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Physician-assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy.

Gleason score from biopsy specimens is important for prostate cancer (PCa) risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50 % and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population. A total of 959 patients with D’Amico low-risk prostate cancer underwent radical prostatectomy at Georgetown University or Washington Hospital Center between January 2005 and July 2012. Race, age, PSA, body mass index (BMI), cancer of the prostate risk assessment (CAPRA) score, and transrectal ultrasound (TRUS) biopsy characteristics (percent of biopsy cores showing adenocarcinoma, highest percent of biopsy core involved with cancer, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analyses to identify significant predictors of GSU while controlling for clinical parameters. Of the 959 cases, 288 (30.0 %) were upgraded on final pathologic specimen with approximately 38 % (133/355) of African-American patients experiencing GSU. BMI (P = 0.02), percent positive biopsy cores (P

A ccording to the American Cancer Society’s Survey, 28,900 new cases of oral cancer emerged in 2000. The death rate associated with oral cancer is particularly high because in more than half of the cases, the cancer is discovered late in its development. In these instances, radiography plays a key role in the diagnosis. Dentists trained in radiographic interpretation can determine the presence of tumors or growths, and can even distinguish malignant tumors from benign tumors based on their radiographic presentation. Interpretation of lesions in the jaws, therefore, is a vital professional skill for dental practitioners. Dentists’ encounters with non-routine radiographic pathology are limited because of the small size of patient pools and the relatively low occurrence rate of certain disease processes. However, meaningful oral and maxillofacial radiographic pathology, including oral cancer cases, do exist and have been diagnosed and treated each year. Furthermore, dentists are less confident about their ability to interpret radiographic images accurately. This lack of confidence could potentially lead to a failure to recognize or misdiagnosis significant pathology including cancer. Dental faculty is faced with the challenge of finding teaching cases from various sources because they often do not have their own. There is a real need to enhance radiographic interpretation and diagnosis skills for both dental students and current practitioners. Interpretation of radiographic dental images is a process of decision making, which requires a broad knowledge and in-depth familiarity with the underlying pathology and consequent radiographic manifestations. It is a significant part of the radiology curriculum taught in every dental school. There are meaningful teaching cases that are not used to full potential because these cases are not properly annotated, archived, and shared. In the case of rare oral disease processes, these cases may occur so infrequently that the student’s sole exposure is the depiction in a textbook. Currently, teaching cases for the training of dentists are developed on an as-needed basis and generally created and maintained locally. This process necessarily limits the exposure of teaching cases to the population served by that dental health center and often to students who work with a particular instructor. Some areas are not sufficiently demographically diverse to account for differences between ethnic groups, population ages or other factors. Most radiology interpretation courses at the pre-doctoral level are given in large lecture format.

Background In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. Objective We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. Methods We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. Conclusions Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

Although 2-dimensional echocardiography with adjunct intravenous contrast media improves endocardial visualization and enhances quality of spectral Doppler signals, widespread use of contrast agents has not occurred for various reasons. Results from this study indicate that discretionary use of contrast media will enhance endocardial and Doppler signal visualization scores without an impact on total procedure duration, lending credence to an argument for a lower threshold for discretionary use of contrast media.

Incidence of breast cancer (BC) varies among ethnic groups, with higher rates in white than in African-American women. Until now, most epidemiological and genetic studies have been carried out in white women. To investigate whether interactions between genetic and reproductive risk factors may explain part of the ethnic disparity in BC incidence, a genetic epidemiology study was conducted, between 1989 and 1994, at the Howard University Cancer Center (Washington, DC), which led to the recruitment of 245 African-American families. Segregation analysis of BC was performed by use of the class D regressive logistic model that allows for censored data to account for a variable age of onset of disease, as implemented in the REGRESS program. Segregation analysis of BC was consistent with a putative dominant gene effect (P < 0.000001) and residual sister-dependence (P < 0.0001). This putative gene was found to interact significantly with age at menarche (P = 0.048), and an interaction with a history of spontaneous abortions was suggested (P = 0.08). A late age at menarche increased BC risk in gene carriers but had a protective effect in non-gene carriers. A history of spontaneous abortions had a protective effect in gene carriers and increased BC risk in non-gene carriers. Our findings agree partially with a similar analysis of French families showing a significant gene x parity interaction and a suggestive gene x age at menarche interaction. Investigating gene x risk factor interactions in different populations may have important implications for further biological investigations and for BC risk assessment.

In May 2011, the clinical ethics group of the Center for Ethics at Washington Hospital Center launched a 40-hour, three and one-half day Clinical Ethics Immersion Course. Created to address gaps in training in the practice of clinical ethics, the course is for those who now practice clinical ethics and for those who teach bioethics but who do not, or who rarely, have the opportunity to be in a clinical setting. "Immersion" refers to a high-intensity clinical ethics experience in a busy, urban, acute care hospital. During the Immersion Course, participants join clinical ethicists on working rounds in intensive care units and trauma service. Participants engage in a videotaped role-play conversation with an actor. Each simulated session reflects a practical, realistic clinical ethics case consultation scenario. Participants also review patients' charts, and have small group discussions on selected clinical ethics topics. As ethics consultation requests come into the center, Immersion Course participants accompany clinical ethicists on consultations. Specific to this pilot, because participants' evaluations and course faculty impressions were positive, the Center for Ethics will conduct the course twice each year. We look forward to improving the pilot and establishing the Immersion Course as one step towards addressing the gap in training opportunities in clinical ethics.

Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their concern is that any guidance offered by the ethics consultant will privilege and empower one party’s viewpoint over—and to the exclusion of—other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new “spaces” for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for “clinical ethics conflict coaching” can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes.

This paper presents the behavioral interview model that we developed to formalize our hiring practices when we, most recently, needed to hire a new clinical ethicist to join our staff at the Center for Ethics at Washington Hospital Center.

How can the suspicion of myocardial ischemia be confirmed without putting the patient through an invasive procedure? In patients who have had myocardial infarction, how can those at risk for pump failure and other complications and future cardiac events be identified? How are such complications detected? The answer to all these questions is echocardiography. The authors review how to use the technique and provide illustrative images.

To examine the impact of mammography screening on treatment options received by a cohort of older breast cancer patients.We studied 718 newly diagnosed breast cancer patients, 67 years and over, diagnosed with TNM Stage I and II disease between 1995 and 1997 at 29 hospitals in five regions.Data were collected from patients, surgeons, and medical records. A breast cancer diagnosis was considered to have been by screening mammography if so reported by both patient and medical records. Bivariate and logistic regression were used to identify predictors of a women having her cancer detected by screening mammography and the relationships between mode of detection, stage of disease at diagnosis, and local treatment.Women with high school or greater education were 1.75 times (95%, CI 1.11-2.75) more likely to have their cancers diagnosed by screening mammography than women who had not completed high school, controlling for other factors. Screening found earlier stage disease: 96% of women with mammographically diagnosed cancer had T1 lesions, compared to 81% of women diagnosed by other means (p = 0.001). Women with mammography detected lesions were more likely to have ductal cancer, and to be referred to radiation oncologists more than women diagnosed by other means. Controlling for stage and histology, screening remained associated with a higher likelihood of receiving breast conserving surgery (BCS) with radiation (RT) (OR 1.56, 95%, CI 1.10-2.22) than other local therapies.Beyond the impact on stage, ductal cancers were more likely to be diagnosed by screening. Mammographically detected lesions were associated with referrals to radiation oncologists and higher rates of BCS and RT. Research is needed to explain the residual independent effects of mammography screening on breast cancer treatment.

The catalytic oxidation of carbon monoxide (CO) to carbon dioxide (CO2) in air by Hopcalite is the basis for a personal sampler for carbon monoxide. Four or eight hour integrated samples are obtained by drawing air at 0.5 liter per minute (lpm) through stripping beds of Ascarite and molecular sieve which remove water vapor and CO2 present in the ambient air. The air sample then passes to a preweighed glass U-tube which contains Hopcalite, Ascarite, and anhydrous magnesium perchlorate. After sampling, the U-tube is reweighed; the increase in weight is due to the trapped CO2 from the oxidized CO. At 0.5 lpm and 70°F, the 1.5 g of catalyst in the U-tube convert more than 90% of the CO to CO2. For a four-hour sample in the range of 20 to 100 parts per million (ppm) CO, the relative standard deviation of duplicate measurements is ±6%.

Actinomycin D and 5-fluorouracil, given with x-ray in a dosage regimen sufficient to produce definite but tolerable gastrointestinal and marrow toxicity, did not increase the percentage of patients with carcinoma of the lung showing shrinkage of lesions in the irradiated field. There was no evidence of a more rapid onset of shrinkage of the tumor or of an additive effect at subtotal doses of x-ray. Patient survival was not affected beneficially by the addition of the chemotherapeutic agents. Toxicity was not correlated with responses induced. Patients classified as responders to therapy lived longer than those classified as nonresponders.