Day of the Week Variation in Emergency Department Arrivals, Chest Pain, and Acute Myocardial Infarction Throughout 2016-2019.

Overcrowding in the Emergency department (ED) necessitates a major challenge in delivering high-quality care in acute settings. This study presents a novel approach to modeling the relationship between the day of the week, ED arrivals, chest pain (CP), and acute myocardial infarction (AMI) using regression analysis. We analyzed data from 2016 to 2019 across three platforms: a nationwide representative sample (NHAMCS), a federated data network (TriNetX), and a regional medical center. For the stated three outcomes, the number of patients in that category on each day of the week was calculated; these were then calculated separately for each year, as well as across all four years. In line with prior studies, this study demonstrates the highest percentage of ED arrival on Mondays and the lowest on the weekends. Similarly, chest pain was more prevalent on Mondays, with similar patterns for TriNetX and the regional medical center. Analyzing NHAMCS data demonstrated Wednesdays as the busiest day for AMI-related ED arrivals, although this observation was not statistically significant. This knowledge will better aid us in resource allocation and system awareness, paving a path toward better patient care, improving disease management, and reducing healthcare costs.

A Dangerous Duo: Spontaneous Pneumomediastinum and Venous Thromboembolism at Presentation in a Patient with COVID-19 Pneumonia.

Background: Coronavirus disease 2019 (Covid-19) is associated with spontaneous pneumomediastinum (SPM) predominantly in those after positive pressure ventilation (PPV) support. Additionally, many cases of venous thromboembolism (VTE) in COVID-19 patients were described. Our case is the first to describe SPM and VTE present on admission in a patient with Covid -19 pneumonia. Case report: A 53-year-old man presented to the hospital with escalating dyspnea. Two weeks prior to this visit, he had been evaluated in an ambulatory setting and was started on antibiotics and systemic steroids. In the hospital, this patient was found to be in acute hypoxic respiratory failure and was placed on noninvasive PPV. Diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) test from nasopharyngeal swab specimen. Chest computed tomography (CT) scan revealed multi-lobar pulmonary emboli (PE) and subcutaneous emphysema with pneumomediastinum. The patient was managed conservatively. He never required closed invasive mechanical ventilation. Subsequent serial imaging displayed the resolution of SPM. Conclusion: The association between VTE and COVID-19 has been established. This report brings attention to SPM as an additional important complication of COVID-19, even in patients without pre-existing predisposing pathology or exposure to PPV.

Learning style preferences of internal medicine residents and in-training examination scores: is there a correlation?

The internal medicine in-training examination (IM-ITE) has been traditionally used as a measuring tool to evaluate the base of knowledge of the residents in internal medicine residency programs across the US. Multiple interventions has been applied and studied to increase the first-time passing rate of ABIM, as it is an indicator of each residency program's performance and ranking. Additionally, studies have demonstrated that different learning styles and preferences are a predictor of exam results; however, it is not well known whether certain preferred learning styles are correlated with certain IM-ITE results. Primary objective of our study was to find a correlation between residents' preferred learning style, based on Kolb learning style inventory, and their PGY1 and PGY2 IM-ITE performance score difference. Secondary objective was to find the correlation between PGY2s' IM-ITE score and their preferred learning styles based on the Kolb learning style inventory. Mean scores of PGY1 and PGY2 IM-ITE were compared in each learning style group. Additionally, the mean difference between the PGY1 and PGY2 IM-ITE scores for each learning group was compared as well. The analysis of the mean IM-ITE score from PGY1 to PGY2 between groups revealed a statistically significant improvement in IM-ITE score from PGY1 to PGY2 in all groups, however, with a larger difference in one of the groups.

Streptococcus agalactiae-Induced Soft Tissue Infection in a Nonpregnant Adult After a Gynecological Procedure.

BACKGROUND We present a case of a 24-year-old woman with type 1- diabetes mellitus who developed necrotizing fasciitis (NF) due to Streptococcus agalactiae after a recent colposcopy. Literature review suggests this as the first case to be reported. CASE REPORT The patient initially presented to the emergency department (ED) with right lower neck pain and spasm of the right sternocleidomastoid muscle (SCM), with decreased range of motion. She was diagnosed with torticollis and was sent home on a nonsteroidal anti-inflammatory drug and spasmolytic. She returned 5 days later because of a lack of response. Magnetic resonance imaging of her neck revealed edema and inflammatory changes in the distal portion of her right SCM; an oral-systemic steroid was added to her treatment. However, she presented to the ED 3 days after her second visit with worsening symptoms. Her complaints of severe pain involving the right chest wall, development of fever, and the findings on imaging studies prompted the diagnosis of necrotizing soft-tissue infection and NF. She promptly underwent successful surgical debridement. Tissue cultures grew abundant Streptococcus agalactiae. Her antibiotics were readjusted and she was discharged to rehabilitation. Retrospective analysis of the case was notable for colposcopy with cervical biopsy and endocervical curettage for chronic cervicitis and low-grade squamous intraepithelial lesion within a week of her first ED visit. CONCLUSIONS NF caused by Streptococcus agalactiae should be suspected in patients who have had recent genitourinary/gastrointestinal procedures.

Exploring faculty development opportunities and strategies in departments of medicine of U.S. community-based teaching hospitals.

Background: Faculty development (FD) activities are offered as a tool to health-care professionals to improve their knowledge, skills, and role as teachers and educators, leaders, researchers, and scholars. Formal FD activities have been more readily available at university-based teaching hospitals than at community-based hospitals. Yet the majority of Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs are sponsored by community-based teaching hospitals. Methods: An electronic survey along with the cover letter/consent form were sent via email to members of the Association of Program Directors of Internal Medicine (APDIM) of Community-Based Teaching Hospitals Assembly. Two researchers analyzed responses and reviewed all answers independently. Consensus was reached by comparison and discussion. Results: A total of 75 program or associate program directors from 53 U.S. Community-Based Teaching Hospitals with internal medicine residency programs participated in the survey. Eleven percent of the respondents reported that they had no faculty development activities in their departments, 44% reported occasional activities, and 45% reported ongoing activities. Forty-three percent reported making arrangements for faculty to attend FD offsite. However, 78% sent less than five people to those programs in the past 2 years. Discussion: The results of this study suggest that for the academic year 2014-2015 still a minority of non-university-based teaching hospitals had ongoing faculty development activities associated with their institution. Increased program commitment and adequate resources for FD instructors and funding can produce the desired increase in the number as well as the quality of the FD programs.

E. coli endocarditis of the tricuspid valve.

Infective endocarditis (IE) is a focus of infection which effects the endocardium, specifically the heart valves or intra-cardiac devices. A 64-year-old male with gastric carcinoma and no prior cardiac history presented to the emergency room with altered mental status. Initial investigations showed the patient had a leukocytosis with a left shift. Blood cultures taken upon arrival eventually grew Esherichia coli, thought to be from the urinary tract, although initial urinalysis was delayed until after initiation of antibiotics. Electrocardiogram showed sinus bradycardia with frequent premature atrial contractions. Chest X-Ray showed bilateral pleural effusions, which were eventually drained and found to be growing E. coli. Transthoracic echocardiogram was done which showed moderate-sized tricuspid valve vegetation with severe tricuspid regurgitation. IE has been increasing in incidence throughout the years. In prior decades IE was a disease primarily affecting patients with known rheumatic heart disease, prosthetic heart valves, and intravenous drug abusers however more commonly it is becoming healthcare acquired. E. coli is not often seen to be a culprit of IE. We present a rare case of E. coli endocarditis of a native tricuspid valve.

Intravascular large B-cell lymphoma presenting as multiple stroke: A case report.

INTRODUCTION: Intravascular large B-cell lymphoma (IVLBCL) is an uncommon disease with a poor prognosis if not diagnosed early. It can present with central nervous system (CNS) manifestations. The diagnosis of IVCBCL is difficult to make given its varied clinical manifestations and the lack of a specific diagnostic modality. CASE PRESENTATION: We report an interesting case of IVLBCL presenting as bilateral strokes. The diagnosis was made by a random skin biopsy, which confirmed IVLBCL. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP).Neurological symptoms improved with R-CHOP. Repeat magnetic resonance imaging (MRI) of the brain showed improvement of the prior lesions. CONCLUSION: IVLBCL is an aggressive disease with high mortality. Timely diagnosis and treatment can be lifesaving.

The changing anatomic position of squamous cell carcinoma of the lung - a new conundrum.

BACKGROUND: Traditionally, squamous cell carcinoma (SCC) of the lung is a central rather than a peripheral form of lung cancer. Rates of SCC in the lung periphery are typically sited in the 15-30% range. Recently, we observed that a significant portion of newly diagnosed SCC was located on a periphery. A comprehensive review of the tumor data at our facility, a busy teaching hospital with a large cohort of cancer patients, was undertaken to assess whether there had been a substantive change in the traditional epidemiologic distributions of the lung cancer, specifically with respect to SCC. Given the differences in cell biology and carcinogenesis of central versus peripheral SCC, a potential epidemiologic shift might suggest a change in tumor biology. METHODS: From May 12, 2012 through May 13, 2013, all histopathologically confirmed diagnoses of SCC of the lung were retrospectively reviewed. Each patient's lesion was then classified as peripheral or central based on CT evidence. RESULTS: A total of 56 patients were diagnosed with SCC. Of these, 55% (n=31) had peripheral and 45% (n=25) had central SCC. Twenty-nine patients did not have any prior history of malignancy. Of this subset of patients, 62% (n=18) had peripheral SCC, and 38% (n=11) had central SCC. CONCLUSION: Our findings appear to correlate with our initial observation that, within our institution, there has been a substantive shift in the traditional distribution of SCC with the majority of these cancers now being diagnosed in the lung periphery as opposed to the more central locations.

When a pulmonary embolism is not a pulmonary embolism: a rare case of primary pulmonary leiomyosarcoma.

Arterial leiomyosarcomas account for up to 21% of vascular leiomyosarcomas, with 56% of arterial leiomyosarcomas occurring in the pulmonary artery. While isolated cases of primary pulmonary artery leiomyosarcoma document survival up to 36 months after treatment, these uncommon, aggressive tumors are highly lethal, with 1-year survival estimated at 20% from the onset of symptoms. We discuss a rare case of a pulmonary artery leiomyosarcoma that was originally diagnosed as a pulmonary embolism (PE). A 72-year-old Caucasian female was initially diagnosed with 'saddle pulmonary embolism' based on computerized tomographic angiography of the chest 2 months prior to admission and placed on anticoagulation. Dyspnea escalated, and serial computed tomography scans showed cardiomegaly with pulmonary emboli involving the right and left main pulmonary arteries with extension into the right and left upper and lower lobe branches. An echocardiogram on admission showed severe pulmonary hypertension with a pulmonary artery pressure of 82.9 mm Hg, and a severely enlarged right ventricle. Respiratory distress and multiorgan failure developed and, unfortunately, the patient expired. Autopsy showed a lobulated, yellow mass throughout the main pulmonary arteries measuring 13 cm in diameter. The mass extended into the parenchyma of the right upper lobe. On microscopy, the mass was consistent with a high-grade primary pulmonary artery leiomyosarcoma. Median survival of patients with primary pulmonary artery leiomyosarcoma without surgery is one and a half months, and mortality is usually due to right-sided heart failure. Pulmonary artery leiomyosarcoma is a rare but highly lethal disease commonly mistaken for PE. Thus, we recommend clinicians to suspect this malignancy when anticoagulation fails to relieve initial symptoms. In conclusion, early detection and suspicion of pulmonary artery leiomyosarcoma should be considered in patients refractory to anticoagulation, prompting initiation of early intervention.