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Blunt cardiac injury (BCI), also referred to in the literature as a cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose this condition in the absence of clear diagnostic criteria. Furthermore, its clinical presentation is highly variable depending on the severity, type, and duration of the trauma, as well as the timing from the initial insult.The clinical manifestation of BCIranges from none to fatal arrhythmiasto cardiac wall ruptureseen on post-mortem examination. Cardiac biomarkers and electrocardiograms (EKG) are usually helpful in identifying cardiac trauma but are not necessarily abnormal in all cases. Falls by slipping on ice are common in the winter, but rarely do people present with a myocardial injury with these mechanical events. We describe the case of a cardiac contusion with an unusual presentation and an unusual cause, whereby both the initial EKG and troponin level were normal, and the patient presented with an atrioventricular (AV) block two weeks after "slipping on ice".

Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (−) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% ( P < .001) in services not receiving peer leader intervention and to >80% ( P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.

Introduction Research suggests that well-being impacts residents' ability to learn and provide patient care. The purpose of this study was to investigate the descriptive statistics, factors and the internal reliability of the Resident Well-being (RWB) scale. Analyses were also conducted to investigate the construct validity of the responses to the RWB. Methods The resource includes an investigation of the descriptive statistics, factors and the internal reliability of residents' responses to the RWB scale. This resource also includes an investigation of the construct validity of the RWB by exploring potential relationships between residents' well-being and two theoretically related constructs: the quantity of sleep and rotation demands. The development of the RWB and an investigation of the internal reliability and validity of the responses help contribute to how educators can assess residents' well-being and inform residency program implementation. This project also serves as the beginning of a long-term project to efficiently measure the well-being of residents and other learners in the health care professions. Results The RWB responses were internally reliable (Cronbach's alpha = .89) and one factor (i.e., well-being) was distinguished. There was a statistically significant relationship between the frequency residents slept and well-being. There was also a statistically significant effect of rotations' time intensiveness on residents' well-being; however, effect sizes suggest the amount of sleep and rotation intensiveness explains only a small to a moderate amount of variance of resident well-being. Discussion The RWB is a tool that program directors may utilize to monitor residents' well-being. Future research is required to investigate how other triggers, such as program quality and life-stressors, may impact residents' well-being. Future research may also investigate how the RWB may be applied to other health professionals, as learners across the disciplines struggle to negotiate a balance between their personal lives, learning, and patient care.

Osteoporosis is a major public health problem. Guidelines recommend osteoporosis screening, primarily with bone mineral density (BMD) testing, of all women agedor =65 and younger women at increased risk. However, BMD testing is underused, and osteoporosis screening practices are not in compliance with guidelines.This was a retrospective cohort study of 809 women patientsor =65 years. The proportion of patients having evidence of BMD testing and factors associated with BMD testing were evaluated.The overall proportion of patients having evidence of BMD testing was 42.9%. A higher proportion of patients from the gynecology practice (72%) had evidence of BMD testing compared with family medicine (42%), general internal medicine (36%), and the Veterans Administration practice (30%) (p0.0001). The proportion of patients with evidence of BMD testing was higher in patients seen by faculty (48%) than in patients seen by midlevel providers (35%) or residents (21%) (p0.0001) and was higher in patients of female providers (54%) than in patients of male providers (31%) (p0.0001). Negative associations with BMD testing were seen with increasing age and numbers of medications (p0.0001 and p0.05, respectively). The numbers of visits and numbers of total and unique ICD-9 codes were each negatively associated with BMD testing (p0.05, p0.005, and p0.05, respectively). In patients with commercial insurance, 48% had evidence of BMD testing vs. 25% in the rest of the subjects (p0.0001). The proportion of patients with evidence of BMD testing also varied by body mass index (BMI).Consideration of factors associated with BMD testing may be useful in developing interventions to increase osteoporosis screening rates.

Introduction This tutorial was designed to address the existing gaps in women's health training. It provides modules in a variety of electronic formats that can be used by medical educators alone or as a supplement to a clinical rotation for primary care residents and/or medical students. This course is designed to teach participants about the primary care of women, with special attention to contraception, menopause, and preventive care. Methods The tutorial includes 14 content modules with various teaching formats and two self-assessment quizzes. The content modules include information on the following topics: breast disorders, cardiovascular disease in women, contraception, eating disorders, female urologic disorders, menopause, menstrual disorders, osteoporosis, pap smears, polycystic ovarian syndrome, vaginitis, women's cancer screening, women's disease prevention, and women's health trials. The self-study quizzes are on topics related to differences and disparities, and medication safety in pregnancy. Results This curriculum was implemented for use in the internal medicine residency program at West Virginia University in September 2006. It enabled our internal medicine program to satisfy the mandatory requirement for women's health training. Pre-/posttests were completed by residents, and standard evaluations were completed by residents after completion of the rotation. Feedback from residents has been positive regarding the online tutorial and several residents suggested that all clinical rotations should contain such components. Discussion We are confident that the material in this tutorial is appropriate for training medical students, family medicine residents and internal medicine residents. This was the first time a computer format was used in the internal medicine residency program for a rotation at our institution, and it was well-received. As a result of this project, many sections within the department of medicine are developing similar online courses and tutorials for use on their rotations. An orientation session with learners at the beginning of the rotation enhanced understanding of the expectations.