Despite exercise benefits for cancer survivor health, most breast cancer survivors do not meet exercise recommendations. Few studies have examined associations between psychosocial symptoms and exercise barriers in this population. To improve physician exercise counseling by identifying survivors with high barriers in a clinical setting, associations between breast cancer symptoms (fatigue, mood, sleep quality) and exercise barriers were investigated. Physically inactive survivors (N = 320; average age 55 ± 8 years, 81% White, 77% cancer stage I or II) completed a baseline survey for a randomized physical activity trial and secondary analyses were performed. Potential covariates, exercise barriers interference score, Fatigue Symptom Inventory, Hospital Anxiety and Depression Scale (HADS), and Pittsburgh Sleep Quality Index were assessed. Based on multiple linear regression analyses, only HADS Global (B = 0.463, p < 0.001) and number of comorbidities (B = 0.992, p = 0.01) were independently associated with total exercise barriers interference score, explaining 8.8% of the variance (R² = 0.088, F(2,317) = 15.286, p < 0.001). The most frequent barriers to exercise for survivors above the HADS clinically important cut point included procrastination, routine, and self-discipline. These results indicate greater anxiety levels, depression levels, and comorbidities may be independently associated with specific exercise barriers. Health professionals should consider mood and comorbidities when evaluating survivors for exercise barriers, and tailoring exercise counseling.

Sarcoidosis-associated fatigue (SAF) occurs in approximately 30% to 90% of patients. While previous reviews examined select medications, these omitted nonpharmacological and emerging treatments that could significantly improve fatigue for individuals with sarcoidosis. Limited guidance exists for excluding alternative causes of fatigue and selecting between treatment options for these patients. This narrative review synthesized pharmacological and nonpharmacological interventions for SAF and interpreted evidence strength to guide clinical decision-making. PubMed was queried in December 2025 for clinical trials, reviews, and meta-analyses published within the last 10 years. This yielded 41 results which were supplemented by manual review of bibliographies, clinical guidelines, and a search of the Cochrane Library. Evidence was interpreted and analyzed for quality using a modified GRADE-informed approach. Treatment of active disease with prednisone or methotrexate improves systemic inflammation but may paradoxically worsen fatigue with chronic use. Stimulants (e.g., dexmethylphenidate, armodafinil) display low-quality evidence for improving SAF and side effects may be prohibitive for some patients. TNF-α inhibitors (e.g., infliximab) have very low-quality evidence with few studies and negative findings. Pulmonary rehabilitation and exercise training show low-to-moderate quality evidence with few adverse effects but lack specific implementation protocols. Diagnosis of SAF requires exclusion of alternative causes which may be challenging. Active disease should be treated appropriately while monitoring for adverse effects. Despite low-to-moderate quality evidence for most interventions, nonpharmacological approaches (e.g., pulmonary rehabilitation, exercise) are recommended as first-line therapy given favorable risk-benefit profiles. Larger, well-designed RCTs are needed given the substantial disease burden.

Background: IgG4‐related disease (IgG4‐RD) can involve the liver and pancreas and may present without conventional autoimmune hepatitis (AIH) autoantibodies, creating diagnostic delay unless IgG4 testing and tissue immunostaining are pursued. We describe an older man with acute hepatocellular injury and marked hyperbilirubinemia who was negative for antinuclear (ANA) and antismooth muscle (ASMA) antibodies but had markedly elevated serum IgG4 and IgG4‐positive plasma cell infiltration on liver biopsy, consistent with IgG4‐related autoimmune hepatitis (IgG4‐AIH). Case Presentation: A man in his 80s presented with abdominal pain followed by progressive jaundice and pruritus, with acute hepatocellular injury and hyperbilirubinemia. Evaluation showed negative ANA and ASMA, elevated total IgG (2166 mg/dL) and IgG4 (442.5 mg/dL), CA 19‐9 1268 U/mL, and CT/MRCP findings consistent with pancreatitis without biliary obstruction or mass. HFE analysis showed compound heterozygosity. Liver biopsy demonstrated interface hepatitis with plasma cell–rich inflammation and increased IgG4‐positive plasma cells (up to 58 per high‐power field), supporting IgG4‐AIH. Minimal iron deposition on biopsy favored inflammation‐related iron study abnormalities rather than primary hemochromatosis. The pancreatic findings were most consistent with probable Type 1 autoimmune pancreatitis. Prednisone 40 mg daily led to improvement, with normalization of transaminases and total bilirubin by Day 57 (approximately 8 weeks) in available follow‐up testing. Conclusion: IgG4‐AIH is diagnostically challenging, particularly in seronegative presentations. Unexpectedly high CA 19‐9 may be seen in IgG4‐RD, which may mimic malignancy. In atypical presentations such as those occurring in older adults without conventional antibody positivity or with concurrent pancreatitis on imaging, clinicians should promptly consider early biopsy with immunostaining to avoid diagnostic delay and enable timely steroid treatment.

Improving clinical reasoning is a national priority to reduce medical error. This commentary advocates for “strong opinions, loosely held” as a cognitive aid to improve reasoning and retention in medical education. Learners should commit confidently to decisions while remaining open to revision as new evidence emerges. Grounded in prediction error theory, which emphasizes memory retention when expectations are upset, this approach mirrors expert clinician strategies. Case-based curricula can operationalize this by prompting early hypotheses and reassessment. Despite concerns about overconfidence, we view discomfort as natural when transitioning from passive to active learning, ultimately promoting autonomy, improved retention, and deeper engagement.