Adult Female With Abdominal Distention.

Gastric outlet obstruction (GOO) is a rare diagnosis that can be challenging to make as its symptoms, which include abdominal distention, nausea, and persistent vomiting, often overlap with many other acute abdominal pathologies. Point-of-care ultrasound (POCUS) can help the clinician identify gastric outlet obstruction in patients who present to the emergency department (ED). Sonographic identifiers include a markedly dilated stomach that is filled with both hyper- and hypoechoic contents and may extend into the lower abdomen in the pelvic views.

The emergency department care for hemodialysis patient during the COVID-19 pandemic.

The COVID-19 pandemic poses significant challenges to patients with end-stage kidney disease who receive treatment in outpatient dialysis centers. These patients represent a fragile population that is at higher risk for both infection and transmission. At the start of the pandemic, many suspected COVID-19 dialysis patients were diverted to the emergency department (ED) for testing/treatment, placing a tremendous burden on the ED and inpatient dialysis units. Several recommendations and guidelines have been established to optimize patient care while also decreasing the burden on the ED and inpatient dialysis units and maximizing the ability to perform outpatient hemodialysis. As the pandemic continues, dialysis facilities will have an increasing burden to provide safe and accessible dialysis, while also being able to direct patients to the ED for either emergent dialysis or COVID-19 treatment/testing. We reviewed opinions, recommendations and guidelines developed by professional organizations and dialysis facilities for the management of "patients under investigation" (PUIs) and COVID-19 positive patients that depend on whether the suspicion occurs while the patient is at home vs. at the dialysis center.

Acute Pancreatitis Masquerading as Inferior Wall Myocardial Infarction: A Review.

A rare presentation of acute pancreatitis is with electrocardiographic (ECG) changes that mimic myocardial ischemia. We present a report of a patient that presented with hemodynamic instability and new ECG changes of ST segment elevations in contiguous leads II, III, and aVF mimicking an inferior wall myocardial infarction. Emergent coronary angiography showed no significant coronary obstruction, but it was followed by a left-sided hemiplegia with radiographic evidence of diffuse embolic stroke. The patient was later found to have an underlying diagnosis of pancreatitis. Additional history that later became available indicated a history of severe acute pancreatitis treated elsewhere a few months prior to the current admission. We present the first comprehensive review of the literature comprising 36 total cases with pancreatitis masquerading as acute myocardial infarction, with inferior wall STEMI pattern being the most frequent. We present this case to highlight the diagnostic dilemma posed by this masquerade of a high acuity myocardial infarction and to highlight alternative diagnoses to be considered in such clinical circumstances.

Perceptions of Third-year Medical Students of a Non-resident Hospitalist Rotation.

Introduction Although medical students in the United States frequently rotate on a non-resident hospitalist team, there is a paucity of literature on their perceptions regarding such rotation. We sought to assess the perceptions of third-year medical students (M3s) regarding a non-resident hospitalist rotation. Methods We conducted a web-based survey of M3s who had previously rotated on a non-resident hospitalist service. We assessed their perceptions regarding patient assignments and complexities, rounding preferences, barriers to learning, and the benefits of the rotation. A descriptive analysis was performed on the responses. Results Out of 49 respondents, 47% preferred carrying a maximum of three patients during rounds and 57% preferred patients with fewer comorbidities. Fifty-one percent preferred rounding on all patients covered by the team as opposed to rounding on their assigned patients only. Despite several perceived benefits of the rotation, students also identified various barriers to learning while rotating in a non-resident hospitalist rotation. Conclusions Our study evaluated the perceptions of M3s regarding the ideal patient load, patient complexities, barriers to learning and various benefits of a non-resident hospitalist rotation. The students' perceptions can potentially be addressed and incorporated to make the non-resident hospitalist rotation more educational for the students.

Cost-effectiveness of Maintenance Capecitabine and Bevacizumab for Metastatic Colorectal Cancer.

Importance: Unregulated drug prices increase cancer therapy costs. After induction chemotherapy, patients with metastatic colon cancer can receive maintenance capecitabine and bevacizumab therapy based on improved progression-free survival, but whether this treatment's cost justifies its benefits has not been evaluated in the United States. Objective: This study sought to determine the influence of capecitabine and bevacizumab drug prices on cost-effectiveness from a Medicare payer's perspective. Design, Setting, and Participants: The incremental cost-effectiveness of capecitabine and bevacizumab maintenance therapy was determined with a Markov model using a quality-of-life penalty based on outcomes data from the CAIRO phase 3 randomized clinical trial (RCT), which included 558 adults in the Netherlands with unresectable metastatic colorectal cancer who had stable disease or better following induction chemotherapy. The outcomes were modeled using Markov chains to account for patients who had treatment complications or cancer progression. Transition probabilities between patient states were determined, and each state's costs were determined using US Medicare data on payments for capecitabine and bevacizumab treatment. Deterministic and probabilistic sensitivity analyses identified factors affecting cost-effectiveness. Main Outcomes and Measures: Life-years gained were adjusted using CAIRO3 RCT quality-of-life data to determine quality-adjusted life-years (QALYs). The primary end point was the incremental cost-effectiveness ratio, representing incremental costs per QALY gained using a capecitabine and bevacizumab maintenance regimen compared with observation alone. Results: Markov model estimated survival and complication outcomes closely matched those reported in the CAIRO3 RCT, which included 558 adults (n = 197 women, n = 361 men; median age, 64 and 63 years for patients in the observation and maintenance therapy groups, respectively) in the Netherlands with unresectable metastatic colorectal cancer who had stable disease or better following induction chemotherapy. Incremental costs for a 3-week maintenance chemotherapy cycle were $6601 per patient. After 29 model iterations corresponding to 60 months of follow-up, mean per-patient costs were $105 239 for maintenance therapy and $21.10 for observation. Mean QALYs accrued were 1.34 for maintenance therapy and 1.20 for observation. The incremental cost-effectiveness ratio favored maintenance treatment, at an incremental cost of $725 601 per QALY. The unadjusted ratio was $438 394 per life-year. Sensitivity analyses revealed that cost-effectiveness varied with changes in drug costs. To achieve an incremental cost-effectiveness ratio of less than $59 039 (median US household income) per unadjusted life-year would require capecitabine and bevacizumab drug costs to be reduced from $6173 (current cost) to $452 per 3-week chemotherapy cycle. Conclusions and Relevance: Antineoplastic therapy is expensive for payers and society. The price of capecitabine and bevacizumab maintenance therapy would need to be reduced by 93% to make it cost-effective, a finding useful for policy decision making and payment negotiations.