Evaluating Internal Medicine Resident Cardiology Knowledge by In-Service Training Exam Performance: A Four-Year Review

The In-Service Training Examination in Internal Medicine (IM-ITE) has been offered annually to all trainees in U.S. medical residency programs since 1988. Its purpose is to provide residents and program directors with an objective assessment of each resident\u27s performance on a written, multiple-choice examination and the performance of the residency program compared with that of its peers. This study aims to determine which measurable educational objectives contributed to improving In-training examinations in cardiology and which did not. Furthermore, we hope to highlight the strengths and weaknesses of the current knowledge to objectively evaluate and improve our cardiology rotation and education

Signs of Rheumatoid Arthritis with Negative Serum Markers: A Diagnostic Challenge

Background: Rheumatoid arthritis affects 1.3 million adults in US and can be challenging to diagnose. Clinicians need to develop a good sense of pretest probability, or likelihood of this disease, before initiating testing. This case explores the association between palmar erythema, rheumatoid arthritis, the differential diagnoses and testing available. Case presentation: This case involves a 55 year old woman with no past medical history who is presenting to the clinic with a 1 year duration of 7 out of 10 throbbing pain of the bilateral palms. There is no arthralgia. The pain worsens with activities that involve the hands and she denies stiffness. It is associated with episodic numbness in the median nerve distribution bilaterally which sometimes wakes her up at night. She denies fever or weight loss. The patient denies chronic illness, history of family illness, tobacco, alcohol, drug or current medication use. She has been treated in the past year for migraine headaches with sumatriptan and for unilateral carpal tunnel with gabapentin. On examination bilateral palms are diffusely erythematous and edematous with some pannus appreciated in the PIP joints. Tinel sign was positive bilaterally. We explored a broad differential including osteoarthritis, inflammatory arthritis, infectious. Our labs included Anti-CCP and RF which both came back negative. Conclusions: Classically, the finding of palmar erythema should prompt investigations into hepatic, endocrine, autoimmune, infections, or neoplastic processes. The additional finding of carpal tunnel warrants investigations into musculoskeletal processes. Features of carpal tunnel include numbness, tingling, burning, pain primarily in the thumb and index, middle, and ring fingers. Features of osteoarthritis include pain during movement, stiffness, tenderness, loss of flexibility, bone spurs and swelling. Features of rheumatoid arthritis include pain, stiffness, tenderness, weight loss, fever, fatigue, weakness. Between 1 and 5 percent of patients with rheumatoid arthritis present with carpal tunnel syndrome. Accordingly, seeing the combination of palmar erythema and bilateral carpal tunnel should prompt investigations into rheumatoid arthritis as the culprit. Rheumatoid factor has a 60-90% sensitivity and 85% specificity for rheumatoid arthritis. Anti-CCP antibodies have a sensitivity of 62-75% and specificity of 94-99%. Physical examination can be used to suggest the diagnosis of rheumatoid arthritis. These include reduced grip strength, palmar erythema, and thickening of the flexor tendons. A survey of the literature reveals that rheumatoid vascular changes can lead to palmar erythema. Due to the combination of palmar erythema, bilateral carpal tunnel syndrome, and the relatively low sensitivities of rheumatoid factor and anti-CCP antibodies in rheumatoid arthritis, clinicians should maintain a high degree of suspicion for rheumatoid arthritis with this clinical presentation, even in the absence of positive serum markers

Barriers to Applying Guidelines for Treatment of Type 2 Diabetes Mellitus in the Rio Grande Valley

Background: Type 2 Diabetes Mellitus affects 29.6% of adults in the Rio Grande Valley and 54% are estimated to be uncontrolled. Established and new pharmacotherapy agents are available, and guidelines exist in individualization of glycemic targets and agent selection. We present a case facing various barriers in applying these guidelines. Case Presentation: A 54-year-old uninsured woman with past medical history of uncontrolled type 2 diabetes mellitus, hypertension, chronic kidney disease stage 3, peripheral artery disease and bilateral below knee amputations presents for follow-up. She denies polyuria, polydipsia and weight changes. She reports compliance with medications and a fasting glucose range of 180-195. Current diabetes medications are insulin glargine, lispro, and dapagliflozin-metformin. Prior intolerance to dulaglutide with gastrointestinal upset. On exam, she had had a recent amputation with signs of infection. Data showed A1C this month at 9.4% from 13.7% 3 months ago and 14.8% 1 year ago. GFR stable at 58 and electrolytes normal. Urine protein creatinine ratio elevated at 1,865. Determined A1C goal to be below 8.0% based on multiple factors and reviewed benefits and risks of pharmacotherapy options. We increased the glargine and dapagliflozin-metformin. Conclusion: Though patient has a relatively young age, multiple factors suggest we have a less stringent target such as 8% including established vascular complications, limited resources as patient is uninsured, and patient self-care capabilities including health literacy. We will review the benefits, risks, and challenges in using sodium-glucose-cotransporter inhibitors and glucagon-like-peptide agonists and how the evidence applies to our patient

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient

Novel pharmacological therapy in type 2 diabetes mellitus with established cardiovascular disease: Current evidence

Cardiovascular diseases (CVDs) remain the leading cause of death in the world and in most developed countries. Patients with type 2 diabetes mellitus (T2DM) suffer from both microvascular and macrovascular diseases and therefore have higher rates of morbidity and mortality compared to those without T2DM. If current trends continue, the Center for Disease Control and Prevention estimates that 1 in 3 Americans will have T2DM by year 2050. As a consequence of the controversy surrounding rosiglitazone and the increasing prevalence of diabetes and CVDs, in 2008 the Food and Drug Administration (FDA) established new expectations for the evaluation of new antidiabetic agents, advising for pre and, in some cases, post-marketing data on major cardiovascular events. As a direct consequence, there has been a paradigm shift in new antidiabetic agents that has given birth to the recently published American Diabetes Association/European Association for the Study of Diabetes consensus statement recommending sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon like peptide-1 receptor agonists (GLP-1RA) in patients with T2DM and established CVD. As a result of over a decade of randomized placebo controlled cardiovascular outcome trials, the aforementioned drugs have received FDA approval for risk reduction of cardiovascular (CV) events in patients with T2DM and established CV disease. SGLT2i have been shown to have a stronger benefit in patients with congestive heart failure and diabetic kidney disease when compared to their GLP-1RA counterparts. These benefits are not withstanding additional considerations such as cost and the multiple FDA Black Box warnings. This topic is currently an emerging research area and this mini-review paper examines the role of these two novel classes of drugs in patients with T2DM with both confirmed, and at risk for, CVD. Core tip: Cardiovascular diseases are of significant concern in patients with type 2 diabetes mellitus. Novel therapies offer a new opportunity for cardiovascular risk reduction and add complexity in terms of selecting antihyperglycemic treatment. These pharmacological therapies, however, also have additional considerations

Navigating The Healthcare System to Increase Quality of Life in the Geriatric Population: Case of an 80-year old Male with Blindness

Bilateral retinal artery occlusion (BRAO) is defined as the blockage of blood to the retina in both eyes and can lead to partial or permanent loss of eyesight. This uncommon diagnosis can necessitate lifestyle changes that require supplemental assistance to help with activities of daily living. Navigating the healthcare system in general is formidable. However, doing so as a geriatric patient with limited eyesight and no social support escalates the challenge. This is the case for an 80-year-old male with history of vision impairment due to BRAO, coronary artery disease, heart failure, atrial fibrillation, chronic kidney disease, basal cell carcinoma of the nose, gout, and tobacco abuse, with no wife or children, who presented to the Internal Medicine outpatient clinic for follow up. He drove to clinic despite his visual impairment and is adamant about being as self-sufficient as possible, stating that he has been in a nursing home previously and that would be the worst outcome for him as he values his freedom at home above all else. The patient is competent and has the capacity to make decisions. His decision to live at home requires finding care that is in line with his wishes and keeps him safe. He is under Medicare but does not qualify for Medicaid according to Adult Protective Services (APS), which has visited his home twice before. However, Medicare is only able to provide Home-Health services for about 10 hours a week, not sufficient for someone with his health status. Shared decision making among the ophthalmologist, APS, and primary physician led to appropriate documentation of ‘Blindness’ as a diagnosis providing a wider range of services to the patient through disability. This case highlights how the role of primary care physicians goes beyond its traditional one. This patient is disabled and without any immediate family, meaning that his healthcare team is the only connection he has to appropriate resources to sustain his quality of life. Documenting this patient’s blindness provided greater access to social services, which is a prime example of why physicians should know how to guide their patients through the healthcare system

Balancing Autonomy and Safety in the Care of a Senior Patient: To Place or Not to Place?

According to the Census Bureau, the United States will have more than 20% of its population above age 65 by 2030, bringing ethical dilemmas in balancing risk and autonomy in geriatric patients to the forefront. Many geriatric persons rely on social support to fulfill their safety and autonomy needs, but those who lack a network are faced with increased challenges. An 80-year-old male with a history of multiple comorbidities presents to the UTRGV-DHR internal medicine outpatient clinic. His medical history includes coronary artery disease, heart failure, atrial fibrillation, chronic kidney disease, basal cell carcinoma of the nose, gout, tobacco abuse and vision impairment. This patient presented for follow up and denied any medical complaints but reported difficulties with tasks of daily living. Due to his vision impairment, he cannot see his food or read his medication labels. However, he still drives himself to appointments. The patient has no social support except for home health services through Medicare that fill pillboxes with his daily medications. During his visit the patient mentioned he had not had a home health visit recently; he was concerned that he might make a mistake taking the medications on his own. The patient insists that living in a nursing home or anything similar would be “worse than being in jail.” He has competency and capacity to make his own decisions and therefore his physicians pursued options to support him at home. This case demonstrates the importance of respecting desired autonomy while simultaneously working to preserve safety and mitigate risk. Providers must balance autonomy with safety including in geriatric patients. All choices in life involve risk. Discussion of patient’s desired risk tolerance in order to preserve which aspects of freedom is key to meaningful shared decision making in the elderly

Prototype of a new Engineering Masters project model: Working with marketing and software faculties to commercially kickstart university research

We describe a Master of Engineering (500-level) project modelled on the real-world arrangement where engineers work with marketing and software groups to prepare a product for commercialisation. A 4-member software team to develop and test embedded firmware and support applications on a mobile platform was provided through a final-year undergraduate software-engineering project course based outside the engineering school, in a separate faculty. A marketing team consisting of interns prepared logos, product names, and advertising materials, with input from a creative 200-level class. This team also considered possible exit strategies based on analysis of the market size and activity. This marketing effort was organised through the management communications group in the management school. The masters student acts as project manager and it is their remit to guide the product towards release on the crowd-sourced venture-capital site kickstarter.com. A small but original product idea is required to provide a viable vehicle for the project. Financial commitment to manufacture, even on a small scale, represents a novel outcome for a university project