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Diagnosing & Staging Esophageal Cancer

Diagnosing & Staging Esophageal Cancer

The overall 5-year survival rates for esophageal cancer are less than 15%. Although esophagectomy has been the traditional gold standard for early stage disease, optimal treatment for localized disease has generated debate in light of the overall poor survival rate. In 2013, the Society of Thoracic Surgeons (STS) published a set of clinical practice guidelines for the diagnosis and treatment of localized esophageal cancer in Annals of Thoracic Surgery. “The guidelines are the first of a series by the thoracic surgical community to use evidence-based practices for evaluating and treating these complex patients,” says Thomas K. Varghese Jr., MD, MS, who was the corresponding author of the STS guidelines. “They set a precedent for surgeons to play a pivotal role. Diagnosing and staging are critical steps in the decision-making process when selecting optimal therapy.” The recommendations were developed to help clinicians deliver evidence-based best practices for all patients at all times. Important Recommendations on Esophageal Cancer A key recommendation in the STS guidelines is that CT of the chest and abdomen or PET-CT are recommended tests for staging locoregionalized esophageal cancer. In addition, endoscopic ultrasonography is recommended for patients who are surgical candidates to determine the locoregional extent of disease, but diagnostic endoscopic mucosal resection should be considered for a more accurate diagnosis in early stages. Flexible endoscopy with biopsy is the diagnostic test of choice in order to determine the presence and location of the cancer and to biopsy any suspicious lesions. The location and length of the tumor, the extent of circumferential involvement, and the degree of obstruction should also be noted. The guidelines recommend that the...
Stratifying Risk in SCD: Planning for the Future

Stratifying Risk in SCD: Planning for the Future

Heart disease remains the leading cause of death in the United States and is responsible for more than 600,000 mortalities each year, according to data from the National Center for Health Statistics. About half of these mortalities are classified as sudden cardiac death (SCD). Of these deaths, about half occur as a victim’s first recognized cardiac event. Research suggests that only a small number of those suffering out-of-hospital cardiac arrests will ultimately survive these events. “SCD is a high priority public health problem that requires multipronged treatment and prevention approaches,” explains Jeffrey J. Goldberger, MD, a professor at Northwestern University’s Center for Cardiovascular Innovation. Recent reports indicate that the incidence of ventricular fibrillation as a cause of out-of-hospital cardiac arrest has been declining but continues to be a leading cause of SCD. Implantable cardioverter-defibrillators (ICDs) are effective but costly and have had a meaningful but, so far, limited impact on SCD. As a result, there are opportunities for new approaches to address SCD (Figure). Approximately $2.4 billion is spent each year on ICDs, but the medical community still has yet to identify the optimal method for determining which patients need these devices most. “Conducting research initiatives to improve our ability to predict risk would enable providers to target ICD use to the most appropriate recipients,” says Dr. Goldberger. “Under current prediction protocols, ICDs are not systematically reaching many patients who can benefit from receiving these devices. By assembling the right resources, there is hope that we can establish risk stratification standards that use medical resources wisely while saving the most lives.” Stratifying Sudden Cardiac Death Risk Developing effective strategies...
Decriminalizing Marijuana: Assessing Unintentional Pediatric Exposure

Decriminalizing Marijuana: Assessing Unintentional Pediatric Exposure

Throughout the United States, the legalization of marijuana is being debated by the public and in government forums. Although still criminalized at the federal level, decriminalization at the state level has received national attention because several states have enacted marijuana legislation for medical and recreational purposes. As of 2013, 18 states and the District of Columbia have passed legislation allowing for the use of medical marijuana, which includes many edible products, and sales are projected to more than double by 2015. More recently, Washington and Colorado have decriminalized small amounts of recreational marijuana. In 2004, the American Academy of Pediatrics released a policy statement that expressed concern about potential abuse of marijuana among adolescents in the context of decriminalization. There has been some evidence of medical marijuana being diverted to adolescents and recent reports of marijuana exposure to younger children. Studies suggest that there has been a slight increase in symptomatic, unintentional marijuana exposures since 2009. “Most of these exposures were from medical marijuana, which was often packaged as food products,” explains George S. Wang, MD, FAAP. “As such, it’s important to examine the effect that decriminalizing marijuana has had on children.” Assessing Trends in Marijuana Exposure In a study from Annals of Emergency Medicine, Dr. Wang and colleagues compared trends in unintentional marijuana exposures to children up to the age of 9 as measured by call volumes that were reported to U.S. poison centers. The authors hypothesized that decriminalized and transitional states would experience greater increases in call volume and have more symptomatic exposures and healthcare admissions than non-legal states. “States that decriminalized marijuana had significant increases in...
Refusal of Curative Care in the ED

Refusal of Curative Care in the ED

Resuscitating and stabilizing acutely ill or injured patients is a top priority for ED personnel, but traditional aggressive approaches to care may sometimes not suit the needs of those with advanced chronic illnesses who present to the ED with critical or terminal events. When seriously ill ED patients decline care targeted to cure disease, it may be challenging to rapidly shift treatment plans, especially if physicians feel unprepared and untrained for such scenarios. Framing the Conversation “When managing seriously ill patients who refuse curative care, it’s important to consider patient decision-making capacity,” says Sangeeta Lamba, MD. Pertinent information and options, including the risks of refusing care, should be provided. Ideally, patients will be able to communicate that they understand this information and verbalize their rationale for refusal based on personal goals. “It’s also important to involve the patient’s family, surrogates, or healthcare proxy,” adds Dr. Lamba. With clinical deterioration, patients may lose their ability to communicate. Others can then assist with decision making, especially if they know what patients value. “ED clinicians should first discuss overall patient goals and values before addressing specific procedures or issues,” Dr. Lamba says. “This information can help physicians frame future conversations and treatment plans to achieve patients’ objectives. It’s vital to understand the ‘why’ behind patient refusal and to use appropriate language and tone when having such conversations.” The ED team should also present viable alternatives if optimal treatment is not desired by patients or their family. Handling Transitions Once goals are clarified, patients may need to be shifted from curative care to a comfort-care approach. This transition must occur seamlessly and be...
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