We found that few patients with heart failure had palliative care services. Additionally, the majority of those who have palliative care involvement do not meet current recommendations for early palliative care involvement in heart failure. This study suggests that the ED may be an appropriate setting to identify and refer high-risk patients with heart failure who could benefit from earlier palliative care involvement.

Calciphylaxis is a rare and poorly understood disease that almost exclusively occurs in endstage renal disease (ESRD). It is characterized by the calcification of medium and small dermal arterioles with resultant gangrenous necrosis. Patients develop exquisitely painful skin ulceration and necrosis, typically in the lower extremities. Treatments are severely limited, and mortality is high, as few treatment options provide a survival benefit. Improvement in a few calciphylaxis cases affecting the extremities or abdomen have been reported using hyperbaric oxygen therapy (HBOT), however, very few have had a favorable response when it affected penile tissue. We present a case of a patient with ESRD on hemodialysis and subtotal parathyroidectomy who had biopsy-proven penile calciphylaxis with refractory pain who ultimately underwent successful HBOT.

original research E732Cite as: Can Urol Assoc J 2013;7(11-12):e732-9. http://dx.doi.org/10.5489/cuaj.372 Published online November 8, 2013. AbstractBackground: The ambivalent results of recent large randomized prostate cancer studies have added a significant layer of uncertainty for clinicians and patients contemplating investigation of early disease. This uncertainty and lack of prescriptive recommendations from professional organizations has led to significant variation in practice in North America. The purpose of this study was to determine the extent of variation in biopsy recommendations by urologists and to discern factors predictive for these recommendations. Methods: An anonymous, cross-sectional, self-report questionnaire was sent to all active members of the Canadian Urological Association practicing in Ontario. The survey consisted of demographic data and 10 closed-ended questions designed to capture biopsy preferences in ambiguous clinical situations. Respondent preferences for recommending a prostate biopsy were compared to a guideline-informed study standard. Descriptive and correlative statistics were used to analyze the responses. Results: The response rate to the survey was 74%. The responses showed considerable variability in recommendations for or against biopsy. While most of the urologists concurred with the research team's study standard recommendations, only 4 scenarios had over 80% concurrence and 1 scenario, which centered on the utility of free PSA, had only had 42% concurrence. None of the respondent's descriptors were associated with trends to recommend biopsy other than the number of biopsies performed per year (p = 0.04). Interpretation: This self-report survey investigating prostate biopsy thresholds identifies considerable variation in practicing urologists in Ontario. The drivers of biopsy recommendations in these relatively ambiguous clinical situations appeared to be age, suspicious rectal examinations, and total PSA.

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On-call coverage by resident physicians is common in academic hospitals, but the interaction between residents and supervising attending physicians varies. Responsibilities are often not clearly defined, which contributes to unclear expectations on the part of both. We developed an institutional “on-call responsibilities” guideline for both residents and attending physicians using a nominal group technique to gain consensus with multiple institutional stakeholders. Three focus groups engaged 31 clinical stakeholders in the development of concise guidelines that include 12 resident responsibilities and 12 attending-physician responsibilities that can be implemented while on-call. Using the nominal group technique allowed us to engage a large number of stakeholders and generate a robust guideline that could be easily operationalized to create a consistent expectation of responsibilities while on call, promote patient safety. It can also potentially reduce resident burnout. This quality-improvement project generated a list of concrete responsibilities that can be used in other centres and provides a robust approach to developing similar policies in other clinical contexts.