Tonsillitis and Tonsilloliths: Diagnosis and Management.

Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States. Tonsillitis is caused by a viral infection in 70% to 95% of cases. However, bacterial infections caused by group A beta-hemolytic streptococcus (Streptococcus pyogenes) account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age. It is important to differentiate group A beta-hemolytic streptococcus from other bacterial or viral causes of pharyngitis and tonsillitis because of the risk of progression to more systemic complications such as abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever after infection with group A beta-hemolytic streptococcus. A variety of diagnostic tools are available, including symptom-based validated scoring systems (e.g., Centor score), and oropharyngeal and serum laboratory testing. Treatment is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic. In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years. Tonsilloliths, or tonsil stones, are managed expectantly, and small tonsilloliths are common clinical findings. Rarely, surgical intervention is required if they become too large to pass on their own.

What Makes a Near-Peer Learning and Tutoring Program Effective in Undergraduate Medical Education: a Qualitative Analysis.

Peer tutoring can benefit both learners and peer teachers that are distinct from the learning that occurs in expert-guided learning environments. This study sought to evaluate the peer tutoring program at a large public medical school to determine the strengths and weaknesses of a near-peer tutoring program and its benefits beyond students' typical classroom-based learning. This was a survey-based study of learners and tutors participating in the peer tutoring program. Fifty-six learners and 20 tutors participated in the survey; most learners received tutoring in the preclinical phase of the curriculum. Narrative responses were thematically analyzed to identify themes for both groups. Learners' responses about the benefit of the near-peer tutoring program were in three primary categories: creating a safe learning environment, direct coaching skills, and pitfalls around the need for individualized direction. Tutors' responses about what made a successful tutoring relationship centered around crucial activities used to engage with learners, beneficial intrinsic qualities of learners such as motivation, and qualifications of tutors that were most helpful such as knowledge base. Peer tutoring programs should emphasize individualized feedback for learners that focuses on metacognitive, content-based, and socio-emotional support. In doing so, such programs can provide a well-structured approach to improve learner success. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01680-0.

Diffuse lymphadenopathy and fever without a rash: an atypical presentation of secondary syphilis.

A woman in her 30s presented to the emergency department with 4 days of fever, headache and back pain. The patient was admitted for pain control, inability to tolerate oral intake and intravenous antibiotics for presumed diagnosis of pyelonephritis. Following admission, CT of the abdomen/pelvis showed multiple prominent pelvic and inguinal lymph nodes, and the patient was noted to have anterior and posterior cervical and submandibular lymphadenopathy on examination. The differential diagnosis was broadened to infectious, haematological, malignant and autoimmune aetiologies of diffuse lymphadenopathy. Workup included serum studies, imaging, lumbar puncture and lymph node biopsy. Rapid plasma reagin (RPR) returned positive with titre 1:16 and confirmatory reactive Treponema pallidum particle agglutination. With an otherwise unrevealing workup, the diagnosis of secondary syphilis was confirmed. This case highlights the differential and diagnostic approach for diffuse lymphadenopathy and an unusual presentation of secondary syphilis. Additionally, it indicates that secondary syphilis can be present even with a relatively low RPR titre.

Management of difficult-to-treat Clostridioides difficile in a patient with chronic osteomyelitis.

A 61-year-old male patient being treated with intravenous antibiotics for left foot osteomyelitis presented to the hospital septic, with several days of worsening abdominal pain, bloating and watery bowel movements. Investigation revealed that the patient had severe, treatment-resistant Clostridioides difficile colitis. He was initially treated with oral vancomycin and intravenous metronidazole, which was switched to oral fidaxomicin. After no improvement in the patient's symptoms, he was treated with two faecal microbiota transplants. He was offered a third faecal microbiota transplant but declined. The patient was placed back on oral fidaxomicin and saw ultimate resolution of his symptoms. This case provides an example of a treatment pathway for refractory C. difficile infection.