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Brain metastases from hepatocellular carcinoma (HCCBM) are encountered very rarely in clinical practice, especially in western countries. Only a minority of patients undergoes resective surgery, as clinical picture is usually complex and presentation is often catastrophic with intra-cerebral hemorrhage (ICH). Neurosurgical intervention can be not only life-saving but may also alleviate significantly the burden of symptoms. We present the case of a patient with six metachronous hemorrhagic HCCBM in which emergent surgery extended survival by 9 months, of which seven spent in near-normal life quality, stressing the role of neurosurgery in the evaluation of HCCBM patients.

Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.

Cardiovascular disease is commonly encountered in the adult population and has large impacts on morbidity and mortality. The ever-expanding evidence base for the use of integrative medicine in cardiology necessitates providers caring for patients with cardiovascular disease to be familiar with these therapies. However, providers may find it difficult to adequately discuss these therapies in an average office visit. Through a case-based, question-and-answer approach, the authors review some clinically relevant and helpful research that addresses the incorporation of integrative medicine in cardiovascular disease prevention.

Depression in older adults is a mood disorder associated with physical and/or cognitive impairment. Though it may be present in a variety of settings, depression is a prominent health concern among long-term care and nursing facility residents. Pharmacologic therapy may be considered in patients with depression who have not responded to nonpharmacologic therapy or are experiencing considerable disability. There are a variety of commonly prescribed antidepressant drug options for this indication. Examples may include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, or serotonin modulators. As the use of these agents continues in older adults, senior care pharmacists should be familiar with the evaluation of its safe and combined use (e.g., drug interactions, adverse effects).

The rapid integration of highly sensitive next-generation sequencing technologies into clinical oncology care has led to unparalleled progress, and yet these technological advances have also made genetic information considerably more complex. For instance, accurate interpretation of genetic testing for germline/inherited cancer predisposition syndromes and somatic/acquired pathogenic variants now requires a more nuanced understanding of the presence and incidence of clonal hematopoiesis and circulating tumor cells, with careful evaluation of pathogenic variants occurring at low variant allele frequency required. The interplay between somatic and germline pathogenic variants and awareness of distinct genotype-phenotype manifestations in various inherited cancer syndromes are now increasingly appreciated and can impact patient management. Through a case-based approach, we focus on three areas of particular relevance to the treating clinician oncologist: (1) understanding clonal hematopoiesis and somatic mosaicism, which can be detected on germline sequencing and lead to considerable confusion in clinical interpretation; (2) implications of the detection of a potentially germline pathogenic variant in a high-penetrance cancer susceptibility gene during routine tumor testing; and (3) a review of gene-specific risks and surveillance recommendations in Lynch syndrome. A discussion on the availability and difficulties often associated with direct-to-consumer genetic testing is also provided.

The School of Veterinary Medicine, University College Dublin, Ireland, restructured the teaching of general pathology, parasitology, and microbiology in third year in 2018 as part of the development of an outcome-based curriculum. A new integrated teaching module was created, called Veterinary Pathobiology, which encompassed the three paraclinical subjects, worth 20 ECTS credits. Subject integration was driven and supported by case-based learning (CBL) activities, and practical classes, which were aimed at facilitating the understanding of basic disease processes, infectious agents, and the application of diagnostic tests. The disciplines maintained their identities within lectures which were aligned by content. The restructuring led to a reduction of contact hours by 20% and of assessment time by 40%. The examinations included integrated questions with an emphasis on the material students had covered in their CBL. Despite positive outcomes, which included equivalent examination scores and positive written feedback by students on teaching and learning, understanding, assessment, relevance, CBL, group work, and generic skills, the average scores for overall student satisfaction dropped dramatically in the second academic year of implementation. This followed the introduction of new regulations by the University relating to student progression, which was capped at "carrying" 10 ECTS credits, thus preventing students that failed the new module from progressing. Other criticisms of the new module by students included too little communication on the changes implemented in its first iteration and a workload perceived to be too heavy. Further restructuring is therefore necessary. This study highlights the process/pitfalls of integration/curricular innovation.

Young adults with sickle cell disease must navigate a difficult road to independence once they age out of pediatric care. The anxiety surrounding transition, the challenges of medical complications, and chronic psychosocial stressors are obstacles to a seamless transition to adult medical care. The two cases presented here demonstrate that a team-based, multidisciplinary approach can facilitate a successful transition.

OBJECTIVE. The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION. A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.

Context.—Professionalism issues in residency training can be difficult to assess and manage. Generational or role-based differences may also exist between faculty and residents as to what constitutes unprofessional behavior and how to manage it. Objective.—To examine and compare how faculty and residents would approach the same 5 case scenarios detailing various aspects of unprofessional behavior. Design.—Five case scenarios highlighting various unprofessional behaviors were presented in a workshop at an annual meeting of pathology department chairs, residency program directors, and undergraduate pathology medical educators (ie, pathologists involved in medical student pathology education). The same cases were presented to a cohort of pathology residents currently in training. A standard set of responses were offered to the participants, polling results were collected electronically, and results were compared. Results.—Faculty and residents were fairly consistent within their respective groups. In a subset of cases, faculty were more likely to favor working with the individual in the scenario, whereas resident respondents were more likely to favor either no response or a severe response. Generational or role-based differences were also potentially evident. Conclusions.—Assessing expectations and differences around professionalism for both faculty and residents should be considered as part of any educational and management approach for professionalism. Although a level of generational differences appears to be evident in this study regarding the recognition and management of unprofessional behavior, there was also agreement in some cases. Further exploration into the discrepant responses between faculty and residents may prove useful in developing educational, assessment, and remediation resources.

Coronary artery disease remains the leading cause of mortality worldwide, and the identification of at-risk individuals represents a significant clinical challenge. In this review, a typical clinical case is presented, followed by a discussion of the cardiovascular risk assessment of such individuals. Specifically, the role of imaging modalities such as carotid intima-media thickness measurements and coronary artery calcium scoring is explored. Case resolution and recommendations are subsequently suggested.

The evaluation of the patient with diarrhea can be complex and the treatment challenging. In this article, the definition of diarrhea and the pathophysiologic mechanisms that lead to diarrhea are reviewed. A simplified 5-step approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday clinical practice. On completion of this article, you should be able to (1) define diarrhea, (2) outline various pathophysiologic mechanisms of diarrhea, and (3) describe a simplified 5-step approach to facilitate the evaluation of diarrhea.

On the basis of an interesting case of a 40-year-old lady with an atrial septal defect, we describe a simple approach for complex shunt volume calculations based on the Fick principle using hemodynamic data obtained in the catheterization laboratory. Understanding Fick's principle allows determination of all relevant flows, flow ratio, and resistances without having to resort to memorization of complex formulae. Those findings significantly impact the managements of patients like ours with hemodynamically and clinically relevant shunting.

For collaborative patient-centered practice models to develop, improved collaboration in the workplace is needed. In this project we aimed to create a model of continuing professional development (CPD) using a case based approach that would allow the exchange of information between primary health care providers in the community. Over 60 participants from community care sectors including physicians, nurses and administrators participated in a planning group and two consultation workshops. Using participatory action research methods, themes contributing to and inhibiting communication, collaboration and coordination of care in the community were identified. Recommendations for solutions were prioritized and implemented. Evaluations suggest that the case scenario and consultation approach successfully focused participants to address relevant local issues to improve collaboration among community providers.

OBJECTIVE: To develop and implement an electronic, interactive, case-based cytopathology educational system for second-year medical students. STUDY DESIGN: Ten different learning modules, corresponding to various organ systems in pathology and encompassing the essence of clinical cytopathology, were developed. The modules are software-based, menudriven, digital programs that are displayed on a computer monitor and can be projected onto a large screen via LCD projectors. Each module takes 15-20 minutes to complete and contains three to four case-based interactive clinical scenarios. Each case contains sequenced, multiple-choice questions with immediate feedback. Each module also includes an atlas mode for viewing all the case images plus additional images to enrich the learning experience. RESULTS: Preliminary feedback from students taking the pathology course has shown encouraging responses. The students enjoyed the practical approach of the modules, finding them easy to use. Their interest level remained high as they discovered how their general medical knowldedge could apply to solving real-life clinical cytopathology cases. CONCLUSION: By utilizing these unique instructionnal modules in the second-year pathology course, medical students learn the application of clinical cytopathology in everyday medical practice. This not only provides them with the theoretical background and morphologic knowledge of the diseases taught but also gives them the ability to apply it in simulated real-life clinical scenarios.

Karl H. Kraus, Steven M. Fox, Fredrick S. Pike and Emily C. Salzer 170 pages, hardback, £59.99 CRC Press. 2016. ISBN 978 1 4987 3242 0 This book has proved popular in a busy first-opinion clinic. The case-based approach is easily accessible and provides a wealth of information without being too taxing. The pictures are large, frequent and good quality. I found it easy to dip into this book and read one or two cases at random. The book is in two parts: ‘Basic concepts’ and ‘Clinical cases’. The first section is devoted to the fundamentals of fracture repair and starts by discussing classification …

Radiologists are familiar with the use of radiographs, computed tomography, magnetic resonance imaging and ultrasound in the acute clinical setting. However, there are some specific clinical scenarios which may be found in nuclear medicine imaging problem-solving tools. These clinical scenarios and imaging techniques are less frequent, and the referring clinician from the emergency department may not consider these alternatives. It is important for the radiologist to be aware of these techniques to be able to guide the clinician to use those tools, which may result in optimal patient care. In this article, we will discuss those nuclear medicine studies which have application in the setting of an emergency radiology practice.

Pain Medicine: An Interdisciplinary Case-Based Approach Eds. SM Hayek, BJ Shah, MJ Desai & TC Chelimsky New York, Oxford University Press; 2015; pp. 429; ISBN 978-0-19-993148-4 Sherlock Holmes is my hero. All his adventures start with a case presentation by a petitioner, followed up by further questions by the great detective. He ruminates about the case, then goes to the scene of the crime, armed with various diagnostic equipment. All relevant information is disclosed by Dr. Watson to the reader. The whole process “starts on the supposition that when you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.” This volume, Pain Medicine: an interdisciplinary case-based approach, follows this time honored format. The four editors have achieved for this volume what Dr. Watson achieved for Sherlock Holmes. The adventures in pain medicine are written with a consistent style devoid of errors. They lead the reader along a logical path through the diagnostic process to a satisfactory conclusion. I found the volume engaging, educational, and entertaining. The chapters all begin with a case presentation, followed by a series of pertinent questions. As each question is addressed, further clinical and …

Introduction Any method to enhance patient care and safety is of great significance to those putting their trust in physicians charged with caring for the ill. Simulation is an effective tool for teaching the complexities of caring for critically ill patients because it allows for the development of the cognitive skills necessary to quickly analyze a situation and intervene in a timely manner to avoid patient harm. This resource describes the approach to a multistage didactic for training critical care fellows using simulation on typical scenarios encountered in the intensive care unit (ICU). Methods The resource comprises seven sessions, each one building upon events encountered in the prior session. The patient in the case, given the severity of her/his condition at the time of admission, would be expected to respond poorly to treatment and have a multitude of complications while being cared for in the ICU. Each session consists of a 25-minute practical part and a 25-minute debriefing. In addition to the trainees, a faculty facilitator, embedded nurse educator (at the bedside to convey information and implement orders), and simulator technician (to monitor the manikin and adjust settings accordingly) are necessary to complete the endeavor. The curriculum is best implemented via monthly sessions and completed over a 7-month period. Results This curriculum has been in place at our medical center for 3 years and has been well received by trainees and facilitators. It was originally implemented in July 2010 with first-year critical care fellows. During the first year of its use, fellows found engaging in the situation easier with each passing month and actually commented on the reality of each session. In July 2011, the case was again used, with minor adjustments based upon feedback from the initial group, including changes to the patient's physiology, laboratory data, and feedback mechanisms to further enhance the learning experience. In July 2012, a third pair of fellows participated in these learning sessions, and the process evolved to incorporate multiple-choice questions for each session (as a mode of objectively testing learners' understanding) plus assigned reading prior to each session. Discussion The simulation format promotes a learning-centered environment encouraging trainees to actively engage in their education and allowing teachers to adjust the educational experience to better address trainees' learning needs. We continue to refine this curriculum based on trainee feedback. The latest iteration has the trainees take on more responsibility, reinforcing the active learning approach the curriculum embraces. In the future, we plan to start collecting data from trainees' pre- and postcurriculum performances in the ICU to better evaluate the effectiveness of this resource.

Noninvasive positive pressure ventilation (NIPPV) has revolutionized the concept of mechanical ventilation with the major benefit of avoiding invasive mechanical ventilation in specific situations, thereby preventing associated complications. Noninvasive positive pressure ventilation has emerged as the first line of management of hypercapnic respiratory failure (due to chronic obstructive pulmonary disease and neuromuscular weakness) and cardiogenic pulmonary edema in addition to standard therapy in the acute setting. There is improvement in gas exchange, relief of respiratory muscle fatigue, and clinical outcome with reduced morbidity and mortality. Nevertheless, contraindications and failures need to be identified early, as delaying endotracheal intubation is associated with increased morbidity and mortality. Despite overwhelming evidence to support its use, NIPPV is underused. Residents and hospitalists need to identify NIPPV as a treatment option in acute respiratory failure.

After a description of the appropriate techniques, the presentation will use a case based approach to describe the value of electrophysiological assessment in the diagnosis and management of paediatric patients.

The lecture will discuss some of the causes of fleck or spot lesions in the retina, and use a case based approach to demonstrate the value of electrophysiological testing in their differential diagnosis.

Introduction Creative approaches to chair development are needed, especially for new college of medicine chairs who confront a host of unique challenges when they assume their roles. This resource was developed and implemented to provide a case-based approach to chair development for a new chairs' retreat. Methods This resource contains the four cases, each of which was developed and facilitated by a content expert who was an experienced chair or a senior dean. Small groups of new chairs plus one experienced chair discussed each case, and then came together to define the issues the case raised for the new chair, and possible approaches to solutions. Results A postretreat anonymous evaluation survey showed that the participants found the case-based structure of the retreat very valuable, the cases highly effective at promoting meaningful discussion, and the involvement of experienced chairs to be an important component. The participants' survey comments highlighted the opportunity for collegial and collaborative chair interactions as being the most valuable aspect of the retreat. Discussion Little has been written about chair development, thus highlighting the significance of the work. The development of the retreat was based on evidence from educational research that suggests that people learn best in an interactive format, and that relationship building is key to creating effective leadership teams.

The Annual Meeting of the Orthopaedic Trauma Association (OTA) continues to grow in size, scope, and number of attendees. The 2013 meeting was held in the desert resort venue of Phoenix, Arizona from October 9th to 12th. The Annual Meeting was preceded by several well attended events including the Basic Science Fracture Forum, the International Trauma Care Forum, a ‘Trauma Boot Camp’ for practitioners needing a trauma refresher, a grant writing workshop, a Masters Level Coding Course, a course for Physicians Assistants and Nurse Practitioners, and a Young Practitioners Forum. Concurrently running with the Annual Meeting was a Residents Basic Fracture Course that uses a case based approach to teaching fracture care fundamentals for orthopaedic trainees. There were 105 podium presentations in nine scientific sessions, along with 128 poster presentations. In the meeting’s well-attended opening symposium, the focus was on evaluating outcomes for the 21st century. The session highlighted the use of a Patient Reported Outcomes Measurement Information System (PROMIS), which is a system of highly reliable, precise measures of patient-reported health status for physical, mental, and social well-being. Several randomised studies were presented in the foot and ankle scientific session. A total of 110 patients were enrolled in a prospective randomised study that compared early weight-bearing and mobilisation with non-weight bearing and immobilisation after open reduction and internal fixation (ORIF) of unstable ankle fractures.1 Patients treated with the early weight-bearing protocol had significantly …

Current guidelines support dual antiplatelet therapy with aspirin and clopidogrel (Plavix) in a number of clinical scenarios, ie, in ST-segment-elevation myocardial infarction (MI), non-ST-elevation MI, and percutaneous coronary intervention. The guidelines are based on strong evidence from several large randomized clinical trials over the last 10 years. The authors present several cases to show how to put this evidence into day-to-day clinical practice.

Corneal dystrophies present huge challenges to eyecare professionals. Apart from visual loss due to opacification many dystrophies cause painful recurrent erosions. Surgery remains the cornerstone of managing these problems. Many surgical approaches have been used to address the complications of dystrophies and this lecture will describe the different approaches so that the practicing optometrist can understand and explain to patients what may be required in their future management if the condition deteriorates.