Actinomyces europaeus as an emerging cause of necrotizing fasciitis.

Necrotizing fasciitis is a type of necrotizing soft tissue infection (NSTI) that can be polymicrobial or monomicrobial in origin. Polymicrobial infections typically involve anaerobes of the Clostridium or Bacteroides family. This case report highlights necrotizing fasciitis caused by an unusual culprit, Actinomyces europaeus, which is a gram-positive anaerobic filamentous bacillus that has only been documented in one prior report to cause NSTI. Currently, about half of the hospitals in the United States are equipped to perform antibiotic susceptibility testing for anaerobes, but less than one-quarter of hospitals actually utilize these tests routinely. Thus, it is common for polymicrobial actinomycoses to be blindly treated with antibiotics that are beta-lactamase resistant and active against anaerobes, such as with piperacillin-tazobactam. Here we examine the potential impact of this lack of testing, as well as the evolution of A. europaeus to cause necrotizing fasciitis.

Assessment of Global Health Education: The Role of Multiple-Choice Questions.

Introduction: The standardization of global health education and assessment remains a significant issue among global health educators. This paper explores the role of multiple choice questions (MCQs) in global health education: whether MCQs are appropriate in written assessment of what may be perceived to be a broad curriculum packed with fewer facts than biomedical science curricula; what form the MCQs might take; what we want to test; how to select the most appropriate question format; the challenge of quality item-writing; and, which aspects of the curriculum MCQs may be used to assess. Materials and Methods: The Medical School for International Health (MSIH) global health curriculum was blue-printed by content experts and course teachers. A 30-question, 1-h examination was produced after exhaustive item writing and revision by teachers of the course. Reliability, difficulty index and discrimination were calculated and examination results were analyzed using SPSS software. Results: Twenty-nine students sat the 1-h examination. All students passed (scores above 67% - in accordance with University criteria). Twenty-three (77%) questions were found to be easy, 4 (14%) of moderate difficulty, and 3 (9%) difficult (using examinations department difficulty index calculations). Eight questions (27%) were considered discriminatory and 20 (67%) were non-discriminatory according to examinations department calculations and criteria. The reliability score was 0.27. Discussion: Our experience shows that there may be a role for single-best-option (SBO) MCQ assessment in global health education. MCQs may be written that cover the majority of the curriculum. Aspects of the curriculum may be better addressed by non-SBO format MCQs. MCQ assessment might usefully complement other forms of assessment that assess skills, attitude and behavior. Preparation of effective MCQs is an exhaustive process, but high quality MCQs in global health may serve as an important driver of learning.

Clinical Impact of Reporting Coronary Artery Calcium Scores of Non-Gated Chest Computed Tomography on Statin Management.

Introduction Coronary artery calcium (CAC) scoring is used as a screening tool for patients with intermediate 10-year arteriosclerotic cardiovascular disease (ASCVD) risk. Results obtained on non-contrast non-gated chest CT (ngCCT) correlate well to those obtained on gated CTs. This paper aims to determine how the routine reporting of CAC scores on ngCCT scans with ASCVD risk of less than 12.5% would change statin management. Methods Data of all patients scanned on a single CT scanner during a four-month window were reviewed. A total of 521 eligible scans were identified. After removing duplicate scans and scans from patients who were not in the age range of 40-75 years, 370 scans remained. Patients were excluded if they had documented ASCVD, type 2 diabetes mellitus, or low-density lipoprotein (LDL) > 190 mg/dL, or if they had ASCVD risk of greater than 12.5%. Ultimately, 36 scans were included in the study. Results Of the 36 patients who qualified, 10 were low-risk (ASCVD risk<5%), 13 were intermediate-risk (ASCVD risk 5-7.5%), and 13 were high-risk (ASCVD risk 7.5%-12.5%). A CAC score of 300 was used as a cutoff for recommending prescribing statins and 0 was used as a cutoff for recommending de-prescribing statins. In 63% of patients (23/36), CAC scoring altered statin recommendations. This included 11/13 (85%) intermediate-risk patients, 6/13 (46%) high-risk patients, and 6/10 (60%) low-risk patients. Conclusions Reporting CAC on ngCCTs obtained for other reasons can significantly impact statin prescribing practices. This may improve cost, patient satisfaction, and patient safety.

Implementing a Practical Global Health Curriculum: The Benefits and Challenges of Patient-Based Learning in the Community.

Background: A growing number of medical schools across the world have incorporated global health (GH) into their curricula. While several schools focus GH education on lecture-based courses, our premise is that global health education should embody a holistic approach to patient care and medical education in local communities. Medical students may learn global health by focusing on real patients, their families and communities as part of a practical curriculum. Aims and Objectives: A unique GH curriculum was devised to compare student learning outcomes on a practical vs. lecture-based course. The premise was that learning from patients would result in a greater breadth of coverage of the global health syllabus as compared to that from a lecture-based course. Methods: A teaching and learning program was developed over 3 years to provide medical students interaction with real patients in the community on a first-preclinical-year Introduction to Global Health and Medical Anthropology course. Learning outcomes on the practical vs. lecture-based course were compared using thematic analysis of the written assignments of both courses: global health case reports and literature reviews, respectively. All members of three cohorts of students undertaking the course in successive academic years were compared (Group A: literature review; Groups B and C: case reports; n = 87). Results: Case reports provided evidence of a greater breadth of learning outcomes when compared to the literature review (p < 0.001). The writing of the case report was enhanced by completion of a field journal and family health needs assessment tool (p < 0.001). Students demonstrated a closeness to their patients that added depth, understanding and motivation to assist patients in health activities and advocate for their needs. Discussion: Placements with patients in the community provided students with a rich learning environment and facilitated the formation of relationships with patients to better understand the social determinants of health and advocate for improvements in their living and working conditions and access to healthcare. Conclusions: Global health may be better learned experientially by following patients rather than from frontal lectures. Patient-based learning inspires a commitment to the individual and facilitates medical schools in meeting their obligations to the communities they serve.

Medical Management of Crohn's Disease.

Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect the entire gastrointestinal tract from the mouth to the anus, sparing the rectum. The goal of medical therapy is to induce remission with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important, as there is an overlap of medications used to induce and maintain remission. Physicians first direct treatment to induce a remission that involves relief of symptoms and mucosal healing of the lining of the colon and then provide long-term treatment to maintain the remission. Standard treatment for CD depends on the extent of involvement and disease severity, for example, mild, moderate, severe, and fulminant.

Increasing Internal Medicine Resident Confidence in Leading Inpatient Cardiopulmonary Resuscitations and Improving Patient Outcomes.

INTRODUCTION: Residents do not feel confident or competent in leading inpatient resuscitations. This is a crucial part of training future internists. Our objective was to develop a low-cost intervention to improve resident confidence in leading cardiopulmonary resuscitations and patient outcomes. METHODS: A "code-conference" including a lecture on a high-yield topic, a low-fidelity simulation, and review of resident-led resuscitations was created at our institution for the 2017-2018 academic year. Patient outcomes were assessed using objective measures of return of spontaneous circulation (ROSC) and survival to discharge (sDC). Confidence was assessed via survey before and after the intervention, with a focus on beginning postgraduate year 2 (PGY-2) residents. RESULTS: In 2017, 8 out of 8 (100%) PGY-2 residents responded, while in 2018, 8 out of 10 (80%) responded. Patient outcomes did not show a statistically significant improvement. There was a trend toward positive outcomes in the resident group alone. Return of spontaneous circulation increased from 63% to 79% (P = .08, total n = 97). Resident confidence was not improved in a statistically significant way, but there was a trend toward improvement and residents agreed it was an important part of their training. DISCUSSION: There was no statistically significant improvement in code-blue outcomes; however, there was a positive trend with increased ROSC and stable sDC for resident-led resuscitations, despite hospital-wide decreases in both. Resident confidence also showed a positive trend with no statistical significant changes. It is possible to institute a low-cost high-yield intervention to improved resident confidence in leading code-blue resuscitations. It may also improve patient outcomes; however, further studies are needed to determine if it can improve patient survival outcomes.

Carcinoid Syndrome: A Review.

Carcinoid syndrome (CS) is a paraneoplastic syndrome caused by the release of serotonin and other substances from well-differentiated neuroendocrine tumors (NETs). The hallmark symptoms of carcinoid syndrome are flushing and diarrhea; atypical signs and symptoms can include wheezing, abdominal pain, valvular heart disease, telangiectasias, pellagra, and the complications of mesenteric fibrosis, including ureteral obstruction, bowel obstruction, and bowel ischemia. These symptoms are mediated by the release of serotonin (5-HT), histamine, kallikrein, prostaglandins, and tachykinins. The diagnosis of CS requires these symptoms and corresponding elevations in lab tests. Treatment options include surgery and medical management with somatostatin analogs.

Renal Replacement Therapy for Undocumented Immigrants: Current Models with Medical, Financial, and Physician Perspectives-a Narrative Review.

Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.

Diagnostic utility of procalcitonin in inpatients at a community hospital.

Procalcitonin is an important diagnostic tool to be used in conjunction with clinical judgement and other data regarding the infectious etiology and appropriate treatment of the patient's present illness.

A Novel Mutation in the Adult-Onset Alexander's Disease GFAP Gene.

The case describes a 25-year-old Caucasian female diagnosed with Alexander's disease (AxD) as an outpatient after extensive inpatient workup. Her presenting complaints included incontinence, clumsiness, seizures, dysphagia, and dysarthria. She was also found to have pancytopenia and dysautonomia. A full neurologic and hematologic workup yielded very little results, until a thorough literature search of her presenting complaints and radiologic findings pointed to adult-onset Alexander's Disease. Alexander's disease is a rare genetic leukodystrophy with a broad variety of presentations. Despite its infrequency in adults and the difficulty in diagnosis, the prevalence of AxD has been increasing due to ease of genetic analysis and identification of key clinical and radiological findings. This case illustrates the necessity of vigilance and persistence in the face of unusual patient presentations; occasionally, the sound of hoofbeats is zebras.

Global Health Education and Advocacy: Using BMJ Case Reports to Tackle the Social Determinants of Health.

Since 2013, BMJ Case Reports (http://casereports.bmj.com/) has published over 70 global health case reports from five continents, written by doctors, nurses, students, and allied health professionals. These cases, a burgeoning repository of evidence of how real patients are affected by disease, trauma, violence, sexual assault, conflict, migration, adverse living and working conditions, and poor access to health care, discuss, in addition to clinicopathological findings, the global health problems affecting each patient. The global health problem analysis examines the problems of individual patients, critically appraises the literature, and describes actual and potential solutions for the patient, the local community, and patients affected by similar issues across the world. At present global health literature and learning materials lack a patient focus and real-life context in the analysis of global health problems. BMJ Case Reports global health case reports are a unique and important tool to learn about and advocate for change in the social, political, cultural, and financial determinants of health as they affect real patients. This growing evidence base brings together clinicians, local service providers, policy makers, and government and non-governmental institutions to effect real change in patients' lives toward improving health. Each global health case report is an excellent resource for learning, and together, these case reports provide essential reading for anyone embarking on a career in global health, and writing their own case report. The online course (http://casereports.bmj.com/site/misc/GHMA_Mar_2017.pptx) at BMJ Case Reports uses these cases and is free to access.

Factors affecting illness in the developing world: chronic disease, mental health and traditional medicine cures.

This is a case report of a 24-year-old Ethiopian woman with a medical history of hepatosplenic schistosomiasis. She suffers from chronic liver failure and portal hypertension. She has been hospitalised for 'hysteria' in the past but did not receive follow-up, outpatient treatment or psychiatric evaluation. After discontinuing her medications and leaving her family to use holy water, a religious medicine used by many Ethiopians, she was found at a nearby monastery. She was non-communicative and difficult to arouse. The patient was rushed to nearby University of Gondar Hospital where she received treatment for hepatic encephalopathy and spontaneous bacterial peritonitis. Her illness is the result of neglected tropical disease, reliance on traditional medicine as opposed to biomedical services and the poor state of psychiatric care in the developing world.

Social determinants of health: poverty, national infrastructure and investment.

This case presentation of a 19-year-old Ethiopian woman diagnosed with nasopharyngeal carcinoma reveals the barriers the patient has to medical treatment, including poverty and a lack of national infrastructure. The patient lives a life of poverty, and the outcome of her illness is a result of her being unable to overcome barriers to accessing health care due to inability to afford transport, lodging and treatment. In this case, the patient's vulnerability to disease due to her poverty is not overcome because of lack of infrastructure. The infrastructure fails to develop because of inadequate investment and other delays in building. The end result is that the patient is vulnerable to disease. Her disease process impacts her family and their contribution to Ethiopia's development.