Effectiveness of SNAPPS Implementation in the Family Medicine Residency Program in Erbil: A Randomized Controlled Trial.

Background and objectives There is a crucial need to embrace modern methodologies for enhancing medical education in disciplines such as Family Medicine. The study introduces the SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, and Select) model, a six-step mnemonic representing a learner-centered case presentation approach that streamlines fact reporting while encouraging clinical reasoning, aiming to evaluate the effectiveness of the SNAPPS method as compared to the traditional model of case presentation in Family Medicine outpatient clinics and to gain insights into how students and preceptors perceive it. Methods A randomized controlled trial was conducted in Family Medicine outpatient clinics in Erbil, Iraq, from March 15, 2023, to August 30, 2023. Using convenience sampling, all Family Medicine board residents (n=30) in Erbil and six preceptors from the Community and Family Medicine department/College of Medicine/Hawler Medical University were randomly assigned into two groups by using the RAND function in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States). The SNAPPS method was introduced to the SNAPPS group employing approved tools and methods, while no intervention was needed in the control group. Subsequently, 30 cases were presented in each group with a total of 60 case presentations; the case presentations served as the units for data analysis. Feedback and data were gathered after each presentation using validated data recording sheets. Results The study showed a significant advantage for the SNAPPS group over the control group in terms of time efficiency, number of basic clinical attributes covered, and justified diagnoses (P value < 0.001). In the SNAPPS group, 90% of the students sought clarification and information, surpassing 30% in the control group (P-value < 0.001). Almost all SNAPPS group students (96.7%) discussed case-related topics, compared to 43.3% in the controls (P-value<0.001). The SNAPPS group received superior overall ratings from both preceptors and students. Conclusion The SNAPPS method enhances clinical diagnostic reasoning in Family Medicine outpatient clinics. It is time-efficient and encourages students to articulate uncertainties, pose questions, and identify case-related topics for self-study.

Peer evaluation as an alternative assessment method for case presentations: A cross-sectional study of dental students' perception.

INTRODUCTION: Peer assessment in dental and medical education is a key tool for evaluating attitudes and communication skills, serving as an effective formative learning method. It not only boosts academic performance and encourages lifelong learning and reflective practice but also fosters collaboration, effective communication, and constructive feedback among peers. OBJECTIVE: This study aimed to assess dental students' satisfaction and perceptions regarding implementing peer assessment in case presentations, including contribution to their learning. METHODS: This cross-sectional study involved third (n = 26), fourth (n = 54), and sixth (n = 71) dental students divided into five groups. Each student received peer assessments (n = 8) from the students of the other groups regarding their clinical presentation. At the end of the process, students were invited to complete an anonymous 9-item questionnaire to assess student perceptions of the peer-assessment process. Data were analyzed to evaluate students' perception and satisfaction with the peer assessment task. The bivariate analysis explored associations among questionnaire items. RESULTS: A total of 151 students participated in the current study. Results showed a high level of agreement for most of the students regarding their preparedness for peer and self-assessment. More than 75% of the students at all academic levels found it challenging to evaluate their peers. Student satisfaction scores increased with the level of education, (4.076, 4.214, and 4.246 out of five, respectively) with moderate correlations between peer evaluation characteristics. CONCLUSION: Peer assessment appears to enhance learning and professional development in dental students. Students' satisfaction with peer assessment grows with education level, reflecting its role in fostering critical evaluation skills and feedback.

Pathologic Complete Response and Long-Term Survival After Preoperative Chemotherapy for Transverse Colon Cancer With Para-Aortic Lymph Node Metastases.

A 52-year-old male patient was diagnosed with transverse colon cancer and synchronous stage IVA para-aortic lymph node (PALN) metastases (cT3N1bM1a of the lymph node). Six courses of mFOLFOX6 plus bevacizumab were administered as neoadjuvant chemotherapy. Computed tomography showed shrinkage of the primary tumor and PALN metastases. Extended right hemicolectomy, D3 lymph node dissection, and PALN dissection were performed. A pathologic examination indicated that the tumor had completely changed and comprised necrotic tissue with no viable cells. Therefore, it was considered that mFOLFOX6 plus bevacizumab resulted in a pathologic complete response. Postoperatively, six courses of mFOLFOX6 were administered. Six years postoperatively, the patient did not exhibit any signs of recurrence. There have been few reports of pathologic complete response after neoadjuvant therapy and resection for colon cancer with synchronous PALN metastases. This report describes a unique case involving a pathologic complete response with long-term survival after mFOLFOX6 plus bevacizumab and radical resection, including PALN dissection. Preoperative mFOLFOX6 plus bevacizumab followed by radical resection and adjuvant mFOLFOX6 therapy was safe and resulted in a good outcome. This regimen should be considered for advanced colon cancer with PALN metastases.

Four Cases of Proximal Release-Type Colon Stents for Obstructive Rectal Cancer.

Malignant colonic obstruction can cause necrosis, bacterial translocation, electrolytic imbalance, and death; therefore, immediate decompression should be performed. Self-expandable metallic colonic stents are an established treatment for the decompression of malignant colonic obstructions. The use of stents that open from the distal side, which have been commonly used until now, requires caution because placing a stent on the dentate line can cause severe pain, and there is a possibility of cutting the stent during rectal resection of the distal side of the tumor. Therefore, we designed a new proximal-release-type colorectal stent for use in our hospital; it is 22 mm in diameter and 70 mm in length, which was placed using the over-the-wire method with a 16 Fr delivery system. We have encountered four cases in which it was appropriate as a bridge to surgical treatment. None of the patients experienced complications, such as bleeding, pain, or other incidents, after stent placement. Additionally, the stents were not affected by the surgical dissection of the rectum on the anorectal side of the tumor. Herein, we presented the four aforementioned cases and discussed the stenting techniques.

Hematometra: A Rare Case of Pelvic Pain in Females Identified with Point of Care Ultrasound.

The differential diagnosis for abdominal or pelvic pain in women of child-bearing age that present to the emergency department is broad. A rare cause of abdominal and pelvic pain is hematometra, or a collection of blood products within the uterus. While blood is normally expelled through menses, this process is disrupted in some patients due to congenital or acquired abnormalities. This can lead to progressive uterine distension and pain, which may ultimately require medical or surgical intervention. Hematometra is rare, but is a serious condition that can be diagnosed easily at bedside using point of care ultrasound.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report.

BACKGROUND: Interstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively. CASE PRESENTATION: A 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22-23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7. CONCLUSION: Interstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Homework as a driver of change in psychotherapy.

BACKGROUND AND OBJECTIVES: The utilization of Between-Session Homework (BSH) holds a longstanding tradition in the field of psychotherapy. Significantly, it serves as a pivotal catalyst for change within behavioral and cognitive-behavioral therapies, and has also garnered endorsement within psychodynamic and humanistic-experiential therapies. While our current conceptualization of BSH is characterized by assimilation and integration, diversity prevails in how BSH is incorporated into the treatment plan, spanning various therapy stages, thus necessitating a customized therapist-client interpersonal dynamic. Far from being a panacea, the employment of BSH emerges as a highly sophisticated and intricate clinical methodology, demanding a high degree of therapist proficiency and competence to facilitate client engagement. METHODS: In this introductory paper, we present an issue of the Journal of Clinical Psychology: In Session that exemplifies the diverse modalities through which BSH can be integrated into clinical practice across various client demographics and within distinct psychotherapeutic paradigms. We place specific emphasis on the pivotal role of BSH and its interplay with proposed mechanisms of change throughout the course of treatment. RESULTS: Initially, we provide an overarching view of the subject and expound on empirical research substantiating the efficacy of BSH in psychotherapy. Subsequently, we delve into strategies for adeptly integrating and monitoring BSH within clinical practice. CONCLUSIONS: Our primary objectives encompass affording readers a more lucid comprehension of (1) the content and nature of homework; (2) the influence of BSH on treatment outcomes; and (3) the ways through which therapists can foster client engagement with BSH. Finally, we introduce the six papers comprising this issue.

The Use of Point of Care Ultrasound in Diagnosis of Peritonsillar Abscess.

The use of point of care ultrasound (POCUS) for diagnosis and treatment of peritonsillar abscess (PTA) is increasing 1. Proven advantages include improved diagnostic accuracy and treatment success rates as well as decreased otolaryngology consultation, computed tomography (CT) usage, return visits to the emergency department (ED), and length of stay 1. We present a case of a patient with a PTA that was diagnosed and successfully treated utilizing POCUS, avoiding the need for otolaryngology consultation and CT.

Cough Causing Abdominal Pain? A Rapid POCUS Diagnosis of Rectus Sheath Hematoma.

We present a case of a 59-year-old man who arrived to the emergency department with abdominal pain and bruising after coughing. Point of care ultrasound (POCUS) was used to make the diagnosis of rectus sheath hematoma (RSH). This diagnosis was made within minutes of arrival to the ED and subsequently confirmed on computed tomography (CT) of the abdomen. As abdominal ultrasound is a technically straightforward imaging technique which includes a sensitivity that rises about 90%, its utilization to identify rectus sheath hematoma can reduce the rate of CT imaging and time to diagnosis for this pathology.

Prenatally Diagnosed Interventricular Septal Aneurysm with Associated Ventricular Dysfunction.

Congenital interventricular septal aneurysms (IVSA) of the muscular septum are rare and can be associated with other familial abnormalities of the ventricular septum, arrhythmias, additional congenital heart disease, and chromosomal abnormalities. IVSA is also linked to ventricular dysfunction and non-compaction, although there are limited reports of this association presenting in utero. We describe a case of fetal ventricular septal aneurysm associated with ventricular dysfunction and pericardial effusion.

Hepatoblastoma en un paciente pediátrico a propósito de un caso

La incidencia de hepatoblastoma alrededor del mundo permanece constante entre 0.5 y 1.5 casos por millón de niños por año. En los Estados Unidos de América se reporta para el hepatoblastoma una incidencia anual de aproximadamente 1 por millón en niños menores de 15 años de edad. En Ecuador, en una investigación realizada en la ciudad de Cuenca, ocupa el séptimo lugar entre los tumores pediátricos. Se trata de un tumor infrecuente, cuya incidencia parece aumentar en los últimos años. Puede aparecer de forma aislada o integrarse en el contexto de un síndrome de predisposición. Presentamos el caso de un paciente pediátrico, femenina, preescolar de 3 años de edad, sin antecedentes perinatales de importancia, producto de la tercera gesta, nacida por cesárea por distocia de presentación a las 39 semanas. Cuenta con esquema de vacunación completo para la edad. Como antecedentes patológicos personales requiere una hospitalización por enfermedad diarreica aguda a los 2 años. Sin antecedentes quirúrgicos, antecedentes patológicos familiares de tía materna con hipotiroidismo. Se realizó exámenes complementarios de sangre y de imagen, los cuales revelaron una masa abdominal dependiente de hígado compatible con hepatoblastoma con niveles de AFP superiores a 1000ng/ml

The incidence of hepatoblastoma around the world remains constant between 0.5 and 1.5 cases per million children per year. In the United States of America, an annual incidence of approximately 1 per million is reported for hepatoblastoma in children under 15 years of age. In Ecuador, in a study carried out in the city of Cuenca, it ranks seventh among pediatric tumors. It is an infrequent tumor, its incidence seems to have increased in recent years. It can appear in isolation or be part of a predisposing syndrome. We present the case of a 3-year-old preschool female pediatric patient with no significant perinatal history, product of a third pregnancy, born by cesarean section due to presentation of dystocia at 39 weeks. She had a complete vaccination for her age. As past medical history, she was hospitalized for acute diarrheal disease at 2 years of age. She had no surgical history, family pathological history except for a maternal aunt with hypothyroidism. Complementary blood and imaging tests were performed, which revealed an abdominal liver-dependent mass, compatible with hepatoblastoma with AFP levels greater than 1000 ng/ml.

A Rare Case of Primary Peritoneal Carcinoma With Large Bowel Metastasis.

Primary serous peritoneal carcinoma (PPC) is a rare malignancy often presenting with a significant disease burden and a poor prognosis. A 65-year-old female was seen in the surgical outpatient clinic with a two-month history of weight loss, altered bowel habits and a CT scan characterizing a heterogenous right paracolic gutter mass and suspicious liver lesions. At colonoscopy, a prominent appendiceal orifice was biopsied to be poorly differentiated carcinoma favouring gynaecological tract origin. The patient was admitted with an acute small bowel obstruction secondary to progression of metastases and underwent neoadjuvant chemotherapy with a near complete response on repeat staging. A debulking hysterectomy, bilateral salpingo-oophorectomy, pelvic peritonectomy and small bowel nodule excision were performed. The diagnosis of PPC was confirmed when no malignancy was found in the pelvic organs. The presence of intraluminal colonic metastasis with PPC is exceedingly rare with this being only the third such case in the literature.

Case report: a rare presentation of typhoid fever due to eating over-ripened pineapple.

Typhoid fever is an acute infection caused by Salmonella typhi, especially when it is waterborne or foodborne. Overripe pineapple causes typhoid fever because overripe pineapple is a desirable host for the survival of S. typhi. The importance of typhoid fever as a public health burden is reduced by early detection and appropriate antibiotic treatment. Case Presentation: A 26-year-old black African male health care worker was admitted to the clinic on 21 July 2022, with a significant chief complaint of headache, loss of appetite, and watery diarrhea. The admitted patient presented with a 2-day history of hyperthermia, headache, loss of appetite, and watery diarrhea, as well as back pain, joint weakness, and insomnia. The H antigen titer was positive, which was 1 : 189 greater than the normal range and showed the past history of S. typhi infection. The O antigen titer value detected was a false negative result because it was done before the 7-day onset of fever. On admission, ciprofloxacillin 500 mg was given orally twice a day for 7 days to treat typhoid by inhibiting the deoxyribonucleic acid replication of S. typhi by preventing S. typhi deoxyribonucleic acid topoisomerase and deoxyribonucleic acid gyrase. Clinical Discussion: Typhoid fever pathogenesis is based on pathogenic factors, infecting species, and host immunity. By using the agglutination biochemical test, the Widal test was able to identify the patient's bloodstream as carrying the S. typhi bacteria that causes typhoid fever. Conclusion: Due to contaminated food or unsafe drinking water sources, typhoid fever is associated with travel to developing nations.

Adaptation to Virtual Assessment during the COVID-19 Pandemic: Clinical Case Presentation Examination.

BACKGROUND: Case presentation assessment is common in both medicine and dentistry and is known under various names depending on the country and institution. It relates mainly to aspects of diagnosis and treatment planning and is considered highly authentic and useful. The COVID-19 pandemic necessitated the movement of this assessment from face-to-face to online. The aim of this investigation was to explore the students' impressions of the two different examination modalities. With this information, a decision on future diets of this examination can be made to accommodate the students' perspectives. METHODS: Quantitative and qualitative data were gathered using an online, self-administered survey. RESULTS: The students were split 50/50 regarding which assessment modality they preferred. Overall, they considered the online examination to be fair, and the majority agreed that the online format allowed them to display their knowledge as well as face-to-face. CONCLUSIONS: The delivery of case presentation examination is possible online. An online case presentation is a fair, useful, and authentic assessment that is appropriate to the needs of the faculty and students. Satisfaction with the two possible methods of conducting this assessment suggests it would be reasonable to conduct this examination online in the future.

Case presentation of 8-year follow up of recurrent malignant duodenal Insulinoma and lymph node metastases and literature review of malignant Insulinoma management.

BACKGROUND: Insulinoma is an uncommon insulin-secreting neuroendocrine tumor that presents with severe recurrent hypoglycemia. Although cases of extrapancreatic insulinomas have been reported, the majority of insulinomas occur in the pancreas. The number of reported cases of ectopic insulinomas with follow-up assessments is limited and they do not report disease recurrence. The current report presents the first documented case of recurrent extrapancreatic insulinoma with 8 years of follow-up, provides relevant literature review, and proposes surveillance and treatment strategies. CASE PRESENTATION: We describe an insulinoma localized in the duodenal wall of a 36-year-old female who presented in 2013 with weight gain and Whipple's triad and was successfully managed with duodenotomy and enucleation. She presented again in 2017 with recurrent Whipple's triad and was found to have metastatic disease localized exclusively to peripancreatic lymph nodes. Primary pancreatic insulinoma was not evident and her hypoglycemia resolved following lymph node dissection. Eight years after initial presentation continuous glucose monitoring (CGM) showed a trend for euglycemia, and PET-CT Gallium 68 DOTATATE scan evaluation indicated absence of recurrent disease. CONCLUSION: Insulinomas are rare clinical entities and extrapancreatic insulinomas are particularly uncommon. Follow-up evaluation and treatment strategies for ectopic insulinoma recurrence presents a significant clinical challenge as the condition has hitherto remained undescribed in the literature. Available evidence in the literature indicates that lymph node metastases of intrapancreatic insulinomas likely do not change prognosis. Given the absence of long-term data informing the management and monitoring of patients with extrapancreatic insulinoma, we suggest patient education for hypoglycemic symptoms, monitoring for hypoglycemia with CGM, annual imaging, and a discussion with patients regarding treatment with octreotide or alternative somatostatin receptor analog therapies.

COVID19-induced immunosuppression and aggressive progression of primary cranial vault lymphoma presenting as a management challenge, a case report, and a literature review.

Background: We needs to study Primary Large cell Non-Hodgkin's Lymphoma of the cranial vault, which is rare, and its association with COVID19 has not been reported, which may have an immunosuppressive effect to aggravate its progression. Patient details: Our patient, a 53-year-old male, noticed fast growth of posterior cranial vault lesion from 2 to 10 cm size in last 6 months after COVID 19 affliction. MRI brain with contrast revealed lesions suggesting meningioma. The whole-body PET scan was normal. Following Subtotal excision of the mass, histopathology revealed large B-cell Non-Hodgkin's lymphoma (DLBCL). Immunohistochemistry showed positive results for CD10, CD20, CD45 (LCA), ALK, and BCL-VE with a Ki-67 index of 90-95%. Following radiotherapy and chemotherapy patient is disease-free on imaging and doing well at 5 months of follow-up. Conclusions: Early intervention with excisional biopsy and timely chemo and radiotherapy in favorable immunostaining may add survival benefits even in malignant features induced by immunosuppressing diseases such as COVID19 in diffuse large B-cell lymphoma (DLBCL) of the scalp.

Partial hydatidiform mole pregnancy ended in full-term delivery of a normal infant: a case presentation.

BACKGROUND: Twin pregnancy with a partial hydatidiform mole (PHM) and a coexistent live fetus is extremely rare. The fetus usually has a normal karyotype. The surviving rate of the fetus till lung maturity is only about 25-40%. PHM pregnancy almost ends in abortion due to the presence of triploid embryo. Here, we report a case of PHM coexistent with a live fetus resulting in a live baby. CASE PRESENTATION: A PHM pregnancy was diagnosed by ultrasonography in a 28-year-old Chinese woman, with normal fetal morphology and mosaicism as indicated by amniocentesis. After being fully informed of the risks, the woman chose to proceed with the pregnancy and finally gave birth to a baby girl and the infant was delivered at term. A single placenta with vesicular changes and peripheral blood diploid chromosomes were observed. There were no serious maternal complications. In conclusion, the diagnosis, management, and monitoring of this condition, which is very rare in clinical practice, remain challenging. Under proper management, a PHM-combined pregnancy can still end in full-term delivery of a normal living fetus.

Now showing: The presentation. Using video recording to enhance Balint leadership training.

Review of video recorded sessions is a powerful teaching tool in medical education, helping students appreciate both spoken and unspoken communications not fully appreciated in the moment. For many years, the American Balint Society has used video review in its Leadership Training Intensive courses, however technical challenges around setting up and operating the equipment have led some faculty to question whether the benefits are worth the effort and anxiety. We describe here an approach to video review in Intensives with a focus on the case presentation. Close attention to the case presentation can uncover important clues about a presenter's feelings and conflicts in a case, clues that may easily be missed on first pass. The Balint group leader listens for clues and cues to the patient's state of mind, and how the clinician is being distracted or deflected from their authentic role. Focusing the video review at an Intensive on the case presentation highlights for novice leaders the importance of maintaining keen focus on this initial section of the Balint group process for information on "what this case is about." Finally, we predict that Balint group leaders who emerge from an Intensive with this new appreciation for close listening to the presentation will not only be more effective Balint group leaders but will also be in a better position to serve as clinical role models, teaching by example to their Balint group members the importance of attending closely to the patient's communications in the patient - clinician encounter.