Entertainment — The painful process of rethinking consent

The principal focus of this article will be upon an area of activity that has over the past decade seen a significant amount of growth in popularity, namely, the infliction of pain and/or injury for the purposes of entertainment, as pioneered by the US TV series and spin-off films Jackass and widely copied in the UK by, for example, Dirty Sanchez and the double act ‘The Pain Men’ on Channel 4’s programme, Balls of Steel. Until recently, and despite its popularity, this type of entertainment has attracted minimal comment from academics or practitioners on the legality of such conduct. However, a campaign begun by Mediawatch in 2010 has brought to prominence some interesting and potentially difficult questions about the ability of a person to consent to injuries caused in the name of entertainment. As the parameters of legally valid consent are both unstable and contested, it is unclear whether the types of conduct under discussion here are capable of being consented to and whether the associated reasons for inflicting the pain and sometimes injury provide any justification for what might otherwise be criminal behaviour. In analysing the application of the criminal law to instances of what is referred to here as ‘painful entertainment’ this article challenges traditional approaches to the categorisation of consensual activities and proposes a rethinking of how the law of offences against the person could be applied to novel situations

The Impact of Native Language Status on the Frequency of Heart Failure Readmissions

Introduction. Heart failure readmissions are costly and lead to poor health outcomes. The efficacy of discharge instructions or other outpatient interventions may be affected by patient’s primary language status. The aim of this study is to look at the impact of primary language status on the frequency of heart failure admissions. Methods. This study was a retrospective chart review of EMRs, on Epic software, at Jefferson academic medical center and community affiliate in Philadelphia, PA between March 2017 and October 2018. Patients were included if they had a principal diagnosis of HF or a diagnosis associated with “acute” heart failure within the first five problems on their discharge problem list. More detailed chart review was performed on ambiguous cases. A patient encounter was classified as ‘readmission’ for any in-hospital stay within 30-days, whether the patient was placed into ‘observation’ or ‘inpatient’ status. Results. There were 2350 acute HF encounters; consisting of 1524 unique patients. Of those 1524, 1425 listed English as their primary language while 99 listed a different primary language. Of the 2350 encounters, 2209 of those were from English-speakers; 469 were thirty-day readmissions (0.212 readmission rate). The non-primary English speakers made up 141 of the total 2350 encounters; 29 were thirty-day readmissions (0.206 readmission rate). Conclusions. Our data, in contrast to other studies, suggests language barriers may not significantly influence HF readmission rates. Results may be regionally specific. Future studies are needed to further delineate the impact of primary language status on frequency of health care admissions

Cost-effectiveness of granulocyte colony-stimulating factor prophylaxis for febrile neutropenia in patients with non-Hodgkin's lymphoma in the United Kingdom (UK)

Introduction: We report a cost-effectiveness evaluation of granulocyte colony-stimulating factors (G-CSFs) for prevention of febrile neutropenia (FN) following chemotherapy for non-Hodgkin’s lymphoma (NHL) in the United Kingdom (UK). Methods: A mathematical model was constructed simulating the experience of patients with NHL undergoing chemotherapy. Three strategies were modelled: primary prophylaxis (G-CSFs administered in all cycles); secondary prophylaxis (G-CSFs administered in all cycles following an FN event), and no G-CSF prophylaxis. Three G-CSFs were considered: filgrastim; lenograstim and pegfilgrastim. Costs were taken from UK databases and utility values from published sources with the base case analysis using list prices for G-CSFs and a willingness to pay (WTP) threshold of £20,000 per QALY gained. A systematic review provided data on G-CSF efficacy. Probabilistic sensitivity analyses examined the effects of uncertainty in model parameters. Results: In the base-case analysis the most cost-effective strategy was primary prophylaxis with pegfilgrastim for a patient with baseline FN risk greater than 22%, secondary prophylaxis with pegfilgrastim for baseline FN risk 8-22%, and no G-CSFs for baseline FN risk less than 8%. Using a WTP threshold of £30,000, primary prophylaxis with pegfilgrastim was cost-effective for baseline FN risks greater than 16%. In all analyses, pegfilgrastim dominated filgrastim and lenograstim. Sensitivity analyses demonstrated that higher WTP threshold, younger age, or reduced G-CSF prices result in G-CSF prophylaxis being cost-effective at lower baseline FN risk levels. Conclusions: Pegfilgrastim was the most cost-effective G-CSF. The most cost-effective strategy (primary or secondary prophylaxis) was dependent on underlying FN risk level, patient age, and G-CSF price

Bilateral Intercostal Lung Herniations: A Rare Incidental Finding in a Dyspneic Patient

A 63-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD), stage IV sarcoidosis on 3-4 liters of home oxygen and chronic prednisone, moderate aortic stenosis, and a prior aspergilloma for which he had a left upper lobe lung resection presented to the hospital with two weeks of worsening shortness of breath

Management of co-existing lung cancer and endobronchal hamartomas

Abstract: The coexistence of lung cancer with an endobronchial hamartoma is infrequent, and requires accurate oncologic evaluation of the endobronchial lesion prior to potential surgical treatment of the lung cancer. We describe a patient who presented with an undiagnosed endobronchial mass and and a biopsy-proven lung cancer which were successfully managed by a staged approach using initial bronchoscopic resection of the endobronchial lesion and subsequent lobectomy for squamous cell lung cancer

Cost-effectiveness of granulocyte colony-stimulating factor prophylaxis for febrile neutropenia in breast cancer in the United Kingdom

Introduction: We report a cost-effectiveness evaluation of granulocyte colony–stimulating factors (G-CSFs) for the prevention of febrile neutropenia (FN) after chemotherapy in the United Kingdom (UK). Methods: A mathematical model was constructed simulating the experience of women with breast cancer undergoing chemotherapy. Three strategies were modelled: primary prophylaxis (G-CSFs administered in all cycles), secondary prophylaxis (G-CSFs administered in all cycles after an FN event), and no G-CSF prophylaxis. Three G-CSFs were considered: filgrastim, lenograstim, and pegfilgrastim. Costs were taken from UK databases and utility values from published sources. A systematic review provided data on G-CSF efficacy. Probabilistic sensitivity analyses examined the effects of uncertainty in model parameters. Results: In the UK, base-case analysis with a willingness-to-pay (WTP) threshold of £20,000 per quality-adjusted life-year gained and using list prices, the most cost-effective strategy was primary prophylaxis with pegfilgrastim for a patient with baseline FN risk greater than 38%, secondary prophylaxis with pegfilgrastim for baseline FN risk 11% to 37%, and no G-CSFs for baseline FN risk less than 11%. Using a WTP threshold of £30,000 and list prices, primary prophylaxis with pegfilgrastim was cost-effective for baseline FN risks greater than 29%. In all analyses, pegfilgrastim dominated filgrastim and lenograstim. Sensitivity analyses demonstrated that higher WTP threshold, younger age, earlier stage at diagnosis, or reduced G-CSF prices result in G-CSF prophylaxis being cost-effective at lower baseline FN risk levels. Conclusion: Pegfilgrastim was the most cost-effective G-CSF. The most cost-effective strategy (primary or secondary prophylaxis) was dependent on the FN risk level for an individual patient, patient age and stage at diagnosis, and G-CSF price

Quality and Safety in Population Health

Why has the volume to value movement become stuck as organizations struggle with downside risk and unaccomplished goals? How do the traditional models of quality improvement and patient safety work in population health? When you are no longer changing one person’s condition, or fixing one organization’s opportunities for improvement, what do you use? This webinar will describe the translation of concepts, methods, and tools from organizational improvement to population health management and provide ideas for simple approaches to create results. Objectives Review the volume to value movement Discuss traditional models of quality improvement and patient safety in population health Describe the translation of concepts, methods, and tools from organizational improvement to population health management Provide ideas for simple approaches to create results Presentation: 56:5

A Guide to Point of Care Ultrasound Lung and IVC Examination of a Volume Overloaded Patient

A patient presents with dyspnea, hypoxia, and lower extremity edema. Their history is notable for recent high salt intake and non-compliance with diuretics, and their lungs have rales bilaterally. Clinically, we can diagnose a heart failure exacerbation with pulmonary edema. However, we often rely on X-ray and computed tomography (CT) imaging to support the clinical diagnosis and explore the etiology of the hypoxia and dyspnea to narrow the differential. Ultrasound is an effective modality for identifying pulmonary edema and pleural effusions while at the same time ruling out other etiologies such as pneumonia and pneumothorax. With bedside point of care ultrasound (POCUS), there is no radiation risk and no delay in obtaining imaging. A systematic review and meta-analysis study by Maw et al. published in 2019 found that lung ultrasound diagnosis of pulmonary edema in the setting of clinical suspicion for acute decompensated heart failure had a pooled sensitivity of 0.88 and specificity of 0.9, which is superior to X-ray imaging which demonstrated a pooled sensitivity of 0.73 and a pooled specificity of 0.9.

A Guide to Point of Care Ultrasound Examination of a Pericardial Effusion

A patient presents with pleuritic chest pain, dyspnea, and a recent viral illness. They have no prior cardiac or pulmonary history. Their X-ray on admission demonstrates no pulmonary findings and an enlarged cardiac silhouette, and their EKG is low voltage with electrical alternans. Ultrasound is an effective modality for identifying pericardial effusion and cardiac tamponade while at the same time evaluating for other causes, such as heart failure. Often patients with symptomatic pericardial ef fusion present with non-specific symptoms. While a “formal” transthoracic echocardiogram remains the gold standard for diagnosis, a bedside point of care ultrasound (POCUS) cardiac evaluation can significantly decrease the time to diagnosis and trigger an order for an urgent “formal” echocardiogram.1 A retrospective study by Hanson and Chan in 2021 found that POCUS led to an expedited average time to diagnosis of 5.9 hours compared to \u3e12 hours with other imaging. Those with a symptomatic pericardial effusion identified by POCUS had a significantly decreased time to treatment; time to pericardiocentesis of 28.1 hours compared to \u3e 48 hours with other diagnostic modalities.