the regular use of podcasts in internal medicine residency training programs; here, we ... and to provide a catalog of clinical pearls that residents could review.
LETTERS We started creating an audio file (podcast) every week containing teaching pearls from each morning report. We thought that this format would take advantage of our residents' interest in technology because, in other settings, learners rate podcasts highly when they are used for teaching (5). We are not aware of other reports describing the regular use of podcasts in internal medicine residency training programs; here, we describe a proof of principle that shows that podcasts can be produced and shared easily for residency teaching. Objective: To help residents identify and learn important clinical information regardless of whether they attended morning report and to provide a catalog of clinical pearls that residents could review at their convenience. Methods: We conduct a 45-minute morning report 5 days per week as part of an internal medicine residency training program accredited by the Accreditation Council for Graduate Medical Education at a tertiary care university hospital. A total of 80% of our morning reports involve a resident presenting a case to medical students and other residents, with an invited faculty member or a chief resident (whom we call an assistant chief of service [ACS]) guiding the discussion. Afi:er each morning report, the ACS uses a smartphone to record a 1- to 2-minute structured conversation with the presenting resident. Before the recording, the ACS helps the resident identify salient teaching pearls and provides guidance about how to summarize them succinctly. At the end of each week, the ACS uploads the audio files onto a desktop computer; converts them to MP3 format using iTunes, Version 11 (Apple, Cupertino, California); and then manually edits them for brevity and clarity and splices them together using a freeware program (www.wavosaur.com). Music written and recorded by one of our residents provides interludes between the interviews, and the ACS adds an introduction and table of contents at the beginning of each podcast. The finalized recording, called Podcast Pearls, is then sent to residents and faculty each week via secure intranet e-mail that provides an index of the topics and presenters for that podcast. We also archive the recordings on a secure intranet Web site to facilitate review. Appropriate measures protect patient confidentiality. Findings: Weekly podcasts can be created relatively cheaply and quickly with existing personnel, a smartphone, a desktop computer, and free software programs. Each podcast averages 8 minutes and requires 5 to 10 MB of computer memory. The ACSs estimate spending 2 hours per week on each podcast; roughly 10 hours were spent in the beginning exploring how to make and refine the podcasts. We encountered no major technical problems in creating and disseminating the podcasts, and residents did not report problems accessing them from e-mails or the Web site. No resident presenter declined to participate in the interview recordings, and most enjoyed working with the ACS to summarize the teaching pearls and playing an active role in creating an educational tool for their peers. After 4 months, we sent a voluntary, anonymous, electronic survey to all 57 residents and 49 faculty members who asked to receive the weekly podcasts. A total of 53% of residents and 37% of faculty members responded. Among residents, 70% reported using the podcasts and 23% reported using one half or more of the podcasts. All of the residents who used the relevant podcast when not able to attend morning report learned something new, with 46% www.annals.org
reporting that they learned something new "often" or "always" in this situation. All of the faculty members who responded to the survey reported listening to 1 or mote podcast. A total of 94% of faculty reported that the Podcast Pearls made them feel more connected to residents, and 56% reported that the podcasts improved their learning. Discussion: Creating a weekly podcast of teaching pearls from daily morning reports within internal medicine residency programs is feasible. We found that the Podcast Pearl was an effective educational supplement for residents who were unable to attend morning report and a unique way to enhance connectedness between faculty and residents. Legal and practical considerations prevent us from distributing our podcasts to other residency programs, but we encourage chief residents and program directors from other residency programs to consider creating their own podcasts. Although further study of objective educational outcomes is needed to determine the value that these podcasts provide, our experience suggests that they help minimize the lost learning opportunities in residency training programs that new residency work-hour regulations have created. Ryan E. Childers, MD Melissa Dattalo, MD, MPH Colleen Christmas, MD Johns Hopkins University Baltimore, Maryland Potential Conflicts of Interest: None disclosed.
References 1. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA. 1986:256:730-3. [PMID: 3723772] 2. DeGroot LJ, Siegler M. The morning-report syndrome and medical search. N Engl J Med. 1979;301:1285-7. [PMID: 503136[ 3. Brancati FL. A piece of my mind. Morning diston. JAMA. 1991:266:1627. [PMID: 1886180] 4. Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform. J Gen Intern Med. 2005;20:l 16572. [PMID: 16423110] 5. Bensalem-Owen M, Chau DF, Sardam SG, Fahy BG. Education research: evaluating the use of podcasting for residents during EEG instruction: a pilot sttidy. Neurology. 2011;77:e42-4. [PMID: 21860003]
Acute Pancreatitis After High-Intensity Focused Ultrasonography for Body Sculpting Background: High-intensity focused ultrasonograj^hy (HIFU) delivers energy to deep subcutaneous tissue. It produces heat capable of destroying tissue, including solid tumors, and is also used for body sculpting because it can ablate adipose tissue and thermally modify collagen. At the lower energy levels tised with HIFU for body sculpting, reported adverse effects have been mild, including discomfort, tenderness, ecchymosis, and edema. Formal studies have involved few participants but found no major adverse events and normal cholesterol, triglycéride, serum amylase, and lipase levels in recipients 7 January 2014 Annals of Internal Medicine Volume 160 • Number 1 71
LETTERS (1—3). To our knowledge, no cases of act:te pancreatitis have been reported after HIFU for body sculpting. Objective: To describe what we believe is the first case of acute pancreatitis after HIFU for body sculpting. Case Report: A 64-year-old man received 2 sessions of HIFU at 2 to 3 W/cm for body sculpting to reduce focal adiposity in subcutaneous tissue. He received 10 minutes of HIFU over the abdominal flanks and 10 minutes over the lumbar zones 7 days later. Twenty-four hours after the second session, he had abdominal pain without fever or vomiting. He came to our emergency department 5 days later because of persistent pain. He had type 2 diabetes mellitus, arterial hypertension, and hypercholesterolemia. Medications included glimepiride, rosuvastatin, telmisartan, aspirin, and omeprazole. He began receiving glimepiride in the past 6 months and has received omeprazole intermittently since 2010. He did not constime alcohol. On physical examination, his abdomen was distended, arterial blood pressure was 150/80 mm Hg, and heart rate was 82 beats/min. Laboratory studies showed a total leukocyte count of 11.6 X 10 cells/L; serum levels of amylase of 3.62 jU,kat/L (normal levels, O.I2 to 2.08 ;nkat/L), lipase 14.6 fikat/L (normal levels, 0.2 to 1.0 jakat/L), triglycérides 1.0 mmol/L (92 mg/dL), calcium 2.40 mmol/L, and glucose 7.7 mmol/L (139 mg/dL); and normal levels of bilirubin and liver enzymes. Ultrasonography showed a normal liver, gallbladder, and biliary tree. Computed tomography showed loss of the glandular pattern in the tail of the pancreas and alteration of the peripancreatic fat, suggesting focal pancreatitis. Magnetic resonance cholangiopancreatography showed a normal biliary and pancreatic tree. The patient received intravenous hydration during the first 24 hours and tramadol to control pain. During the next 48 hours, his symptoms resolved and laboratory valties returned to normal. Discussion: We believe that the patient's abdominal pain was acute pancreatitis without an obvious cause. Although isolated cases of acute pancreatitis ftom glimepitide (4) and omeprazole (5) have been reported, out patient had been receiving these agents for a long time without recent changes in dose. A single case report cannot establish cause and effect, but we were impressed with the temporal relationship between HIFU and the onset of symptoms in the absence of other causes of pancreatitis. As a result, we alert other clinicians to the possibility of acute pancreatitis after HIFU for body sculpting. Daniel Gonzalo Grassi, Physician Beatriz Gavier, MD Jose Trueco, Physician Matías Tisi Baña, Physician Hospital Universitario Austral Pilar, Buenos Aires Province, Argentina
7 2 7 January 2014 Annals of Internal Medicine Volume 160 • Number 1
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/aurhors/icmje/ConflictOflnterestFotms.do?msNum = L13-1095.
References 1. Jewell ML, Weiss RA, Baxter RA, Cox SE, Dover JS, Donofrio LM, et al. Safety and tolerability of high-intensity focused ultrasonography for noninvasive body sculpting: 24-week data from a randomized, sham-controUed study. Aesthet Surg J. 2012;32:86876. [PMID: 22942114] 2. Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-intensity focused ultra.sound. Aesthetic Plast Surg. 2011;35:901-12. [PMID: 21461627] 3. Shalom A, Wiser I, Btawer S, Azhari H. Safety and tolerability of a focused ultrasound device for treatment of adipose tissue in subjects undergoing abdominoplasty: a placebo-control pilot study. Dermatol Surg. 2013;39:744-5I. [PMID: 23432811] 4. Dtiboeuf T, De Widerspach-Thor A, Scotto B, Bacq Y. [Acute glimepirideinduced pancteadds] [Letter]. Gastroenterol Clin Biol. 2004;28:409-10. [PMID: 15146162] 5. Youssef SS, Iskandar SB, Scruggs J, Roy TM. Acute pancteadds associated with omeprazole. Int J Clin Pharmacol Ther. 2005:43:558-61. [PMID: 16372517]
CORRECTION
Correction: Screening For Cognitive Impairment In Older Adults A recent review (1) had errors in a few places. Page 604, first column, last paragraph: "the short or ftill Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) {k=5,n= 1108)" [not 1251]. Page 605, first column, second paragraph: "Only 6 instruments were examined in mote than one study: the MMSE {k = 15, n = 6166)" [not 5758]. Page 605, first column, thitd paragraph: "We identified 1 systematic review ftom 2008 and 130 trials" [not 118]. Page 608, second column, second paragraph: "We identified 32 trials [n = 4668)" [not 5662]. Appendix Table 2 footnote: "t Cut point of 23/24 points [not 23 of 24] or 24/25 points" [not 24 of 25]. (Cut points for cognitive screening instruments ate repotted in the format of "#/#" meaning, fot example, a score of 23 or lower is impaired and a score of 24 or higher is not." This has been corrected in the otiline version.
Reference 1. Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognirive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;159:601-12.
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