Reasoning on Rounds: a Framework for Teaching Diagnostic Reasoning in the Inpatient Setting.

Internal medicine trainees learn a variety of clinical skills from resident clinical teachers in the inpatient setting. While diagnostic reasoning (DR) is increasingly emphasized as a core competency, trainees may not feel entirely comfortable teaching it. In this perspective article, we provide a framework for teaching DR during inpatient rounds, which includes focusing on the one-liner, structuring a reasoning-focused A&P, and performing a day of discharge reflection.

Vedolizumab Therapy in Refractory Microscopic Colitis: A Single Center Case Series.

Microscopic colitis (MC) is a disease characterized by chronic watery diarrhea secondary to colonic inflammation. Endoscopically, the mucosa is usually normal but biopsies show characteristic histologic findings.1.

Morning report for all: a qualitative study of disseminating case conferences via podcasting.

BACKGROUND: Despite its long-established importance, diagnostic reasoning (DR) education has suffered uneven implementation in medical education. The Clinical Problem Solvers (CPSolvers) podcast has emerged as a novel strategy to help teach DR through case conferences with expert diagnosticians and trainees. CPSolvers has 25,000 listeners in 147 countries. The aim of this study was to evaluate the podcast by eliciting the developers' goals of the podcast, then determining to what extent they aligned with the listeners' actual usage habits, features they valued, and perceptions of the podcast. METHODS: We conducted semi-structured interviews with 3 developers and 8 listeners from April-May 2020, followed by qualitative thematic analysis. RESULTS: Three major developer goals with sub-goals resulted: 1. To teach diagnostic reasoning in a case-based format by (1a) teaching schemas, (1b) modeling expert diagnostic reasoning, (1c) teaching clinical knowledge, and (1d) teaching diagnostic reasoning terminology. 2. To change the culture of medicine by (2a) promoting diversity, (2b) modeling humility and promoting psychological safety, and (2c) creating a fun, casual way to learn. 3. To democratize the teaching of diagnostic reasoning by leveraging technology. Listeners' usage habits, valued features, and perceptions overall strongly aligned with all these aspects, except for (1c) clinical knowledge, and (1d) diagnostic reasoning terminology. Listeners identified (1a) schemas, and (2c) promotion of psychological safety as the most valuable features of the podcast. CONCLUSION: CPSolvers has been perceived as a highly effective and novel way to disseminate DR education in the form of case conferences, serving as an alternative to traditional in-person case conferences suspended during COVID-19. CPSolvers combines many known benefits of in-person case conferences with a compassionate and entertaining teaching style, plus advantages of the podcasting medium - democratizing morning report for listeners around the world.

New and emerging technology in the diagnosis and treatment of pancreatic cysts.

Pancreatic cysts have always presented as a diagnostic dilemma due to the difficulties in identifying patients with current imaging modalities that could most benefit from surgical intervention. Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystadenomas (MCNs) carry the highest malignant potential of all pancreatic cysts and pancreatic adenocarcinoma carries a high mortality as the fourth leading cause of cancer-related deaths. However, surgery to remove benign cysts also carries a high morbidity and occasional mortality. Opportunities to identify and reduce pre-cancer lesions must be aggressively pursued. Multidetector helical CT (MDHCT) or an up-to-date MRI is the first diagnostic tool to evaluate a suspected pancreatic lesion. Currently, review by a multidisciplinary group who specialize in pancreatic cysts and pancreatic cancer is advised to review factors such as a patient's comorbidities, the type of surgery needed to remove the cyst and the estimated morbidity and mortality associated with the procedure. Some recent data are emerging to assist with identifying those at highest risk such as cyst fluid analysis, laser endomicroscopy, and artificial intelligence (AI). This article reviews the current status, benefits, challenges and future prospects on diagnosis and treatment of pancreatic cysts. Further prospective randomized control trials are needed to determine the optimal management and treatment for patients with pancreatic cysts.

Morning report goes virtual: learner experiences in a virtual, case-based diagnostic reasoning conference.

OBJECTIVES: Participation in case-based diagnostic reasoning (DR) conferences has previously been limited to those who can attend in-person. Technological advances have enabled these conferences to migrate to virtual platforms, creating an opportunity to improve access and promote learner participation. We describe the design and evaluation of virtual morning report (VMR), a novel case-based DR conference that aimed to expand access to these conferences, leverage a virtual platform to create new opportunities for learner participation, and improve learner confidence in performing DR. METHODS: VMR took place on a videoconferencing platform. Participants included health professions students, post-graduate trainees, and practitioners. In designing VMR, we adapted concepts from the experience-based model of learning to design opportunities for learner participation. Teaching strategies were informed by information-processing and situativity theories. We evaluated learner experiences in VMR using a survey with open and closed-ended questions. Survey items focused on accessing case-based teaching conferences outside of VMR, participant perceptions of the educational value of VMR, and VMR's impact on participants' confidence in performing DR. We used thematic analysis to manually code open-ended responses and identify themes. RESULTS: 203 participants (30.2%) completed the survey. 141 respondents (69.5%) reported they did not otherwise have access to a DR conference. The majority of participants reported increased confidence performing DR. Respondents highlighted that VMR supplemented their education, created a supportive learning environment, and offered a sense of community. CONCLUSIONS: VMR can expand access to DR education, create new opportunities for learner participation, and improve learner confidence in performing DR.

Liver transplantation for alcoholic hepatitis.

Alcoholic hepatitis (AH) is associated with a high short-term mortality. Currently, most transplant centers require minimum six months of abstinence from alcohol use before considering liver transplant for patients with end stage liver disease. Some recent data are emerging on the benefits and safety of early liver transplantation for patients with severe AH, a population who cannot meet the minimum six months sobriety. This article reviews the current status, benefits, challenges, barriers, and future prospects on early liver transplantation in patients with severe, acute AH.

A Rare Cause of Acute Pancreatitis in a Transgender Female.

Acute pancreatitis is defined as an acute inflammation of the pancreas and is most commonly caused by gallstones and alcohol followed by elevated triglycerides and medications. Estrogen as a cause of secondary hypertriglyceridemic pancreatitis is a rare but known phenomenon in females on hormonal therapy; however, it is not well described in the transgender female population. In this article, we present a case of a 31-year-old transgender female who developed acute, severe pancreatitis after a few months of using estrogen as transition therapy. To our knowledge, this is the third case report of a transgender female presenting with acute pancreatitis secondary to estrogen. Long-term supraphysiologic doses of sex hormones are required to maintain secondary sex characteristics placing this population at a higher risk of developing acute pancreatitis. Further research is needed to determine risk and screening methods to prevent this side effect.

Recent updates on alcoholic hepatitis.

Alcoholic hepatitis (AH) is a unique clinical syndrome that affects patients with chronic and active harmful alcohol consumption, and is associated with a high mortality of up to 40% at 1 month from presentation. It is important to assess disease severity and prognosis at time of presentation to identify patients at risk for high mortality and potential candidates for specific therapies. The cornerstone therapy for AH is enteral nutrition and abstinence. Steroids remain the only pharmacological option for severe AH however, adverse effects and lack of long-term benefit limit their routine use. Early liver transplantation is a potential salvage therapy for select severe AH patients. This review article comprehensively covers recent advances on the clinical unmet needs in the field including newer therapies and therapeutic targets, role of liver transplantation, and emerging biomarkers throughout the disease process from diagnosis, assessing prognosis and disease severity, and predicting responsiveness to medical therapies for severe AH.

Endoscopic Retrograde Cholangiopancreatography-Induced Splenic Injury in a Patient With Sleeve Gastrectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure with significant complications. Splenic hematoma is an extremely rare but known complication following ERCP that has been increasingly reported in the past several years. We report the case of a 44-year-old patient with a history of sleeve gastrectomy who underwent an ERCP that was complicated by both acute pancreatitis and splenic hematoma. She was managed conservatively under close monitoring in the intensive care unit. Clinicians should be aware of this potentially life-threatening complication to make a prompt diagnosis and begin early appropriate management.

Lymphocytic Esophagitis: A Rare Disease on the Rise.

Lymphocytic esophagitis is a rare, poorly understood disease. This case report presents a patient with a history of squamous cell carcinoma of the tongue who presented with dysphagia. He received esophageal dilation that unfortunately resulted in perforation. Biopsies showed lymphocytic esophagitis. There are very few cases in the literature describing perforation in lymphocytic esophagitis. In addition, management and treatment have been challenging for physicians; however, this case represents a complete symptomatic improvement in four to six weeks with a proton pump inhibitor.

Rats! Hantavirus: A Case Report of a Suspected Case in Eastern Tennessee.

INTRODUCTION: Hantavirus is an RNA virus that is transmitted to humans by inhalation of aerosolized excrement from infected rodents. This case report demonstrates the value of taking a thorough social history and highlights the challenges associated with early diagnosis of this viral infection. CASE PRESENTATION: We highlight a case of suspected hantavirus infection with subtle gastrointestinal and pulmonary symptoms that challenged the initial diagnosis. DISCUSSION: Efforts are needed to improve clinical recognition and rapid detection of hantavirus infections, to reduce associated mortality. In a patient presenting with gastrointestinal prodromal symptoms followed by cardiopulmonary findings, physicians should pay special attention to that patient's living conditions and maintain a high index of suspicion for hantavirus infection. Early diagnosis is critical to prevent rapid deterioration to hantavirus pulmonary syndrome in some patients.

Recurrent Gastric Gastrointestinal Stromal Tumor in a Patient with Neurofibromatosis.

Neurofibromatosis type 1 is an autosomal dominant neurocutaneous disorder characterized by a mutation of the neurofibromin 1 (NF1) gene, resulting in increased susceptibility for multiple tumors, namely, gastrointestinal stromal tumors (GISTs)-the most common types of mesenchymal neoplasms in the gastrointestinal tract. Despite these tumors' predilection for the stomach, it seems to be the least likely part of the gastrointestinal (GI) tract to be affected in cases of neurofibromatosis. Herein, we report a case of a 61-year-old male patient with known neurofibromatosis, who presented with acute blood loss anemia due to a recurrent gastric GIST, requiring partial gastrectomy due to its size and multiple recurrences.