Leading a New Team: Critical Lessons Learned.

Leading medical teams as a new attending physician can be a challenging task. This case highlights the important role of leaders in fostering a positive learning environment, developing interpersonal relationships, and establishing clear expectations with regular feedback to improve team function to deliver effective health care.

It's Not Lupus This Time! A Case of Worsening Hypothyroidism in a Patient With Nephrotic Syndrome.

Nephrotic syndrome can result in worsening of existing hypothyroidism in patients requiring thyroid hormone supplementation. The urinary loss of thyroxine-binding globulin, as well as increased gut edema, likely lead to reduced absorption and retention of exogenous thyroid hormone. Here, we present a case of a patient with Hashimoto's thyroiditis, previously well-controlled on levothyroxine, who developed symptomatic hypothyroidism as a result of newly diagnosed nephrotic syndrome, whose symptoms improved with transition to an alternative formulation of levothyroxine and treatment of her underlying nephrotic syndrome. It is important to consider nephrotic syndrome as a cause of worsening hypothyroidism in a patient on a fixed dose of levothyroxine given the potential morbidity associated with a missed diagnosis and often need for escalation of dosage. There is no standardized therapy for hypothyroidism exacerbated by nephrotic syndrome, but liquid or gel formulations of levothyroxine may be more effective in patients with absorption problems.

Endohepatology - current status.

PURPOSE OF REVIEW: This article discusses the most recent studies regarding the emerging field of endohepatology - the use of diagnostic and therapeutic endoscopic tools for the management of patients with liver disease and portal hypertension. RECENT FINDINGS: New research has shown that liver biopsy specimens obtained by each Endoscopic ultrasound (EUS)-guidance, the percutaneous approach, and the transjugular approach contained sufficient portal triads to adequately analyzed by experienced pathologists - suggesting that any of these routes of liver biopsy is clinically acceptable; further, all had similar rates of adverse events. An initial prospective study showed that EUS guided portal pressure measurement was safe, effective, and accurate. A recent metanalysis showed that EUS-guided cyanoacrylate injection and coil embolization was statistically more efficacious and with less complications than EUS guided cyanoacrylate injection and EUS guided coil injection alone, suggesting that combination therapy appears to be the preferred approach for gastric varices (GV) bleeding. A prospective study evaluating focal liver lesions showed that the use of artificial intelligence had up to 100% sensitivity and 81% specificity for identifying malignant focal liver lesions. SUMMARY: EUS guided liver biopsy is safe and enables accurate diagnosis of underlying liver disease. EUS guided portal pressure measurement is also safe and is accurate. Combination therapy of EUS guided cyanoacrylate injection and coil embolization is more efficacious and has less complications than injection or coil therapy alone when used for GV bleeding. Artificial intelligence is highly sensitive and specific when used in conjunction with EUS in the diagnosis of malignant focal liver lesions. Endohepatology is a rapidly expanding field with great potential.

ß-Blocker-Induced Liver Injury: A Class Effect With Incidental Rechallenge.

Drug-induced liver injury is a common cause of acute liver failure. ß-blockers are a widely prescribed class of medications; however, hepatotoxicity is a rare adverse effect of this medication of which clinicians must be aware. This case suggests that hepatotoxicity may be a class effect of ß-blockers.

Heart Under Attack: Cardiac Manifestations of Inflammatory Bowel Disease.

There is a well-established association between chronic inflammation and an elevated risk of heart disease among patients with systemic autoimmune conditions. This review aims to summarize existing literature on the relationship between inflammatory bowel disease and ischemic heart disease, heart failure, arrhythmia, and pericarditis, with particular attention to approaches to management and treatment.

Real-time methylomic aberrations during initiation and progression of induced human mammary epithelial cell tumorigenesis.

AIM: Neoplastic transformation provides one of the few existing opportunities to analyze molecular changes in real time during the initiation and progression of breast cancer. MATERIALS & METHODS: Human mammary epithelial cells underwent neoplastic reprogramming, generating one line of semitransformed, premalignant cells and two separate, temporal lines of fully transformed human mammary epithelial cells (THMECs). An Illumina Infinium HumanMethylation27 BeadChip was used to analyze DNA methylation alterations in 27,578 CpG loci at three consecutive time points over an 80-day (d) transformation period. RESULTS: The mean ß value for semitransformed human mammary epithelial cells CpG loci (0.245) was much greater than for either THMEC-40d (0.055) or THMEC-80d (0.066), indicating a large loss of methylation after neoplastic induction. In addition, 54% of CpG loci were hypermethylated during the THMEC-40d to THMEC-80d transition. We observed that the CpG loci exhibiting DNA methylation changes during early oncogenesis were enriched for biological functions like cellular movement; this was distinctly different than in the later, more progressive stages of the transformation process enriched for processes involving differentiation. CONCLUSION: The timing of major methylomic changes may be important in directing the cell toward a more cancerous phenotype. In addition, gene-specific hypermethylation appears to silence developmentally related genes, leading to dedifferentiation.