Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study.

BACKGROUND: As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital. AIMS: To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital. METHODS: Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019. RESULTS: Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively. CONCLUSIONS: As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.

Nonspecific ileitis: Impact of histopathology and gastrointestinal ultrasound in achieving the diagnosis of Crohn's disease.

Background and Aim: Nonspecific ileitis is inflammation of the ileum without specific diagnostic features. A minority may go on to develop Crohn's disease, but optimal pathways of further investigation have not been established. This study aimed to identify a cohort of patients with nonspecific ileitis and to determine the value of ileal histology and gastrointestinal ultrasound in identifying/excluding Crohn's disease. Patients and Methods: In a retrospective analysis, all patients having nonspecific ileitis at colonoscopy from January 2010 to August 2021 were identified. Clinical associations with those subsequently diagnosed with Crohn's disease were examined with specific reference to ileal histology and gastrointestinal ultrasound. Results: Of 29 638 procedures, 147 patients (0.5%) had nonspecific ileitis. Crohn's disease was subsequently diagnosed in 8 patients (5.4%) at a median of 148 (range 27-603) days after colonoscopy. The presence of chronic inflammation on ileal biopsies was more common in those subsequently diagnosed with Crohn's disease (63% vs 20%; P = 0.0145). On gastrointestinal ultrasound, none of the 26 patients with normal bowel wall thickness (<3 mm) were subsequently diagnosed with Crohn's disease, and repeat ultrasound in 15 patients 1 year later showed no change. Of the nine patients with abnormal sonographic findings, three were diagnostic for Crohn's disease. Repeat ultrasound revealed Crohn's disease in two, while four had resolution of the abnormal findings. Conclusion: Although ileal histology was of limited value in identifying patients with nonspecific ileitis who were subsequently diagnosed with Crohn's disease, gastrointestinal ultrasound was highly informative. Prospective studies are needed to confirm the value of gastrointestinal ultrasound as a diagnostic and monitoring tool in this setting.

The technique and accuracy of breast specimen ultrasound in achieving clear margins in breast conserving surgery.

INTRODUCTION: The aim of this prospective study was to determine whether breast specimen ultrasound (SUS) can reliably be used to confirm whether ultrasound (US) visible breast malignancies are excised with clear margins during breast-conserving surgery (BCS), in order to avoid a second operation and recurrence. METHODS: A total of 95 consecutive participants with US visible malignancies, undergoing BCS, had the excised breast specimen transported to the radiology department intraoperatively. Breast SUS was used to confirm the presence of the lesion and measure the medial, lateral, superior and inferior margins. Margins < 10mm prompted a call to theatre to recommend an immediate cavity shave. The accuracy of the SUS technique in confirming the lesion is contained within the specimen, and the correlation of radial margins on US and histology was assessed retrospectively. RESULTS: Breast SUS had 100% accuracy in confirming the presence of 99 lesions. 384 corresponding US and invasive carcinoma histological margins were compared. A 10mm or greater margin on US has a sensitivity of 56% (95% CI 21-86), specificity of 93% (95% CI 90-95) and accuracy of 92% (95% CI 89-95) in predicting no ink on tumour histologically, with a positive predictive value of 16% (95% CI 5-34) and negative predictive value of 99% (95% CI 97-99%). The area under the curve was 0.746 (95% CI 0.572-0.921). CONCLUSIONS: Breast SUS is a fast and reliable technique. Mammographically occult breast malignancies that are sonographically evident should undergo SUS to confirm the presence of the lesion and assess its macroscopic margins to avoid a re-excision.