BELLS PALSY AND HYPERTENSION SECONDARY TO DISCONTINUATION OF ANTIHYPERTENSIVE TREATMENT. S. Yakoob 1 , K. Barnard 1 , J. Haretos 1 ; 1 UPMC Shadyside, Pittsburgh, PA LEARNING OBJECTIVES: 1. Recognition of an association between facial nerve paralysis and accelerated hypertension.2. High dose corticosteroid therapy often prescribed for facial nerve palsy has serious consequences in hypertensive patients.3.Facial palsy resulting from severe hypertension may be distinguished from Bell's palsy by lack of pain and preservation of taste. CASE INFORMATION: An 84-year-old male who presented with a two-day history of rightside facial drooping, difficulty in chewing and inability to close his right eye. His past medical history is significant for hypertension controlled on quinapril and bisoprolol/HCTZ. Two days prior to the onset of symptoms, the patient had discontinued his medications. Physical examination was remarkable for a blood pressure of 190/96 and signs of right lower motor neuron facial nerve palsy. Diagnostic evaluation included CT scan of the brain that was negative for hemorrhage and a maxillofacial CT that showed thickening of paranasal sinuses. An EMG revealed decreased conduction over the right facial nerve.The patient's blood pressure was controlled by oral metoprolol and quinapril. High dose corticosteriod therapy was started and subsequently discontinued when the patient's blood pressure increased to 205/ 105 mm Hg. This case is similar to two other case reports in the literature of abrupt withdrawal of antihypertensive treatment resulting in an acute increase in the blood pressure and subsequent facial paralysis. DISCUSSION: LEARNING OBJECTIVES: To recognize toxic methemoglobinemia as a rare but potentially lethal complication of local anesthetics so that prompt diagnosis and treatment can be initiated. CASE INFORMATION: A 37 year old white female patient with negative past medical history, presented to our clinic with a complaint of epigastric pain and was scheduled for endoscopy. Benzocaine spray was administered topically in the oropharynx during endoscopy and the procedure was uneventful, but approximately 10 minutes after completion, the patient oxygen (O2) saturation began to fall and she became cyanotic despite administration of 100% O2 via a non-rebreathing mask. Intravenous Narcan and Flumazenil were administered without improvement. The O2 saturation continued to fall with the lowest level obtained was 81%. Arterial blood gas analysis showed PaO2 of 367mmHg and PaCO2 of 23mmHg so methemoglobinemia was suspected. Methemoglobin level was sent and later showed a level of 37.6%. Methylene blue was given intravenously, the patient started to improve gradually and within 20 minutes O2 saturation rose to 96% and cyanosis was resolved. The patient was transferred to intensive care unit, where her O2 saturation rose to 99% and methemoglobin level dropped to 1% . The remainder of hospital stay was unremarkable. DISCUSSION: Methemoglobinemia is a rare complication of local anesthetics that has been reported with procedures including bronchoscopy, endoscopy, tracheal intubation and dental procedures. Methemoglobin is formed normally in the body because small amount of ferrous iron in hemoglobin is continuously oxidized to ferric iron which can't carry oxygen or carbon dioxide. Red cell defense against accumulated methemoglobin is methemoglobin NADH reductase which is responsible for 99% of in vivo reduction of methemoglobin to form normal hemoglobin. Methemoglobinemia has both acquired and congenital forms. Acquired methemoglobinemia can be associated with toxic shock or can result from ingestion or skin exposure to oxidizing agents which oxidizes hemoglobin to methemoglobin. Although cyanosis may appear with levels as low as 15%, acquired methemoglobinemia is rarely symptomatic when levels are below 20%. Lethargy, dizziness, lightheadedness and anxiety are present between levels of 30 ± 40%. Coma, seizures, arrhythmias and acidosis could be caused with levels of50 ± 70%. Levels more than 70% are fatal. We were first alerted to the presence of methemoglobinemia by decrease in O2 saturation inspite of normal O2 tension (PaO2) which is almost a universal finding. Methylene blue given intravenously 1 ± 2mg/Kg over 5 minutes acts a cofactor in the transfer of an electron from NADPH to ferric iron and methemoglobinemia should resolve within one hour, if not the dose may be repeated. LEARNING OBJECTIVES: 1) To consider dural venous sinus thrombosis in the differential diagnosis of puerperal psychoneurotic symptoms. 2) Initiating management as soon as the diagnosis is recognized can cause major decrease in morbidity and mortality. CASE INFORMATION: 21 year old female patient with no significant past medical history, had normal vaginal delivery 3 weeks prior to admission, presented with depressed mood, poor concentration and headache. Physical examination was negative. Brain computed tomography scan (CT) was done and found to be negative so the patient was diagnosed as a case of postpartum depression and was admitted to psychiatric floor. One day after admission patient became drowsy and her level of consciousness dropped. Head and neck CT scan with contrast showed thrombosis of the right jugular vein. Magnetic resonance image (MRI), magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) were done and showed thrombosis of the superior sagittal sinus, right transverse and deep venous sinus. Patient developed respiratory distress and was intubated and was started immediately on Intravenous Heparin. After few days she was extubated and transferred to medical floor where she was switched to oral anticoagulants. Patient depressive symptoms improved and her mood returned back to normal. DISCUSSION: Dural venous sinus thrombosis is an unusual disorder most often attributed to hematological disorders, oral contraceptives, association with pregnancy and puerperium, Bechets disease, cardiac disease and post operative conditions. Patients usually present with nonspecific symptoms as headache, seizures, hemiplegia or other neurological symptoms. Brain swelling and bilateral involvement can produce lethargy or stupor early in the course. Diagnosis depend on recognition of impaired venous flow. On contrast CT scan a nonenhanced triangular area surrounded by contrast in the posterior sinus (the empty delta sign), should suggest the diagnosis. Cerebral angiography has been considered the gold standard for the diagnosis but MRI, MRA and MRV are becoming the diagnostic studies of choice.Management increasingly relies on the use of anticoagulation even in the presence of superimposed parenchymal hemorrhage. Venous occlusions are serios and often fatal but acute anticoagulation started as soon as the diagnosis recognized appears to lessen substantially the morbidity and mortality of the condition. Nonanticoagulated venous sinus thrombosis that is not complicated by infection carries a mortality rate of 25 to 40% . Uncontrolled series suggest that early heparin treatment can reduce mortality by more than a half. OBJECTIVES: Reflective practice may enable physicians to become more competent and successful practitioners. This technique, however, is usually developed at the faculty level. The objective of this workshop is to begin to develop this skill at an earlier level. Students may then begin to utilize this skill for success at the student/resident level as well as honing this skill for use when at the faculty level, for both clinical practice and teaching. METHODS: Students will be given a brief (approximately 1 1/2 hour)skill session in the use of reflective practice. Intervention outcome will be assessed using the following:Pre/post test for knowledge, skills and attitudes regarding reflective practice.Randomization of the same class of students (Class of 2005)À 1/2 to intervention, 1/2 no intervention. Each group will then be given a reflective practice questionnaire following an OSCE exercise, to assess utilization of the skill. OBJECTIVES: The UCSF Division of General Internal Medicine (DGIM) faculty development program trains general internists to be effective teachers in primary care settings that serve a diverse patient population. During the first year of our program, we recruited general internists from community based health centers and faculty of the DGIM at UCSF. We developed and taught a 9-month long curriculum with six core content areas: teaching skills, evidence based medicine, cultural competency/caring for vulnerable patients, psychosocial medicine, population medicine, and leadership. Sessions were 3.5 hours long, two afternoons per month. METHODS: Prior to implementing our program we conducted a baseline needs assessment among trainees. An external evaluator met with the trainees during and at the end of the year to elicit feedback and to assess if the program was meeting its' objectives and the trainee's learning goals. RESULTS: Twelve trainees, 5 from under-represented minority groups, participated in the program last year. The evaluation concluded that the most valued aspect of the program for the trainees was the opportunity to learn and practice new teaching skills. The trainees also expressed interest in developing a tangible product, such as a new curriculum, at the completion of the program. RESULTS: Primary care physicians in the SF Bay Area have adequate access to new medical knowledge, but have limited opportunities to learn and refine new teaching skills. Now in year 2, the program has been modified to put greater emphasis on learning and practicing teaching skills, and less time is devoted to teaching the trainees new medical knowledge. Trainees are now required to develop a project, with the guidance of a program mentor, that is relevant to their own teaching setting. The faculty development program has enabled community and academically based general internists to form a common bond around teaching. METHODS: Instructional methods supporting individualized learning plans were enhanced by yearlong, on-site, one-on-one educational support from faculty development specialists. Curriculum has evolved to address the changing medical education environment. The program was examined within grant objectives, historical records, and archival data obtained through written surveys and focus groups. RESULTS: Focus groups and survey results have tentatively identified that the one-on-one consultation enhanced the 59 participants' ability to provide curriculum instruction within SCS member hospitals. 88% of graduates continue to teach in SCS institutions, using skills obtained through the program. 33% of the participants have received teaching awards with two winning national poster awards. 95% of the participants have remained in primary care. Some graduates have moved to higher positions within medical education. CONCLUSION: Developing part-time, community-based faculty is a multi-faceted endeavor. Faculty are challenged between providing service versus training others. The focus of providing a yearlong stipend supported program with one-on-one consultation support by specialists has proven to be a successful model in attracting and developing part-time, community-based faculty. OBJECTIVES: Primary care physicians are challenged to be clinically productive and effective teachers. A critical review of the literature revealed limited evidence regarding effectiveness of four often cited teaching methods: 1-2 focal teaching points; priming; teaching in the patient's presence [TIPP] ; and feedback. To address this gap seven experienced clinician educator [CEs] faculty (4 general internists; 3 pediatricians), participated in a faculty development project to evaluate the effectiveness of the four selected clinical teaching methods. METHODS: During monthly faculty development sessions, CEs were trained on the teaching methods using multiple strategies including simulations and written exercises. Each CE recorded use of these methods over a 10-month period on a Palm Pilot(tm) using a specially designed form. Baseline (July 1997 ± June 1998) and study period clinical teaching evaluation ratings for CEs (treatment) and non-participating faculty in their specialties (control) were compared using ANOVA. RESULTS: CEs reported using all targeted teaching methods > 50% of time during recorded teaching sessions (N=1,176 sessions) with use of priming and feedback increasing over baseline while use of the other two methods remained constant. CEs reported that the teaching methods focused both the learner and the clinical teacher, making subsequent encounters more productive and efficient. CEs teaching evaluations were significantly higher (p < .001) on three items during the study period while control group's ratings showed no change (i.e., responded to student initiated learning issues; emphasized comprehension of concepts; instructor had sufficient data to assess learner performance). During the study period, two CEs were first time recipients of major department teaching awards with three CEs receiving highly competitive, college-wide teaching awards one-year post study period. CONCLUSION: Experienced CEs who participate in a faculty development program can improve their clinical teaching ratings using four literature-based clinical teaching methods. Recognition by learners and peers of the CEs educational excellence through awards was an unanticipated outcome. OBJECTIVES: The population of older persons is rapidly rising in developed countries like Japan. Oldest old patients aged 90-year-old and more had occasionally utilized acute care hospital emergency department in recent years. To our knowledge, there were no study evaluating clinical reasons and outcomes of these highly aged population. METHODS: To determine the short-term outcomes and predictors of outcome, we reviewed medical records of elderly patient aged over 90-year-old visiting emergency department in Okinawa Chubu Hospital, acute care community hospital in rural Okinawa, Japan, in 1999. RESULTS: Three hundred seventy one patients (95 men, 276 women: mean age 92.9 years old) were studied. Five common chief complaints were fever (65 cases),shortness of breath (46), consciousness disturbances (33), leg pain (29),and nausea or vomiting (21). Pulmonary diseases (94) were the commonest category of disorders, followed by orthopaedic diseases (43) and gastroenterologic diseases (42). Only 42(11% ) patients were dead during hospitalization following admission from emergency department except for 14cardiopulmonary arrests at arrival. In multiple logistic regression analysis, cognitive dysfunction was only significant predictor for short-term mortality. CONCLUSION: Majority of oldest old patients had survived to discharge following emergency department admission. Cognitive function was important in terms of survival prediction.