Colonic Stenting for Nonmalignant Large Bowel Obstruction to Avoid Emergency Decompressive Surgery

Self-expanding metallic stents (SEMSs) are frequently used to decompress malignant large bowel obstruction (LBO) and avoid emergent surgery with often permanent colostomy creation. However, limited data are available on the use and outcomes of SEMS in patients with nonmalignant LBO. We present a case series of 4 patients who were found to have nonmalignant LBO for which they underwent emergent colonic stenting as a bridge to elective surgery following interdisciplinary discussion between gastroenterology, colorectal surgery, and radiology. Through each patient vignette, we illustrate the use of SEMSs as a potential alternative to emergent surgery. 2 of 4 patients avoided stoma creation at the time of surgery, and 1 patient avoided surgery altogether; overall, however, the outcomes of this approach were mixed in this series, indicating a need for further investigation to better identify the patient population that would benefit most from initial SEMS placement for decompression of nonmalignant LBO.

Emotional intelligence in palliative medical education

The death of a patient is one of the most stressful situations a healthcare professional can face for the first time at work or during training. Palliative and end of life care education aims to impart appropriate awareness and understanding of key issues arising at the end of life, but also to develop learners' interpersonal skills in leadership, communication and management of their own emotional load. There is a pressing need to be explicit around death, dying and care at the end of life and to equip clinical staff with the ability to manage the emotions that are experienced by their patients, their teams and themselves. Emotional intelligence is considered as a framework for medical educators to use in this setting with presentation of a simulated patient vignette to contextualise this.

"Look Doctor, I'm a Carnivore"

This patient vignette explores a Vietnam Veteran's effort to reverse atherosclerotic heart disease. In the process, he experiences the reversal of the dietary preference most central to his identity in three weeks.

Individualised targets for insulin initiation in type 2 diabetes mellitus—the influence of physician and practice: a cross-sectional study in eight European countries

ObjectivesTo determine at what glycated haemoglobin (HbA1c) level physicians from eight European countries would initiate insulin in type 2 diabetes, which physician or practice related factors influenced this level and whether physicians would differentiate between a younger uncomplicated patient and an older patient with comorbidities.DesignCross-sectional study with data from the Guideline Adherence to Enhance Care study.Setting and participants410 physicians from both primary and secondary care from Belgium, France, Germany, Italy, Ireland, Sweden, the Netherlands and the UK.Outcome measuresPhysicians were asked at which HbA1c level they would initiate insulin for a young, uncomplicated patient (vignette 1) and for an older, complicated patient (vignette 2). We evaluated differences in HbA1c levels between physicians from different countries using analysis of variance. To identify physician and practice related factors associated with HbA1c level at initiation of insulin, we performed multivariable linear regression. Multiple imputation was used to deal with missing data.ResultsIn Germany, Ireland, Sweden, the Netherlands and the UK, the HbA1c levels for initiating insulin in vignette 2 (range: 60.0 to 66.0 mmol/mol; 7.6% to 8.2%) were higher than for vignette 1 (range: 57.2 to 64.2 mmol/mol; 7.4% to 8.0%). In multivariable analysis, the HbA1c level at which insulin was initiated only differed between countries (vignette 1): Dutch physicians initiated insulin at a lower HbA1c level compared with Belgium, France and the UK. No physician or practice factors were independently associated with HbA1c level at insulin initiation.ConclusionsWhen deciding on individualised HbA1c targets for insulin initiation, physicians from five countries took patient’s age and comorbidity into account. The HbA1c level at which physicians would initiate insulin therapy differed between countries.

PDE5i as a Cure for Older Adults: An Indicator of Ageist Practices among Physicians

Objective: The aim of this study is to determine whether physicians have an age bias regarding sexual dysfunction in older vs. younger patients in terms of diagnosis, attributed etiology, proposed treatment and perceived prognosis. Design and Method: An on-line survey consisting of one of two, randomly administered, case vignettes, which differed only by age (28 or 78). In both cases, the patient was described as suffering from occasional erectile dysfunction with a clear psychosocial indication. A total of 236 physicians responded to the survey. Overall, 110 physicians received an old patient vignette and 126 physicians received a young patient vignette. Results: Even though both cases presented with a clear psychosocial etiology, the young patient vignette was more likely to be diagnosed with performance anxiety, whereas the old patient vignette with erectile dysfunction. The old patient vignette dysfunction was more likely to be attributed to hormonal changes, health problems and decreased sexual desire. Physicians were more likely to recommend hormonal and PDE5 inhibitors (PDE5i; such as Sildenafil; Vardenafil; Tadalafil) treatment as well as urology referral to the old patient vignette. The young patient vignette was more often referred to a sexologist and received a more positive prognosis than the older patient. Conclusions: This study demonstrates an age bias among physicians regarding sexuality in later life. Of particular note is the increased prescription of PDE5i to the older patient, despite the clear psychosocial indication presented in the case vignette.