Core Practical Objectives: a means to standardize the 4th-year emergency medicine clerkship.

BACKGROUND: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. PURPOSE: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). METHODS: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. RESULTS: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. CONCLUSIONS: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.

Practice makes perfect: progressive improvement of laparoscopic pyloromyotomy results, with experience.

INTRODUCTION: Pyloric stenosis can now be treated effectively with laparoscopic pyloromyotomy (LP). Few large outcome studies have been published regarding the laparoscopic technique. In this paper, we describe our experience with the first 185 consecutive LPs. MATERIALS AND METHODS: An institutional review board-approved retrospective outcomes analysis was performed on our first 185 consecutive LPs. Previous publications comparing open pyloromyotomy (OP) and LP are reviewed. Our hypothesis is that, with experience, the outcome of LP will equal or surpass that of OP. RESULTS: A total 185 infants underwent LPs during the study period. The infants had median values of age: 33 days; body weight: 4 kg; surgery duration: 25 minutes; postoperative length of stay (LOS): 25.5 hours; and total LOS: 45 hours. There were 7 complications (3.78%): 4 incomplete pyloromyotomies (2.2%), 1 pyloric mucosal perforation (0.5%), 1 delayed duodenal perforation (0.5%), and 1 wound infection (0.5%). There has been a progressive reduction in the time required for surgery, from a median of 29 minutes in the first 60 cases to 21.5 in the last 65. Postoperative LOS has fallen from a median of 26 hours in the first half to 24.5 in the later half. Complications occurred primarily in the first third of our cases. CONCLUSIONS: We are able to demonstrate that, with experience, one can expect progressive improvement in the outcomes following LP in infants. Our surgery duration and complications in the last 65 cases are better than most published results for OP or LP.

Metastatic breast cancer presenting as linitis plastica of the stomach.

Early detection and treatment of breast cancer, leading to longer survival, has revealed the natural history of this disease process. Linitis plastica of the stomach is a potential long-term sequela of metastatic breast cancer. Here we present a case of metastatic breast cancer presenting as linitis plastica, as well as the treatment algorithm for this rare clinical entity. The world literature describes a clear pattern of linitis plastica for metastatic infiltrating lobular breast cancer and a discrete nodular pattern for infiltrating ductal cancer, in regard to metastasis to the stomach. To our knowledge, this is the first case of infiltrating ductal cancer presenting as linitis plastica of the stomach.