BACKGROUND: Many residency programs have struggled to meaningfully meet the ACGME quality improvement (QI) requirements. Similarly, our residents were receiving limited QI education, and their longitudinal projects were ineffective. AIM: Create an integrated didactic and experiential learning environment that equips residents to become leaders of QI. SETTING AND PARTICIPANTS: Internal medicine (IM) residency program of 45 residents in a large community hospital. PROGRAM DESCRIPTION: This curriculum included eight content areas. Games, real-life application, and project celebrations cultivated engagement. Sessions occurred during residents' 2-week outpatient rotations. Project development was standardized. PROGRAM EVALUATION: The QI Knowledge Application Tool-Revised (QIKAT-R) and separate surveys were used before and after the curriculum's implementation to evaluate resident QI knowledge and confidence, respectively. We also tracked QI scholarship and faculty engagement. Mean QIKAT-R scores improved significantly from 7.0 (SD 2.9) at baseline to 16.6 (SD 4.7) post-curriculum (n = 37 pairs, p = 0.043). Residents' adverse event reporting increased from 44% (19/43) at baseline to 90% (28/31) post-curriculum. Seven presentations were accepted for local, regional, and national conferences, compared with one presentation the preceding year. DISCUSSION: A QI curriculum can be successfully integrated in a B4 + 2^program.

Goals and Background: Using natural language processing to create a nonalcoholic fatty liver disease (NAFLD) cohort in primary care, we assessed advanced fibrosis risk with the Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Score (NFS) and evaluated risk score agreement. Materials and Methods:In this retrospective study of adults with radiographic evidence of hepatic steatosis, we calculated patientlevel FIB-4 and NFS scores and categorized them by fibrosis risk. Risk category and risk score agreement was analyzed using weighted κ, Pearson correlation, and Bland-Altman analysis. A multinomial logistic regression model evaluated associations between clinical variables and discrepant FIB-4 and NFS results.Results: Of the 767 patient cohorts, 71% had a FIB-4 or NFS score in the indeterminate-risk or high-risk category for fibrosis. Risk categories disagreed in 43%, and scores would have resulted in different clinical decisions in 30% of the sample. The weighted κ statistic for risk category agreement was 0.41 [95% confidence interval (CI): 0.36-0.46] and the Pearson correlation coefficient for log FIB-4 and NFS was 0.66 (95% CI: 0.62-0.70). The multinomial logistic regression analysis identified black race (odds ratio = 2.64, 95% CI: 1.84-3.78) and hemoglobin A1c (odds ratio = 1.37, 95% CI: 1.23-1.52) with higher odds of having an NFS risk category exceeding FIB-4. Conclusions:In a primary care NAFLD cohort, many patients had elevated FIB-4 and NFS risk scores and these risk categories were often in disagreement. The choice between FIB-4 and NFS for fibrosis risk assessment can impact clinical decision-making and may contribute to disparities of care.

Pyogenic liver abscess (PLA) is an important clinical entity to consider in a patient with fever and abdominal pain. Previously, the condition was difficult to diagnose and treat, but with the introduction of widely available and reliable imaging techniques, its diagnosis has become more straightforward. Although uncommon, PLA should especially be considered in the differential diagnosis for patients with specific predisposing conditions such as underlying biliary tract disease, whether as a result of chronic inflammatory disease or malignancy. The introduction of percutaneous drainage has revolutionized the management of PLA, and thus, this disease has become largely correctable.

Rocky Mountain spotted fever (RMSF), a tick-borne illness, can cause serious illness or death even in a healthy individual. Unfortunately, this illness can be difficult to diagnose as symptoms are nonspecific and oftentimes mimic benign viral illnesses. Delayed diagnosis can be detrimental as the timing of antibiotic administration is critical to prevent associated morbidity and mortality. A careful travel and social history can sometimes provide clues to make the diagnosis. Being aware of lesser-known objective findings such as hyponatremia, neurologic derangements, transaminitis, and thrombocytopenia may help raise suspicion for the disease. This is a case of a 72-year-old woman who presented with nonspecific symptoms and hyponatremia without known tick exposure. She was eventually diagnosed with RMSF. The timing of her presentation corresponded with a surge in COVID-19 infections throughout her area of residence, which further complicated her presentation and contributed to a delayed diagnosis.