Barry O. Kassen

Tick-Borne Relapsing Fever in the Northwestern United States and Southwestern Canada

Records from 182 cases of tick-borne relapsing fever (TBRF) were reviewed. In confirmed cases, there was febrile illness, and spirochetes were identified on peripheral blood preparations. In probable cases, there were clinical features of TBRF and either the same exposure as a confirmed case or serological (indirect fluorescent antibody test and western blotting [WB]) evidence of infection with Borrelia hermisii. Sera also were tested for antibody to Borrelia burgdorferi. We identified 133 confirmed and 49 probable cases of TBRF. A Jarisch-Herxheimer reaction was reported in 33 (54.1%) of 61 cases for which this information was available. Most patients who had antibodies to B. hermsii were serologically positive for B. burgdorferi, and WB demonstrated false positivity of testing for B. burgdorferi. Thirty-five (21%) of 166 cases were unreported to public health authorities. In 52 cases, there were more than two relapses before the diagnosis. This study demonstrates that TBRF is underrecognized and underreported and may be falsely identified as Lyme disease.

Assessing the mini-Clinical Evaluation Exercise in comparison to a national specialty examination

Purpose  To evaluate the reliability and validity of the Mini‐Clinical Evaluation Exercise (mini‐CEX) for postgraduate year 4 (PGY‐4) internal medicine trainees compared to a high‐stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination).

Incorporating simulation technology in a canadian internal medicine specialty examination: a descriptive report.

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SPs lack of real physical abnormalities. The authors report on the development and implementation of physical examination stations that combine simulation technology in the form of digitized cardiac auscultation videos with an SP assessment for the 2003 Royal College of Physicians and Surgeons of Canadas Comprehensive Objective Examination in Internal Medicine. The authors assessed candidates on both the traditional stations and the stations that combined the traditional SP examination with the digitized cardiac auscultation video. For the combined stations, candidates first completed a physical examination of the SP, watched and listened to a computer simulation, and then described their auscultatory findings. The candidates’ mean scores for both types of stations were similar, as were the mean discrimination indices for both types of stations, suggesting that the combined stations were of a testing standard similar to the traditional stations. Combining an SP with simulation technology may be one approach to the assessment of clinical competence in high-stakes testing situations.

Assessing cardiac physical examination skills using simulation technology and real patients: A comparison study

Objective  High‐stakes assessments of doctors’ physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists’ cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs).

Transient syndrome of inappropriate antidiuretic hormone secretion during pregnancy.

Plasma osmolality normally decreases in early pregnancy, reaching a minimum at approximately 10 weeks and remaining depressed until term. This is associated with a mean decrease of 4 mEq/L in the plasma sodium level, and with an altered threshold for arginine vasopressin (AVP) release and for thirst. We describe a patient who developed more severe hyponatremia (120 mEq/L), which accompanied the development of hypertension and edema at 37 weeks in her fourth pregnancy. Hyponatremia and hypo-osmolality were associated with marked elevation of the plasma AVP level. The hyponatremia and elevated AVP level resolved after the delivery of the infant. To our knowledge, this is the first reported example of transient inappropriate antidiuretic hormone secretion (SIADH) associated with pregnancy.

Assessing the relationship between cardiac physical examination technique and accurate bedside diagnosis during an objective structured clinical examination (OSCE)

Background Many standardized patient (SP) encounters employ SPs without physical findings and, thus, assess physical examination technique. The relationship between technique, accurate bedside diagnosis, and global competence in physical examination remains unclear. Method Twenty-eight internists undertook a cardiac physical examination objective structured clinical examination, using three modalities: real cardiac patients (RP), “normal” SPs combined with related cardiac audio–video simulations, and a cardiology patient simulator (CPS). Two examiners assessed physical examination technique and global bedside competence. Accuracy of cardiac diagnosis was scored separately. Results The correlation coefficients between participants’ physical examination technique and diagnostic accuracy were 0.39 for RP (P < .05), 0.29 for SP, and 0.30 for CPS. Patient modality impacted the relative weighting of technique and diagnostic accuracy in the determination of global competence. Conclusions Assessments of physical examination competence should evaluate both technique and diagnostic accuracy. Patient modality affects the relative contributions of each outcome towards a global rating.

Development and validation of a cardiac findings checklist for use with simulator-based assessments of cardiac physical examination competence.

Introduction: Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist. Methods: A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance. Results: Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station. Conclusion: Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

Does physical examination competence correlate with bedside diagnostic acumen? An observational study.

Aim: To examine the relationship between a physicians ability to examine a standardized patient (SP) and their ability to correctly identify related clinical findings created with simulation technology. Method: The authors conducted an observational study of 347 candidates during a Canadian national specialty examination at the end of post-graduate internal medicine training. Stations were created that combined physical examination of an SP with evaluation of a related audio-video simulation of a patient abnormality, in the domains of cardiology and neurology. Examiners evaluated a candidates competence at performing a physical examination of an SP and their accuracy in diagnosing a related audio-video simulation. Results: For the cardiology stations, the correlation between the physical examination scores and recognition of simulation abnormalities was 0.31 (p < 0.01). For the neurology stations, the correlation was 0.27 (p < 0.01). Addition of the simulations identified 18% of 197 passing candidates on the cardiology stations and 17% of 240 passing candidates on the neurology stations who were competent in their physical examination technique but did not achieve the passing score for diagnostic skills. Conclusions: Assessments incorporating SPs without physical findings may need to include other methodologies to assess bedside diagnostic acumen.

Diffuse abdominal gallium uptake

A 62-YEAR-OLD white male presented with a 6-month history of progressive 50-1b weight loss in association with diffuse upper abdominal tightness and discomfort. The only additional relevant history was that of exposure to asbestos 20 years ago; the patient also was known to have pleural plaques on chest x-ray. On physical examination, the patient was emaciated and afebrile, and no abdominal masses could be palpated. Laboratory tests showed anemia, thrombocytosis, decreased serum albumin and proteins, and a low serum B~2 and folate. Barium studies of the stomach and small and large bowel were normal. Ultrasound demonstrated a 3.8-cm lobulated mass within the liver and porta hepatis. A C T scan of the liver and remainder of the abdomen and pelvis was reported as normal. A hepatic angiogram failed to confirm the presence of a mass lesion in the liver. Because of the abdominal symptoms and the inconclusive results of ultrasound and CT, a gallium 67 citrate scan was requested, which demonstrated diffuse accumulation of activity throughout the abdomen and pelvis (Figs 1 and 2). There were no clearly identifiable loops of bowel, and the distribution of the radiogallium was the same at 24 and 48 hours in spite of laxatives and cleansing enemas. A diffuse neoplastic or chronic inflammatory process was suspected, and the patient subsequently underwent a laparotomy. This revealed massive carcinomatosis of the whole abdominal cavity obliterating virtually all peritoneal spaces and covering all peritoneal organs. Peritoneal biopsies were taken and have subsequently shown a mesothelioma. The most common cause of generalized increased gallium activity in the abdomen is

Moxifloxacin Use and Its Association on the Diagnosis of Pulmonary Tuberculosis in An Inner City Emergency Department.

BACKGROUND Moxifloxacin can be used in the treatment of tuberculosis, its effect on the diagnosis and treatment of pulmonary tuberculosis is not well characterized. OBJECTIVE To identify patients from the St. Pauls Hospital emergency department (ED) treated with moxifloxacin who also had sputum sent for investigation of possible tuberculosis and the impact on sensitivity of acid-fast bacilli (AFB) smears and time to initiation of tuberculosis treatment. METHODS We conducted a retrospective single-center cohort study on patients that were prescribed moxifloxacin in the ED during a 5-year period and had samples collected for pulmonary tuberculosis. All AFB samples obtained throughout the hospital in patients not exposed to moxifloxacin during the same time period were also examined. RESULTS Two-thousand six hundred and seventy-three patients who were admitted to St. Pauls Hospital through the ED received moxifloxacin during the study period. 273 (10.2%) of these patients were subsequently investigated for tuberculosis, with 9 positive cases of Mycobacterium tuberculosis (3.3%). One-thousand three hundred and sixty-nine patients not exposed to moxifloxacin were screened for tuberculosis with 33 active cases (2.4%). The false-negative rate for AFB smears in the exposed group was 85.2% vs. 53.8% in the unexposed group (relative risk of false-negative AFB = 1.55; 95% CI 1.24-2.03). Time to initiation of anti-tuberculosis therapy was significantly delayed in the exposed group, with median time to initiation of 14 days vs. 2 days (p = 0.013). CONCLUSIONS Exposure to moxifloxacin is associated with significantly increased rates of false-negative AFB smears and was associated with a significant delay in the initiation of anti-tuberculosis therapy.