Death Pronouncement: Preparing Incoming Residents for Duties When Life Ends.

Introduction Undergraduate Medical Education (UME) prepares future residents for many aspects of medical practice, but it is rarely all-inclusive. Death pronouncement (DP), a highly important aspect of clinical training for residents, seems to be inadequately addressed and taught in undergraduate institutions. Studies have indicated that most first-year residents received minimal DP training and felt unprepared for this duty. Despite being a challenging situation, a formal teaching course is not universally taught, with most institutions merely delivering point-of-care DP instruction to medical trainees provided by supervising faculty, senior residents, and nurses. Our primary objective was to provide formal education in Duties When Life Ends (DWLE), with the goal of enhancing familiarity, knowledge, and confidence in addressing the circumstances surrounding death for graduating medical students transitioning to residency. Methods As a part of a Transition to Residency (TTR) course for students entering nonsurgical specialties, we developed a curriculum to provide formal education to fourth-year medical students in DWLE that included a two-hour didactic session delivered virtually, followed by an in-person simulation session. The didactic session covered the history, processes of DP, death physical examination, identification of medical examiner (ME) case, education on how to deliver death news to family, information about autopsies and organ donation, distinction between the cause and mechanism of death, and documentation of death notes and certificates, as well as provider self-reflection and appropriate coping mechanisms for patient death. In the 45-minute simulation, students were divided into small groups and given a case summary. During the first half, they performed a physical examination and a verbal pronouncement on cadavers, followed by an interactive small group session where students reviewed the case and worked to identify the cause of death, determine if the death was a medical examiner's case, deliver death news to the family, and complete a death progress note and certificate. Pre- and post-session questionnaires were administered, assessing three components: process familiarity, knowledge, and confidence. Finally, participants assessed course usefulness and had a free response opportunity for comments and feedback.  Results Overall, 198 students participated in all sessions, with 182 completing both pre- and post-session questionnaires. Pre-survey revealed that 70% of participants reported witnessing DP previously, with only 20% being familiar with the process of DP and 6% with documentation. Following the intervention, a comparison of the pre- and post-course questionnaires assessing process familiarity, knowledge, and confidence using a five-point Likert scale demonstrated statistically significant improvement in the mean scores in all three domains, with reported course usefulness of 96%. Conclusion A DWLE curriculum, as a part of the TTR course, was effective in improving self-reported familiarity, knowledge, and confidence regarding physician duties associated with patient death. The curriculum was well received by students. The incorporation of DWLE curriculum into TTR courses allows for vital preparation and education in the duties related to patient death. This may make a stressful process somewhat less stressful and may aid future physicians in developing competence in conducting these final physician duties.

A Novel Case of Metformin-Induced Pancreatitis in an Individual With Normal Dosing and No Underlying Chronic Kidney Disease.

It is well known that most medications have side effects, and many of them have gone through years of testing with thousands of test subjects before entering the market. However, as physicians it is important to assess how patients react to the initiation of new medications not only looking for known side effects but also rare ones. Our case highlights a rare presentation of metformin-induced pancreatitis in the setting of normal renal function and appropriate dosing. We are hoping our case will create more awareness and inspire future research in exploring the pathophysiology and causes of metformin-induced pancreatitis. Moreover, we aim to make healthcare professionals mindful so that they may recognize acute pancreatitis as a side effect of metformin even in a healthy patient.

The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula.

Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.

Scleroderma hypertensive renal crisis among systemic sclerosis patients: A national emergency department database study.

BACKGROUND: Literature regarding trends for incidence and mortality of scleroderma renal crisis (SRC) in systemic sclerosis (SSc) within the United States (US) emergency departments (EDs) is limited. OBJECTIVE: To study the mortality of SRC among SSc patient encounters within the US EDs. METHODS: Data from the National Emergency Department Sample (NEDS) constitutes 20% sample of hospital-owned EDs and inpatient sample in the US were analyzed for SSc with and without SRC using ICD-9 codes. A linear p-trend was used to assess the trends. RESULTS: Of the total 180,435 encounters with the diagnosis of SSc in NEDS for the years 2009 2014, 771 or 4.27/1000 patients (mean age 59.6 ± 15.5 years, 75.4% females) were recorded with SRC. The numerical differences in mortality among SRC (32 or 4.1%) and non-SRC subgroups (5487 or 3.1%) did not reach statistical significance (p = 0.3). Major complications among SRC in comparison to non-SRC subgroup include ischemic stroke (5.6% vs 0.98%, p = 0.001), new-onset AF (8% vs 6.9%, p = 0.001), new-onset congestive heart failure (24.1% vs 8.8%, p = 0.001), pulmonary arterial hypertension (15.8% vs 10.9%, p = 0.001), respiratory failure (27.5% vs 10.5%, p = 0.001), and deep vein thrombosis (4.7% vs 4.6%, p = 0.001). Congestive heart failure (CHF) was strongly associated with SRC among SSc (OR 4.3 95%CI 2.7-6.7; p < 0.001). The absolute yearly rate of SRC had increased over the study years from 2.11/1000 to 5.79/1000 (linear p-trend 0.002) while the mortality trend remained steady. CONCLUSION: SRC is a relatively rare medical emergency. Although there has been a significant rise in the rate of SRC among SSc patients over the study years, mortality rates had remained steady. SSc patients with CHF should be considered to have low threshold for admission to inpatient services from EDs.

Recurrent Bacterial Vaginosis: An Unmet Therapeutic Challenge. Experience With a Combination Pharmacotherapy Long-Term Suppressive Regimen.

BACKGROUND: Recurrence of bacterial vaginosis (RBV) is a major challenge to effective therapy. Women experiencing intractable and frequent recurrences are ill-served by available treatment options, such as both antimicrobial and use of probiotics. METHODS: One hundred five women with RBV failing all recommended regimens seen in the clinic were prescribed combination oral nitroimidazole 500 mg twice a day for 7 days and simultaneous boric acid 600 mg daily per vagina therapy for 30 days; thereafter, they were prescribed twice-weekly vaginal metronidazole gel for 5 months in an attempt to prevent recurrence and followed by a 6-month observation period. Results reflect standard of clinic care in this uncontrolled retrospective cohort analysis. RESULTS: An initial regimen of nitroimidazole and simultaneous but prolonged vaginal boric acid achieved a satisfactory response (BV cure ≤2 Amsel criteria) in 92 of 93 available patients. Thereafter, a maintenance metronidazole gel prevented symptomatic BV recurrence in 69.6% of compliant patients at 6-month follow-up. Long-term cure at a 12-month follow-up was demonstrated in almost 69% of women reaching the 6-month observation phase. Vaginal candidiasis frequently complicated prolonged antibiotic prophylaxis requiring frequent antifungal rescue or prophylaxis. Frequent loss to follow-up in this long-term study influenced efficacy evaluation. CONCLUSIONS: In the absence of new antimicrobials or proven probiotic regimens, women with RBV may benefit from a prolonged drug-intensive antimicrobial regimen incorporating antibiofilm activity until newer measures are available. Additional randomized, control studies are needed.

Diagnosis and Management of Gastrointestinal Neuroendocrine Tumors: A Comprehensive Literature Review.

Neuroendocrine tumors (NETs) are epithelial neoplasms with predominant neuroendocrine differentiation and the ability to synthesize and secrete variable hormones and monoamines. They are relatively rare, accounting for 2% of all malignancy cases in the United States. The most common system affected by NETs is the gastrointestinal tract. Clinical presentation depends on the organ being involved and the hormone being secreted. It can be variable from asymptomatic incidental findings on imaging to intestinal obstruction, or carcinoid syndrome (CS). Several biochemical testings are developed to help with the diagnosis of NETs including 5-hydroxyindoleacetic acid (5-HIAA) and chromogranin A (CgA). Computerized tomography (CT) scans and magnetic resonance imaging (MRI) are the most commonly used modalities to localize the primary tumor and evaluate for metastasis. However, radionuclide imaging using somatostatin receptor-based imaging techniques has improved accuracy to detect smaller neoplasm. Surgical removal is the mainstay of treatment for locoregional tumors. Several medical managements are available for non-respectable NETs which include SSAs, peptide receptor radionuclide therapy (PRRT), and platinum-based chemotherapy agents.

Ocular Toxoplasmosis Mimicking Lymphoma: Exploring the Correlation and Distinction.

We present a case of a 74-year-old woman with chronic lymphocytic leukemia (CLL) who presented with unilateral blurry vision that had progressively worsened over a few weeks. Ophthalmic examination revealed unilateral anterior chamber, vitreous body inflammation along with retinal infiltration which was initially diagnosed with posterior uveitis. Analysis of vitreous fluid aspiration was negative for bacteria, fungal and viral etiologies. Despite the broad-spectrum intraocular antibiotics, her vision continued to decline, and she later developed retinal detachment. Cytology for lymphoma was negative. However, polymerase chain reaction (PCR) with internal transcribed spacer-specific (ITS) primer set detected Toxoplasma gondii, and the patient was diagnosed with intraocular toxoplasmosis. Treatment with systemic clindamycin, pyrimethamine, leucovorin, prednisone, and topical clindamycin for four weeks successfully prevented further ocular damage.