Faculty Bibliography

Learning Objective #1: Explain how the hemodynamics of pericarditis can produce the clinical manifestations (signs and symptoms) seen in pericarditis. Learning Objective #2: Categorize the progressive electrocardiogram stages consistent with pericarditis. CASE: A 70 year-old female with hypertension and diabetes presented to the hospital with a one-day history of non-positional, left-sided chest pain associated with shortness of breath and subjective fevers. Physical exam and vitals were unremarkable. Work up included three negative troponins, EKG in normal sinus rhythm (Figure 1), and D-Dimer of 1100 ng/mL. CTA chest revealed a right subsegmental middle lobe filling defect consistent with pulmonary embolism for which patient was initiated on anticoagulation with resolution of chest pain. Approximately 24 hours after initial presentation the patient reported a new chest pain described as sharp, pleuritic, worse with lying flat and improved with sitting forward. Vitals revealed fever to 100. 5 F. Repeat EKG demonstrated diffuse ST elevations (Figure 2). Labs showed a negative troponin and ESR and CRP at 63 mm/hr and > 190 mg/L, respectively. Echo showed a trace pericardial effusion, normal ejection fraction, and no evidence of right heart strain. The patient was diagnosed with acute pericarditis and initiated on colchi-cine and NSAIDs with resolution of symptoms. Common causes for pericarditis including viral URI, TB, connective tissue disorders, and malignancy were ruled out with a negative review of symptoms, subsequent laboratory analysis and additional history from the patient's primary care provider. Given the unlikeliness of other etiologies, her acute pericarditis was felt to be secondary to her pulmonary embolism. IMPACT/DISCUSSION: Between 80-90% of pericarditis cases are idiopathic or presumed to be of viral etiology. Given the relatively benign course of the majority of causes of pericarditis a definitive work up is often not performed. However, this case highlights an additional "can't miss" cause of pericarditis-pulmonary embolism. Although rare, post-pulmonary embolism pericarditis is a well-documented phenomenon associated with elevated ESR, CRP, and low-grade fevers as in this patient's presentation. Proposed mechanisms include increased friction of an enlarged pulmonary artery and right ventricle against the pericardium and an immunologic response, similar to Dressler syndrome.
Conclusion(s): Despite being a known cause of pericarditis, pulmonary embolism is frequently overlooked or completely excluded from clinicians' differentials. Although the exact cause of pericarditis is often unknown, in patients with idiopathic pericarditis with no infectious signs, pulmonary embolism should always be considered based on history and physical exam findings to avoid missing a "can't miss" diagnosis

Needs and Objectives: Residents often fail to escalate care due to uncertainty resulting in delays of care and possible harm. Multiple studies have identified trainee self-reported barriers to escalation, but none have evaluated the impact of a multi-faceted curriculum aimed to reduce perceived escalation barriers. Our objective was to identify, address, and improve residents' perceived barriers to escalation. Setting and Participants: This study was conducted at an urban, academic medical center within the Internal Medicine residency program over one year. Description: A baseline Likert-scale survey categorized residents' perceived escalation issues. A four-lecture curriculum about common causes of patient deterioration and an objective structured clinical examination (OSCE) were created to address the found issues. In the OSCE PGY1 residents first entered the room with the option to escalate to a PGY2 or a PGY3 acting as the rapid response team (RRT) leader with an attending physician creating pushback/intimidation throughout. Debrief focused on both knowledge and collapsing hierarchies. A retrospective pre-post Likert-scale survey evaluated for change in resident attitudes after the interventions in three areas: Communication Skills, Awareness/proper knowledge base of the problem, and Self-assertiveness/handling intimidation from superiors. Evaluation: A total of 54/77 of IM residents completed the baseline survey. Only the PGY1,2 received intervention, and 34/54 completed the pre-post survey. Baseline survey Results Identified barriers included feeling intimidated when escalating (33% rated this as at least a fairly common problem), feeling pushback when escalating (31%), worrying others will view them negatively (10%), gaps in knowledge (12%)/awareness (32%), and misunderstanding severity of the problem (11%). Retrospective Pre-Post Results Paired T-tests were conducted on pre and post summary scores. All post-intervention summary scores rose compared to pre scores, and the Awareness scale approached significance (p=.08). The seven most targeted questions were examined using Wilcoxin Sign tests. Three questions showed statistically significant improvement: improved frequency of being told information needing escalation (p=0.004), less feelings of self-blame (p=0.035), less limitation of autonomy with mandatory RRTs (p=0.009). The other four questions including comfort with, worries about repercussions for, feeling intimidated about, and viewing self negatively if needing to escalate showed change in the positive direction without reaching statistical significance. Discussion/Reflection/Lessons Learned: This study demonstrates the implementation of a year-long curriculum and OSCE can lead to significant change in resident attitudes about perceived escalation barriers. It is likely this study was hindered by a small sample size due to the number of near-significant findings. Future studies are needed involving larger numbers of residents and looking at changes in RRT instances and outcomes to determine if clinical change accompanies the found perceptual change

PURPOSE: The purpose of this study was to look at the functional outcomes of arthroscopic repair of anterosuperior rotator cuff tears with open biceps tenodesis when indicated. METHODS: We retrospectively reviewed the cases of 17 patients (17 shoulders) who underwent arthroscopic repair of anterosuperior tears with concurrent open biceps tenodesis. At final follow-up, an independent examiner collected shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Objective information including range of motion and strength was also collected. RESULTS: Of the 17 patients, 13 (77%) were available for evaluation with a mean age of 52.7 +/- 7.0 years at the time of surgery (range, 32 to 65 years) and a mean follow-up of 34.6 +/- 10.5 months (range, 14 to 52 months). The mean American Shoulder and Elbow Surgeons score improved from 50.6 +/- 18.9 (range, 13 to 75) preoperatively to 89.6 +/- 7.5 (range, 50 to 100) postoperatively (P < .001). There was a significant increase in the mean Simple Shoulder Test score from 6.1 +/- 3.2 preoperatively (range, 0 to 10) to 10.7 +/- 1.2 (range, 9 to 12) postoperatively (P < .001). Of the 13 patients, 11 (85%) patients were "delighted" with the surgical outcome and the other 2 patients (15%) were "pleased." CONCLUSIONS: Arthroscopic repair of anterosuperior rotator cuff tears with open biceps tenodesis provides a significant improvement in pain relief and shoulder function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Injuries to the pectoralis major muscle are relatively infrequent but result in pain, weakness, and deformity of the upper extremity. The usual injury mechanism is during eccentric shortening of the pectoralis major under heavy load, such as when performing a bench press exercise. The ability to detect and treat a pectoralis major rupture is important for both the clinician and the patient and is aided with knowledge of the anatomy, the clinical findings, and results of nonoperative and operative care. It is important to understand the physical demands and desires of the patient as well as to understand the outcomes of both nonoperative and operative care to make an informed decision regarding optimal treatment. This article highlights the importance of the clinical examination in identifying the injury, examines various surgical techniques to repair the rupture, and reports on potential complication and reinjury rates.

A biceps tenodesis is a common surgical procedure that is often carried out in conjunction with other surgical shoulder repairs to relieve biceps tendonitis. This case presents a 50-year-old woman who suffered a humerus fracture following an open keyhole biceps tenodesis. The potential reasons for the fracture as well as a brief analysis of the technique itself are presented. To our knowledge, this is the first case report of a humerus fracture following keyhole biceps tenodesis in the English-language literature.

BACKGROUND: Tenodesis of the long head of the biceps tendon is a common procedure used to alleviate pain caused by instability or inflammation of the tendon. The purpose of this study is to report on the incidence and types of complications following an open subpectoral biceps tenodesis (OBT) procedure. HYPOTHESIS: Our hypothesis was that the rate of adverse events after OBT was low. METHODS: From January 2005 to December 2007, all patients that underwent an OBT with bioabsorbable interference screw fixation performed by 1 of the 2 senior authors for biceps tendonitis were reviewed, excluding tenotomy, revision cases, or fixation methods other than interference screw fixation. RESULTS: Over a 3-year period, 7 of 353 patients had complications with OBT with an incidence of 2.0%. The mean age of patients with complications was 44.67 years, with 57.1% males and 42.9% females. There were 2 patients (0.57%) with persistent bicipital pain. Two patients (0.57%) had failure of fixation resulting in a Popeye deformity. One patient (0.28%) presented with a deep postoperative wound infections that necessitated irrigation and debridement with intravenous antibiotics. Another patient (0.28%) developed a musculotaneous neuropathy. Another patient (0.28%) developed reflex sympathetic dystrophy necessitating pain management and stellate ganglion block. CONCLUSION: The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2.0%.