Acute Esophageal Necrosis and Duodenal Disease in the Setting of Recently Initiated Chemotherapy.

Introduction: Acute esophageal necrosis (AEN), commonly referred to as "black esophagus" or Gurvits syndrome, is a rare condition characterized by diffuse black mucosa in the distal esophagus. Most often, the patient is an older male with multiple comorbidities, presenting with upper gastrointestinal bleeding. The exact pathogenesis is unclear, but it is often thought to be secondary to acute vascular hypo-perfusion or ischemia of the esophageal mucosa in critically ill patients with certain secondary comorbid conditions such as renal insufficiency, diabetes mellitus, dyslipidemia, coronary artery disease, malnourishment, alcohol abuse, or association with an underlying malignancy. Case Presentation: We present a case of AEN in a 78-year-old female following the recent start of a chemotherapy regimen with carboplatin and paclitaxel two weeks prior. The patient underwent EGD and was found to have AEN throughout the entirety of her esophagus with necrosis and eschars seen up to the second part of the duodenum. The patient initially improved after receiving blood transfusions, being made nil-per-os, and starting proton pump inhibitor (PPI) therapy, but she ultimately died given the severity of her clear cell uterine cancer and other comorbidities. Conclusion: Although it is rare that initiation of chemotherapy leads to AEN, it should be considered as a potential etiology.

Esophageal Cancer Complicated by a Distal Acquired Esophagopulmonary Fistula.

Description Esophageal respiratory fistulas, commonly found as a tracheoesophageal fistula (TEF), are abnormal connections between the esophagus and trachea. These can be congenital (infants) or acquired (malignancy). A more rare form of an esophageal respiratory fistula is an abnormal connection between the esophagus and the lung parenchyma-also known as an esophagopulmonary fistula. In our case, we present a middle-aged male with a history of esophageal cancer undergoing chemotherapy and radiation presenting into the intensive care unit for increasing shortness of breath and vomiting after eating found to have a rare form of a TEF causing his symptoms.

Case of Enterococcus cecorum Human Bacteremia, United States.

Description Enterococcus cecorum rarely serves as a human pathogen, and only 6 cases of this microbe inoculating humans have been documented. We present an elderly female with a marked vascular history presenting with epigastric pain and diarrhea, followed by shaking chills. Laboratory findings revealed leukocytosis, with imaging showing diffuse colonic thickening. She had a bout of bloody diarrhea, raising the likelihood of ischemic colitis with her vascular history. To our surprise, both sets of blood cultures drawn on admission grew Enterococcus cecorum. This case is unique as it is the first documented case of E. cecorum human infection in the United States.

Impact of objectively assessing surgeons' teaching on effective perioperative instructional behaviors.

IMPORTANCE: Advancing surgical technology and decreasing resident learning hours have limited exposure to perioperative training, necessitating more effective and efficient perioperative teaching by faculty surgeons. Participation in collaborative efforts and process improvement can change behaviors and enhance teaching. OBJECTIVES: To promote deliberate teaching of residents, change resident perception of their teachers, and produce sustainable improvements by objectively measuring surgeons' perioperative teaching performance. DESIGN, SETTING, AND PARTICIPANTS: This 3-phase observational study of surgeons' perioperative teaching behaviors included university-based surgeons, general surgery residents, and preclinical student observers and involved elective cases at a 600+ bed tertiary hospital. Initially, we measured teaching behaviors by surgeons unaware of study objectives, provided aggregate and confidential individual feedback, and developed standardized preoperative briefings and postoperative debriefings. Phase 2 applied a deliberate teaching model and reinforced behaviors with continuous process improvement efforts (Plan, Do, Check, Act) and repeat observations. Phase 3 used resident prompts to enhance teaching behaviors and demonstrate sustainability. Resident surveys conducted 3 times assessed perceptions of deliberate guidance by faculty when compared with national benchmarks. INTERVENTIONS: Introduction of deliberate faculty preprocedural focusing and postprocedural reinforcement to facilitate resident learning. MAIN OUTCOMES AND MEASURES: More frequent and complete perioperative teaching by faculty and the perception of enhanced teaching by residents. RESULTS: Faculty more commonly and more completely performed the 10-step preoperative briefings and postoperative debriefings (P < .001) during phase 2 (250% improvement over baseline). Intraoperative teaching styles significantly improved and residents' survey-reported assessments of faculty teaching improved over national data for describing procedural steps (P = .02) and requests for resident self-evaluation (P = .006). CONCLUSIONS AND RELEVANCE: Objective recording of teaching behavior frequency motivated adoption of deliberate guided teaching behaviors by surgeons, resulting in both subjective reports by residents of more frequent teaching and objective recording of parallel improvements. A deliberate focus on objectively assessing surgeon educators' periprocedural teaching may motivate improved teaching.