Inclusion in the clinical learning environment: Building the conditions for diverse human flourishing

Abstract

Aim: While diversity, equity, and inclusion are much proclaimed aspirational goals in education programs, the clinical learning environment (CLE) frequently falls short of meaningful incorporation of these concepts in processes, policies, and local culture. In this paper, we explore how inclusion, diversity, and equity can and should be defined and operationalized within medical education.

Methods: Three cases, organized around Hafferty’s curricular framework (formal, informal, and hidden), we illustrate lapses and potential best practices in inclusion in the CLE.

Results: The essential “best-practice” of programs inclusive of diverse individuals is the design of policies, processes, and behavioral norms co-creatively with all community members. Potential pitfalls to greater inclusion include nostalgic reference to “the past”, a neutrality that is operationalized without the rudder of explicit values and not recognizing that ethical obligations between teachers, learners, and programs are at the heart of the discussion of how inclusive learning and work environments are built.

Conclusion: Inclusive CLE’s provide space for co-creation, understand the need to ensure the voices of the vulnerable (i.e. learners) are heard and valued and through this promote the flourishing of diverse human capital, in keeping with a model that views diversity as a key attribute or organizational excellence.     

PleurX drain use in the management of malignant ascites: safety, complications, long-term patency and factors predictive of success

Objectives

The aim of this article was to assess the success, safety, complication profile and factors associated with long-term patency of tunnelled peritoneal drains (PleurX) in the treatment of refractory malignant ascites.

Methods

Over a 4-year period, 28 consecutive patients (32 drain insertions) with refractory malignant ascites were treated with a PleurX drain. The study group comprised 7 males and 21 females (mean age, 61 years). A combination of fluoroscopic and ultrasound guidance was used to insert 4 drains; the remaining 28 drains were inserted under ultrasound guidance alone. Patient history, biochemical profiles, pathological and procedural records and clinical follow-up until death were reviewed. Statistical analysis included multivariate logistic regression analysis and Kaplan–Meier curves (p<0.05 was considered significant).

Results

There was a 100% technical success rate for the insertion of the drain; there were no procedure-related deaths and no major complications. Only minor complications were reported: three (10%) immediate; three (10%) early; and two (7%) late. Factors significantly associated with these complications included current chemotherapy, low haemoglobin levels, low albumin levels, high white cell count and high c-reactive protein levels. The length of time the drains remained in situ, and therefore patent, ranged from 5 to 365 days (mean, 113 days). Out of the original 28 tunnelled drains, 24 (86%) remained in situ and functioning until the patients’ death. Four (14%) drains dislodged and a subsequent PleurX drain was inserted on the opposite side of the abdominal wall. These new drains remained patent until the patient’s death. The annual event rate was 0.45 events per year. A comorbid diagnosis of renal disease or chemotherapy was significantly related to a decreased length of patency.

Conclusion

The use of tunnelled peritoneal drains is safe and effective and we would advocate their use as a first-line approach in patients with refractory malignant ascites. Care and regular follow-up is indicated following insertion of the drain in all patients, especially those on chemotherapy and those with a pre-procedure diagnosis of renal disease.The development of ascites is usually a manifestation of terminal metastatic malignancy with anticipated life expectancy ranging from 1 to 4 months [1]. Intractable ascites is usually caused by peritoneal infiltration, liver metastases causing secondary portal venous compression, lymphangitic carcinomatosis, lymphatic obstruction or a combination of these factors. Distressing symptoms include tense abdominal distension, early satiety, nausea and vomiting, reflux oesophagitis, shortness of breath, lower limb oedema, fatigue and reduced mobility. Current treatment strategies for the palliation of these symptoms include repeated paracentesis, placement of indwelling intraperitoneal catheters, peritoneovenous shunting, intraperitoneal chemotherapy, diuretic treatment and dietary restrictions [2-4]. These approaches can have a significant impact on patients’ remaining quality of life.Various studies have found that the PleurX catheter is an effective option for the management of malignant ascites with a low complication rate [5-7]. The PleurX drain is a tunnelled indwelling peritoneal catheter that can be managed at home to remove small (500 ml) aliquots of ascites on a regular basis or when it becomes symptomatic. Once the patient and their family have been shown how to use the drainage system and vacuum bottles, and how to recognise complications, patients can control and manage their ascites safely at home with minimal district nurse input. This also allows patients to limit the potential complications and frequent hospital admissions previously required for repeated paracentesis.The aims of this study were to assess the success, long-term patency and complications associated with the use of PleurX drains in the management of malignant ascites. Furthermore, we wanted to assess the number of interventions and repeat hospital admissions required to maintain patency of the indwelling catheter. A secondary aim was to identify predictors of successful long-term catheter patency.     

Reliability and validity of the International Prostate Symptom Score in a Malaysian population.

OBJECTIVE: To validate the English version of the International Prostate Symptom Score (IPSS) in patients with and without urinary symptoms in a Malaysian population. PATIENTS AND METHODS: Validity and reliability were assessed in patients with lower urinary tract symptoms (LUTS) and in patients with no LUTS. Reliability was evaluated using the test-retest method and internal consistency using Cronbach's alpha. Sensitivity to change was expressed as the effect size in the score before and after intervention in additional patients with LUTS who underwent transurethral resection of the prostate (TURP). RESULTS: Internal consistency was excellent; there was a high degree of internal consistency for each of the seven domains and for the total score (Cronbach's alpha > or = 0.60 and > or = 0.79, respectively) in the populations studied. The test-retest correlation coefficient for the seven domain scores was highly significant. The intra-class correlation coefficient was high (> or = 0.59). There was a high level of sensitivity and specificity for the effects of treatment, with a very significant change between the seven scores domains in the treated group but not in the control group. CONCLUSIONS: The IPSS is suitable, reliable, valid and sensitive to clinical change in the Malaysian population.     

Benign parotid tumors: a 24-year experience

The medical records of 125 patients benign parotid neoplasms surgically treated over a 24-year period were retrospectively reviewed; 128 tumors were excised. These included 90 pleomorphic adenomas, 33 Warthin's tumors, 3 benign lymphoepitheliomas, and 2 oncocytomas. The surgical procedures consisted of 2 local excisions, 6 enucleations, 88 superficial parotidectomies, 13 subtotal parotidectomies, and 3 radical parotidectomies. The morbidity rate was 49%. There was one total permanent facial nerve paralysis (0.7%), four (3%) partial permanent facial nerve paralysis, five (5%) transient total facial nerve paralysis, and 32 (25%) partial transient facial nerve paralysis. After a median follow-up of 84 months, there was one recurrence (0.7%). A superficial parotidectomy is the minimum procedure that should be performed for the treatment of a benign parotid neoplasm.     

Metastatic patterns in squamous cell cancer of the head and neck

This retrospective study on 832 head and neck cancer patients who died between 1961 and 1985 was carried out to determine the incidence and sites of distant metastases. All patients were staged prior to definitive treatment and were autopsied. The overall incidence of distant metastases was 47 percent. The hypopharynx had the highest incidence of distant metastases (60 percent), followed by the base of the tongue (53 percent) and the anterior tongue (50 percent). Of the 387 patients with distant metastases, 91 percent died with uncontrolled tumor either at the primary site or in the neck. The lung was the most common site of distant metastases (80 percent), followed by the mediastinal nodes (34 percent), the liver (31 percent), and bone (31 percent). Overall, 6 percent of the patients had stage I disease, 20 percent had stage II disease, 32 percent had stage III disease, and 43 percent had stage IV disease. The highest incidence of distant metastases was found in those patients with stage IV disease (193 of 350 patients, 55 percent). We believe that the initial stage of disease does appear to be related to the ultimate development of the distant metastases.     

Immunocyte derived amyloidosis

A case of immunocyte derived amyloidosis (primary systemic amyloidosis) is being reported because of its rarity. The absence of petechiae and pinch purpura is particularly intriguing.     

Immunochemistry and lung cancer: application in diagnosis, prognosis and targeted therapy

Immunochemistry is now an established ancillary technique in lung cancer diagnosis. Not only does it help in supporting the morphological diagnosis of malignancy, but its role now extends to the determination of cell lineage, ascertaining the primary site of tumour origin and contributing to decisions on prognosis and treatment. Early detection and confirmation of lung cancer facilitate early treatment decisions. Lung cancer management now has a multidisciplinary approach which includes cytopathologists and clinicians. Some clinicians may not understand what immunochemistry is and what its role is in lung cancer diagnosis, prognosis and therapy. The purpose of this paper is to define immunochemistry, on the background of basic respiratory airway epithelial structure and cancer biology, and discuss its application in the diagnosis, treatment and determination of prognosis of lung cancer.