Timothy Craig Allen (2019) The Evolution of Decedent Ownership. Archives of Pathology & Laboratory Medicine: September 2019, Vol. 143, No. 9, pp. 1048-1051.

EDITORIAL

The Evolution of Decedent Ownership

Timothy Craig Allen, MD, JD

From the Department of Pathology, University of Mississippi Medical Center, Jackson.

Corresponding author: Timothy Craig Allen, MD, JD, Department of Pathology, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 (email: tcallen@umc.edu).

"As society’s mores evolve into and through the 21st century, the issue of autopsy and periautopsy consent will require increased attention by state legislatures and courts."

Ann Diagn Pathol. 2019 Aug;41:43-50. doi: 10.1016/j.anndiagpath.2019.04.008. Epub 2019 Apr 24.

Micropapillary adenocarcinoma of lung: Morphological criteria and diagnostic reproducibility among pulmonary pathologists.

Monroig-Bosque PDC1, Morales-Rosado JA2, Roden AC3, Churg A4, Barrios R1, Cagle P1, Ge Y1, Allen TC5, Smith ML3, Larsen BT3, Sholl LM6, Beasley MB7, Borczuk A8, Raparia K9, Ayala A1, Tazelaar HD10, Miller R1, Kalhor N11, Moran CA12, Ro JY13.

Author information

1

Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Weill Medical College of Cornell University, Houston, TX, USA.

2

Health Sciences Research Department, Mayo Clinic, Rochester, MN, USA.

3

Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.

4

Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

5

Department of Pathology, The University of Mississippi Medical Center, MS, USA.

6

Department of Pathology, Harvard Medical School, Boston, MA, USA; Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA.

7

Department of Anatomic Pathology, The Mount Sinai Hospital, New York, NY, USA.

8

Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY, USA.

9

Kaiser Permanente, Santa Clara Medical Center and Medical Offices, Santa Clara, CA, USA.

10

Department of Pathology, Mayo Clinic, Phoenix, AZ, USA.

11

Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

12

Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Weill Medical College of Cornell University, Houston, TX, USA; Health Sciences Research Department, Mayo Clinic, Rochester, MN, USA.

13

Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Weill Medical College of Cornell University, Houston, TX, USA. Electronic address: JaeRo@houstonmethodist.org.

Abstract

CONTEXT:

Invasive micropapillary adenocarcinoma (MPC) is an aggressive variant of lung adenocarcinoma, frequently manifesting with advanced stage lymph node metastasis and decreased survival.

OBJECTIVE:

Identification of this morphology is important, as it is strongly correlated with poor prognosis regardless of the amount of MPC component. To date, no study has investigated the morphological criteria used to objectively diagnose it.

DESIGN:

Herein, we selected 30 cases of potential MPC of lung, and distributed 2 digital images per case among 15 pulmonary pathology experts. Reviewers were requested to diagnostically interpret, assign the percentage of MPC component, and record the morphological features they identified. The noted features included: columnar cells, elongated slender cell nests, extensive stromal retraction, lumen formation with internal epithelial tufting, epithelial signet ring-like forms, intracytoplasmic vacuolization, multiple nests in the same alveolar space, back-to-back lacunar spaces, epithelial nest anastomosis, marked pleomorphism, peripherally oriented nuclei, randomly distributed nuclei, small/medium/large tumor nest size, fibrovascular cores, and spread through air-spaces (STAS).

RESULTS:

Cluster analysis revealed three subgroups with the following diagnoses: "MPC", "combined papillary and MPC", and "others". The subgroups correlated with the reported median percentage of MPC. Intracytoplasmic vacuolization, epithelial nest anastomosis/confluence, multiple nests in the same alveolar space, and small/medium tumor nest size were the most common criteria identified in the cases diagnosed as MPC. Peripherally oriented nuclei and epithelial signet ring-like forms were frequently identified in both the "MPC" and "combined papillary and MPC" groups.

CONCLUSIONS:

Our study provides objective diagnostic criteria to diagnose MPC of lung.

What does your waist say about your health? According to a new study, a lot more than you’d think.

"Excess visceral fat — the fat that collects around your abdominal organs — has been linked to poor metabolic health. The problems start with unhealthy cholesterol and triglyceride levels, chronic inflammation and insulin resistance, when the insulin the body produces has trouble getting blood sugar into cells. These conditions increase the risk of heart disease and other chronic health problems."

Natl Med J India. 2018 Nov-Dec;31(6):364-365. doi: 10.4103/0970-258X.262898.

Defensive medicine: Sword of Damocles.

Dudeja S1, Dhirar N2.

Author information

1

Department of Paediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.

2

Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.

Abstract

Defensive medicine is the deliberate departure by doctors from standard operating procedures with a view to safeguard themselves against possible medical malpractice litigation. It is on the rise in both developed and developing nations and across all fields of medicine. Different aspects of this practice are evident and many new are unfolding by the day. It is silently encroaching on the healthcare systems and could be detrimental for patients, doctors and healthcare systems. We probe the determinants of defensive medicine, the possible implications and the recommendations for addressing it.

Ninth Circuit Punts On Whether Obesity Is A Disability Under the ADA

The district court granted summary judgment in favor of the employer, holding that “obesity, no matter how great, cannot constitute a disability under the applicable EEOC regulations unless the obesity is caused by an underlying physiological condition.” According to the district court, the plaintiff could not make the showing, and granted summary judgment.

The Ninth Circuit, on the other hand, chose not to confront the question of whether obesity in and of itself qualifies as an actionable “impairment” under the ADA, as its four sister circuits have. Instead, the court determined that the plaintiff had failed to show a causal relationship between his obesity (or his “disabling knee condition”) and his termination. The plaintiff admitted that he had not completed the maintenance tasks, and he had already been employed for more than 10 years, always weighing in excess of 300 pounds. Thus, according to the Ninth Circuit, there was no basis to conclude he was terminated for any reason other than the falsified maintenance records.

Employers in the Ninth Circuit defending an ADA claim relating to an employee’s obesity will have to wait for a “definitive stand” on whether obesity alone qualifies as an impairment under the ADA. That said, the Valtierra case serves as a helpful reminder that ADA claims require evidence of a causal relationship between an adverse employment action and a purported disability.

Medical students: As you consider your specialty direction as you become a physician, consider pathology!

Medical students: As you consider your specialty direction as you become a physician, consider pathology!

J Clin Med. 2019 Aug 14;8(8). pii: E1211. doi: 10.3390/jcm8081211.

Nutrition in Cancer Patients.

Ravasco P1,2,3.

Author information

1

University Hospital of Santa Maria, 1649-035 Lisbon, Portugal. p.ravasco@medicina.ulisboa.pt.

2

University of Lisbon, 1649-028 Lisbon, Portugal. p.ravasco@medicina.ulisboa.pt.

3

Centre for Interdisciplinary Research in Health (CIIS) of the Portuguese Catholic University, 1649-023 Lisbon, Portugal. p.ravasco@medicina.ulisboa.pt.

Abstract

Background: Despite being recognised that nutritional intervention is essential, nutritional support is not widely accessible to all patients. Given the incidence of nutritional risk and nutrition wasting, and because cachexia management remains a challenge in clinical practice, a multidisciplinary approach with targeted nutrition is vital to improve the quality of care in oncology.

Methods: A literature search in PubMed and Cochrane Library was performed from inception until 26 March. The search consisted of terms on: cancer, nutrition, nutritional therapy, malnutrition, cachexia, sarcopenia, survival, nutrients and guidelines. Key words were linked using "OR" as a Boolean function and the results of the four components were combined by utilizing the "AND" Boolean function. Guidelines, clinical trials and observational studies written in English, were selected. Seminal papers were referenced in this article as appropriate. Relevant articles are discussed in this article. 

Results: Recent literature supports integration of nutrition screening/assessment in cancer care. Body composition assessment is suggested to be determinant for interventions, treatments and outcomes. Nutritional intervention is mandatory as adjuvant to any treatment, as it improves nutrition parameters, body composition, symptoms, quality of life and ultimately survival. Nutrition counselling is the first choice, with/without oral nutritional supplements (ONS). Criteria for escalating nutrition measures include: (1) 50% of intake vs. requirements for more than 1-2 weeks; (2) if it is anticipated that undernourished patients will not eat and/or absorb nutrients for a long period; (3) if the tumour itself impairs oral intake. N-3 fatty acids are promising nutrients, yet clinically they lack trials with homogeneous populations to clarify the identified clinical benefits. Insufficient protein intake is a key feature in cancer; recent guidelines suggest a higher range of protein because of the likely beneficial effects for treatment tolerance and efficacy. Amino acids for counteracting muscle wasting need further research. Vitamins/minerals are recommended in doses close to the recommended dietary allowances and avoid higher doses. Vitamin D deficiency might be relevant in cancer and has been suggested to be needed to optimise protein supplements effectiveness. 

Conclusions: A proactive assessment of the clinical alterations that occur in cancer is essential for selecting the adequate nutritional intervention with the best possible impact on nutritional status, body composition, treatment efficacy and ultimately reducing complications and improving survival and quality of life.

"'The fight against climate change,' said the tenured professor, 'is already lost. What’s left to us is to cultivate new modes of becoming.' The audience nodded sagely and clapped. Cheeks distended with Goldfish, I clapped too."

Apocalypse
Chic

For some professors, a shallow, fashionable nihilism is all the rage.

“The fight against climate change,” said the tenured professor, “is already lost. What’s left to us is to cultivate new modes of becoming.”

The audience nodded sagely and clapped. Cheeks distended with Goldfish, I clapped too.

When doctors fat shame their patients, everybody loses

Doctors fail when they conflate weight and health, believe their patients to be lazy or noncompliant or avoid discussing the topic altogether.

"But weight stigma can cause patients to avoid the doctor, meaning such conditions won’t be addressed or discovered. This status quo, in which patients are stigmatized and offered poor health care by a biased physician workforce, is unacceptable."

"Children who grow up sharing family meals are also more likely to exhibit prosocial behavior as adults, such as sharing, fairness and respect."

Family Meals Matter

"Children who grow up sharing family meals are also more likely to exhibit prosocial behavior as adults, such as sharing, fairness and respect. Research has also shown that with each additional family meal shared during the week, adolescents are less likely to show symptoms of violence, depression and suicide; less likely to use or abuse drugs or run away; and less likely to engage in risky behavior or delinquent acts.

In addition, adults and children who eat at home more regularly are less likely to suffer from obesity, and increased family meals are associated with greater intake of fruits and vegetables."

#WhoIsJohnGalt

The Last of the Ayn Rand Acolytes

This year's Objectivist Conference revealed that her cult of hyper-capitalism has a major recruiting problem: All the young people want to be socialists!

"This was the grim setting for a nearly week-long celebration of Rand’s genius that coincided with the fiftieth anniversary of her clarion call for a capitalist-aligned cultural and aesthetic movement, The Romantic Manifesto. Thrumming in the background was a related, similarly unnerving trend for Objectivists: The romance of the movement has lost a good deal of its cachet in an unequal, austerity-battered America—particularly when it comes to pulling in the young recruits who were once the backbone of the Rand insurgency. All the kids these days are becoming socialists and communists. Only 45 percent of young Americans view capitalism positively, compared with 51 percent who profess a fondness for socialism. They want higher taxes, regulations, a Green New Deal. Their thousand-page tome of choice isn’t Atlas Shrugged; it’s Marx’s Capital (or perhaps Thomas Piketty’s Capital in the Twenty-First Century)."

From Tim Mackey and colleagues: Surgical Data Recording Technology: A Solution to Address Medical Errors?

Ann Surg. 2019 Jul 25. doi: 10.1097/SLA.0000000000003510. [Epub ahead of print]

Surgical Data Recording Technology: A Solution to Address Medical Errors?

Shah NA1, Jue J2, Mackey TK1,3.

Author information

1

Global Health Policy Institute, San Diego, CA.

2

Joint Masters Program in Health Policy and Law, University of California, San Diego School of Medicine, San Diego, CA.

3

Department of Anesthesiology and Division of Infectious Diseases and Global Public Health, University of California, San Diego School of Medicine, San Diego, CA.

Abstract

: Reducing preventable medical errors remains a universal goal, yet implementing effective solutions remains a challenge. The development of surgical data recording technology shows promise to generate robust qualitative and quantitative data in the surgical theater. These data can allow physicians and their teams to capture specific sources of error and implement corrective interventions. Surgical data recording technology encompasses rudimentary data tabulation on notecards, to integrated audio-video systems containing cameras, microphones, and sensors, capturing and synthesizing intraoperative, environmental, and instrumentation information, along with devices tailored to robotic surgical systems. There is growing interest in the implementation of such technology in medical centers, particularly in the United States, Canada, and Europe, but existing medicolegal and regulatory challenges necessitate further research and clinical assessment in order for this technology to facilitate improved surgical patient safety.

The False Promise of Fish Oil Supplements

After decades of promises that they “may work” to reduce cardiovascular the lack of demonstrated benefit leads me to conclude that consumers are wasting their money

"Because the US Food and Drug Administration (FDA) classification for dietary supplements such as fish oil is different from that of prescription drugs, these supplements are not manufactured or reviewed by the FDA in as stringent a manner. Most found on the market—unlike prescription medications and certain over-the-counter (OTC) drugs—have not demonstrated effectiveness and safety in placebo-controlled clinical trials. This can be confusing: fish oil supplements, for example, are readily available to patients and often have labels that imply a benefit to cardiovascular health, yet they are not intended to treat any medical condition."

"The existing medical malpractice system increases medical spending mainly because it has evolved in tandem with other inflationary features of the health care system and may make those features even more difficult to change."

Forum Health Econ Policy. 2012 Sep 10;15(3):83-106. doi: 10.1515/fhep-2012-0010.

Both Symptom and Disease: Relating Medical Malpractice to Health-Care Costs.

Sage WM1.

Author information

1

Vice Provost for Health Affairs, James R. Dougherty Chair for Faculty Excellence, The University of Texas, 727 E. Dean Keeton Street, Austin, TX 78705.

Abstract

Tort reformers blame the high cost of American health care on defensive responses to rampant medical malpractice litigation. Defenders of the tort system counter that holding health care providers liable for negligence improves safety and ensures compensation for injury. The relationship between medical malpractice and health care expenditures is more complex than either of these positions reflects. The existing medical malpractice system increases medical spending mainly because it has evolved in tandem with other inflationary features of the health care system and may make those features even more difficult to change. In other words, medical malpractice is both a symptom of a costly health care system and a costly disease in its own right.

"...until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue."

J Healthc Risk Manag. 2019 Aug 21. doi: 10.1002/jhrm.21388. [Epub ahead of print]

Overriding advance directives: A 20-year legal and ethical overview.

Banja J, Sumler M.

Abstract

Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethicalanalysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.

‘Sport has changed my life’: Serena Williams on how it can benefit girls and boys

"Serena also emphasised that more girls should be encouraged to participate in sports. 'I think sport, especially in young ladies’ lives, is incredibly important at whatever level you choose to play at,' she added."

Regulating Artificial Intelligence for a Successful Pathology Future.

Allen TC

From the Department of Pathology, University of Mississippi Medical Center, Jackson.

"Physicians, including pathologists, must now rethink what it means to be caring, and how to preserve and foster social interaction with patients while using AI efficiently. It will be especially important that physicians use AI in a manner that respects physician and patient heterogeneity and supports equity. It is physicians, with pathologists at the head of the table, who must lead and forever maintain this conversation with policymakers, providing regulatory guidance that ensures empathy is always considered and respected throughout the complicated discussion around AI regulation and governance."

Men often don't get medical help because of self-image issues

"Some may be surprised by this result, but according to the report, weight stigma is pervasive in men with obesity and as many as four out of 10 say that this stigma stops them from reaching out the physicians to get help for other medical issues." 

OBESITY CANCER RISK 

Being fat is almost as likely as smoking to cause cancer, experts warn

Referring to the study, he said: “Many people don’t yet realise that obesity causes cancer and now there is evidence that it’s a graver danger than first thought.

“If we continue to pile on the pounds we’re heading for thousands more avoidable cancer deaths every year.”

Curr Oncol Rep. 2019 Jul 29;21(9):80. doi: 10.1007/s11912-019-0829-8.

Malnutrition in Older Adults with Cancer.

Zhang X1,2, Edwards BJ3.

Author information

1

Department of Medicine, Epidemiology & Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, One Baylor Plaza, MS: BCM307, Room 613D, Houston, TX, 77030, USA.

2

Department of Epidemiology, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

3

Geriatric Medicine, Supportive Care, Central Texas Veterans Healthcare System, Temple, TX, 76504, USA. bjedwards2400@gmail.com.

Abstract

PURPOSE OF REVIEW:

Malnutrition is a common and under-recognized geriatric condition in older adults with cancer. This review describes the public health burden, malnutrition prevention, and the relationship among cancer cachexia, malnutrition, and sarcopenia. Finally, clinical practice recommendations on malnutrition and prevention are presented.

RECENT FINDINGS:

Advanced age and cancer stage, frailty, dementia, major depression, functional impairment, and physical performance are important risk factors for malnutrition in older adults with cancer. The Mini Nutrition Assessment (MNA), Malnutrition Universal Screening Tool (MUST), and Patient Generated Subjective Global Assessment (PG-SGA) are the most commonly used assessment tools in older adults with cancer. In addition, malnutrition is independently associated with poor overall survival and quality of life, longer hospital stays, greater hospital cost, and hospital readmission. Comprehensive malnutrition prevention is required for improving the nutrition status among older adults with cancer.

Arch Pathol Lab Med. 2019 Aug 7. doi: 10.5858/arpa.2019-0191-RA. [Epub ahead of print]

Chondroblastoma-like Osteosarcoma.

Hmada YA1, Bernieh A1, Morris RW1, Lewin J1, Allen T1.

Author information

1

From the Departments of Pathology (Drs Al Hmada, Bernieh, Lewin, and Allen), and Radiology (Dr Morris), University of Mississippi Medical Center, Jackson.

Abstract

CONTEXT.—:

Chondroblastoma-like osteosarcoma is an exceedingly rare variant of osteosarcoma, with 22 cases reported in the English-language literature. The tumor is slightly more common in males, with a broad age range (from childhood to elderly). The most commonly involved bones are the metatarsus and tibia, followed by the femur. Most tumors have malignant or worrisome radiographic findings. Prognosis is variable, depending on the presence or absence of lung metastases, local recurrence, and probably tumor location. Histologically, chondroblastoma-like osteosarcoma is characterized by monotonous, minimally to moderately atypical rounded cells with ovoid nuclei resembling chondroblastoma, and abnormal osteoid deposition with destruction of the bone.

OBJECTIVE.—:

To review the clinical, radiographic, and histopathologic features of chondroblastoma-like osteosarcoma.

DATA SOURCES.—:

PubMed-published chondroblastoma-like osteosarcoma cases in the English-language literature.

CONCLUSIONS.—:

Although exceedingly rare, chondroblastoma-like osteosarcoma should be considered in the differential diagnosis of chondroblastoma, especially in the presence of radiologic findings suggestive of an aggressive lesion.

Asleep At The Wheel - "The House Of Blue Lights" [Live from Austin, TX]

Mona Charin: So, You Want Canadian Health Care? "Advocates respond that Canadians are happy with their system, and that’s fine. It’s their choice. But Americans tend not to be so docile about delays."

So, You Want Canadian Health Care?

"Advocates respond that Canadians are happy with their system, and that’s fine. It’s their choice. But Americans tend not to be so docile about delays."

A Better Way to End Surprise Medical Bills

Happily, there is a better way, an alternative approach that can end surprise bills without harming patients’ access to care. It consists of two elements: 

1. A market-based default payment. Instead of the median rate, the benchmark would be set at the current average rate paid to all similar providers in the area, or alternatively at the individual provider’s most recent contracted rate, if a contract has ever existed. Insurers would have to pay this default rate to out-of-network providers, up front.

2. Baseball arbitration. If either party were dissatisfied with the default payment, they could take their dispute to so-called baseball arbitration, in which both parties would present a first-and-final offer and then a neutral arbitrator would choose one of the two offers without change.

"Back in the 1960s, China suffered a devastating famine that killed nearly 20 million people. But now, the country faces a new scourge: Obesity."

Obesity: China's Big Problem

After famine comes obesity. 101 East explores China's unconventional methods for getting its citizens fit and healthy.

"Back in the 1960s, China suffered a devastating famine that killed nearly 20 million people. But now, the country faces a new scourge: Obesity.

One in five children - and tens of millions of adults - are now overweight or obese."