Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia. © 2010 Mayo Foundation for Medical Education and ResearchOn completion of this article, you should be able to (1) P alliative sedation (PS) refers to the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. The practice of PS has gained attention in the literature during the past 20 years. In 1994, Cherny and Portenoy 1 first offered an algorithm for determining appropriate indications for use of PS. During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life. 2,3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%, 4 usually defined as the patient, family, or physician's perceived relief of refractory physical symptoms. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries. 4 When PS is used, it is a measure of last resort rather than general care. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar. PrActIcAl ISSueSThe following sections explore issues of the application of PS. Detailed guidelines for practicing PS, although beyond the scope of this article, have been published. 5
Background: The use of breast magnetic resonance imaging (MRI) for screening high-risk patients is well established. However, the role of MRI as a diagnostic problem-solving tool is less well studied. With the increasing availability of MRI, its use for problem solving has increased. This small retrospective study examines the use and utility of breast MRI in evaluating palpable breast masses with negative diagnostic mammogram and ultrasound studies. Methods: We reviewed our breast MRI database, selecting breast MRI studies performed to assess palpable abnormalities with negative mammogram and ultrasound findings. Evidence of cancer was determined by biopsy. Results: Seventy-seven studies were included, comprising 1.3% of all breast MRI studies performed at our institution during the study period (2005)(2006)(2007)(2008)(2009)(2010)(2011). Twenty-two patients underwent biopsy, and 55 were followed clinically without biopsy. Approximately half (27 of 55) of the patients without biopsy were lost to follow-up after negative MRI, and the rest had no evidence of cancer on imaging or clinical examination at 1 year. Of the 22 patients who underwent biopsy, 2 were diagnosed with cancer, both with positive MRI studies. Sensitivity of MRI when compared to tissue diagnosis was 100%, and specificity was 70%. Positive and negative predictive values were 25% and 100%, respectively. Conclusions: When used for evaluation of a palpable breast mass with negative traditional imaging, breast MRI likely offers low yield of cancer diagnosis and low specificity. Negative MRI results may cause a low compliance rate for recommended follow-up. Because a biopsy is indicated for persistent palpable masses, the addition of diagnostic MRI only adds another step, with associated costs and burdens.
Idiopathic granulomatous mastitis (IGM) is an uncommon breast disease often mistaken for breast infection or abscess. We present a case of IGM diagnosed after prolonged ineffective treatment of presumed infectious mastitis with abscess. Once the diagnosis was made with biopsy and further evaluation to exclude other causes of granulomatous disease, sinus tract debridement and closure by secondary intent resulted in resolution of symptoms in our patient. Many cases of IGM require immunosuppression with steroids, methotrexate or extensive surgery. To prevent morbidity, IGM should be considered in the differential diagnosis when presumed infectious mastitis with breast abscess does not respond to usual treatment.
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