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The article presents a case study of a 62-year-old woman with rheumatoid arthritis (RA) presented fro evaluation of chronic pleuritic chest pain, odynophagia, and migratory joint pains. She has no signs of underlying connective tissue disease (CTD). Her outpatient evaluation reveals an elevated erythrocyte sedimentation rate and C-reactive protein value. The article discusses the clinical overlap between systemic lupus erythematosus (SLE) and RA.

The article presents the case of the 25-year-old woman with increasing abdominal girth and shortness of breath. It states that on physical examination, the patient had severe kyphoscoliosis with a scoliotic angle of 116 degrees and T4 paraplegia. It also discusses the cause of the patient's condition which is idiopathic pulmonary hypertension.

OBJECTIVE: To examine the association of medical knowledge acquisition with attendance at specific conference types during internal medicine residency. PARTICIPANTS AND METHODS: Attendance at residency core curriculum, morbidity and mortality, and medical grand rounds conferences was tracked for 195 residents who took the internal Medicine in-Training Examination (IM-ITE) 421 times while attending the Internal Medicine Residency Program at Mayo Clinic's site in Rochester, MN, between October 1, 1999, and October 1, 2003. Random effects modeling was used to adjust for variables known or hypothesized to be associated with IM-ITE scores and allowed discrimination of effects of individual conferences on IM-ITE scores. RESULTS: Total conference attendance was significantly associated with increased IM-ITE scores, with cohort mean increase of 2.30% (95% confidence interval [Cl], 1.24% to 3.36%; P<.001). Core curriculum conferences accounted for much more of this association than either medical grand rounds or morbidity and mortality, with cohort mean increases of 2.05% (95% Cl, 0.13% to 3.90%; P=.04), 0.24% (95% Cl, -0.56% to 1.03%; P=.61), and 0.03% (95% Cl, -1.69% to 1.69%; P=.97), respectively. CONCLUSION: Conference attendance is associated with improved knowledge acquisition as measured by improved performance on IM-ITE. This finding does not appear to apply to all conferences at our institution but rather is specifically attributable to attendance at the core curriculum series. [ABSTRACT FROM AUTHOR]

This article discusses the case report of a 76-year-old man with back pain and progressive leg weakness. Although mechanical back pain is a common presenting symptom that may lead to radicular pain, it rarely causes constant pain or progressive motor abnormalities. It is not associated with constitutional symptoms, making this choice unlikely. Neoplasm is the most likely choice in this patient because he presented with constitutional symptoms, continuous pain, and progressive motor symptoms. The initial clinical impression was that the patient had multiple myeloma. The degree of hypercalcemia was concerning at the time of admission.

The American College of Cardiology In-Training Exam (ACC-ITE) is incorporated into most U.S. training programs, but its relationship to performance on the American Board of Internal Medicine Cardiovascular Disease (ABIM CVD) Certification Examination is unknown. ACC-ITE scores from third-year fellows from 2011 to 2014 (n = 1,918) were examined. Covariates for regression analyses included sex, age, medical school country, U.S. Medical Licensing Examination Step, and ABIM Internal Medicine Certification Examination scores. A secondary analysis examined fellows (n = 511) who took the ACC-ITE in the first and third years. ACC-ITE scores were the strongest predictor of ABIM CVD scores (p < 0.0001), and the most significant predictor of passing (p < 0.0001). The change in ACC-ITE scores from first to third year was a strong predictor of the ABIM CVD score (p < 0.001). The ACC-ITE is strongly associated with performance on the ABIM CVD Certification Examination. [ABSTRACT FROM AUTHOR]

The article author focuses on the causes of the disorder osteogenesis imperfecta. A case study has been elaborated involving a 41-year-old man who was diagnosed to have an osteopenia and compression fractures after a vehicle accident. The author pointed out that although the cause of osteopenia and compression fractures is rare, osteogenesis imperfecta should be considered in young patients who present with a history of multiple fractures and osteopenia.

A quiz concerning the Buerger's disease is presented.

A quiz concerning the condition of a 78-year-old Somali man with emesis and jaundice is presented.

OBJECTIVE: To determine the feasibility, efficacy, and outcomes of teaching Internal Jugular (IJ) central venous line placement (CVLP) to internal medicine residents in a hands-on training experience with adult patients. SUBJECTS AND METHODS: Data were obtained from 47 residents during their 3-year residency program through questionnaires and a proprietary system that tracks resident procedures. Twenty-five postgraduate year (PGY) 2 residents at the Mayo Clinic in Rochester, Minn, were assigned to IJ-CVLP training in the cardiac catheterization laboratory from January 2001 to June 2001. Their experience, analyzed immediately after training and at completion of residency, was compared with that of 22 PGY-2 residents in the same class who were not assigned to IJ-CVLP training. RESULTS: The median Liked scores of the residents' self-reported perception of independence in IJ-CVLP increased from 3.0 (mean ± SD score, 2.8±1.4) before the intervention to 5.0 (4.4±0.9) after the intervention (P<.001, signed rank test). At graduation, trained residents had performed more IJ-CVLPs than the control residents (mean ± SD, 17.8±8.4 vs 9.8±6.3, respectively; P<.001). Residents who received IJ-CVLP training, compared with those who did not, showed a significant increase in the mean percentage of IJ- CVLPs performed independently between PGY-1 (2.2%) and PGY-3 (31.2%) (P=.008). CONCLUSIONS: Training internal medicine residents to perform IJ-CVLP is feasible in the cardiac catheterization laboratory with supervision from an attending cardiologist. Trained residents performed significantly more IJ-CVLPs independently during their third year compared with their first year of training. We believe this initiative may be implemented successfully in graduate medical education curriculums. [ABSTRACT FROM AUTHOR]

Reports on the case of an 81-year-old woman which nausea and fatigue. Prescription of floxacin for presumed urinary tract infection; Increasing fatigue and dyspnea; Admittance to the hospital for pneumonia and volume overload; Persistence of symptoms; Medical history remarkable for hypertension and left ventricular hypertrophy with heart failure.

OBJECTIVE: To determine whether standardized admissions data in residents' Eiectronic Residency Application Service (ERAS) submissions were associated with muitisource assessments of professionaiism during internship. PARTICIPANTS AND METHODS: ERAS applications for all internal medicine interns (N=191) at Mayo Clinic entering training between July 1, 2005, and July 1, 2008, were reviewed by 6 raters. Extracted data included United States Medical Licensing Examination scores, medicine clerkship grades, class rank, Alpha Omega Alpha membership, advanced degrees, awards, volunteer activities, research experiences, first author publications, career choice, and red flags in performance evaluations. Medical school reputation was quantified using U.S. News & World Report rankings. Strength of comparative statements in recommendation letters (0 = no comparative statement, 1 = equal to peers, 2 = top 20%, 3 = top 10% or "best") were also recorded. Validated multisource professionalism scores (5-point scales) were obtained for each intern. Associations between application variables and professionalism scores were examined using linear regression. RESULTS: The mean ± SD (minimum-maximum) professionaiism score was 4.09±0.31 (2.13-4.56). in muitivariate analysis, professionalism scores were positively associated with mean strength of comparative statements in recommendation letters (β=0.13; P=.002). No other associations between ERAS application variables and professionalism scores were found. CONCLUSION: Comparative statements in recommendation letters for internal medicine residency applicants were associated with professionalism scores during internship. Other variables traditionally examined when selecting residents were not associated with professionalism. These findings suggest that faculty physicians' direct observations, as reflected in letters of recommendation, are useful indicators of what constitutes a best student. Residency selection committees should scrutinize applicants' letters for strongly favorable comparative statements. Mayo Clin Proc. 2011;86(3):197-202 [ABSTRACT FROM AUTHOR]

OBJECTIVE: To measure the effect of duty periods no longer than 16 hours on patient care and resident education. PATIENTS AND METHODS: As part of our Educational innovations Project, we piloted a novel resident schedule for an Inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekiy surveys, end of rotation evaluations, and an electronic card-swlpe system. RESULTS: Patient care metrics, Including 30-day mortality, 30-day readmisslon rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P=.006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and pro- fessional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P=.40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P=.004). CONCLUSION: Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quaiity of education, and time off between shifts may be adversely, affected. Mayo Clin Proc. 2011;86(3):192-196. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To measure actual and perceived resident physician knowledge of underserved patient populations. PARTICIPANTS AND METHODS: Using the existing literature on vulnerable patient populations and interviews with experts in the field, we designed a cross-sectional, multi-institutional survey to assess actual and perceived resident knowledge of topics related to underserved populations. The survey of actual knowledge consisted of 30 multiple-choice questions, and the survey of perceived knowledge consisted of 15 items based on 3-point Likert scales of confidence. RESULTS: A total of 498 surveys were completed at 18 residency programs representing 7 different specialties at 10 US institutions. Assessment of perceived knowledge demonstrated that residents were very confident only 14.0% of the time, somewhat confident 66.4% of the time, and not at all confident 19.6% of the time. Assessment of actual knowledge revealed that the average percent correct across all 30 questions was 38%. Women scored better than men (average score, 40.6% vs 36.0%; P=.01), and African Americans scored higher than members of other racial or ethnic groups (average score, 43.5% vs 38.0%; P=.04). Associations between residents' perceived and actual knowledge were generally high. CONCLUSION: For the US residents surveyed, the actual and perceived knowledge about most topics relating to underserved populations was low, whereas associations between actual and perceived knowledge were high. These findings suggest the need to improve resident education regarding underserved patient populations. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the educational benefits of international elective rotations during graduate medical education. PARTICIPANTS AND METHODS: We studied Mayo International Health Program (MIHP) participants from April 1, 2001, through July 31, 2008. Data from the 162 resident postrotation reports were reviewed and used to quantitatively and qualitatively analyze MIHP elective experiences. Qualitative analysis of the narrative data was performed using NVivo7 (QRS international, Melbourne, Australia), a qualitative research program, and passages were coded and analyzed for trends and themes. RESULTS: During the study period, 162 residents representing 20 different specialties were awarded scholarships through the MIHP. Residents rotated in 43 countries, serving over 40,000 patients worldwide. Their reports indicated multiple educational and personal benefits, including gaining experience with a wide variety of pathology, learning to work with limited resources, developing clinical and surgical skills, participating in resident education, and experiencing new peoples and cultures. CONCLUSION: The MIHP provides the structure and funding to enable residents from a variety of specialties to participate in international electives and obtain an identifiable set of unique, valuable educational experiences likely to shape them into better physicians. Such international health electives should be encouraged in graduate medical education. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To define outcomes from contrast-Induced nephropathy (CIN) after both intra-arterial and intravenous administration of contrast medium. PATIENTS AND METHODS: We performed a retrospective case- matched cohort study at Mayo Clinic's site In Rochester, MN, from April 1, 2004, to March 31, 2006. All contrast procedures were evaluated for inclusion. Contrast-induced nephropathy was defined as creatinine elevation of 25% or more after contrast exposure or of more than 0.5 mg/dL within 7 days of contrast exposure. Cases of CIN were matched 1:3 with controls by age, sex, preprocedure creatinine elevation, diabetes mellitus, and type of Imaging procedure. RESULTS: A total of 809 patients who developed CiN were matched to 2427 patients who did not develop CIN after contrast exposure. in multivariate analyses, CiN was significantly associated with 30-day mortality (odds ratio, 3.37; 95% confidence interval [Cl], 2.58-4.41; P<.001) and overall mortality (hazard ratio, 1.57; 95% CI, 1.32-1.86; P<.001) after adjustment for heart failure, hypertension, medications, total hydration, iodine ioad, prior contrast exposure, and au matched variables during the study period, intravenous contrast administration was a risk factor for 30-day mortality (odds ratio, 2.91; 95% CI, 1.17-7.23; P=.02) and overall mortality (hazard ratio, 3.02; 95% CI, 1.89- 4.82; P<.001) compared with intra-arterial administration of contrast after adjustment for heart failure, hypertension, medications, total hydration, iodine load, prior contrast exposure, and all matched variables during the study period. CONCLUSION: Contrast-Induced nephropathy after administration of contrast medium is associated with increased mortality. This risk is higher in patients In whom contrast medium is administered Intravenously than In those in whom It Is administered intra-arterially. [ABSTRACT FROM AUTHOR]

Two letters to the editor are presented in response to articles in previous issues including the evaluation of mortality risk after contrast-induced nephropathy (CIN) and the mortality due to CIN.

A letter to the editor is presented in response to the article on the measurement of urinary tobacco alkaloid in patients with thromboangiitis obliterans (TAO).