When less is more: Updates in active surveillance and watchful waiting in the management of prostate cancer.

BACKGROUND: Prostate cancer is the second most common cancer among men globally. A range of management options are available for prostate cancer, including surgery, radiation therapy, hormone therapy, chemotherapy, or surveillance. Conservative strategies include active surveillance and watchful waiting, which differ in their intent. OBJECTIVE: We provide a targeted instructive management algorithm for improving understanding of conservative strategies in prostate cancer. DISCUSSION: Active surveillance involves close monitoring with curative intent when there is evidence of disease progression. In contrast, watchful waiting is palliative in intent and focuses on delaying treatment until symptoms or complications develop. Conservative approaches have demonstrated similar long-term oncological outcomes to radical treatment, while reducing harm from overtreatment, and maintaining quality of life by avoiding potential side effects such as urinary incontinence and erectile dysfunction. The decision to employ a conservative approach is determined by both patient and disease factors. Conservative management strategies play a vital role in the management of prostate cancer.

The Effect of the Consent Process on Patient Satisfaction With Pain Management: A Randomized Controlled Trial.

STUDY OBJECTIVE: We aim to determine whether the timing and context of informed consent affects the subjective outcome of patient satisfaction with pain management. METHODS: We conducted a randomized controlled trial in a single emergency department (ED). Patients aged 18 years or older with a triage pain score of greater than or equal to 4 provided consent to participate in a pain management study. They were randomized to consent in the ED or at follow-up. All patients were followed up at 48 hours post-ED discharge. Patients who consented at follow-up were unaware of the study until cold called. The primary outcome was patient satisfaction with pain management. Secondary analyses examined effects on follow-up and participation rates. Variables associated with patients' being very satisfied were determined with multivariate logistic regression. RESULTS: Outcome data were obtained on 655 of 825 patients enrolled (79.4%). Patients who provided consent at follow-up were less likely to be very satisfied compared with those who consented in the ED (difference in proportions 11.5%; 95% confidence interval 3.5 to 19.4). Follow-up and participation rates did not differ between the groups. Patients who received pain advice and adequate analgesia (both as defined in this study) were more likely to be very satisfied (odds ratio 5.18, 95% confidence interval 2.82 to 9.52; and odds ratio 1.54, 95% confidence interval 1.07 to 2.22, respectively). CONCLUSION: The timing and context of informed consent significantly affect the subjective outcome of patient satisfaction, and this should be considered during study design. Clinicians should strive to provide pain advice and adequate analgesia to maximize their patients' satisfaction.

Outcomes of laceration suture repair in the emergency department.

OBJECTIVE: To assess patient satisfaction with laceration management, post-ED care, cosmesis and complication rates. METHODS: We undertook a prospective observational study of adult patients with lacerations sutured in two EDs over a 4-month period. ED data included participant demographics, laceration characteristics and management. A telephone survey was undertaken approximately 14 days post-ED discharge. Patient satisfaction with post-ED pain management, advice on wound care and follow up, overall management and wound cosmesis were evaluated using a six-item satisfaction scale (very dissatisfied to very satisfied). Details of wound infection, dehiscence and suture failure were recorded. RESULTS: Eighty-nine patients participated. The number (% [95% confidence interval]) of patients very satisfied with their laceration management were: post-ED pain management 55 (62.5% [51.5-72.4]), wound care advice 51 (57.3% [46.4-67.6]), follow-up advice 39 (43.8% [33.5-54.7]), overall management 61 (68.5% [57.7-77.7]) and cosmetic appearance 46 (51.7% [40.9-62.3]). Infection, dehiscence and suture failure occurred in 5 (5.6%), 8 (9.0%) and 8 (9.0%) cases, respectively. These complications were not associated with being very satisfied overall (P = 0.96). Patients very satisfied with post-ED pain management, wound care advice, follow-up advice or wound cosmesis were much more likely to be very satisfied overall (P < 0.001). CONCLUSIONS: Most patients are very satisfied with their laceration management. However, there is scope for improvement, especially for follow-up and wound care advice. Complications are infrequent and not associated with overall satisfaction.

Nature and outcomes of sanctioned medical misconduct in six international jurisdictions: a case series.

Objective The aim of this study was to determine the types of medical misconduct, the practitioner, specialities and jurisdictions at risk, patient outcomes and the sanctions imposed. Methods This study was a retrospective case series of 822 adverse medical tribunal determinations in Australia, New Zealand, Canada (Ontario, Alberta), Pennsylvania (USA), Singapore and Hong Kong in 2013-17. Results Inappropriate medical care and illegal or unethical prescribing were the most common types of misconduct. Misconduct varied with practitioner sex, international medical graduate status, speciality and jurisdiction (P<0.05). Cases of inappropriate medical care were more common in Singapore (46.7% of all Singapore cases; 95% confidence interval (CI) 31.9-62.0) and among surgeons (47.6% of all surgeon cases; 95% CI 36.5-58.8). Illegal or unethical prescribing was more common in Australia (31.1%; 95% CI 24.8-38.2) and among general or family practitioners (26.9%; 95% CI 20.0-35.0). Misconduct not related to patients was more common in Pennsylvania (30.3%; 95% CI 25.2-36.0) and among local graduates (20.5%; 95% CI 17.1-24.5). Sexual misconduct was more common in Australia (29.6%; 95% CI 23.4-36.6) and among males (19.6%, 95% CI 16.7-22.8). Healthcare dishonesty was more common in Hong Kong (21.8%; 95% CI 14.0-32.2) and among surgeons (13.4%; 95% CI 7.2-23.2). The most common patient outcomes were patient risk (40.6%; 95% CI 36.1-45.4) and death and actual physical harm combined (31.2%; 95% CI 26.9-35.7). Sanctions were most commonly suspension or deregistration. Deregistration was most common in cases of sexual misconduct. Conclusion Medical misconduct varies widely. Risk factors for particular misconduct types are apparent among jurisdictions and practitioner characteristics. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury. What is known about the topic? Medical misconduct is a continuing problem. Tribunals and medical boards sanction misconduct to protect patient safety and public trust. What does this paper add? Tribunals and boards differ in misconduct reporting and permitting public access to determinations. Types of misconduct vary between international jurisdictions, practitioner sex, international graduate status and speciality. Risk and physical injury (including death) are the most common patient outcomes. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury. What are the implications for practitioners? Medical colleges should tailor trainee programs to address the common types of misconduct within their specialities. Standardisation of misconduct reporting, and report access, across jurisdictions would facilitate ongoing surveillance and intervention evaluation.

Discordance between patient-reported and actual emergency department pain management.

OBJECTIVE: To determine patient knowledge of the nature of their pain management in the ED. METHODS: This was a planned sub-study of data collected during a randomised, controlled trial of the nature of the informed consent process in a single ED. Patients aged ≥18 years, with a triage pain score of ≥4, were enrolled. Forty-eight hours post-ED discharge, patients were asked if they had declined analgesia or if a range of pain management options had been administered. The primary outcome was discordance between the patient report and the ED report (proportion of cases where these reports differed). RESULTS: Outcome data were collected on 655 patients. There was significant discordance for all variables examined (P < 0.001). Discordance for patients declining analgesia was lowest at 8.9% (95% confidence interval [CI] 6.8-11.4). Discordance for administration of pain management 'other' than analgesia was highest at 32.6% (95% CI 29.0-36.4). Discordance for the administration of oral analgesia or 'any' analgesia was 17.1% (95% CI 14.3-20.3) and 14.4% (95% CI 11.8-17.3), respectively. For both of these outcomes, patients with chest pain and lower triage pain scores were more likely to report discordant responses. With the exception of 'other' pain management, smaller proportions of patients incorrectly reported not receiving management than incorrectly reporting that they did receive it. CONCLUSION: Patients are often unaware of the nature of their pain management. They are most often unaware of management other than analgesia. Patients with chest pain and lower triage pain scores had the least knowledge of their pain management.