Ethics of Child and Adolescent Palliative Care (DRAFT)

2018 ◽  
Author(s):  
Robert C. Macauley
Keyword(s):  
Treatment Plan ◽  
Treatment Options ◽  
Dual Process ◽  
Undue Influence ◽  
Diagnosis And Prognosis ◽  
Appropriate Treatment ◽  
Decision Making Capacity ◽  
Differences Of Opinion ◽  
Age Of Majority ◽  
Logistical Barrier

Over the course of childhood a patient’s decision-making capacity evolves. While eighteen is the age of majority in most states, younger patients may well have the ability to process information and make informed decisions. At the same time, the “dual process theory” of maturation reveals that emotional considerations may outweigh cognitive ones. Physicians must understand how to respond to parental requests for nondisclosure of diagnosis and prognosis, as well as differences of opinion between the patient and parents as to appropriate treatment options. Even when a child agrees with her parents regarding a treatment plan, this may reflect undue influence rather than voluntariness. And even when a treatment has a favorable benefit/burden ratio, an adolescent’s refusal may present such a logistical barrier that a modified treatment plan may need to be implemented.

scholarly journals The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Masayoshi Koike ◽  
Mie Yoshimura ◽  
Yasushi Mio ◽  
Shoichi Uezono
Keyword(s):  
Patient Safety ◽  
Retrospective Study ◽  
High Risk ◽  
Treatment Plan ◽  
Treatment Options ◽  
High Risk Patients ◽  
Appropriate Treatment ◽  
Risk Patients ◽  
Treatment Plans ◽  
Multidisciplinary Conference

Abstract Background Surgical options for patients vary with age and comorbidities, advances in medical technology and patients’ wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee. Methods In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018. Results A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported. Conclusions Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

Updates in insomnia diagnosis and treatment

2019 ◽  
Vol 54 (4-5) ◽  
pp. 275-289 ◽  
Author(s):  
Scott Bragg ◽  
JJ Benich ◽  
Natalie Christian ◽  
Josh Visserman ◽  
John Freedy
Keyword(s):  
Drug Therapy ◽  
Behavioral Therapy ◽  
Treatment Plan ◽  
Treatment Options ◽  
First Line ◽  
Safety Concerns ◽  
Diagnostic And Statistical Manual ◽  
First Line Therapy ◽  
Appropriate Treatment ◽  
Central Nervous System Depression

Introduction Insomnia is the most commonly reported sleep disorder and remains undertreated in many patients. New changes to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, have changed the way insomnia is diagnosed. In patients who suffer from insomnia, a number of available treatment options exist including both behavioral therapy and medications. Literature Review: First line therapy for insomnia should always include behavioral modifications such as sleep hygiene and insomnia-oriented cognitive behavioral therapy. In patients deemed to need pharmacotherapy, first line medications include nonbenzodiazepine hypnotics (i.e., z-drugs) and antidepressants depending on the patients’ needs and comorbidities. The risk of next day impairment, parasomnias, and central nervous system depression are some of the most feared side effects with z-drugs. Second line drug therapy includes melatonin and suvorexant. Several concerns exist for suvorexant similar to other insomnia medications, but melatonin remains one of the safest medication alternatives. Other medication options such as benzodiazepines, antihistamines, and antipsychotics should rarely be used because of weak effectiveness data or serious safety concerns. Discussion The most appropriate treatment plan needs to be tailored to meet the needs of individual patients. Many patient factors (e.g., age, other comorbidities, specific problems with sleep) need to be considered before prescribing drug therapy for patients suffering from insomnia. Medications with the best evidence and fewest safety concerns should be prioritized when clinicians work with patients to determine the most appropriate treatment plan. Conclusions Nondrug treatment should be the emphasis for managing insomnia, but several options exist for patients needing multimodal therapy to improve their symptoms and maximize their quality of life. Z-drugs and antidepressants are first line medications options, but other options may be considered when tailored to individual patients. Medications should only be used intermittently and short term until nondrug treatments help to change a patient’s sleep routine.

Approach to Radiculopathy

2021 ◽  
Vol 41 (06) ◽  
pp. 760-770
Author(s):  
Rafid Mustafa ◽  
Narayan R. Kissoon
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Treatment Approach ◽  
Treatment Plan ◽  
Treatment Options ◽  
Accurate Diagnosis ◽  
Clinical Approach ◽  
Low Back ◽  
Appropriate Treatment ◽  
Neurology Clinic

AbstractLow back pain and neck pain, often with associated radiculopathy, are two of the most common reasons for referral to the outpatient neurology clinic. A thorough clinical evaluation remains paramount in establishing an accurate diagnosis and subsequently an appropriate treatment plan. In this article, we review anatomic considerations for spondylotic radiculopathy; outline the clinical approach for the evaluation of these patients, including discussion of electrodiagnostic and imaging modalities; and address treatment options based on a stratified treatment approach.

scholarly journals Complete dentures – assessment of the loose denture

Dental Update ◽  
2019 ◽  
Vol 46 (8) ◽  
pp. 760-767
Author(s):  
Arek Dziedzic ◽  
James Puryer
Keyword(s):  
Clinical Examination ◽  
Clinical Relevance ◽  
Treatment Plan ◽  
Treatment Options ◽  
Complete Dentures ◽  
Potential Treatment ◽  
Edentulous Patient ◽  
Appropriate Treatment ◽  
Examination Process ◽  
Careful History

Patients with complete dentures will often present to a clinician complaining that their dentures are loose. A careful history, clinical examination and denture examination is needed so that the cause of their loose dentures can be determined. Only once a suitable diagnosis has been reached can an appropriate treatment plan be developed. This paper aims to guide readers through this history and examination process to help them formulate a suitable diagnosis before embarking on any potential treatment options. CPD/Clinical Relevance: The paper provides a guide as to how to assess an edentulous patient presenting with loose complete dentures.

Candida albicans endocarditis involving a normal native aortic valve in an immunocompetent patient

2020 ◽  
Vol 13 (11) ◽  
pp. e236902
Author(s):  
Taha Sheikh ◽  
Jeremy C Tomcho ◽  
Mohammed T Awad ◽  
Syeda Ramsha Zaidi
Keyword(s):  
Candida Albicans ◽  
Mortality Rate ◽  
Aortic Valve ◽  
High Mortality ◽  
Treatment Options ◽  
Immunocompetent Patient ◽  
Fungal Endocarditis ◽  
Appropriate Treatment ◽  
Mechanical Valves ◽  
Serious Infection

Fungal endocarditis, specifically from Candida species, is a rare but serious infection with a high mortality rate. Most cases occur in bioprosthetic or mechanical valves and are uncommon in native, structurally normal valves. When Candida endocarditis is detected and appropriate treatment is initiated earlier, there is an improvement in mortality. While the recommendation is usually to treat with a combination of surgery and antifungal medications, patient comorbidities may limit treatment options.

scholarly journals The Role of Artificial Intelligence in the Diagnosis and Prognosis of Renal Cell Tumors

Diagnostics ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. 206
Author(s):  
Matteo Giulietti ◽  
Monia Cecati ◽  
Berina Sabanovic ◽  
Andrea Scirè ◽  
Alessia Cimadamore ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Renal Cancer ◽  
Renal Cell ◽  
Treatment Plan ◽  
Molecular Data ◽  
Receiver Operating Curve ◽  
Diagnosis And Prognosis ◽  
Study Results ◽  
Gene Panels ◽  
Next Generation Sequencing Ngs

The increasing availability of molecular data provided by next-generation sequencing (NGS) techniques is allowing improvement in the possibilities of diagnosis and prognosis in renal cancer. Reliable and accurate predictors based on selected gene panels are urgently needed for better stratification of renal cell carcinoma (RCC) patients in order to define a personalized treatment plan. Artificial intelligence (AI) algorithms are currently in development for this purpose. Here, we reviewed studies that developed predictors based on AI algorithms for diagnosis and prognosis in renal cancer and we compared them with non-AI-based predictors. Comparing study results, it emerges that the AI prediction performance is good and slightly better than non-AI-based ones. However, there have been only minor improvements in AI predictors in terms of accuracy and the area under the receiver operating curve (AUC) over the last decade and the number of genes used had little influence on these indices. Furthermore, we highlight that different studies having the same goal obtain similar performance despite the fact they use different discriminating genes. This is surprising because genes related to the diagnosis or prognosis are expected to be tumor-specific and independent of selection methods and algorithms. The performance of these predictors will be better with the improvement in the learning methods, as the number of cases increases and by using different types of input data (e.g., non-coding RNAs, proteomic and metabolic). This will allow for more precise identification, classification and staging of cancerous lesions which will be less affected by interpathologist variability.

scholarly journals From Rheumatoid Factor to Anti-Citrullinated Protein Antibodies and Anti-Carbamylated Protein Antibodies for Diagnosis and Prognosis Prediction in Patients with Rheumatoid Arthritis

2021 ◽  
Vol 22 (2) ◽  
pp. 686
Author(s):  
Chao-Yi Wu ◽  
Huang-Yu Yang ◽  
Shue-Fen Luo ◽  
Jenn-Haung Lai
Keyword(s):  
Rheumatoid Arthritis ◽  
Treatment Options ◽  
Clinical Manifestations ◽  
Bone Destruction ◽  
Response To Therapy ◽  
Current Evidence ◽  
Prognosis Prediction ◽  
Diagnosis And Prognosis ◽  
Systemic Inflammatory Disease ◽  
Citrullinated Protein

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease mainly involving synovial inflammation and articular bone destruction. RA is a heterogeneous disease with diverse clinical presentations, prognoses and therapeutic responses. Following the first discovery of rheumatoid factors (RFs) 80 years ago, the identification of both anti-citrullinated protein antibodies (ACPAs) and anti-carbamylated protein antibodies (anti-CarP Abs) has greatly facilitated approaches toward RA, especially in the fields of early diagnosis and prognosis prediction of the disease. Although these antibodies share many common features and can function synergistically to promote disease progression, they differ mechanistically and have unique clinical relevance. Specifically, these three RA associating auto-antibodies (autoAbs) all precede the development of RA by years. However, while the current evidence suggests a synergic effect of RF and ACPA in predicting the development of RA and an erosive phenotype, controversies exist regarding the additive value of anti-CarP Abs. In the present review, we critically summarize the characteristics of these autoantibodies and focus on their distinct clinical applications in the early identification, clinical manifestations and prognosis prediction of RA. With the advancement of treatment options in the era of biologics, we also discuss the relevance of these autoantibodies in association with RA patient response to therapy.

scholarly journals How the Future of Sonography May Change the Outlook for Patients With Osteosarcoma

2018 ◽  
Vol 34 (5) ◽  
pp. 368-373
Author(s):  
Stacey Hoya ◽  
Linda Wogeman ◽  
Sara Allstadt ◽  
Glen King
Keyword(s):  
Quality Of Life ◽  
Focused Ultrasound ◽  
Treatment Plan ◽  
Treatment Options ◽  
Therapeutic Ultrasound ◽  
Bone Lesions ◽  
Pulsed Ultrasound ◽  
Low Intensity Pulsed Ultrasound ◽  
Ultrasound Applications

Sonography currently provides a variety of tools to support the diagnosis and treatment of osteosarcoma and, with the development of therapeutic ultrasound practices, could play an increasingly important role in the treatment of future patients with osteosarcoma. Currently, computed tomography, magnetic resonance imaging, and radiography are the preferred imaging modalities for bone lesions; treatment options for osteosarcoma primarily include highly toxic chemotherapies and surgeries that often result in limb loss. Unfortunately, osteosarcoma is rarely eliminated, and despite this, patients lose their lives after having a significant reduction in quality of life. Evolving therapies such as high-frequency focused ultrasound, ultrasound-enhanced delivery of photodynamic therapy, and low-intensity pulsed ultrasound may offer these patients an improved quality of life while also increasing efficacy of treatment. This canine case study illustrates the various ways in which sonography might contribute to the treatment plan for patients with osteosarcoma. It may provide a comparable model for the reimagining of treatment for future patients with osteosarcoma using a suite of therapeutic ultrasound applications.

Non-operative treatment options for knee osteoarthritis: current concepts

2018 ◽  
Vol 3 (5) ◽  
pp. 274-281
Author(s):  
David A Parker ◽  
Corey Scholes ◽  
Thomas Neri
Keyword(s):  
Knee Osteoarthritis ◽  
Operative Treatment ◽  
Treatment Plan ◽  
Treatment Options ◽  
Primary Care Providers ◽  
Care Plan ◽  
Care Providers ◽  
Coordinated Care ◽  
Management Options ◽  
Functional Benefit

Knee osteoarthritis in younger patients can be a challenging condition to manage. The patient and clinician have a range of non-operative management options available, although the guidance to effectively apply these options is lacking. The following review summarises a range of non-operative treatment options as an accessible reference for primary care providers to establish a coordinated care plan in consultation with the patient as part of a shared decision making process. Options are summarised in non-pharmacological and pharmacological treatments. These options are based on the latest guidelines based on authoritative recommendations, as well as recent articles with a good level of evidence that have not yet been incorporated into these official contents. The coordination of treatment using a range of modalities remains poorly explained in the literature and the current review proposes a conceptual model for coordinated care to be provided. In this model, the patient is central to the interaction between the coordinator and specialist providers, and the treatment plan is tailored to provide the optimal pain relief and functional benefit specific to the patient.

scholarly journals A Brief Review of Severe Asthma

2021 ◽  
Vol 6 (2) ◽  
pp. 4-12
Author(s):  
Muhammad Amin Ibrahim ◽  
Ahmad Izuanuddin Ismail ◽  
Mohammed Fauzi Abdul Rani
Keyword(s):  
Severe Asthma ◽  
Treatment Options ◽  
Oral Steroid ◽  
Inhaler Technique ◽  
Inhaled Corticosteroid ◽  
Asthma Care ◽  
Asthmatic Patients ◽  
Appropriate Treatment ◽  
Considerable Morbidity ◽  
The Cost

Severe asthma describes an asthma condition that requires a substantial amount of inhaled corticosteroid and bronchodilators to keep it under control including the frequent additional need for oral steroid to avoid exacerbations. The incidence of severe asthma in Malaysia is unknown but data elsewhere shows that it is around 5 to 10 % of asthmatics. This category of asthmatic patients has considerable morbidity, is disproportionate cost-wise to the number of sufferers and requires specialised and focused care. The management of severe asthma should be undertaken at a severe asthma clinic led by a physician with a special interest in its management. The diagnosis needs confirmation, comorbidities identified and triggering factors addressed. Inhaler technique and compliance are major contributing issues and must be addressed at all consultation opportunities. Once the diagnosis of severe asthma is confirmed, the disease needs phenotyping to plan for the most appropriate treatment, termed as a personalised approach to severe asthma care. The advances in biologics have changed the landscape of treatment of this disease but in Malaysia especially, there are many limitations namely the cost. This article briefly explores the current understanding of severe asthma, the assessment including phenotyping and possible treatment options.

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