Delivering Bad News: Should Physicians Express their Emotions?

The traditionally assumed medical dictum is that a physician who expresses his or her emotions in font of patients or their families is almost deemed unprofessional. This feeling may be common place, particularly among traditional physicians who still hold the belief that professionalism is endangered if physicians deliver bad news laced with their true emotions. Discussion of this important topic surfaces now and then and are then hidden away without definite answers possibly due to lack of attention by physician's fraternity to dispense with this out-of-date dictum. Though we understand the protection of professionalism is the basis for this practice, the topic is rarely revisited because the community of physicians remains distant from this sensitive issue, in spite of its importance in achieving high care satisfaction from patients and their families. In view of the increased emphasis on enhancing patients’ hospital experiences and satisfaction, the demonstration of sensitivity on the part of physicians in some form as a component of their compassionate care may require renewed attention.

Improving Management of Osteoarthritis: Patients’ Perceptions of a Surgical Readiness Interview Tool

Almost half of patients referred to orthopedic surgeons for Total Joint Arthroplasty (TJA) do not require TJA at that time or are not appropriate surgical candidates. The objective was to explore patients’ perspectives of a Surgical Readiness Interview Tool and its potential utility in the Osteoarthritis (OA) management process. Semi-structured qualitative interviews were conducted with a convenience sample of patients from arthroplasty clinics in Alberta. All interviews were digitally recorded and transcribed verbatim. Analysis was conducted iteratively, applying a constant comparison method. Nine patients were interviewed. Participants found the interview tool to be relevant and comprehensible. Suggestions were made on how to improve tool clarity and administration processes. Patient orientation versus that of the doctor, and expectation management emerged as salient factors in the meaningful application of the tool. As a result of the interviews, a revised tool was developed which incorporated the participant suggestions. Patients were positive about the interview tool and felt that it would lead to better care provision, particularly with incorporation of participants’ suggestions. The data suggest that the interview tool could improve the conversation on surgical readiness, conservative management, and addressing modifiable risk factors prior to TJA.

Related Adverse Events after Immunotherapy in Patient with NK/T-Cell Lymphoma: a Case Report

A 29-year-old male with pathologically confirmed extranodal NK/T cell lymphoma of the tonsil, nasal type was admitted to Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine. The patient was provided with several cycles of anti-PD-1 immunotherapy and obtained a Complete Response (CR) outcome. Despite the response, the patient also suffered from severe adverse effects, including a worsening pulmonary inflammation and severe laryngeal edema. A tracheotomy was performed to remove the white pseudo-membrane of laryngeal. via pathological analysis, necrosis of granuloma lymphoid cells and rhabdomous granuloma was found in this removed section. Meantime, a large amount of Candida nivaria, Klebsiella pneumoniae, and carbapenem-resistant Enterobacter was present in the patient’s sputum culture. The level of inflammatory cytokines (e.g., TNF-a, IL-1, IL-6, IL-17 and IFN-γ,) also increased significantly, indicating immune-related adverse events. Subsequently, the doctors adjusted immunotherapy to single-agent chemotherapy with additional anti-fungal and anti-bacterial infection treatment. The infection was well under control after these adjustments. 18F-FDG PET/ CT recorded the series of changes in the course of the patient from the start of immunotherapy.

Multimicrobial Pneumonia during the Early Stages of a Global Pandemic

Community-acquired pneumonia is an acute infection of lung parenchyma which causes local and systemic inflammatory changes via cytokines. Several bacteria and viruses are responsible for this type of pneumonia, and the most common bacterial cause is Streptococcus pneumoniae. The classic symptoms are cough, fever, and pleuritic chest pain. In the Winter of 2020, a new strain of coronavirus known as SARS-CoV-2 spread throughout the world and was responsible for a global pandemic that transformed the way we live our lives. A 93-year old female presented to the hospital with respiratory distress and was found to have not only COVID-19 pneumonia but also superimposed Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa pneumonia. Following the most up-to-date guidelines, she was determined to have community-acquired pneumonia. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa are uncommon causes of communityacquired pneumonia. She was treated with the standard of care at the time, which included vancomycin, piperacillin-tazobactam, and hydroxychloroquine. This case highlights the rarity of this specific presentation of community acquired pneumonia in regards to microbial etiology. It showcases that patients may develop certain diseases despite not having any risk factors. A major takeaway point is that apt decision making is a critical and time sensitive matter when determining whether a bacterial co-infection is present since it can affect patient outcomes. Since co-infections are relatively infrequent, antibiotic use in COVID-19 positive patients needs to be tailored accordingly. At the same time, it is crucial to keep in mind that co-infections are associated with increased severity of COVID-19 as well as poorer outcomes.

A Glimpse From Behind the Mask: Thoughts from the Old Clinician

This is an article/essay with focus on the question of the conflict between professional mystique and transparency in the clinician-patient relationship. Implied is the assumption that the professional “mask” influences treatment outcome and can distort or enhance the genuine nature of the relationship between those being served and those who serve them. The simple purpose of the question asked in the article is to stimulate discussion as to the relative utility of the professional mystique and professional transparency as to the degree that each influences treatment outcome and clinician satisfaction.

Revisiting the Differential for Left Lower Quadrant Pain: A Case of Epiploic Appendagitis

Appropriate triage of abdominal pain in the outpatient setting is critical for safe and effective management of patients. Abdominal pain has a broad differential, heavily dependent on elicitation of a clear history, and pertinent physical exam findings. In adults >50 with left lower quadrant pain, diverticulitis is the most common cause. Diverticulitis can cause significant morbidity in this population, frequently requiring inpatient management, systemic antibiotics, and occasionally surgical intervention. A frequently overlooked cause of left lower quadrant pain in adults is Epiploic Appendagitis (EA). While similar in presentation, unlike diverticulitis, EA rarely requires more than outpatient treatment with non-steroidal anti-inflammatories for pain management. Here we present a report of left lower quadrant pain consistent with diverticulitis in a 55 yo female in the outpatient setting, found to have EA by imaging. This case demonstrates that the differential for LLQ pain without signs of an acute abdomen in an adult, should include EA.

The Management of Irritable Bowel Syndrome: The Viewpoint of Italian General Practitioners in Activity and in Training

Background: Guidelines on Irritable Bowel Syndrome (IBS) are usually developed by specialists, with a possible translational gap in primary care. Aims: To evaluate the knowledge of IBS of Italian General Practitioners (GPs) and the difference compared to doctors in Training for General Practice (ITGPs). Methods: A questionnaire was completed by 170 GPs and 64 ITGPs. Results: The Rome Criteria and Bristol Scale are more familiar to ITGPs than GPs. The most frequently used diagnostic symptoms are abdominal pain, bowel movement frequency and bloating. GPs and ITGPs think that bloating and abdominal discomfort should be introduced into the definition of IBS. Intestinal motility disorders and psychological factors are considered to be the most probable cause of IBS. GPs report more frequently than ITGPs that the patient's request and difficulties in managing the disorder are reasons for a gastroenterological referral. Conclusions: There is still a gap between the indications provided by the experts and clinical practice, and this seems greater on the part of GPs than ITGPs. Abdominal pain and bowel frequency changes are considered the main symptoms for diagnosing IBS, but most GPs and ITGPs would like to include bloating among the diagnostic criteria. It would be highly desirable to develop commonly shared guidelines between gastroenterologists and GPs.

A Case Report: Acute Respiratory Distress in a Patient with Anemia

Acute respiratory distress can be life threatening if proper management is delayed. The cause of respiratory distress needs to be diagnosed quickly in order to administer appropriate and timely treatment. However, it is sometimes difficult to tease out various conditions that can present as acute respiratory distress. We present such a unique case of acute respiratory distress in a patient with anemia. We show how the ability to differentiate between cardiogenic and non-cardiogenic pulmonary edema can help in diagnosis and appropriate timely management of acute respiratory distress.

Follow-up Care of Monoclonal Gammopathy of Undetermined Significance: A Guide for Primary Care Physicians

Monoclonal Gammopathy of Undetermined Significance (MGUS) is a condition in which M protein, an abnormal monoclonal immunoglobulin, is present in the blood at a nonmalignant level. Specifically, it is defined by: blood serum M protein concentration <3 g/dL (<30 g/L), <10% plasma cells in the bone marrow, and no evidence of end organ damage [1,2]. Evidence of end organ damage includes hypercalcemia, renal insufficiency, anemia, and bone lesions. These are indicative of MGUS progression and which can be attributed to the monoclonal plasma cell proliferative process [3]. MGUS occurs in 3% of the general population older than 50 years. Incidence increases with age and varies with sex with higher rates observered in males than females [1,4]. MGUS is the most common plasma cell disorder, with 60% of patients that present to the Mayo Clinic with a monoclonal gammopathy being diagnosed with MGUS [3]. While it is typically an asymptomatic condition, it is premalignant disorder to other monoclonal gammopathies. Multiple Myeloma (MM) is almost always preceded by MGUS and the majority of patients will have detectable levels of M protein for at least 5 years prior to MM diagnosis [5,6]. MGUS also precedes immunoglobulin light chain (AL) amyloidosis and Waldenstrom Macroglobulinemia (WM) and tends to progress to disorders at a fixed but unrelenting rate of 1% per year [4].

Diabetic Ketoacidosis Triggered by an Emphysematous Urinary Tract Infection: A Case Report and Mini-Review of Literature

Generally, the most common triggers for Diabetic Ketoacidosis (DKA) are infectious diseases, such as Urinary Tract Infections (UTIs) or pneumonia. However, emphysematous infections are significant diseases rarely associated with DKA. Here, we present two cases of emphysematous urinary tract infection associated to diabetic ketoacidosis, highlighting the importance of a timely intervention and treatment. We review the need for appropriate laboratory and image testing in the context of infected patients who do not reach inflammatory/ glycemic goals to diagnosticate complicated infectious processes. This case report and mini-review also explore pathophysiology, the association of DKA and urinary emphysematous infections and treatment options.