Acquired intercostal lung herniation: conservative management may lead to continuation of symptoms and other adverse consequence.

BACKGROUND: It is quite rare for lung to herniate between a patient's ribs, most often seen after surgery; it is, however, also rarely seen in other situations, notably during coughing fits situations such as coughing spells. There is minor controversy in the literature regarding management, namely, a question of whether to manage conservatively or with surgical correction, since this is such a rare entity physicians, may face difficulty in knowing how to proceed. Here, we provide evidence supporting acquired lung herniation management to be repaired surgically, and early, while at the same time medically optimizing the patient's risk factors for further herniation events or intercostal muscle tears. PRESENTATION: We report a 79-year-old man who suffered a right-sided lung herniation as a result of vigorous coughing, he initially was managed conservatively, and symptoms worsened but then underwent surgical repair which was associated with a suitable outcome. CONCLUSION: Lung herniation will may resolve on its own and prompt correction should be considered instead of conservative management. We recommend early surgical repair for all intercostal lung herniations, even if they are asymptomatic, to prevent complications or extension of the defect into the abdominal wall. Surgery may offer the best results, with low morbidity and no mortality reported to date.

Confidence with and Barriers to Serious Illness Communication: A National Survey of Hospitalists.

OBJECTIVE: To describe the concerns, confidence, and barriers of practicing hospitalists around serious illness communication. BACKGROUND: Hospitalist physicians are optimally positioned to provide primary palliative care, yet their experiences in serious illness communication are not well described. METHODS: Web-based survey, conducted in May 2016. The survey link was distributed via email to 4000 members of the Society of Hospital Medicine. The 39-item survey assessed frequency of concerns about serious illness communication, confidence for common tasks, and barriers using Likert-type scales. It was developed by the authors based on prior work, a focus group, and feedback from pilot respondents. RESULTS: We received 332 completed surveys. On most or every shift, many participants reported having concerns about a patient's or family's understanding of prognosis (53%) or the patient's code status (63%). Most participants were either confident or very confident in discussing goals of care (93%) and prognosis (87%). Fewer were confident or very confident in responding to patients or families who had not accepted the seriousness of an illness (59%) or in managing conflict (50%). Other frequently cited barriers were lack of time, lack of prior discussions in the outpatient setting, unrealistic prognostic expectations from other physicians, limited institutional support, and difficulty finding records of previous discussions. DISCUSSION: Our results suggest opportunities to improve hospitalists' ability to lead serious illness communication by increasing the time hospitalists have for discussions, improving documentation systems and communication between inpatient and outpatient clinicians, and targeted training on challenging communication scenarios.