Background Resident dissatisfaction in ambulatory care training has prompted the need for new scheduling models that support a positive learning climate. Intervention We instituted a 3∶1 scheduling model for postgraduate year (PGY)–2 and PGY-3 residents. We hypothesized this model would provide a more structured ambulatory educational atmosphere, better continuity of care, and more exposure to subspecialty outpatient medicine. This model would also eliminate conflict with inpatient duties and contribute to enhance residents′ satisfaction with ambulatory medicine and their ambulatory education experience. The model used weeklong ambulatory blocks every fourth week, consisting of morning continuity clinic and afternoon subspecialty clinics. The PGY-1 residents maintained a traditional schedule. Results Residents were surveyed regarding their ambulatory experience, with an overall response rate of 73 of 80 (91%). The PGY-2 and PGY-3 responses were analyzed descriptively and compared with PGY-1 responses. Residents reported that the 3∶1 model positively affected their satisfaction with residency training in general, their satisfaction with outpatient/primary care training, and their outpatient/clinic educational experience. Residents in the 3∶1 model perceived improvements in continuity of care and in the quality of care they provided for patients. The experience in ambulatory subspecialty training was positive. Conclusions A 3∶1 scheduling model appears to mitigate some of the conflict between inpatient and outpatient duties. Residents agreed the new model promoted an improved ambulatory experience.

Background Antitachycardia pacing (ATP) provides safe and painless termination of reentrant ventricular arrhythmias in patients with implantable cardioverter defibrillator (ICDs), improving their quality of life. Established predictors of ATP responsiveness are not well known; only longer ventricular tachycardia (VT) cycle length and higher ejection fraction have been found to predict ATP success. Objective To investigate clinical and ECG predictors of ATP response in ICD patients with monomorphic VT. Methods The ICD clinic database was searched for monomorphic VT events requiring ICD therapy in patients with ischemic or non‐ischemic cardiomyopathy. Each patient's first ICD encounter for VT was assessed. Patient demographics, clinical characteristics, VT rate, and ATP responsiveness (always, sometimes, and never successful) were recorded. An ECG was analyzed for QRS morphology and duration. Data was assessed for predictors of ATP responsiveness. Results In 527 patients, characteristics associated with always successful ATP included ACE‐I/ARB therapy and slower VT rate (never successful ATP 197 ± 28 bpm, sometimes successful ATP 190 ± 27 bpm, always successful ATP 183 ± 22 bpm, P < .0001). Secondary prevention indication, amiodarone therapy, and longer QRS duration were associated with ATP failure. After multivariate analysis, only faster VT rate and amiodarone therapy were predictive of ATP failure. Conclusions Neither QRS morphology nor duration was predictive of ATP success. Slower VT rate was predictive of repeated ATP responsiveness. Amiodarone therapy, which is known to increase VT cycle length, interestingly was associated with ATP failure for unclear reasons. More individualized and possibly more aggressive ATP programming may be warranted in patients on amiodarone.

We present a 66-year-old woman with 2 months of visual hallucinations, unintentional weight loss, and short-term memory decline, whose clinical presentation and EEG supported a diagnosis of limbic encephalitis. Subsequent evaluation for a paraneoplastic etiology revealed a renal mass, which was resected and identified as clear cell renal carcinoma. The patient's clinical condition improved after resection of the mass. When patients present with incongruous subacute neuropsychiatric symptoms, clinicians should be mindful of paraneoplastic neurological disorders, as early diagnosis and treatment of malignancy may lead to symptomatic improvement. CASE DESCRIPTIONA 66-year-old woman presented with 2 months of new visual hallucinations. She initially saw spiders on the walls; at the time of her presentation, however, she was having more vivid hallucinations, including seeing known deceased people harm her neighbors. While these visions were disturbing to her, she recognized that they were hallucinations and did not respond to them. Over the same period, her family also noticed shortterm memory decline and an unintentional weight loss of 20 pounds. Her review of systems was otherwise normal, including a lack of symptoms suggestive of depression, and she had no medical, psychiatric, or relevant family history. She did not take medicines and denied use of tobacco, alcohol, and illicit drugs.On physical examination, the patient was hemodynamically stable and had a normal cardiovascular, respiratory, abdominal, and pulmonary examination. Detailed neurological examination revealed no focal neurological deficits, including normal cranial nerves, intact and symmetric strength throughout, normal reflexes, no nystagmus, intact finger-to-nose testing, normal gait, and no dysdiadochokinesia with rapid alternating movement. She performed poorly on the Montreal Cognitive Assessment 1 , having particular difficulty with visuospatial skills, naming, and both immediate and delayed recall. Comprehensive laboratory assessment was performed and revealed normal urinalysis, complete blood count, basic metabolic panel, hepatic function panel, thyroid-stimulating hormone, free thyroxine, ammonia, folate, and vitamin B12. HIV testing and urine toxicology screen were negative. Cerebrospinal fluid (CSF) was colorless, with only one white blood cell (monocyte), one erythrocyte, glucose level of 65 mg/dL (normal range, 40-85 mg/dL), and protein level of 43 mg/dL (normal range, 15-45 mg/dL). CSF was negative for herpes simplex virus via PCR, fungal staining, and New York State Viral Encephalitis panel. CSF cytology was negative, and CSF protein electrophoresis did not identify any oligoclonal bands. Serum electrophoresis detected a distinct monoclonal band in the gamma region, but immunofixation was not performed. MRI of the brain, with and without contrast, revealed mild diffuse atrophy and subcortical hyperintensities on T2 and FLAIR imaging, findings which were nonspecific and possibly related to microvascular disease, but also potentially co...

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