A Case of Reverse Takotsubo Cardiomyopathy After Administering a Local Anesthetic Containing Epinephrine.

Takotsubo cardiomyopathy (TCM) is a rare syndrome characterized by acute and transient distinctive wall motion abnormalities accompanied by other defined objective findings. There are many variants of TCM, including the reverse (or basal) subtype. While the pathogenesis is not fully understood, both endogenous and exogenous catecholamines have been implicated. This case report describes a 30-year-old active-duty military female who developed reverse TCM immediately following local anesthetic with epinephrine administration in preparation for an elective septorhinoplasty. She developed electrocardiogram (ECG) changes, temporary hemodynamic instability, and cardiac troponin elevation. Transthoracic echocardiogram (TTE) demonstrated significantly reduced systolic and diastolic function, with akinesis of the basal segments and normal wall motion of the apical segments, consistent with a reverse Takotsubo pattern. Coronary computed tomography (CT) angiography showed normal coronary arteries. Repeat TTE was performed two days after the initial event and showed near-complete resolution of the wall motion abnormalities. Fourteen days later, TTE showed normalization of cardiac function. While there is a favorable prognosis for most patients with this diagnosis, there does remain the potential for significant adverse outcomes, risk of recurrence, and a non-negligible mortality rate. It is widely known that physical and emotional triggers can precipitate TCM through the release of catecholamines. This case, in addition to numerous other case reports, provides further documentation and support that exogenous epinephrine administration is also associated with the development of TCM. Clinicians should consider the diagnosis of Takotsubo cardiomyopathy if hemodynamic or ECG changes arise following epinephrine administration.

The House Cup: Using Longitudinal Gamification to Improve Didactic Attendance.

OBJECTIVE: Determine if a point-based attendance system combined with longitudinal gamification is feasible and improves didactic session attendance and learner perceptions at our internal medicine residency. METHODS: A prospective before-after cohort study. Weekly attendance was tracked from June 2022 through April 2023 at our university-affiliated internal medicine residency program. We implemented a point-based longitudinal game incentivizing residents to attend didactics with positive reinforcement in July 2022 (C: carrot). We added tiered positive reinforcement and positive punishment to the game in January 2023 (CS: carrot and stick). Attendance during these periods was compared to pre (P) and postintervention (S). Perceptions were assessed during the P, C, and CS periods with Likert scale ratings. RESULTS: CS was associated with higher attendance than other study periods (P = .002). Median attendance was P-51% (IQR 37.5-64.5), C-65% (IQR 50-74), CS-81% (IQR 78-94), and S-66% (IQR 63-71). Perceptions were similar during pre and intervention study periods, including perceptions of camaraderie (P-4.4, C-4.4, CS-4.5; P = .56), interest in attending didactic sessions (P-3.7, C-3.4, CS-3.2; P = .21), and mandate as the primary reason for attending didactics (P-3.1, C-3.1, CS-3.2; P = .96). CONCLUSIONS: A point-based attendance system combined with a longitudinal game that included tiered positive reinforcement and positive punishment was feasible and associated with higher didactic attendance but not associated with changes in resident perceptions.

Novel In-Training Evaluation Report in an Internal Medicine Residency Program: Improving the Quality of the Narrative Assessment.

OBJECTIVE: To determine whether incorporating our novel in-training evaluation report (ITER), which prompts each resident to list at least three self-identified learning goals, improved the quality of narrative assessments as measured by the Narrative Evaluation Quality Instrument (NEQI). METHODS: A total of 1468 narrative assessments from a single institution from 2017 to 2021 were deidentified, compiled, and sorted into the pre-intervention form arm and post-intervention form arm. Due to limitations in our residency management suite, incorporating learning goals required switching from an electronic form to a hand-deliver form. Comments were graded by two research personnel utilizing the NEQI's scale of 0-12, with 12 representing the maximum quality for a comment. The outcome of the study was the mean difference in NEQI score between the electronic pre-intervention period and paper post-intervention period. RESULTS: The mean NEQI score for the pre-intervention period was 2.43 ± 3.34, and the mean NEQI score for the post-intervention period was 3.31 ± 1.71, with a mean difference of 0.88 (p < 0.001). In the pre-intervention period, 46% of evaluations were submitted without a narrative assessment (scored as a zero) while 1% of post-intervention period evaluations had no narrative assessment. Internal consistency reliability, as measured by Ebel's intraclass correlation coefficient (ICC), showed high agreement between the two raters (ICC = 0.92). CONCLUSIONS: Our findings suggest that implementing a timely, hand-delivered paper ITER that incorporates resident learning goals can lead to overall higher-quality narrative assessments.

Implementation and Evaluation of a Longitudinal Flipped-Classroom Point-of-Care Ultrasound Curriculum at an Internal Medicine Residency Program.

BACKGROUND: Point-of-care ultrasound (POCUS) has extensive clinical utility in internal medicine, but formal and uniform curricula in internal medicine are lacking. OBJECTIVE: To determine the effectiveness of a longitudinal, flipped-classroom, academic half-day curriculum on internal medicine resident confidence, utilization, and changes in clinical management. METHODS: We implemented an asynchronous, flipped-classroom, academic half-day curriculum from November 2020 to November 2021 and conducted an evaluation with a prospective, before-after cohort study. Curriculum included 4 rotating sessions comprised of 20 to 30 min of image interpretation followed by 1.5 to 2 h of image acquisition. Confidence was rated via Likert scale. Utilization was reported via indicating never, 1 to 2, 3 to 4, 5 to 6, or >6 times per month (recorded as 1-5, respectively). Image interpretation was assessed via a 6-question, multiple-choice video assessment. RESULTS: Nineteen of 99 potential residents (19%) completed a pre- and post-curriculum evaluation. Residents attended a median of 4 sessions. Confidence improved from 2.47 to 3.53 (P = .002). Utilization did not improve overall (2.11-2.42, P = .22), but utilization of left ventricular function assessment (1.53-2.00, P = .046) and pulmonary assessment (1.53-2.00, P = .039) increased. The percentage of residents that had ever changed their clinical management by POCUS increased from 47% to 84% after implementation of the curriculum. Cardiac, pulmonary/pleural, volume assessment, and abdominal free fluid exams were reported as the most clinically useful. CONCLUSION: Implementation of a longitudinal, academic half-day curriculum for POCUS resulted in improved confidence, increased POCUS utilization for the cardiac and pulmonary examination, and changes in clinical management based on POCUS.

A Case of Primary Epstein-Barr Virus Infection Masquerading As Drug Reaction With Eosinophilia and Systemic Symptoms.

In this case report, we discuss the diagnostic dilemma presented by a patient admitted for elevated liver enzymes and rash, who had a history of recent amoxicillin use. This presentation initially appeared to fit the criteria for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. However, histologic evaluation determined the rash was consistent with Miliaria rubra rather than the lymphocytic infiltrate of DRESS. This necessitated broad diagnostic testing to determine the underlying etiology of the patient's syndrome. Serology subsequently demonstrated primary Epstein-Barr Virus (EBV) infection, which explained her acute liver injury. Her eosinophilia was potentially related to an allergic reaction to surgical tape but was never definitely diagnosed. This case demonstrates the importance of maintaining a wide differential even when clinical diagnostic criteria are apparently met.

Severe Urinary Retention Resulting in Extreme Post-obstructive Diuresis and Decompressive Hematuria.

Post-obstructive diuresis and decompressive hematuria are rare but potentially serious complications of severe urinary retention. This is a case report of a 73-year-old patient with undiagnosed severe large-volume urinary retention who developed extreme cases of both complications after presenting with progressive weight gain, lower extremity edema, worsening dyspnea, and new-onset urinary incontinence. Upon further evaluation, the patient was determined to have acute renal failure, bilateral hydroureteronephrosis, a severely distended urinary bladder, and an enlarged prostate. Foley catheterization produced 5.9 L of urinary output with initial placement. He required prolonged hospitalization for hemodynamic monitoring requiring fluid resuscitation, serial electrolyte monitoring requiring repletion, acute blood loss anemia requiring four units of red blood cell transfusion, continuous bladder irrigation, three cystoscopies under anesthesia, and intravesicular fibrinolysis inhibitor instillations. This case illustrates an extreme severity of post-obstructive diuresis and decompressive hematuria in chronic urinary retention that has not been previously described in the literature.

Examining the initial prescription leading to long-term opioid use at a military medical treatment facility.

OBJECTIVE: Chronic pain is common in the military, and over a quarter of active-duty military members have received a prescription for opioids. This study reviewed the initial opioid prescription among those who became future long-term users at an Air Force base in the United States and reports the characteristics of the provider and patient. METHODS: Our single-center retrospective study evaluated initial opioid prescriptions leading to long-term use within the military's electronic medical record at a large military medical treatment facility including active-duty patients and veterans. Of the 3,701 charts reviewed, 348 patients met the inclusion criteria for the long-term opioid use. RESULTS: Older patient groups received a higher initial amount of opioids than younger groups (p = 0.007). Primary care outpatient clinics started 43 percent of initial long-term opioid users, while surgical specialties contributed to 34 percent of the sample. In our study, 35.9 percent of the long-term opioid users were given their first opioid prescription within 30 days of an operation. Veterans or those separated from the military were less likely to have a behavioral disorder than active duty or family members. CONCLUSIONS: Our sample mirrored the civilian population in terms of age, gender, and most common pain diagnosis. We found that older patients initially received a higher dispensed amount compared to our younger patients. There was a concerning trend for surgical patients to develop into chronic opioid users.

Non-toxic Megacolon Secondary to High-Grade Large-Bowel Obstruction.

A 92-year-old male presented from an outside hospital for treatment of a chronic obstructive pulmonary disease exacerbation (COPD) and subsequently developed worsening abdominal distention with pain during the course of his hospitalization. He was found to have a high-grade large-bowel obstruction with a dilated colon of 20 cm measuring upward. The patient ultimately underwent a hemicolectomy to prevent bowel ischemia and reformation of another volvulus. We present this case to elucidate the need for vigilant monitoring in patients with chronic bowel obstruction due to lack of typical symptoms, to demonstrate a successful management approach, and to exhibit an extreme example of the resulting megacolon.

Acute Right Ventricular Dysfunction Secondary to Hereditary Angioedema Exacerbation.

This is a case report of a 31-year-old woman with past medical history of hereditary angioedema (HAE) who developed acute right ventricular dysfunction. The patient presented to the emergency department with complaints of acute abdominal pain and swelling. Her electrocardiogram demonstrated sinus tachycardia and T wave inversion in leads V1-V3, otherwise without findings suggestive of ischemia. Troponin was elevated at 1.83 ng/mL. A transthoracic echocardiogram showed normal left ventricular function with ejection fraction of 65-70%, but the right ventricle (RV) was dilated and severely hypokinetic and there was moderate tricuspid regurgitation. Patient was managed symptomatically for her HAE exacerbation. Her abdominal swelling resolved, troponins continued to trend down, and she was discharged home after three days. A follow up echocardiogram done six months later demonstrated normal RV function.

Ruptured Renal Abscess From Streptococcus agalactiae Invasion in a Postpartum Female.

Streptococcus agalactiae (Group B Streptococcus or GBS)is an exceptionally rare causative organism of a ruptured renal abscess. We report a case of this normally commensal organism causing a large ruptured renal abscess in a 17-year-old postpartum female. Although S. agalactiae is known to cause postpartum neonatal morbidity and mortality, it has rarely caused invasive infections in the last 20 years in adults. While this diagnosis often presents with nonspecific findings that can easily be overlooked during the postpartum period, the patient responded well to the established treatment of broad-spectrum antibiotics and a percutaneous drain.

Prevasculitic Eosinophilic Granulomatosis With Polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is an exceptionally rare systemic necrotizing vasculitis. The disease is clinically characterized by asthma with concomitant blood and tissue eosinophilia, often progressing to eosinophilic vasculitis. From the onset of asthma, there is usually a three to nine year delay of EGPA diagnosis. We report a case of this highly uncommon disease identified in an early stage.

Scurvy: A Case Report and Literature Review.

Scurvy is a rare disease which can manifest in a variety of presentations. Classically, scurvy is associated with poor dentition and bleeding diatheses. Rarely, scurvy can present with life-threatening hemodynamical instability. Herein, we report the case of a 69-year-old female with a history of hypertension and depression who presented with four months of weakness and a 20-pound weight loss. Her presentation was complicated by lower extremity bruising and myalgias over the last three weeks. The patient's blood pressure in the emergency department was 86/54 mmHg. On further examination, she had poor dentition and extensive ecchymoses in different stages of resolution over her posterior thighs and calves. The patient was also noted to have perifollicular hemorrhages. An ascorbic acid level was checked and the result was 0.0 mg/dL (normal range: 0.4 to 2.0 mg/dL). During her admission, she slowly improved with a provided diet and multivitamins. Her blood pressure consistently remained over 120/65 mmHg. The patient was advised to adjust her diet and take supplemental ascorbic acid. On a follow-up visit two weeks later, the patient endorsed an improvement in pain and exercise tolerance and was noted to have marked improvement in skin findings.  Ascorbic acid is an essential piece of multiple biochemical pathways. Humans are required to attain ascorbic acid from their diet. People who consume diets lacking in ascorbic acid develop scurvy.