Bhagra, Anjali

A growing number of patients and consumers are seeking integrative medicine (IM) approaches as a result of increasing complex medical needs and a greater emphasis on prevention and health promotion. Health-care professionals need to have knowledge of the evidence-based IM resources that are safe and available to patients. Medical institutions have acknowledged the need for education and training in various IM modalities and whole-health approaches in medical curricula. There is a strong need to develop and incorporate well-structured IM curricula across all levels of learning and practice within medicine. This article provides an example of the development, implementation, impact, and assessment of IM education curricula across all learner levels at a large academic medical center.

Background: In general, women report higher stress levels than men. High baseline anxiety, depression, and stress levels are associated with greater risk of cardiovascular diseases. Current evidence for efficacy of stress management interventions for women is limited. This study aimed at assessing the effect of a stress management and resiliency training (SMART) program for decreasing stress, anxiety, and depressive symptoms. Methods: Fifty moderately or severely stressed Women's Heart/Preventive Cardiology Clinic patients consented to the SMART intervention delivered online ( n = 36) or in-person ( n = 9). Primary outcome measures were the observed changes between baseline and at 12 weeks for the following psychometric tools: General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaires (PHQ-9), Perceived Stress Scale (PSS), and Brief Resiliency Scale (BRS). Results: Forty-five patients completed the study. We observed significant improvements in PSS and GAD-7, but not in PHQ-9 or BRS, after the SMART intervention. When assessing outcomes among those with depressive symptoms at baseline (PHQ-9 > 15), we observed significant changes in PSS, GAD-7, and PHQ-9. No differences between online and in-person program delivery methods were found (all p -values >0.05). Conclusions: Training exposure using the SMART program to decrease stress and anxiety in women seeking preventive cardiology services was feasible and similarly effective, whether delivered online or in a single in-person session. Impacts on depression and resilience likely require a more intensive approach. In the future, larger randomized clinical trials with additional training and longer follow-up are warranted.

EXECUTIVE SUMMARY We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. We recommend that using real‐time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation‐based practice, should be used to teach novices how to perform ultrasound‐guided paracentesis. We recommend that simulation‐based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasound‐ guided paracentesis. We recommend that competence in performing ultrasound‐guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Many hospitalists incorporate point‐of‐care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision‐making processes surrounding POCUS program management.

The notion that cardiovascular disease (CVD) primarily occurs in men is slowly disappearing. More women than men die of CVD every year, and when women survive, the burden and consequences are worse than in men. Markers of stress and other psychosocial factors have been associated with poor outcomes. Multiple studies have demonstrated sex-based differences in the vascular and endothelial responses to mental stress. Psychosocial stressors were also found to be independent risk factors for the development and progression of CVD. This review arises from accumulating evidence suggesting that psychological well-being may improve cardiac-related outcomes, independent of cardiac risk factors. Despite the fact that positive physician-patient engagement is likely to play a critical role in promoting positive psychological traits and healthy behaviors, current physician awareness and advocacy are rather suboptimal, despite active awareness campaigns such as the American Heart Association's Go Red for Women ® . There is a need to further study the role and management of stress as a CVD risk factor, especially in women, who are disproportionately affected.

Purpose of review Due to medical advances and an aging population, the number of cancer survivors continues to rise. Survivors often experience late and long-term sequelae of cancer and its treatment (e.g., fatigue, pain, fear of recurrence, and stress). As a result, some patients have utilized or expressed interest in integrative medicine (IM) modalities for prevention of recurrence, optimizing health, enhancing quality of life, and managing symptoms. The purpose of this review is to focus on research published during the past year that informs our understanding of the utility of IM for cancer survivors. Recent findings Physical activity, diet, dietary supplements, mind–body modalities, acupuncture, and massage therapy all may play a role in the management of the physical (e.g., fatigue and pain) and emotional (e.g., anxiety and fear) issues faced by cancer survivors. Summary IM therapies are appealing to and utilized by many cancer survivors and may reduce symptom burden. Clinicians who provide cancer survivorship care may improve patient care by understanding the evidence for and against their use.

A 57-year-old woman with diabetes mellitus type 1, status postcadaveric pancreas transplant alone 11 years ago, on chronic immunosuppression, and dialysis-dependent end-stage renal disease, presented with 2 months of progressive generalised weakness, lumbar back pain with right lower extremity radiculopathy and episodic symptomatic hypotension. Preliminary infectious disease work up was unremarkable. She was discharged following symptomatic improvement. She represented 3 days later with continued functional decline and leucocytosis. Chest X-ray demonstrated diffuse pulmonary nodules, confirmed on chest CT scan. CT-guided biopsy of a right upper lobe nodule was performed; studies confirmed Nocardia farcinica. Further imaging revealed bilateral white matter intracranial lesions, and extensive Nocardia-positive fluid collections in the right gluteal and vastus musculature, requiring periodic surgical debridement. She was treated with multiple antimicrobials, including trimethoprim-sulfamethoxazole, amoxicillin/clavulanate and moxifloxacin. She was discharged after a 6-month hospitalisation.

ABSTRACT Background Point-of-care ultrasound is a rapidly evolving component of internal medicine (IM) residency training. The optimal approach for teaching this skill remains unclear. Objective We sought to determine whether the addition of a longitudinal ultrasound curriculum to a stand-alone workshop for ultrasound training improved knowledge retention in IM residents. Methods We conducted an observational cohort study from July to December 2013. All postgraduate year (PGY)-1 IM residents attended an ultrasound workshop during orientation. Ability to identify static images of ascites, kidney, thyroid, pleural fluid, inferior vena cava, and internal jugular vein was assessed immediately after the workshop. An ultrasound curriculum, including morning report and ultrasound rounds, was initiated during the inpatient medicine rotation. PGY-1 residents were randomly assigned to participate in the longitudinal curriculum. Six months later, we conducted a follow-up survey with all PGY-1 residents. Results Forty-eight PGY-1 residents (67%) completed the postworkshop test and the 6-month follow-up test. Of these, 50% (24 of 48) had participated in the ultrasound curriculum. Residents not exposed to the curriculum showed a decline in the identification of ascites, pleural effusion, and internal jugular vein at 6 months (P < .05), whereas those who participated in the curriculum maintained their performance (P < .05). Conclusions Six months after exposure to a longitudinal ultrasound curriculum, residents were more likely to correctly identify ultrasound images of ascites, kidney, and pleural effusion. The addition of a longitudinal ultrasound curriculum may result in improved knowledge retention in IM residents.

A 23-year-old woman presented to the emergency department with severe occipital headache, nausea and fever. She was treated with intravenous antibiotics for suspected meningitis. After a brief period of response, her symptoms relapsed and remained refractory despite continuing intravenous antibiotics for 10 days leading to referral to our centre. Physical examination was significant for tender right cervical lymph node. Initial tests included pancytopenia, elevated C reactive protein, lactate dehydrogenase and unremarkable cerebrospinal fluid. Extensive infectious and rheumatology work-up was negative. Massive posterior cervical, axillary and inguinal lymphadenopathy was revealed on imaging. Excisional biopsy of the deep cervical lymph node showed histiocytic necrotising lymphadenitis suggesting a diagnosis of Kikuchi disease. Her course was complicated by acute renal failure. Her symptoms resolved in about a week with supportive treatment along with improvement in pancytopenia and renal function. She had two additional self-limited recurrences in the next 3 months and remains symptom free thereafter.

Introduction. We present a case of a sports injury. The initial presentation and clinical examination belied serious intra-abdominal injuries.Case Presentation. A 16-year-old male patient came to emergency department after a sports-related blunt abdominal injury. Though on clinical examination the injury did not seem to be serious, FAST revealed an obscured splenorenal window. The CT scan revealed a large left renal laceration and a splenic laceration that were managed with Cook coil embolization. Patient remained tachycardic though and had to undergo splenectomy, left nephrectomy, and a repair of left diaphragmatic rent. Patient had no complication and had normal renal function at 6-month followup.Conclusion. The case report indicates that management of blunt intra-abdominal injury is complicated and there is a role for minimally invasive procedures in management of certain patients. A great deal of caution is required in monitoring these patients, and surgical intervention is inevitable in deteriorating patients.