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A female in her 60s with vague abdominal symptoms was found to have a pancreatic mass in her CT scan. A core needle biopsy done endoscopically demonstrated a poorly differentiated adenocarcinoma. The patient completed nine cycles of neoadjuvant systemic mFOLFIRINOX. Repeat staging demonstrated a partial radiographic response. She underwent an open pylorus-preserving pancreatoduodenectomy with segmental superior mesenteric vein resection with primary reconstruction (ISGPS Type 3). The final pathology demonstrated a poorly differentiated adenosquamous carcinoma, R1 margin status. The case report demonstrates the effect of mFOLFIRINOX on pancreatic adenosquamous (PASC) carcinoma with a review of the microscopic pictures following the neoadjuvant therapy. It can be postulated that glandular component being the major component in a PASC has a good response to mFOLFIRINOX like that seen in pancreatic ductal adenocarcinoma with some presumed effect on the squamous component as well. From the above case report, we are proposing that mFOLFIRINOX can be an effective chemotherapy regime in the management of PASC. [ABSTRACT FROM AUTHOR]

Objectives: Many medical specialties have adopted the use of ultrasound, creating demands for higher‐quality ultrasound training at all levels of medical education. Little is known about the long‐term benefit of integrating ultrasound training during undergraduate medical education. This study evaluated the effect of a longitudinal fourth‐year undergraduate medical education elective in ultrasound and its impact on the future use of ultrasound in clinical practice. Methods: A cross‐sectional survey of medical graduates from The Ohio State University College of Medicine (2006–2011) was done, comparing those who participated and those who did not participate in a rigorous ultrasound program for fourth‐year medical students. A 38‐item questionnaire queried graduates concerning ultrasound education in residency, their proficiency, and their current use of ultrasound in clinical practice. Results: Surveys were completed by 116 respondents, for a return rate of 40.8% (116 of 284). The participants of the undergraduate medical education ultrasound elective (n = 61) reported more hours of ultrasound training after graduation (hands‐on training, bedside scanning, and number of scans performed; P <.001), higher ultrasound proficiency (proficiency in using ultrasound for clinical decision making, use in emergency settings, and use of novel techniques; P<.001), and higher rates of ultrasound use in clinical practice (P <.001). Conclusions: The longitudinal undergraduate medical education ultrasound elective produced physicians who were more likely to seek additional training in residency, evaluate themselves as more proficient, and use ultrasound in their clinical practice. Early training in bedside ultrasound during undergraduate medical education yields physicians who are better prepared for integration of ultrasound into clinical practice. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 47-year-old male who was diagnosed with acute respiratory distress syndrome. The patient had inhaled chlorine gas while mixing an industrial grade chlorine solution and developed dyspnea. The patient administered with emergent endotracheal intubation for positive airway pressure. It highlights the acute management of chlorine gas inhalation injury through an inhalation therapy.

Gallbladder rupture, though rare, is a serious complication often arising from choledocholithiasis and subsequent interventions such as endoscopic retrograde cholangiopancreatography (ERCP). In this case, the patient presented with acute choledocholithiasis and underwent ERCP with sphincterotomy and stone extraction, followed by placement of a fully covered metal stent in the common bile duct (CBD). While the use of covered stents is appropriate, it is important to note that these stents can obstruct the cystic duct orifice in patients with a gallbladder. This occurs in more than 33% of patients with a low cystic duct junction, leading to obstructive acute cholecystitis, as seen in patients with pancreatic ductal adenocarcinoma (PDAC) or distal cholangiocarcinoma who receive metal biliary stents. In this case, the patient developed a liver abscess following a gallbladder rupture, likely due to the stent obstructing the cystic duct. The liver abscess was managed with percutaneous drainage, and cultures grew Streptococcus anginosus , a common pathogen in hepatobiliary infections. The patient was treated with IV piperacillin-tazobactam, followed by oral amoxicillin-clavulanate for a 4-6 week course. Additionally, portal vein thrombosis, a known complication of severe infection, was identified and treated with anticoagulation. This case highlights the need for careful stent selection and possible prophylactic cholecystectomy in patients with a functioning gallbladder to prevent post-ERCP complications like cholecystitis and abscess formation. Early diagnosis, timely drainage, and appropriate antibiotic therapy are critical to managing such complex hepatobiliary conditions., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Louis et al.)

Minimally invasive distal pancreatectomy has had significant adoption in the United States over the past decade. Robotic distal pancreatectomy is a type of minimally invasive technique which affords greater dexterity and visualization compared to traditional laparoscopy. In addition to standard distal pancreatectomy procedures with or without splenectomy, the use of robotic surgical systems has been efficacious in performing more complex techniques such as radical antegrade modular pancreatosplenectomy (RAMPS) or spleen-preservation. There are important technical considerations to performing robotic distal pancreatectomy procedures which differ from other minimally invasive approaches. The purpose of this report is to describe the rationale and technical considerations for implementation of robotic distal pancreatectomy procedures in clinical practice., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

This project was designed to use existing evidence in education and clinical quality improvement to design an educational and clinical model specific for physician-performed focused sonography. The I-AIM model (indication, acquisition, interpretation, and medical decision making) was created to serve as both a mnemonic and checklist. The model follows a stepwise logic for performing focused sonographic examinations and contains detailed subcomponent listings that cover specific areas to improve use and performance. Although validation and reliability studies will be required before implementation, the I-AIM model represents the first effort to standardize and improve clinical and educational focused-sonography.

Objectives: Ultrasound image interpretation and education relies on obtaining a high-quality ultrasound image; however, no literature exists to date attempting to define a high-quality ultrasound image. The purpose of this study was to design and perform a pilot reliability study of the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method for ultrasound quality image assessment., Methods: A single sonologist performed a Trinity hypotensive ultrasound protocol on 3 participants of varying body types. Each participant's ultrasound examination was repeated in 4 locations; static clinic location, mobile ambulance, airplane, and helicopter. Images were reviewed by a sonographer, radiologist, and emergency medicine physician using the B-QUIET method and underwent statistical analysis using generalizability theory for reliability of the assessments using the tool., Results: The B-QUIET method showed high reliability of most subscale items. Approximately two-thirds of the reviewed images had complete inter-rater reliability on 90% of the items. There was relatively low inter-rater reliability for the Identification/ Orientation subscale items. The inter-rater reliability κ value was calculated as 0.676 overall for the method., Conclusions: The need for a standardized method to evaluate the quality of an ultrasound image is well documented. The B-QUIET method represents the first attempt to quantify the sonographer component of ultrasound images. Further reliability and validation studies of this method will be needed; however, it represents a tool for standardized ultrasound interpretation, ultrasound training, and institutional quality assessment.

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.