Surveying the Knowledge and Practices of Primary Care Residents in Managing Adult Patients with Obesity.

BACKGROUND: The prevalence of obesity is increasing worldwide at an alarming rate, yet obesity remains under-addressed during clinic encounters. A lack of training in how to treat obesity is one crucial factor contributing to this deficiency. OBJECTIVE: This study explored resident physicians' perceptions of their education on obesity and its relationship with confidence and practice behaviors when caring for patients with obesity. DESIGN: A survey was distributed to residency directors to share with residents in their programs. Participation was voluntary and anonymous. Data was collected over a 3-month period. PARTICIPANTS: Residents in Family Medicine and Internal Medicine programs in West Virginia and Indiana who saw adult patients in an ambulatory care setting. MAIN MEASURES: The electronic survey queried the presence of a formal curriculum on Obesity Medicine (OM) and each resident's knowledge, confidence, practice behaviors, and attitudes pertaining to OM. KEY RESULTS: The survey was distributed to 490 residents in 12 programs. Response rate was 22.9% (112 resident physicians). All respondents felt that medical training in obesity should be strengthened. Residents who reported having a formal curriculum on OM were more likely than those without a curriculum to rate their confidence as "high" when discussing weight (35.0% vs. 16.7%, p = 0.03) and when counseling patients about diet and nutrition (37.5% vs. 18.1%, p = 0.02). They also more frequently reported learning enough from faculty to manage obesity (65.0% vs. 29.2%, p < 0.001). Residents with an OM curriculum reported discussing obesity as a problem with patients (100.0% vs. 86.1%, p = 0.01), and completing motivational interviews (90.0% vs. 58.3%, p = < 0.001), more frequently than their peers without a curriculum. CONCLUSIONS: Residents with a formal OM curriculum were more confident in addressing and discussing obesity with patients. Formal training in OM will strengthen resident training to better address and treat patients with obesity.

Graves' Disease Exacerbation with Impending Thyroid Storm After SARS-CoV-2 Infection: A Case Report.

BACKGROUND Since the COVID-19 pandemic, several cases of COVID-19 have been linked to the development of autoimmune disorders, including of the thyroid. Graves' disease (GD) is a rare complication that can occur following SARS-CoV-2 infection. Reports have linked COVID-19 to new onset and exacerbation of GD. We present a case of a 42-year-old woman with a history of GD presenting with impending thyroid storm 3 weeks following a diagnosis of COVID-19. CASE REPORT A 42-year-old woman with a history of GD presented to the Emergency Department (ED) for an acute exacerbation of hyperthyroidism 3 weeks after SARS-CoV-2 infection was diagnosed on a home test. Symptoms included daily headaches, increased bilateral eye pressure, fatigue, muscle weakness, episodes of confusion and agitation, persistent heart palpitations, and goiter. Elevated free T4 of 5.57, free T3 of 15.68, total T3 of 4.43, and near-absent thyroid stimulating hormone were noted. The Burch-Wartofsky scale was 40, which was concerning for an impending thyroid storm; however, at the time of admission, she was not in a thyroid storm. Treatment included propylthiouracil, potassium iodide oral solution, and propranolol, with symptom improvement. Due to prior history of intolerance to antithyroid medications and recent exacerbation, a thyroidectomy was performed once she was in a euthyroid state. CONCLUSIONS Our case demonstrates the importance of recognizing COVID-19 as an etiology or a trigger for new onset or exacerbation of GD. Our case highlights that being vigilant to recognize the association between COVID-19 and thyroid abnormalities for early diagnosis and treatment is imperative.

Cryptogenic Abdominal Pain: Recognizing False Leads.

BACKGROUND Lead toxicity is a rare yet serious condition which can be difficult to diagnose due to vague presenting symptoms. Other pathologies can also mimic the symptoms of chronic lead toxicity, making an already difficult diagnosis more challenging. There are multiple environmental and occupational contributors to lead toxicity. A thorough history and an open differential is the key to diagnosing and treating this rare disease. With increasing diversity of our patient population, we should keep an open differential, as the epidemiological features of presenting concerns have diversified as well. CASE REPORT A 47-year-old woman presented with persistent nonspecific abdominal pain despite extensive prior work, surgeries and a prior diagnosis of porphyria. This patient was eventually diagnosed as having lead toxicity when her most recent work-up for abdominal pain revealed no urine porphobilinogen and a high lead level. The cause of lead toxicity was attributed to be an eye cosmetic called "Surma", which can have variable lead levels. Chelation therapy was advised for the patient. CONCLUSIONS It is important to recognize the difficulty in this challenging diagnosis for nonspecific abdominal pain and to eliminate the mimickers. This case is interesting because the patient was initially diagnosed with porphyria, highlighting how heavy metals, lead in this case, can lead to a false-positive diagnosis of porphyria. Accurate diagnosis requires awareness of the role of urine porphobilinogen, checking lead levels, and an open differential. This case also emphasizes the importance of avoiding anchor bias to make a timely diagnosis of lead toxicity.

Successful Hemodialysis Treatment of Severe Hypercalcemia Following COVID-19 in Multiple Myeloma: A Case Report.

BACKGROUND Hypercalcemia, a serum calcium exceeding 10.5 mg/dL, is a multi-factorial metabolic disorder that results from an imbalance in calcium homeostasis. CASE REPORT We report a case of a 67-year-old male with recently diagnosed multiple myeloma who presented to our emergency department 3 weeks after COVID-19 infection with altered mental status and a fall. On admission he was found to have severe hypercalcemia with a level over 18.0 mg/dL. Despite IV fluids, calcitonin, steroids, and zoledronic acid, he had persistent, critically elevated calcium levels. The decision to initiate hemodialysis was made, which successfully treated his hypercalcemia. CONCLUSIONS This report presents a case of malignant hypercalcemia in an individual with COVID-19 and multiple myeloma and highlights the importance of considering dialysis as a viable treatment for hypercalcemia when other modalities have failed.

Synovial sarcoma of the lung presenting late with compression of mediastinal structures and its successful resection: A case report.

Synovial sarcoma accounts for 5-14% of all soft tissue tumours. We present a case of 35 year-old male who presented with five months history of progressively increasing shortness of breath and cough. On evaluation, there was no air entry on the left side. CAT scan chest showed a large necrotic mass involving the entire left hemi-thorax. The tru-cut biopsy of this mass was done and it showed synovial sarcoma. The entire tumour along with the lung and the pericardium was removed completely. The patient had an uneventful recovery and was discharged home in 10 days with follow-up for adjuvant chemotherapy. Due to the rarity of this disease, no guidelines for the treatment are available. Main existing treatment includes surgery followed by either radiation, chemotherapy or both. Synovial sarcoma should be considered in the differentials of an adolescent or adult male patient presenting with a mass in the thorax.

Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis.

Subclavian artery thrombosis is a rare complication of clavicle fractures. We reported a 20-year-old man who was admitted to the emergency room after a road traffic accident. He was a pedestrian who was initially hit by a bus and after he fell down on the road, he was run over by a car. On evaluation, he was found to have multiple facial and rib fractures, distal right humerus and right clavicle fracture. Significantly, right radial pulse was absent. After further evaluation including Doppler studies and an angiography which revealed complete obstruction of right subclavian artery just distal to its 1st portion, the patient was urgently taken to the operation room. A midclavicular fracture was adjacent to the injured vessel. We established proximal and distal control, removed damaged part. After mobilizing the subclavian artery, an end-to-end anastomosis was made. Then open reduction and internal fixation of right distal humerus was performed. The rest of the postoperative course was unremarkable. To prevent complications of subclavian artery thrombosis, different treatment modalities can be used, including anticoagulation therapy, angioplasty, stenting and bypass procedures.