Whereas the definition of sepsis moves away from SIRS, SIRS-based criteria may still have clinical benefit as an easy-to-automate detection tool for all-cause clinical deterioration among medical inpatients.
A 63-year-old Puerto Rican male presented with penile swelling, discomfort, and difficulty urinating. On physical examination, the patient was noted to have a firm, nodular umbilical mass, initially thought to be an irreducible umbilical hernia (Fig. 1, Panels a and b). Abdominal computed tomography (CT) confirmed a 4-cm umbilical nodule (Fig. 2, Panel a), a 10-cm mass posterior to the bladder (Fig. 2, Panel b), and multiple additional masses in the inguinal canal, liver, and retroperitoneum. Biopsy of the umbilical nodule was consistent with malignant peritoneal mesothelioma.This umbilical lesion is a so-called Sister Mary Joseph (SMJ) nodule, indicative of underlying abdominal malignancy and poor prognosis. Named for Sister Mary Joseph , the first assistant for Dr. William Mayo at the Mayo Clinic, these lesions were often associated with advanced abdominal malignancies at the time of surgery. 1 SMJ nodules are seen in 1-3 % of all intra-abdominal and pelvic malignancies 2 and are metastases most commonly from primary tumors of the gastrointestinal and genitourinary tracts. 3 SMJ nodules may be the first and only sign of an underlying neoplasm in approximately 30 % of cases. 4 This patient ultimately elected to pursue treatment near family in Puerto Rico, and was discharged from our care.
Rotation schedules for residents must balance individual preferences, compliance with Accreditation Council for Graduate Medical Education guidelines, and institutional staffing requirements. Automation has the potential to improve the consistency and quality of schedules. We designed a novel rotation scheduling tool, the Automated Internal Medicine Scheduler (AIMS), and evaluated schedule quality and resident satisfaction and perceptions of fairness after implementation. We compared schedule uniformity, fulfillment of resident preferences, and conflicting shift assignments for the hand-made 2017–2018 schedule, and the AIMS-generated 2018–2019 schedule. Residents were surveyed in September 2018 to assess perception of schedule quality and fairness. With AIMS, 71/74 (96.0%) interns and 66/82 (80.5%) residents were assigned to their first-choice rotation, a significant increase from the 50/72 (69.4%) interns and 25/82 (30.5%) residents assigned their first-choice in the 2017–2018 academic year. AIMS also yielded significant improvements in the number of night shift/day shift conflicts at the time of rotation switches for interns, with a significant decrease to 0.3 conflicts per intern compared to 0.7 with the prior manual schedule. Twenty-two of 82 residents (27%) completed the survey, and average satisfaction and perception of fairness were 0.7 and 0.9 points higher on a 5-point Likert scale for the AIMS-generated schedule when compared to the non-AIMS schedule. There was no significant difference in the preference for assigned vacation blocks, or in variance for night or ICU rotations. Automated scheduling improved several metrics of schedule quality, as well as resident satisfaction. Future directions include evaluation of the tool in other residency programs and comparison with alternative scheduling algorithms.
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