruitment. METHODS: A 25-item questionnaire was mailed after the match to all students who interviewed but did not match with our program from 1994 to 1997. RESULTS: The response rate varied from 35% in 1994 to 70% in 1997. Variables that showed significant improvement after intervention included brochure mailings, resident greeting, resident luncheon, and perceived resident satisfaction. There was a 50% increase in program applications and the percent of applicants rating our program in their first 3 choices rose from 21% in 1995 to 51% in 1997. CONCLUSIONS: The major factors influencing our applicant's decisions regarding our program included resident involvement and brochure development/mailings. We have focused our efforts on those components to make the greatest impact on increasing the attractiveness of our program for internal medicine training.

Ileal perforation secondary to histoplasmosis in AIDS.

Our patient presented with abdominal pain, weight loss, and fever with evidence of oral thrush and pelvic inflammatory disease on exam. Radiographs demonstrated a small bowel obstruction with free air. An exploratory laparotomy demonstrated 2 perforations of the distal ileum. Pathologic exam revealed features consistent with histoplasmosis. We discuss gastrointestinal involvement of histoplasmosis in AIDS and its treatment.

First, do no harm: the use of covert video surveillance to detect Munchausen Syndrome by Proxy--an unethical means of "preventing" child abuse.

Since it was first identified in 1977, Munchausen Syndrome by Proxy has uniquely affected the way in which the medical and legal communities deal with the issue of child abuse. Inherent in the medical response to the disease are issues of suspicion, investigation, identification, confrontation, and, of course, the health of an innocent child. Given the deceptive dynamics of this disease, however, denial and disbelief naturally overshadow every action taken by medical professionals in pursuing these issues. Fortunately, as medical knowledge about the dynamics of the disease continues to develop, medical professionals become more willing and better able to identify the disease and focus their response on the safety of the child. The greatest problem in prosecuting Munchausen Syndrome by Proxy is that judges and juries remain unwilling to accept the reality of the disease. Consequently, in an effort to confirm medical suspicions and quell legal doubts, the medical community has resorted to covert video surveillance of the abuse while it is being perpetrated in the hospital. In this Article, Flannery argues that this response is an unnecessary and unethical, means of preventing Munchausen Syndrome by Proxy and protecting the child. Flannery supports the approach taken by the Family Court of New York in addressing Munchausen Syndrome by Proxy cases. The Family Court of New York recognizes the unique dynamics of this bizarre disorder, and, therefore, considers all cumulative circumstantial evidence in a Munchausen Syndrome by Proxy case, comparing the facts of the subject case to the commonly accepted features of confirmed cases. Part of the circumstantial evidence that should be considered, Flannery argues, is the dissipation of the child's condition upon temporary separation from the alleged perpetrating parent. As is done by the Flannery Court of New York, a res ipsa loquitur standard should then be applied, and an appropriate disposition for the child should be determined. By employing this standard, the court may confirm suspicions of Munchausen Syndrome by Proxy while avoiding the unnecessary harm to the child inherent in the covert video surveillance of Munchausen Syndrome by Proxy.

Telephone medical care administered by internal medicine residents: concerns of program directors and implications for residency training.

The objective of this study was to determine the need for telephone medicine curricula and to help define important content for internal medicine residencies using scales that measure program director attitudes toward telephone medicine. Data were collected by surveying all 416 program directors of accredited internal medicine residencies in the United States. We applied factor analysis to develop reliable attitudinal scales and employed regression models to identify predictors of these attitudes. Response rate was 60%. Formal training for telephone medicine was available in only 6% of programs. The factor analysis showed three attitudinal concepts; all described marked program director discomfort with aspects of resident telephone prescription. Predictors of improved program director comfort included more frequent documentation of resident telephone calls, chart availability, and clear definition of resident roles pertaining to telephone interactions with patients (P < 0.02 for all predictor variables). These results identify a need for telephone curricula and suggest components that might alleviate program director discomfort with resident telephone practices.

Pneumocystis carinii pneumonia with an atypical granulomatous response.

Pneumonia due to Pneumocystis carinii may present atypical radiographic and pathologic findings. We report the case of a 32-year-old man with acquired immune deficiency syndrome (AIDS) whose chest roentgenogram showed a bilateral diffuse nodular pattern suggestive of miliary tuberculosis. Diagnosis ultimately required open lung biopsy, which showed evidence of an atypical granulomatous reaction with Pneumocystis carinii in the absence of other organisms. P carinii pneumonia must be considered in the differential diagnosis of patients with AIDS with nodular pulmonary densities and evidence of an atypical granulomatous reaction on pathologic specimens.

Pneumatosis cystoides intestinalis in progressive systemic sclerosis: a case report and literature review.

Pneumatosis cystoides intestinalis (PCI) is an uncommon disease manifestation characterized by the presence of air in the bowel wall. It is a benign condition that often responds to conservative management; however, it may be a harbinger of end stage disease, particularly in progressive systemic sclerosis. The authors report a case of pneumatosis cystoides intestinalis in a patient with progressive systemic sclerosis in the setting of mixed connective tissue disease that responded to conservative treatment. They review the current literature on pneumatosis cystoides intestinalis, focusing on possible etiologies and potential therapies.

Telephone management training in internal medicine residencies: a national survey of program directors.

BACKGROUND: Little is known about how internal medicine residents train for and practice telephone management. To address this deficiency, a national survey of program directors at accredited internal medicine training sites was conducted to evaluate residents' training for and practice of telephone medicine. METHOD: A 43-item questionnaire was mailed in December 1993 to all program directors at the 416 accredited internal medicine training sites in the United States. A limited questionnaire, regarding the most essential training questions, was mailed to all non-responders. RESULTS: The response rate was 60% (250) for the full questionnaire. Only 15 (6%) of the programs offered formal training in telephone management to their residents. This training usually consisted of single lectures (nine programs) or reading materials (seven programs). The respondents felt that formal training in telephone management was very important (155, 62%) and that such training should be a part of every internal medicine curriculum (150, 60%). CONCLUSION: Few internal medicine programs offered training in telephone management. When training occurred, it was usually limited and informal. Most program directors felt that training was important and that current training efforts were unsatisfactory, emphasizing the need for curriculum development and implementation in telephone management.

Can you hold please? How internal medicine residents deal with patient telephone calls. Telephone Encounters Learning Initiative Group.

Little is known about the mechanisms used in internal medicine residency programs to handle patient telephone calls. To address this, a survey of internal medicine residents was conducted at 10 different internal medicine residency programs. The response rate was 76% (N = 388). Approximately 90% of the residents handled patient telephone calls. The residents saw a mean of 7 patients per week in clinic (standard deviation +/- 2) and received an average of 2 patient calls daily (standard deviation +/- 2). The mean number of patient calls received each night on-call was 3 (standard deviation +/- 6) and on weekend call days, an average of 4 patient calls were received (standard deviation +/- 8). Internal medicine residents reported spending an average of 7 minutes per call talking to the patient (standard deviation +/- 5) and 8 minutes in follow-up activities (standard deviation +/- 6). Residents reported documenting calls less than 35% of the time. Residents disagreed with the statements "I am very satisfied with my patient telephone call system" and "My patients are very satisfied with my telephone call system." Most internal medicine residents handle a significant amount of patient telephone calls, and the systems for handling these calls are less than satisfactory. The procedures used to manage patient calls and the training for this component of practice should be improved.

Hodgkin's disease masquerading as sclerosing mediastinitis.

Cases in which fibrotic variants of Hodgkin's disease have been confused with sclerosing mediastinitis have rarely been reported. Sclerosing mediastinitis typically involves the superior/middle mediastinum and, in the United States, is most commonly due to histoplasmosis. We describe the case of a patient who came to us with fevers, a mixed anemia, and a posterior mediastinal mass that on pathologic examination appeared to be due to idiopathic sclerosing mediastinitis. Only inclusion of a biopsy specimen from a local celiac node, after a new porta hepatis mass was found, revealed the correct diagnosis of Hodgkin's disease of the nodular sclerosing type. With the correct diagnosis, early intervention and appropriate therapy resulted in clinical cure.

Case report: recurrent pneumothorax in a patient with rheumatoid arthritis.

Rheumatoid arthritis is a multi-system disease. Pulmonary manifestations and complications include pleural disease, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis. Pulmonary rheumatoid nodules, including rheumatoid pneumoconiosis (Caplan's Syndrome), can result in spontaneous pneumothorax. In this article, the authors present a patient with rheumatoid arthritis and recurrent spontaneous pneumothorax. Through investigation, a bronchopleural fistula caused by a rheumatoid nodule was revealed. The authors also discuss the potential pitfalls caused by a lung nodule in a patient with rheumatoid arthritis, including the overlap with bronchogenic carcinoma and confusion with tuberculosis.

The Ides of March. The match 1993 in perspective.

BACKGROUND: The total number of US medical school graduates who selected categorical programs in internal medicine in this year's match fell by 7.9%. Consequently, the program fill rate for US graduates declined for the eighth consecutive year, from 55.9% to 53.1%. Preliminary positions and international graduates continue to increase, though questions remain whether these residents serve as good role models to encourage student interest in internal medicine. METHODS: We reviewed the 1993 National Resident Matching Program data and several curricular reforms implemented in our internal medicine clerkship and residency program to evaluate whether such reform might enhance interest in general internal medicine. RESULTS: Reform in our internal medicine clerkship curriculum included increased emphasis on problem-based learning and exposure to generalist role models. This resulted in substantial increases on the average miniboard examination and a 22% increase in the number of students pursuing residency in internal medicine from the previous year. Residency curricular reform centered around enhanced ambulatory care teaching along with improved exposure to generalist role models. This resulted in a gradual increase in the number of residency graduates who were staying in general internal medicine from 21% in 1991 to 40% in 1993. CONCLUSIONS: Innovative curricular changes in our internal medicine clerkship and residency programs have led to enhanced interest in general internal medicine. Although our results are preliminary, such change is necessary, not only to continue program excellence, but for simple survival.

Case report: the spectrum of autoimmune thyroid disease with urticaria.

Urticaria has many known etiologies. An association with autoimmune thyroid disease is described. One individual had the triad of urticaria, Hashimoto's thyroiditis, and rheumatoid arthritis, whereas the other individual had urticaria preceding Graves' disease by over 1 year.

Case report: hypothalamic tuberculoma associated with secondary panhypopituitarism.

Tuberculosis of the central nervous system remains quite rare in developed countries, accounting for only 0.53% of cases of tuberculosis in the United States. The most common form of intracranial tuberculosis is tuberculous meningitis; however, involvement may also take the form of a solid granulomatous mass (tuberculoma), which accounts for 15% to 30% of the neurosurgical cases in developing countries. An unusual case of a hypothalamic tuberculoma is presented in a man, who initially presented with signs and symptoms consistent with panhypopituitarism. Brain biopsy on two occasions confirmed caseating granuloma, and treatment with several antituberculous medications led to clinical improvement and radiographic resolution of the disease.

Paraneoplastic syndromes for the primary care physician.

To summarize, we have reviewed the major endocrine, hematologic, neurologic, dermatologic, and miscellaneous paraneoplastic syndromes. These entities are of great importance to the primary care physician because, when recognized, they can permit early diagnosis of the neoplasm. Further, treatment can afford palliation of symptoms. We can expect more definite identification of the causes of the paraneoplastic syndromes in the future because more of the substances that are released by tumors will be identified and analyzed. We need to watch with anticipation for the development of specific treatments for the paraneoplastic syndromes as the causes are identified.

Erythromycin associated hearing loss in a patient with prior cis-platinum induced ototoxicity.

A case is reported of reversible sensorineural hearing loss associated with intravenous erythromycin treatment. Cis-platinum induced high frequency hearing loss developed nine months previously during treatment for stage IV papillary cystadenocarcinoma. Renal and hepatic function were normal; however, serum erythromycin levels were elevated. Clinical recovery promptly followed discontinuation of erythromycin.

Fluconazole in the treatment of hepatosplenic candidiasis.

Hepatosplenic candidiasis has increased in frequency among immunocompromised hosts. Risk factors include hematologic malignancy, intensive chemotherapy, prolonged neutropenia, and treatment with broad-spectrum antibiotics. Patients most commonly present with abdominal pain, persistent fevers despite antibiotic therapy, and an elevated alkaline phosphatase level that is out of proportion to other hepatic enzyme levels. Gastrointestinal mucosal damage secondary to intensive chemotherapy may allow colonization with Candida species and subsequent seeding of the portal vein. Treatment has consisted of prolonged courses of amphotericin B, with mortality rates approaching 50%. We report a case of hepatosplenic candidiasis in a patient with acute myelogenous leukemia who had clinical and radiographic improvement during fluconazole therapy. Fluconazole may be an efficacious and less toxic alternative to amphotericin B.