Background Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety. Methods We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days. Results There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as “page me if you need me,” resulted in approximately 50% of residents reporting they would “rarely” or “never” call and another 41% reporting they would only “sometimes” call their attending physicians. Conclusions Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as “page me if you need me,” rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.

Background Distinguishing sepsis from other inflammatory syndromes continues to be a clinical challenge. The goal of risk stratification tools is to differentiate sepsis from other conditions. We compare the ability of quick sepsis-related organ failure assessment (qSOFA) and systemic inflammatory responses syndrome (SIRS) scores to predict prolonged length of stay (LOS) among patients who presented to the emergency department and hospital ward with acute pancreatitis (AP). Methods We compiled a retrospective database of all adult patients hospitalized for AP during 2015 - 2018 at a single tertiary care center. Independent t -tests, Pearson’s correlation and multiple regressions were performed with hospital LOS as the dependent variable, versus demographic characteristics and etiology of the pancreatitis as independent variables. Prolonged LOS was defined as > 5 days. Results The sensitivity and specificity of an SIRS score of 2 or greater for the detection of patients with prolonged LOS were 61% and 80%, respectively. The qSOFA score of 2 or greater corresponded to a diagnosis of significant AP with a specificity of 99% and a sensitivity of 4%. Multiple regression analysis demonstrated that each point increase in an SIRS score is associated with 2.24 days in additional hospital LOS. Interestingly, SIRS scores were found to correlate with the LOS, but not qSOFA. Conclusion The qSOFA is a tool designed to identify patients at high risk of mortality due to sepsis. The data suggest that as with sepsis, patients with AP who are triaged with only qSOFA could be underrecognized and subsequently undertreated. Secondarily, the data suggest that SIRS scoring has the potential to promptly predict how long patients with AP will stay in the hospital.

Nephrocolic fistula is a rare, abnormal fistulous connection between the urinary system (kidney/ureters) and colon. Different benign and malignant etiologies are implicated in the formation of a nephrocolic fistula. Even though conservative treatment options have been tried recently (especially for benign etiologies), surgical resection has been the treatment of choice and should be pursued if conservative management fails. We report the first case of a nephrocolic fistula after a radiofrequency ablation of a renal cell carcinoma, which required surgical resection after conservative management failed.

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AIMTo evaluate the clinical and economical efficacy of lumen apposing metal stent (LAMS) in the treatment of benign foregut strictures.METHODSA single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and five-parameter regression analysisRESULTSNine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS (stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall. LAMS was cost effective after two dilations in the Post-surgical stricture subgroup.CONCLUSIONEndoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.