Diffuse Arterial Atherosclerosis Presenting With Acute Ischemic Gastritis.

Ischemic gastritis is a rare cause of gastrointestinal bleeding due to the rich blood supply of the stomach. A 66-year-old lady with a history of coronary artery disease and hyperlipidemia presented with acute abdominal pain, diarrhea, and recent coffee-ground emesis. She had diffuse abdominal tenderness on physical exam with mild leukocytosis. A CT scan of the abdomen showed new peripheral wedge-shaped hypoenhancing regions in the spleen and both kidneys, suggestive of embolic infarcts. Posterior pneumatosis of the stomach suggestive of gastric wall ischemia was detected, with associated portal venous gas. She was started on heparin anticoagulation, broad-spectrum antibiotics, and intravenous fluids and underwent an urgent upper endoscopy showing hemorrhagic mucosa and fibrinous debris. A transesophageal echocardiogram showed mild aortic atherosclerosis. A CT angiogram of the abdomen showed calcified plaques at the origins of the hepatic artery, celiac artery, and superior mesenteric artery with severe ostial narrowing. Symptoms resolved, and she was started on statin therapy, prophylactic anticoagulation with apixaban, and high-dose peptic ulcer prophylaxis with pantoprazole. This ischemic gastritis case with multiple embolic spleen and kidney lesions is likely a sequela of extensive atherosclerosis and suggests that extensive atherosclerosis should be considered as a rare cause of acute gastrointestinal bleeding.

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.

The Role of Using Red-Topped - Non-Additive-Containing - Collecting Tube in Diagnosing Pseudohyperkalemia in Chronic Lymphocytic Leukemia.

Pseudohyperkalemia in the context of chronic lymphocytic leukemia (CLL) is becoming a common clinical presentation in our daily practice, yet the recognition and the overall approach to this condition remains a challenge as clinicians ponder on whether it's a true rise of serum potassium or not, weighing the risk-benefit ratio of giving the full anti-hyperkalemia measures, dreading the potential iatrogenic hypokalemia if it proves to be a pseudohyperkalemia instead.