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Background: Alkaline-encrusted pyelitis (AEP) is rare and most often stems from a triad of immunodeficiency, urogenital tract trauma, and alkaline urinary infection. Corynebacterium Group D2 is the most common organism. It results in encrusting calcifications that adhere to most of the urothelial lining of the pelvicaliceal system and ureter. Left unchecked, or unrecognized, the disease process can progress to renal compromise. Studies suggest that management is based on elimination of the bacterium, acidification of the urine, and elimination of calcified plaques and encrustations. Herein, we report a case of a 56-year-old woman who developed AEP in her second transplanted kidney, and detail the diagnosis and treatment of the uncommon, yet potentially devastating, disease. Case Presentation: A 56-year-old woman with a history of lupus, end-stage renal disease, who was on her second renal transplant presented with symptoms of urinary tract infection. Urine was consistently alkaline with cultures repeatedly growing urease-splitting Corynebacterium. Subsequent imaging showed large obstructing ureteral and renal stones concerning for AEP. She was treated with transplant kidney percutaneous nephrolithotomy, culture-specific antibiotics, and urinary acidification. Conclusion: Clinical presentation, urinalysis, culture, and renal imaging, often with CT, are the mainstays for diagnosing AEP. If not addressed, AEP can advance to renal failure. Management often includes a multimodal approach involving treatment and prevention of the underlying infection, urinary acidification, and percutaneous or endoscopic removal of obstructing and large burden stones and encrustation.

Allison A Vanderbilt,1 Sara Q Perkins,2 Moriah K Muscaro,2 Thomas J Papadimos,3 Reginald F Baugh4 1Department of Family Medicine, 2College of Medicine and Life Sciences, University of Toledo, 3Department of Anesthesiology, 4Department of Surgery, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA Abstract: Medical education has been under a constant state of revision for the past several years. The overarching theme of the curriculum revisions for medical schools across the USA has been creating better physicians for the 21st century, with the same end result: graduating medical students at the optimal performance level when entering residency. We propose a robust, thorough assessment process that will address the needs of clerkships, residents, students, and, most importantly, medical schools to best measure and improve clinical reasoning skills that are required for the learning outcomes of our future physicians. The Accreditation Council for Graduate Medical Education (ACGME) evaluates and accredits medical school graduates based on competency-based outcomes and the assessment of specialty-specific milestones; however, there is some evidence that medical school graduates do not consistently meet the Level 1 milestones prior to entering/beginning residency, thus starting their internship year underprepared and overwhelmed. Medical schools should take on the responsibility to provide competency-based assessments for their students during the clinical years. These assessments should be geared toward preparing them with the cognitive competencies and skills needed to successfully transition to residency. Then, medical schools can produce students who will ultimately be prepared for transition to their residency programs to provide quality care. Keywords: ACGME Core Competencies, milestones, clerkships, medical education, evaluation&nbsp