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BACKGROUND AND OBJECTIVES: Hospice and palliative medicine (HPM) is one of three Accreditation Council for Graduate Medical Education accredited clinical subspecialties available to family medicine graduates for fellowship training. Despite this, training is not currently a curriculum requirement. We have pioneered a required 4-week palliative medicine rotation into the curriculum. METHODS: Twenty-eight residents who completed the palliative medicine rotation across four classes were surveyed to assess how the rotation improved their level of comfort with providing end-of-life (EOL) care and to demonstrate the need of formal palliative medicine training. Wilcoxon signed ranks test was used to detect statistical differences between the mean level of comfort of residents pre- and postrotation with providing the basic skills needed to practice HPM. RESULTS: The HPM rotation significantly improved the residents' level of comfort in all areas of measured EOL care (P<0.001). All residents surveyed strongly agreed that the rotation was valuable to their future and 100% of residents strongly agreed that an HPM rotation should be required. CONCLUSIONS: Formal HPM training should be a required component in residency education and considerations should be given to the 4-week format. This rotation provides a model that can be implemented in other residency programs nationally. Implementation of this rotation may help close the enormous gap of patients not receiving quality EOL care.
Asunto(s)
Acreditación , Competencia Clínica/normas , Medicina Familiar y Comunitaria/educación , Internado y Residencia , Medicina Paliativa/educación , Curriculum , Educación de Postgrado en Medicina , Cuidados Paliativos al Final de la Vida , Humanos , Medicina Paliativa/normasRESUMEN
Background. Takotsubo cardiomyopathy is defined as a transient left ventricular dysfunction, usually accompanied by electrocardiographic changes. The literature documents only two other cases of Takotsubo cardiomyopathy in the latter setting. Methods. A 78-year-old female presented to the ED with severe shortness of breath, hypertension, and tachycardia. On physical exam, heart sounds (S1 and S2) were regular and wheezing was noticed bilaterally. We found laboratory results with a WBC of 20.0 (103/µL), troponin of 16.52 ng/mL, CK-mb of 70.6%, and BNP of 177 pg/mL. The patient was intubated for acute hypoxemic respiratory failure. A chest X-ray revealed a large left-sided tension pneumothorax. Initial echocardiogram showed apical ballooning with a LVEF of 10-15%. A cardiac angiography revealed normal coronary arteries with no coronary disease. After supportive treatment, the patient's condition improved with a subsequent echocardiogram showing a LVEF of 60%. Conclusion. The patient was found to have Takotsubo cardiomyopathy in the setting of a tension pneumothorax. The exact mechanisms of ventricular dysfunction have not been clarified. However, multivessel coronary spasm or catecholamine cardiotoxicity has been suggested to have a causative role. We suggest that, in our patient, left ventricular dysfunction was induced by the latter mechanism related to the stress associated with acute pneumothorax.
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An obturator hernia is an infrequent but significant cause of intestinal obstruction. The incidence of obturator hernias is between 0.05 and 1.4% of all hernias. The mortality rate can be as high as 70% when acutely incarcerated due to the difficulty in diagnosis and delay in surgical treatment Three progressive stages of obturator herniation have been classified and can be one of three different varieties depending on the pathway the herniated sac follows. Knowledge of the anatomy and pathogenesis of obturator herniation is essential in diagnosis and treatment. The most common clinical presentation is intestinal obstruction (90%) and this is often seen in elderly, emaciated, multiparous women with predisposing conditions. Other classic signs, though not always present include obturator neuralgia, the Howship-Romberg sign and the Hannington-Kiff sign. Computed tomography scan is the most favored diagnostic imaging method. The abdominal surgical approach is most preferred when a diagnosis is uncertain and laparoscopy should be employed in elective early surgeries. This aim of this article is to review the diagnosis and treatment of obturator hernia by describing the anatomy, embryology, clinical presentation, diagnosis, and management currently in use. Increased awareness and proper management of this condition will result in decreased morbidity and mortality.