Metastatic Invasive Lobular Breast Cancer Presenting Clinically with Esophageal Dysphagia

Background. Intra-abdominal metastases of invasive lobular breast cancer (ILBC) may be insidious. We report a case of metastatic ILBC that presented with dysphagia within weeks of a negative mammogram and before the development of intra-abdominal symptoms. Case. A 70-year-old female developed esophageal dysphagia. She underwent EGD which showed a short segment of stricture of the distal esophagus without significant mucosal changes. Biopsy was unremarkable and patient underwent lower esophageal sphincter (LES) dilation. Severe progressive dysphagia led to esophageal impaction and three LES dilatations. CT scan showed bilateral pleural effusions, more prominent on right side, and ascites. The pleural effusions were transudative. Repeat EGD with biopsy showed lymphocytic esophagitis, and she was started on swallowed fluticasone. Abdominal ultrasound with Doppler showed that the main portal vein had atypical turbulent flow that was felt to possibly be due to retroperitoneal process. The patient underwent diagnostic laparoscopy which revealed diffuse punctate lesions on the peritoneum. Pathology was consistent with metastatic ILBC. Conclusion. Dysphagia in the setting of peritoneal carcinomatosis from metastatic ILBC is a rare finding. The case highlights the importance of metastatic ILBC as a differential diagnosis for female patients with progressive dysphagia and associated ascites or pleural effusions

Attendance, engagement and performance in a medical school curriculum: early findings from competency-based progress testing in a new medical school curriculum

Introduction Medical students often do not value attending in-person large group sessions. It is also not clear from prior research whether attendance at large group sessions impact on performance in medical school. The goal of this study was to assess the relationship between voluntary attendance in large group sessions organized as a “flipped classroom” in a new innovative curriculum and students’ mastery of clinical applications of basic science knowledge. Methodology Our students’ ability to apply basic science knowledge to clinical problems is assessed via progress testing using three methodologies: a locally developed multiple-choice examination, written examination developed through the National Board of Medical Examiners (NBME) Customized Assessment Services Program and post encounter questions included in a clinical skills examination. We analyzed the relationship between voluntary attendance at weekly large group “flipped classroom” sessions and the students’ performance on examinations given at four intervals over the initial 24-week module of the medical school curriculum. Results Complete data were available for 167 students. A total of 82 students (49.1%) attended all large group sessions, 65 students (38.9%) missed one or two sessions and 20 students (12.0%) missed three or more sessions. There were no difference between the students in the groups on their medical admission (MCAT) examination scores. The growth in performance from each time point until the next was statistically significant. There was no statistically significant difference in growth between the students who had no absences and those who had one or two absences. Students who missed three or more sessions performed significantly lower than their peers over the 24 week module and were more likely to score one or more standard deviations below the class mean on the assessments. Conclusions We found no relationship between attendance and MCAT scores suggesting the differences in performance on the progress tests was not due to initial differences in knowledge or reasoning skills. While the study was not experimental, it suggests large group sessions using a “flipped classroom” approach to provide reinforcement, feedback and practice may be effective for increasing learning and retention in the application of basic science knowledge among first year medical students

Isolated Left Main Coronary Artery Stenosis after Thoracic Radiation Therapy: To Operate or Not to Operate

Radiation therapy of neoplasms involving the chest or mediastinum results in a wide spectrum of cardiac complications including coronary artery disease, which can present in patients with few or no traditional cardiac risk factors. We report a case of radiation induced coronary artery disease in a 60-year-old female with a history of stage IIIA nonsmall cell lung carcinoma which was diagnosed eight years earlier and treated with chemotherapy and radiotherapy. She presented to the hospital with atypical chest pain that had occurred intermittently over the preceding week. Her initial electrocardiogram and cardiac enzymes were within normal limits. However, following an indeterminate exercise nuclear stress test, she developed chest pain and elevated cardiac enzymes. Coronary angiography demonstrated 90% stenosis of the left main coronary artery ostium, without any evidence of atherosclerotic disease or stenosis in other coronary arteries. She underwent surgical revascularization, which revealed dense adhesions surrounding the heart. During surgery, she developed severe bleeding and died. Coronary artery disease can present within years of radiation exposure, and ostial lesions are typical. Treatment is often challenging because of the effects of radiation on other tissues and the risks of revascularization procedures. Therefore, a multidisciplinary team approach should be considered

A randomized trial comparing digital and live lecture formats [ISRCTN40455708

BACKGROUND: Medical education is increasingly being conducted in community-based teaching sites at diverse locations, making it difficult to provide a consistent curriculum. We conducted a randomized trial to assess whether students who viewed digital lectures would perform as well on a measure of cognitive knowledge as students who viewed live lectures. Students' perceptions of the digital lecture format and their opinion as whether a digital lecture format could serve as an adequate replacement for live lectures was also assessed. METHODS: Students were randomized to either attend a lecture series at our main campus or view digital versions of the same lectures at community-based teaching sites. Both groups completed the same examination based on the lectures, and the group viewing the digital lectures completed a feedback form on the digital format. RESULTS: There were no differences in performance as measured by means or average rank. Despite technical problems, the students who viewed the digital lectures overwhelmingly felt the digital lectures could replace live lectures. CONCLUSIONS: This study provides preliminary evidence digital lectures can be a viable alternative to live lectures as a means of delivering didactic presentations in a community-based setting

Coagulopathy and Extremely Elevated PT/INR after Dabigatran Etexilate Use in a Patient with End-Stage Renal Disease

Introduction. Dabigatran is an oral direct thrombin inhibitor which has been approved for prophylaxis of stroke in patients with atrial fibrillation. The use of dabigatran etexilate increased rapidly due to many benefits. However, questions have been raised constantly regarding the safety of dabigatran etexilate. Case. A 58-year-old Caucasian male with a history of recurrent paroxysmal atrial fibrillation status after pacemaker and end-stage renal disease on hemodialysis came to the Emergency Department with the complaint of severe epistaxis. He had been started on dabigatran 150 mg twice a day about 4 months ago as an outpatient by his cardiologist. His prothrombin time (PT) was 63 seconds with international normalized ratio (INR) of 8.8 and his activated partial thromboplastin time (aPTT) was 105.7 seconds. Otherwise, all labs were unremarkable including the liver function test. Dabigatran was stopped immediately. His INR and aPTT trended downward, reaching normal levels 5 days after admission. Conclusion. Dabigatran is contraindicated in patients with severe kidney insufficiency as it is predominantly excreted via the kidney (~80%). Elderly patients over 75 and patients with chronic renal impairment should be carefully evaluated before starting dabigatran. Despite studies showing only mild increase in aPTT and PT/INR in patients receiving dabigatran, close monitoring may be reasonable in patients with renal insufficiency

Using a formative simulated patient exercise for curriculum evaluation

BACKGROUND: It is not clear that teaching specific history taking, physical examination and patient teaching techniques to medical students results in durable behavioural changes. We used a quasi-experimental design that approximated a randomized double blinded trial to examine whether a Participatory Decision-Making (PDM) educational module taught in a clerkship improves performance on a Simulated Patient Exercise (SPE) in another clerkship, and how this is influenced by the time between training and assessment. METHODS: Third year medical students in an internal medicine clerkship were assessed on their use of PDM skills in an SPE conducted in the second week of the clerkship. The rotational structure of the third year clerkships formed a pseudo-randomized design where students had 1) completed the family practice clerkship containing a training module on PDM skills approximately four weeks prior to the SPE, 2) completed the family medicine clerkship and the training module approximately 12 weeks prior to the SPE or 3) had not completed the family medicine clerkship and the PDM training module at the time they were assessed via the SPE. RESULTS: Based on limited pilot data there were statistically significant differences between students who received PDM training approximately four weeks prior to the SPE and students who received training approximately 12 weeks prior to the SPE. Students who received training 12 weeks prior to the SPE performed better than those who received training four weeks prior to the SPE. In a second comparison students who received training four weeks prior to the SPE performed better than those who did not receive training but the differences narrowly missed statistical significance (P < 0.05). CONCLUSION: This pilot study demonstrated the feasibility of a methodology for conducting rigorous curricular evaluations using natural experiments based on the structure of clinical rotations. In addition, it provided preliminary data suggesting targeted educational interventions can result in marked improvements in the clinical skills spontaneously exhibited by physician trainees in a setting different from which the skills were taught

Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians

In this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians examine the state of graduate medical education (GME) financing in the United States and recent proposals to reform GME funding. They make a series of recommendations to reform the current funding system to better align GME with the needs of the nation's health care workforce. These recommendations include using Medicare GME funds to meet policy goals and to ensure an adequate supply of physicians, a proper specialty mix, and appropriate training sites; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per-resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles

A Case of Diverticular Perforation in a Young Patient with Rheumatoid Arthritis on Methotrexate

Background. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX), are associated with gastrointestinal toxicity. MTX inhibits dihydrofolate reductase, but it is unclear if polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene predict toxicity. Case. We describe a 33-year-old male with polyarticular rheumatoid arthritis who developed sigmoid diverticular perforation while receiving methotrexate, folic acid, prednisone, and naproxen. He tested heterozygous for the C677T allele MTHFR gene. Discussion. Rheumatoid arthritis and its treatments are associated with increased risk of gastrointestinal disease. In one study, perforation was highest among individuals with concomitant exposure to NSAIDs, nonbiologic DMARDs, and glucocorticoids. Multiple mutations of the MTHFR gene have been identified, but their association with MTX toxicity is unclear. This case adds to a growing body of literature that could help inform the treatment of others in the future