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In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient's capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

Early liver transplantation (LT) for severe alcoholic hepatitis (AH) is a rescue therapy for highly selected patients with favorable psychosocial profiles not responding to medical therapy. Given the expected increase of AH candidate referrals requiring complex care and comprehensive evaluations, increased workload and cost might be expected from implementing an early LT program for AH but have not been determined. Some centers may also view AH as a strategy to expeditiously increase LT volume and economic viability. The aim of this study was to determine the health care use and costs of an early LT program for AH. Analyses of prospective databases of AH, interhospital transfers, and the hospital accounting system at a single center were performed from July 2011 to July 2016. For 5 years, 193 patients with severe AH were evaluated at our center: 143 newly referred transfers and 50 direct admissions. Annual increases of 13% led to 2 to 3 AH transfers/month and AH becoming the top reason for transfer. There were 169 (88%) nonresponders who underwent psychosocial evaluations; 15 (9%) underwent early LT. The median cost of early LT was $297,422, which was highly correlated with length of stay (r = 0.83; P

Objective Early liver transplantation (LT) is considered for patients with alcohol use disorder (AUD) despite limited sober time when acute mortality risk from liver disease is high. The objective of this paper is to find psychosocial tools that do not rely on extended sober time and predict alcohol relapse post-LT. Methods We conducted a systematic review of Pubmed, Embase, and Scopus for studies testing psychosocial tools that used numeric scoring to predict post-LT alcohol relapse. Tools that afforded points for length of sobriety were excluded. Each study was analyzed for its clinical context, post-LT relapse outcomes and predictive validity. Results Five scoring systems across fourteen samples showed varied validity in predicting post-LT alcohol relapse. Relapse to any alcohol use after LT revealed an average relapse rate of 23%. Most scoring systems were understudied but four of five provided cut-off scores with high negative predictive values for relapse. Conclusion Scoring systems may have a place in candidate selection but the data on cut-off scores and predictability are still lacking for their use alone in high stakes LT selection. Larger studies with prospective scoring and standardized follow ups for relapse post-LT will better allow the predictive validity of these psychosocial tools to be compared.

INTRODUCTION Donor nephrectomy (DN) is a procedure performed to provide recipients with a kidney to treat end-stage renal disease. The following analysis evaluated depression diagnosis in DN patients compared to controls. METHODS DN patients and matched controls were identified between 2000 and 2009 from the Statewide Planning and Research Cooperative System database. Cohorts were tracked for depression incidence. Multivariable logistic regression was used to determine independent predictors of a postoperative depression diagnosis. RESULTS The total study cohort included 2108 DN cases and 2108 controls. In both donors and controls, the baseline rate of depression was 0.95% (n = 20). The 5-year incidence of depression diagnosis after exposure increased in both cohorts (donors: 2.5%, n = 53; controls: 7.2%, n = 152; P < .001). The 5-year relative risk for developing depression was 2.65 (CI 1.59-4.42, P = .0002) in donors and 7.60 (CI 4.79-12.07, P < .001) in controls. On multivariable regression, being a donor was associated with reduced risk of developing postoperative depression (OR = 0.322, CI 0.233-0.445, P < .001), and the greatest risk factor for postoperative depression was a prior depressive diagnosis (OR = 7.811, CI 3.814-15.997, P < .001). CONCLUSION Our analysis shows that the strongest risk factor for depression was a prior diagnosis of depression. However, willingness to undergo donor nephrectomy is associated with less subsequent depression than the control population, suggesting that kidney donors may be a more resilient cohort.

Objectives We aimed to audit current United Kingdom (UK) practice of Head and Neck Cancer (HNC) post-treatment surveillance against national guidelines, and determine the outcomes of these practices in detecting recurrence. Design National cross-sectional study of current HNC surveillance practice. Setting UK HNC outpatient departments. Participants HNC patients reviewed for post-treatment surveillance. Main outcome measures Compliance with UK multidisciplinary guidelines, and rates of cancer recurrence detection by time, clinic type and symptoms. Results Data were analysed from 5,123 consultations across 89 UK centres. 30% of consultations were in dedicated multidisciplinary clinics, with input from Allied Health Professionals (AHPs) available on the day in 23% of all consultations. Recurrence was suspected in 344 consultations and investigated with MRI in 29.6% (n=102) and PET-CT in 14.2% (n=49). Patient education regarding recurrence symptoms, and smoking and alcohol advice, was provided in 20.4%, 6.2%, and 5.3% of cases, respectively. Rates of recurrence detected were 35% in expedited appointments and 5.2% in planned follow-ups (p=0.0001). Of the expedited appointments, 63% were initiated by patients and 37% by clinicians. Recurrence was higher in those with new symptoms (7.1% versus 2.2%). The strongest predictors of recurrence were dyspnoea (positive predictive value (PPV)=16.2%), neck pain (PPV=10.4%) and mouth/throat pain (PPV=9.2%). Conclusions Dedicated multidisciplinary clinics comprise a minority of consultations for HNC surveillance in the UK, with low availability of AHPs. PET-CT and MRI were underutilised for the investigation of suspected recurrence. There may be scope for greater emphasis on patient education and consequent patient-initiated symptom driven follow-up.

Background:Epistaxis is a common condition that can be associated with significant morbidity, and it places a considerable burden on our healthcare system. This national audit of management sought to assess current practice against newly created consensus recommendations and to expand our current evidence base.Methods:The management of epistaxis patients who met the inclusion criteria, at 113 registered sites across the UK, was compared with audit standards during a 30-day window. Data were further utilised for explorative analysis.Results:Data for 1826 cases were uploaded to the database, representing 94 per cent of all cases that met the inclusion criteria at participating sites. Sixty-two per cent of patients were successfully treated by ENT clinicians within 24 hours. The 30-day recurrent presentation rate across the dataset was 13.9 per cent. Significant event analysis revealed an all-cause 30-day mortality rate of 3.4 per cent.Conclusion:Audit findings demonstrate a varying alignment with consensus guidance, with explorative analysis countering some previously well-established tenets of management.

A 57-year-old woman presented with a 3-month history of an enlarging thyroid mass causing breathlessness and dysphagia. Cross-sectional imaging showed a thyroid tumour infiltrating the trachea and abutting the oesophagus. She underwent panendoscopy, total thyroidectomy and planned tracheal resection, but due to intraoperative findings, a staged procedure was planned instead. Histological analysis revealed a poorly differentiated squamous cell carcinoma (SCC) which was positive on paired box gene 8 (PAX8) immunostaining, suggesting a diagnosis of primary thyroid SCC. She subsequently underwent total laryngectomy and bilateral neck dissections followed by radiotherapy with concurrent cisplatin chemotherapy. The patient remains disease-free 22 months after treatment. Median overall survival is 10 months for macroscopically completely resected tumours. PAX8 immunostaining is a novel technique which helps with the diagnostic challenge of distinguishing between primary thyroid SCC and SCC metastatic to the thyroid from extrathyroidal sites. Complete surgical resection with adjuvant chemoradiotherapy may result in a favourable outcome despite conflicting reports in the literature.

Mucoepidermoid carcinomas (MECs) are the most common malignant tumour of the salivary glands. MECs have also been reported to occur in atypical sites. Primary MECs of the thyroid gland are extremely rare, accounting for 0.5% of thyroid malignancies with approximately 48 cases reported in the literature. In most cases, these are low-grade neoplasms with good long-term prognosis. We present the case of a 74-year-old patient with poorly differentiated MEC of the thyroid gland, which behaved aggressively resulting in rapid decline and death of the patient. The exact pathophysiology of the disease remains unclear and there is no consensus on the optimal treatment for this histological subtype. Recognition and diagnosis of this rare neoplasm are important as this can help guide optimal treatment, although in high-grade poorly differentiated cases, treatment options remain limited.

Summary Background Contributing to the education of students as a junior doctor, with a busy rota, in an ever-evolving health care system can be challenging. Methods A 4–month timetable was organised to fit in with both the commitments of 60 foundation doctors and 120 final-year medical students. Using the already established online undergraduate timetable system, foundation doctors created regular sign-up teaching sessions for students to attend. Foundation doctors had their teaching assessed by senior colleagues, enabling work-based assessments to be completed and mapped to their curriculum. Feedback from both students and foundation doctors was collected using free-text answers and scale ratings. Results A total of 49 foundation doctors and 70 medical students were involved in the pilot teaching scheme. Using thematic analysis from the feedback, 76 per cent of foundation doctors reported an increased confidence in delivering teaching. In relation to the students, 75 per cent attended regular teaching sessions, 80 per cent found the teaching sessions relevant to their learning and preparation for final examinations, and 97 per cent would recommend this scheme to the next cohort of students. Discussion Teaching hospitals should encourage regular undergraduate teaching led by foundation trainees. Incorporating a flexible timetable and ensuring teacher availability can allow the delivery of high-quality teaching that is not only beneficial for the student but also for junior doctors keen to enhance their teaching ability. By being involved in regular teaching, junior doctors are able to build the skills, attitudes and practices of being competent clinical teachers, thereby preparing them to become the educators and trainers of the future. Contributing to the education of students as a junior doctor....can be challenging

This study assessed the impact of the revision of the Preadmission Screening and Resident Review (PASRR) regulation changes in September 2011, which increased the turnaround time for PASRR evaluations from 3 to 5 days to 2 to 3 weeks.From January 2013 to March 2013, we tracked all patients' charts in a 25-bed inpatient geriatric psychiatric unit in New York where PASRR evaluations were requested. The turnaround time and related issues were analyzed.There were 27 patients who had PASRR requests during the study period; 9 patients were not included in the study because of incomplete data. The average turnaround time for the 18 patients was 14.89 days and the additional hospital bed cost per patient was $11,911.11.Although PASRR has played a positive role in identifying persons with serious mental illness and the need to provide the services they need, the recent revision of the PASRR regulation in 2011 has significantly increased the hospital bed costs.

Infratentorial subdural empyema is a neurosurgical emergency that is associated with an alarmingly high morbidity and mortality if appropriate management is delayed. It is an important differential to consider when confronted with a patient with a reduced Glasgow Coma Scale, focal neurology and symptoms of raised intracranial pressure in the presence of a head and neck infection. It is also important that the primary team managing these patients is aware of the many pathogens that may be involved, including Escherichia coli. Early recognition, prompt diagnosis, timely involvement of the appropriate multidisciplinary teams, including neurosurgery, otorhinolaryngology, radiology and microbiology should be sought, and urgent intervention are imperative in avoiding a fatal outcome. This article presents a case of E coli-positive infratentorial subdural empyema secondary to mastoiditis due to underlying cholesteatoma, and a review of the pertinent literature.

Recurrent croup is a distinct clinical entity from viral croup. It is not a specific diagnosis and its presence should alert the clinician to explore the underlying cause. We discuss an evidence-based structured approach to management of a child with recurrent croup.

This article describes the fabrication, characterization and application of an epidermal temporary-transfer tattoo-based potentiometric sensor, coupled with a miniaturized wearable wireless transceiver, for real-time monitoring of sodium in the human perspiration. Sodium excreted during perspiration is an excellent marker for electrolyte imbalance and provides valuable information regarding an individual's physical and mental wellbeing. The realization of the new skin-worn non-invasive tattoo-like sensing device has been realized by amalgamating several state-of-the-art thick film, laser printing, solid-state potentiometry, fluidics and wireless technologies. The resulting tattoo-based potentiometric sodium sensor displays a rapid near-Nernstian response with negligible carryover effects, and good resiliency against various mechanical deformations experienced by the human epidermis. On-body testing of the tattoo sensor coupled to a wireless transceiver during exercise activity demonstrated its ability to continuously monitor sweat sodium dynamics. The real-time sweat sodium concentration was transmitted wirelessly via a body-worn transceiver from the sodium tattoo sensor to a notebook while the subjects perspired on a stationary cycle. The favorable analytical performance along with the wearable nature of the wireless transceiver makes the new epidermal potentiometric sensing system attractive for continuous monitoring the sodium dynamics in human perspiration during diverse activities relevant to the healthcare, fitness, military, healthcare and skin-care domains.