Metastatic mixed VIPoma/PPoma-induced diarrhoea causing renal failure.

Summary: Vasoactive intestinal peptide-secreting tumours (VIPomas) are an extremely rare form of functional pancreatic neuroendocrine tumour with an estimated annual incidence of 1 in 10 million. Associated tumour hypersecretion of other peptides, including pancreatic polypeptide (PPomas), may also be seen. These malignancies classically present with a defined triad of refractory diarrhoea, hypokalaemia and metabolic acidosis known as Verner-Morrison syndrome. Diagnosis is frequently delayed, and the majority of patients will have metastatic disease at presentation. Symptoms are usually well controlled with somatostatin analogue administration. Here we report a case of metastatic mixed VIPoma/PPoma-induced diarrhoea causing renal failure so severe that ultrafiltration was required to recover adequate renal function. Learning points: Profuse, watery diarrhoea is a common presenting complaint with a multitude of aetiologies. This, combined with the rarity of these tumours, makes diagnosis difficult and frequently delayed. A functional neuroendocrine tumour should be suspected when diarrhoea is unusually extreme, prolonged and common causes have been promptly excluded. These patients are likely to be profoundly unwell on presentation. They are extremely hypovolaemic with dangerous electrolyte and metabolic abnormalities. Aggressive initial rehydration and electrolyte replacement are imperative. A somatostatin analogue should be commenced as soon as the diagnosis is suspected. This is an extreme example of Verner-Morrison syndrome. We are unaware of another case where renal failure secondary to diarrhoea and dehydration was so severe that renal replacement therapy was required to restore adequate renal function, further emphasising how critically unwell these patients can be. Both the primary tumour and metastases showed a remarkably good and rapid response to somatostatin analogue administration. Cystic change and involution were noted on repeat imaging within days. Prior to his illness, this patient was extremely high functioning with no medical history. His diagnosis was an enormous psychological shock, and the consideration and care for his psychological well-being were a crucial part of his overall management. It highlights the importance of a holistic approach to cancer care and the role of the clinical nurse specialist within the cancer multidisciplinary team.

"Flipped Learning" in Disaster Triage: Polarizing Medical Student Attainment?

"Flipped learning" has become increasingly popular in medical education as a means of developing independent learning skills in students. The article by Zheng at al. (2020) highlights the potential utility of this approach in disaster triage training. However, the article also highlights to us some concerns regarding how "flipped learning" may favor certain learners over others in the provision of disaster triage education. Specifically, the article demonstrates the necessity for increased preclassroom preparation when a "flipped classroom" model is used, which inevitably privileges those with a higher ability to engage with self-directed learning. Although such a skill is important to develop in medical education, we fear it may lead to polarized student attainment rather than ensuring a maximum number of students achieve the requisite standard required. More research is consequently needed to inform the most efficacious means of facilitating disaster triage training that supports all students sufficiently, while also helping to nurture their independent learning skills.

Medical Teaching and Assessment in the Era of COVID-19.

The coronavirus pandemic has had a significant influence on medical education, most notably in terms of content delivery and provision of assessments. These unique times have facilitated the introduction of many new educational methods in medical schools globally each of which with potential merits and drawbacks. Importantly, the use of remote platforms to carry out online teaching has been especially vital in ensuring the continued training of doctors but other techniques such as telemedicine, online clinical case repositories and even virtual reality headsets are also being used to overcome these difficult circumstances. Some institutions also opted for open book written examinations raising issues surrounding this format's legitimacy and potential benefits. Practical examinations are even harder to facilitate and although most were cancelled, this crisis may result in innovation which changes their future format. For example some may include audible clinical signs played online through a computer speaker to replace clinical examination. Overall, the COVID-19 pandemic has caused an overhaul of medical school orthodoxy that whilst disruptive, may serve to expose institutions to novel means of teaching and assessment which may ultimately improve medical education in future.