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Refining Neurosurgery Practices

Refining Neurosurgery Practices

The American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently joined the American Board of Internal Medicine’s Choosing Wisely campaign with their own list of five practices to avoid in neurosurgery. “The purpose,” says Daniel K. Resnick, MD, “is to alert patients and physicians to common practices that may not be necessary or efficacious.” The Recommendations 1) Do not administer steroids after severe traumatic brain injuries. According to Dr. Resnick, high-quality studies from the last 20 years demonstrate that although steroids decrease intracranial pressure, they are also associated with several side effects. “The net effect of steroids in patients with severe head injuries is a negative one,” he says. 2) Do not obtain imaging (plain radiographs, MRI, CT, or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags. “Decades of experience and hundreds of papers indicate that the chance of finding an issue on imaging that would need to be addressed in patients with acute low back pain but without certain red flags is miniscule,” says Dr. Resnick. “Such imaging leads to unnecessary spending and is a hassle for patients. It often discloses information that is irrelevant and causes angst for patients. It could also lead to needless referrals to surgeons and may promote fear/avoidance behaviors in patients.” 3) Do not routinely obtain CT scans in children with mild head injuries. CT scans expose children to radiation, which has been shown in these patients to increase risks for the later development of cancer, explains Dr. Resnick. “CT should be reserved for children with severe injuries or neurological...
Assessing the Surgical Care of Breast Cancer

Assessing the Surgical Care of Breast Cancer

Clinical trials have shown that survival rates appear to be similar for patients with early-stage breast cancer who are treated with breast-conserving surgery and radiation or with mastectomy. “However, recent studies have indicated that the use of mastectomy is increasing, particularly bilateral mastectomy, among women in the United States with breast cancer,” says Allison W. Kurian, MD, MSc. Typically, bilateral mastectomy is considered both a treatment for the affected breast and a prevention measure for the contralateral breast. Bilateral mastectomy is increasingly being used to treat unilateral breast cancer despite the absence of evidence showing that it offers a survival benefit to the average woman with breast cancer. Bilateral mastectomy has been shown to be an effective secondary prevention strategy for high-risk women with BRCA1/2 mutations, but the procedure may also have detrimental effects. These include higher risks for complications, increased costs, and a negative impact on body image and sexual function. “We need a better understanding of the use of bilateral mastectomy and outcomes associated with its use to improve cancer care,” Dr. Kurian says. A Comprehensive Analysis In a study published in JAMA, Dr. Kurian, Scarlett Gomez, PhD, and colleagues compared the use of bilateral mastectomy, breast-conserving therapy (lumpectomy) with radiation, and unilateral mastectomy and the mortality associated with these procedures. The goals were to determine if there were particular types of patients who were likely to receive a bilateral mastectomy and find out if there were relative differences in mortality among the three procedures. “We could address these questions because we used data from the California Cancer Registry, which covers almost all women diagnosed with breast...

Adverse Events in California Hospitals: Look at the Data

According to a Bay Area television station’ s investigative exposé, California hospitals reported 6,282 adverse events to the state over the last 4 fiscal years combined. It sounds like a lot until you realize that there are 410 hospitals in California. That means the average number of adverse events per hospital is only 15.3—fewer than 4 per year. A brief summary of this story appeared on a website called California Healthline. Its lede mentioned the total number and followed it with possibly the understatement of the year “but the number of actual adverse events could be higher.” Ya think? Analyzing data by calculating averages sometimes can be misleading. For example, Stanford Hospital reported a total of 211 adverse events, and the UCSF Medical Center reported 169. That means some hospitals must have reported far fewer than the average number. The NBC article has a handy interactive tool that enables the user to click on the name of any hospital in northern California to see its total number and types of reported adverse events. Use it and note that several hospitals reported only one adverse event over the entire 4-year period. Another interesting statistic is that 3,959 or 63% of the adverse events reported were bedsores. Although bedsores can be serious problems and in most cases preventable, they pale in comparison to death or serious disability associated with the use of restraints or bed rails, operating on the wrong body part, or leaving a foreign body in a patient after surgery. Surgery performed on the wrong body part occurred 140 times. Even one is too many. One California hospital managed...
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