Efficacy and Safety of Tunneled Pleural Catheters in Adults with Malignant Pleural Effusions: A Systematic Review

BackgroundMalignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE.ObjectiveTo systematically review published data on the efficacy and safety of the TIPC for treatment of MPE.DesignWe searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies.Main measuresSymptomatic improvement and complications associated with use of the TIPC.Key resultsNineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%).ConclusionsBased on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE

Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors

BACKGROUND: A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION: Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY: The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards

Factors Associated with a Career in Primary Care Medicine: Continuity Clinic Experience Matters

BackgroundDue to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice.MethodsWe conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000-2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher's exact tests for categorical variables and t tests for continuous variables.ResultsOf the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups.ConclusionsStrong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians

Decisions in the Dark: An Educational Intervention to Promote Reflection and Feedback on Night Float Rotations

BackgroundNight float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning.AimImprove night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection.Setting/participantsSecond- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017.Program descriptionResidents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents.Program evaluationSixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions.DiscussionStructured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication

Conventional and semi-automatic histopathological analysis of tumor cell content for multigene sequencing of lung adenocarcinoma.

Targeted genetic profiling of tissue samples is paramount to detect druggable genetic aberrations in patients with non-squamous non-small cell lung cancer (NSCLC). Accurate upfront estimation of tumor cell content (TCC) is a crucial pre-analytical step for reliable testing and to avoid false-negative results. As of now, TCC is usually estimated on hematoxylin-eosin (H&E) stained tissue sections by a pathologist, a methodology that may be prone to substantial intra- and interobserver variability. Here we the investigate suitability of digital pathology for TCC estimation in a clinical setting by evaluating the concordance between semi-automatic and conventional TCC quantification. TCC was analyzed in 120 H&E and thyroid transcription factor 1 (TTF-1) stained high-resolution images by 19 participants with different levels of pathological expertise as well as by applying two semi-automatic digital pathology image analysis tools (HALO and QuPath). Agreement of TCC estimations [intra-class correlation coefficients (ICC)] between the two software tools (H&E: 0.87; TTF-1: 0.93) was higher compared to that between conventional observers (0.48; 0.47). Digital TCC estimations were in good agreement with the average of human TCC estimations (0.78; 0.96). Conventional TCC estimators tended to overestimate TCC, especially in H&E stainings, in tumors with solid patterns and in tumors with an actual TCC close to 50%. Our results determine factors that influence TCC estimation. Computer-assisted analysis can improve the accuracy of TCC estimates prior to molecular diagnostic workflows. In addition, we provide a free web application to support self-training and quality improvement initiatives at other institutions

Developing Entrustable Professional Activities as the Basis for Assessment of Competence in an Internal Medicine Residency: A Feasibility Study

BACKGROUND: Graduate medical education programs assess trainees’ performance to determine readiness for unsupervised practice. Entrustable professional activities (EPAs) are a novel approach for assessing performance of core professional tasks. AIM: To describe a pilot and feasibility evaluation of two EPAs for competency-based assessment in internal medicine (IM) residency. SETTING/PARTICIPANTS: Post-graduate year-1 interns (PGY-1s) and attendings at a large internal medicine (IM) residency program. PROGRAM DESCRIPTION: Two Entrustable professional activities (EPA) assessments (Discharge, Family Meeting) were piloted. PROGRAM FEASIBILITY EVALUATION: Twenty-eight out of 43 (65.1 %) PGY-1 s and 32/43 (74.4 %) attendings completed surveys about the Discharge EPA experience. Most who completed the EPA assessment (10/12, 83.8 %, PGY-1s; 9/11, 83.3 %, attendings) agreed it facilitated useful feedback discussions. For the Family Meeting EPA, 16/26 (61.5 %) PGY-1s completed surveys, and most who participated (9/12 PGY1s, 75 %) reported it improved attention to family meeting education, although only half recommended continuing the EPA assessment. DISCUSSION: From piloting two EPA assessments in a large IM residency, we recognized our reminder systems and time dedicated for completing EPA requirements as inadequate. Collaboration around patient safety and palliative care with relevant clinical services has enhanced implementation and buy-in. We will evaluate how well EPA-based assessment serves the intended purpose of capturing trainees’ trustworthiness to conduct activities unsupervised. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11606-013-2372-x) contains supplementary material, which is available to authorized users