Michael S. Putman

Quality of Life and Recommendations for Further Care

Objectives:Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations. Design, Setting, and Subjects:A 2010 mailed survey of practicing U.S. physicians (1,156/1,878 or 62% of eligible physicians responded). Measurements and Main Results:Measures included an end of life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment. Conclusions:Physician judgments about quality of life are highly correlated with recommendations for further care. Patients and family members might consider these biases when negotiating medical decisions.

Myositis-associated Interstitial Lung Disease: Predictors of Failure of Conventional Treatment and Response to Tacrolimus in a US Cohort

Objective. Patients with myositis-associated interstitial lung disease (MA-ILD) are often refractory to conventional treatment, and predicting their response to therapy is challenging. Recent case reports and small series suggest that tacrolimus may be useful in refractory cases. Methods. A retrospective cohort study of patients with MA-ILD comparing clinical characteristics between those who responded to or failed conventional treatment. In those who failed conventional treatment and received adjunctive tacrolimus, response to tacrolimus was measured by the improvement in myositis, ILD, and change in the dose of glucocorticoids. Results. Thirty-one of 54 patients (57%) responded to conventional treatment based on the predefined variables of improvement in myositis and/or ILD. Patients with polymyositis (PM)-ILD were more likely to respond to conventional treatment than those with dermatomyositis (DM)-ILD (67% vs 35%, p = 0.013). Twenty-three patients failed conventional treatment, 18 of whom subsequently received adjunctive tacrolimus. Ninety-four percent had improvements in ILD and 72% showed improvement in both myositis and ILD. The mean doses of prednisone decreased from baseline by 65% at 3–6 months (p = 0.002) and 81% at 1 year (p < 0.001). Conclusion. Patients with PM-ILD were more likely to respond to conventional treatment than patients with DM-ILD, but clinical characteristics and serology did not otherwise predict response to therapy. A majority of patients with MA-ILD refractory to conventional therapy improved while receiving tacrolimus and were able to decrease their dose of both glucocorticoids and other disease-modifying antirheumatic drugs.

Unilateral Do Not Resuscitate Orders: Physician Attitudes and Practices

AFFILIATIONS: From the Division of Pulmonary and Critical Care Medicine (Drs Marik, Hooper, and Khangoora), Eastern Virginia Medical School; the Department of Pharmacy (Dr Rivera), Sentara Norfolk General Hospital; the School of Medical Diagnostic and Translational Sciences (Dr Catravas), College of Health Sciences, Old Dominion University; and the Departments of Medicine and Physiological Sciences (Dr Catravas), Eastern Virginia Medical School. FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest. CORRESPONDENCE TO: Paul E. Marik, MD, FCCP, Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Ste 410, Norfolk, VA 23507; e-mail: marikpe@evms.edu Copyright 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2017.04.182

US Physicians Overwhelmingly Endorse Hospice as the Better Option for Most Patients at the End of Life

Background: Utilization of hospice has increased significantly over the past 2 decades, but there has been no recent assessment of US physicians’ opinions regarding and practices of referring patients to hospice. Methods: We surveyed 2016 US physicians from various specialties. Respondents agreed or disagreed with 2 statements: “For most patients, hospice provides better care at the end of life than they would otherwise receive without hospice” and “Many patients who enter hospice end up missing out on medical interventions from which they would have benefited.” Physicians were also asked, “In the past 12 months, approximately how many patients and/or their surrogates have you encouraged to consider entering hospice?” Results: Ninety-eight percent of physicians agreed that hospice provides better care at the end of life than the patient would receive without hospice. Only 11% of physicians agreed that patients who enter hospice miss out on medical interventions from which they would have benefitted. Ninety-two percent encouraged at least 1 patient to consider hospice in the previous 12 months. Oncologists were the most ambivalent about whether patients who enter hospice miss out on beneficial interventions, but they also referred more patients to hospice than physicians from other specialties. Conclusion: US physicians overwhelmingly believe hospice is the best form of care for most patients at the end of life. Compared to a study published in 1998, the median oncologist reports referring fewer patients to hospice, but the median general internist reports referring more.

Adult-onset Still's disease: current challenges and future prospects

Adult-onset Still’s disease (AOSD) – a multi-systemic inflammatory condition characterized by high fevers, polyarthritis, an evanescent rash, and pharyngitis – has been a challenging condition to diagnose expediently and treat effectively. Questions remain regarding the underlying pathophysiology and etiology of AOSD. Pathognomonic diagnostic tests and reliable biomarkers remain undiscovered. Over the past decade, important progress has been made. Diagnostic criteria employing glycosylated ferritin have improved specificity. More important, novel biologic therapies have offered important clues to AOSD’s underlying pathophysiology. Cytokine-specific biologic therapies have been instrumental in providing more effective treatment for disease refractory to conventional treatment. While IL-1 therapy has demonstrated efficacy in refractory disease, novel therapies targeting IL-6 and IL-18 show great promise and are currently under investigation.

Student-run free clinics and complementary curricula.

enhance or detract from the learning in PBL tutorials? We solicited 10 volunteer tutors (out of 36) within a 4-week GI system block in the second year of our medical school program, who would allow their students (8 per tutor) to bring an electronic device of their choice into their tutorial sessions. Up to this point, devices were disallowed and only a medical dictionary was used in the tutorial sessions. At the completion of the block, the participating students and tutors were invited to complete an electronic online survey including a Likert questionnaire as well as open-ended questions reflecting their experience during the interventions. Of the respondents, fifty-four different types of devices were reported being used in the tutorial sessions. Tablets (35%) and smart phones (46%) were the most popular type of device used by students and tutors with laptops making up a small percentage of use (16%). Five percent of them felt that the devices did not improve PBL, 39% were neutral, and 55% either agreed or strongly agreed that the devices improved PBL. Ten percent of the students and tutors felt that the devices did adversely affect group dynamics, 17% were neutral, and 74% felt that the devices did not interfere with group dynamics. Five percent of those responding felt it did not improve accuracy. Sixteen percent were neutral, and 80% felt that it did improve accuracy. Overall, 89% were in favor of recommending while 11% were not. In this pilot study, we found that PBL tutors and students overwhelmingly supported allowing the use of electronic devices into the PBL tutorials. This has led to a policy change, and devices are encouraged, but individual usage determined by group agreement only.