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 hermsii. 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.

By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.

BACKGROUND:Efficacy of simulators in teaching central venous catheterization (CVC) in an internal medicine residency program is unknown.OBJECTIVE:To determine whether or not learning CVC on simulators is associated with improvement in performance of CVC, knowledge about the procedure, and self‐reported confidence.METHODS:All consenting first‐year internal medicine residents who completed training in CVC on simulators were included. Participants were evaluated pre‐ and post‐training by video‐recorded CVC insertion and multiple‐choice knowledge assessments. Procedural technique was rated in a blinded fashion by two independent adjudicators. Knowledge retention and self‐reported confidence were reassessed at 18 months.MEASUREMENTS:Primary outcome of CVC performance was assessed based on global rating score (minimum 1, maximum 5). Secondary measures include checklist score (out of ten), knowledge score and self‐reported confidence (6‐point Likert scale ranging from “none” to “complete”).RESULTS:Median global rating scores in 30 participants increased from 3.5 (IQR = 3‐4) to 4.5 (IQR = 4‐4.5) (P < 0.001). Checklist score increased from 9 (IQR = 6‐9.5) to 9.5 (IQR = 9‐9.5) (P < 0.001). Knowledge score increased from 65.7 ± 11.9% to 81.2 ± 10.7% (P < 0.001). Confidence increased from 3 (“moderate”, IQR = 2‐3) to 4 (“good”, IQR=3‐4) (P < 0.001). Sixteen participants completed the retention tests. Improvement in knowledge score and confidence at 18 months was retained compared with baseline (P = 0.002 and P < 0.0001 respectively).CONCLUSIONS:Use of simulators in teaching CVC in an internal medicine residency program results in improved procedural performance, knowledge, and self‐reported confidence. Improvement in knowledge and confidence was retained at 18 months. Journal of Hospital Medicine 2009;4:410–416. © 2009 Society of Hospital Medicine.

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SP's 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 Canada's 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.

Age over 70 years, comorbid illness and CDAD recurrence are significant risk factors for severe disease and a poor outcome in patients admitted to hospital for CDAD.

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We report the case of a 52-year-old male patient with recurrent thrombosis from ‘primary antiphospholipid syndrome’ who developed renal microangiopathy. Despite anticoagulant therapy with coumadin, serum creatinine progressively increased from 398 to 592 μmol/l and platelets decreased to 43,000. The patient responded to high-dose methylprednisolone and aspirin and the renal function improved. A review of the literature disclosed 4 other cases of association between primary antiphospholipid syndrome and renal microangiopathy. The clinical characteristics of these cases are discussed.