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Is the Surgeon Still “Captain of the Ship”?

A Kentucky appeals court recently ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patient’s abdomen. According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure. An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patient’s exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen during laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but “no one in the OR claimed any knowledge or responsibility.” The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiff’s lawyer’s failure to prove that the surgeon was responsible for the actions of the hospital staff. In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing. I wrote another post last year on the subject in response to another surgeon’s blog entitled “Everything’s my fault: How a surgeon says I’m sorry.” I felt that many things that happened to patients were beyond the control...
CME: Guidelines for Managing Fatigue in Cancer Survivors

CME: Guidelines for Managing Fatigue in Cancer Survivors

With recent advances in cancer screening and treatment, the number of cancer survivors in the United States has increased substantially in recent years. The American Cancer Society estimates that there are about 13.7 million cancer survivors in the U.S., and this figure is expected to rise to nearly 18 million by 2022. Over the years, the Cancer Survivorship Committee of the American Society of Clinical Oncology (ASCO) has issued evidence-based clinical practice guidelines, assessment tools, and screening instruments to help identify and manage late effects of cancer and its treatment. Recently, ASCO released a guideline for managing survivors who experience symptoms of fatigue after completing primary cancer treatment. The practice guideline pertains to cancer survivors diagnosed at age 18 or older who have completed treatment with curative intent and are in clinical remission without the need for therapy. It is also applicable to patients who are disease free and have transitioned to maintenance or prophylactic therapy. Examples of these patients include breast cancer survivors receiving hormonal therapy and people with chronic myelogenous leukemia receiving tyrosine kinase inhibitors. ASCO’s guidelines are intended to inform all members of patients’ healthcare team as well as patients, family members, and caregivers of cancer survivors. Fatigue Is a Common Problem “Many cancer survivors will experience some level of fatigue during their course of treatment,” explains Julienne E. Bower, PhD, who was co-chair of the ASCO writing group that developed the guidelines. “About 20% to 30% of cancer survivors deal with persistent fatigue for years after they’ve been treated for cancer. Fatigue is among the most common and distressing long-term effects of cancer treatment and...
Is Marcus Welby Medicine Dead?

Is Marcus Welby Medicine Dead?

The patient was an elderly priest who had been awake all night vomiting. He was too sick to come to the office and not sick enough that he wanted to go to the ER. I walked into his bedroom where he was lying weak in bed. It was one of the rare home visits that I still do. After ascertaining that all his vital signs were stable and that he was not severely dehydrated, I gave him a shot of Phenergan and instructions on taking frequent sips of fluids. I checked on him periodically by phone throughout the day, and by evening he was doing better. People often lament that Marcus Welby-type medicine is gone. You know the type where a doctor is in a small practice and knows all his patients, even what positions their kids play on the baseball team and what grades they got in math? While I strive to continue to provide such care, I fear our healthcare system is moving away from this type of model. In fact, it has been estimated that only 30% of doctors remain in private practice. Medicine is being driven by the push for turning patients into data. People discuss the clinical records and recording metrics. We are now told to achieve certain clinical outcomes and give a number, such as target LDL number, as a benchmark to achieve. Doctors are being herded into large practices and judged by the RVUs they generate. These days, everything is about numbers, not people. “Patients are not in the room curing themselves while the doctor sits there capturing their data.”   It...
CME – Hypertension: Examining Cost Effectiveness of Treatment

CME – Hypertension: Examining Cost Effectiveness of Treatment

According to current estimates, 44% of the 64 million adults in the United States with hypertension did not have their condition controlled in 2014. In 2014, the Eighth Joint National Committee released its first updated guidelines on hypertension since 2003. Several important changes were made from the earlier guideline, including recommendations to focus on diastolic rather than systolic blood pressure (BP) for adults younger than 60 and setting more conservative BP goals for adults aged 60 and older (150/90 mm Hg) as well as for patients with diabetes or chronic kidney disease (140/90 mm Hg). Estimating Cost Effectiveness “Few analyses have examined the health benefits and cost-effectiveness of treating hypertension in the U.S.,” says Andrew E. Moran, MD, MPH. To address this research gap, Dr. Moran and colleagues published a study in the New England Journal of Medicine that sought to estimate the incremental health gains and cost-effectiveness of implementing the strongest recommendations for hypertension therapy in the 2014 guidelines among adults. Using the Cardiovascular Disease Policy Model, the study team simulated drug-treatment and monitoring costs, costs averted for the treatment of cardiovascular disease (CVD), and quality-adjusted life-years gained by treating previously untreated adults between the ages of 35 and 74 from 2014 through 2024. “Our model pulled together data from many studies to quantify the value of treating hypertension,” adds Dr. Moran. “This information is important for policy-makers and physicians to determine if controlling hypertension is a worthwhile investment.” Big Rewards for Achieving Goals The study found that, on average, about 860,000 people with existing CVD and hypertension who are not being treated with antihypertensive medications would be...
High Expectations & Physician Suicide

High Expectations & Physician Suicide

A friend on Facebook recently forwarded a news article and a link to a physician blog about the media response to a physician’s suicide. A lot of the concern centered on the lack of compassion for the physician who took his own life and the seemingly self-centered comments of several ‘patients’ at the hospital. Lost in the coverage was any exploration of the problem of physician suicide or suicide in general. Anyone who works in trauma or emergency medicine is acutely aware of both sides of this issue. We are the first line of treatment for these patients and must deal with the immediate repercussions on the families and loved ones left behind. Our profession also has a higher than average rate of suicide among the doctors, nurses, and other providers who work in this environment. Many of the comments regarding this particular incident focused on the lack of help for residents who are struggling with the demands of training. It doesn’t get much better after one leaves the nest of the residency and goes into practice. Doctors are expected to remain cool and objective, to be able to deal with adversity and come through unscathed and secure in their daily lives. We all know it’s BS, but we all tacitly buy into the myth because it preserves our standing as ‘professionals’. Displays of emotion, except under tightly circumscribed control, are seen as weakness and as ‘unprofessional’. So we cover up pain and uncertainty, limit our responses to well-rehearsed bromides, and box up our regrets like toxic waste to be buried or locked away never to be seen again....
ADA 2015

ADA 2015

New research was presented at ADA 2015, the annual scientific sessions of the American Diabetes Association, from June 5 to 9 in Boston. The features below highlight some of the studies that emerged from the conference. Telemonitoring for Metabolic & Cardiovascular Risk in Diabetics The Particulars: Telemedicine systems combine home monitoring with remote educational interventions and may be a desirable strategy for treating patients with diabetes. Little is known regarding the use of these systems in addressing metabolic control and overall cardiovascular risk in patients. Data Breakdown: Study investigators randomized patients with type 2 diabetes to usual care or a home telehealth system intervention that enabled patients to monitor body weight, blood glucose, and blood pressure. The telehealth system also offered remote educational support and feedback to the physician. Patients in the home telehealth group achieved statistically significant reductions in A1C levels at 12 months when compared with the usual care group. The home telehealth group also had better quality-of-life scores and reported few specialist visits. Take Home Pearl: When compared with usual care, use of a home telehealth system among patients with type 2 diabetes appears to improve metabolic control and quality of life and reduces resource utilization. Comparing Insulin Delivery Approaches The Particulars: Prior studies comparing continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in patients with type 2 diabetes have provided inconclusive findings. Data Breakdown: Patients with poor glycemic control who were taking multiple doses of insulin were randomized to CSII or MDI for a study. Patients in the CSII group achieved significantly greater reductions in A1C when compared with those in the MDI...
Preventing SSIs: An Evidence-Based Update

Preventing SSIs: An Evidence-Based Update

According to recent data, surgical site infections (SSIs) are common complications in acute care facilities, occurring in 2% to 5% of patients undergoing inpatient surgery. Approximately 160,000 to 300,000 SSIs occur each year in the United States, making these infections one of the most common and costly healthcare-associated infections (HAIs). “As society continues to age, older patients are increasingly undergoing surgical procedures,” says Keith S. Kaye, MD, MPH. “These patients are particularly vulnerable to SSIs. As surgical advances continue to evolve, we must continue to find ways to further improve our ability to prevent SSIs.” Studies have shown that as many as 60% of SSIs are preventable if clinicians follow evidence-based guidelines. SSIs account for about 20% of all HAIs in hospitalized patients, and each case is associated with at least 7 days of prolonged hospitalization. Research has indicated that SSIs account for $3.5 billion to $10 billion annually in healthcare expenditures. Dr. Kaye notes that the outcomes and costs attributable to SSIs vary depending on the type of operation and the type of infecting pathogen. A Welcome Update In 2008, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA) released their Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. The document was designed to help healthcare institutions prioritize and implement strategies to reduce the number of infections. Recently, SHEA and IDSA released an update of these guidelines and published them in Infection Control and Hospital Epidemiology. The updated evidence-based recommendations are broader and more inclusive than other clinical guidelines that are currently available. They include 15 strategies for prevention...
Hip Fracture Surgery: Costs & Benefits

Hip Fracture Surgery: Costs & Benefits

According to current estimates, more than 300,000 patients—mostly people aged 65 and older—sustain a hip fracture each year in the United States, and the annual incidence is expected to exceed 500,000 by 2040. Hip fractures often result in nursing home stays, higher mortality, and lower quality of life. The expected rising incidence will place a significant financial burden on patients, families, insurers, and other key stakeholders. Surgery is the primary treatment strategy for hip fractures because it can reduce mortality risk and improve physical function, but less is known about the societal cost implications of hip fractures. New Data Little is known about the return on investment of surgery for hip fracture patients, says Lane Koenig, PhD. “Policymakers and payers are increasingly focusing on value, making it critical to understand the return from healthcare spending,” he says. To investigate this further, Dr. Koenig and colleagues conducted a study—published in Clinical Orthopaedics and Related Research—that estimated the impact of surgical and nonsurgical treatment in patients aged 65 and older. The research team reviewed published literature and expert opinions to examine a comprehensive set of outcomes, including long-term medical costs, home modification costs, and costs associated with long-term nursing home care. For the study, Dr. Koenig and colleagues developed a predictive tool to account for various possible outcomes so that they could measure the cost and potential savings of repairing hip fractures with surgery. “Our results showed that surgery provided a significant societal benefit and value by returning patients to active, independent living,” Dr. Koenig says. The average lifetime societal benefits in the U.S. reduced medical and nursing home costs of...
APA 2015

APA 2015

New research was presented at APA 2015, the American Psychiatric Association’s annual meeting, from May 16 to 20 in Toronto. The features below highlight some of the studies that emerged from the conference. Anxiety & Suicide in Hospitalized Psychiatric Patients The Particulars: Studies have shown that suicide risk is highest in the first 2 months after a psychiatric hospitalization. However, few studies have explored factors that may raise risks for return psychiatric visits. Data Breakdown: For a study, patients hospitalized for suicidality were assessed for state and trait anxiety at admission and discharge. Patients who returned to the psychiatric emergency room within 2 months had significantly lower self-assessment scores on state and anxiety from admission to discharge. Those with a lifetime history of suicide attempts requiring major medical care had significantly greater decreases in self-assessed trait anxiety. Take Home Pearl: Acute anxiety reactivity appears to predict returns to the emergency room following psychiatric hospitalization. Delirium Poorly Detected The Particulars: Delirium affects 10% to 30% of hospitalized patients, but the prognosis for these patients tends to be poor. Research shows that delirium detection rates are low among primary treating physicians. Data Breakdown: Study investigators reviewed the charts of hospitalized patients diagnosed with delirium following a psychiatry consult for reasons other than delirium, confusion, or disorientation. Several delirium symptoms were not detected or misidentified by the primary treating physician but were later detected during the psychiatry consult. These included a reduced ability to focus or shifting attention, memory deficits, fluctuating symptoms during the course of the day, and psychomotor retardation. Take Home Pearls: Subtle signs and symptoms of delirium appear to...
Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

The term cardiometabolic risk refers to having a high 10-year and/or lifetime risk for cardiovascular disease (CVD). Specific causes that can increase cardiometabolic risk include hyperglycemia, hypertension, dyslipidemia, obesity, and insulin resistance. When patients have one or more of these risk factors and are physically inactive or smoke, cardiometabolic risk is further increased. “Patients with type 2 diabetes often have many risk factors associated with cardiometabolic risk,” explains Cecilia C. Low Wang, MD, FACP (Figure). “It’s important to consider cardiometabolic risk as part of a comprehensive approach to patient care.” This allows clinicians to consider multiple disease pathways and risk factors to facilitate earlier intervention. The State of Risk According to current estimates, two of every three Americans are overweight or obese, and about 86 million have prediabetes. Nearly half of all adults in the United States have high cholesterol, and about one-third have high blood pressure (BP). “While it’s important to track A1C among patients with type 2 diabetes, it’s also critical to manage BP and cholesterol because these are two of the most important cardio-metabolic risk factors,” Dr. Low Wang says. Research has shown that good BP control can reduce diabetes-related deaths by 32% and lower the risk of stroke by 44% and micro-vascular complications by 37%. Addressing Risk Factors There are non-modifiable and modifiable cardio-metabolic risk factors to consider when managing patients with type 2 diabetes. Non-modifiable risk factors include age, race and ethnicity, gender, and family history. Modifiable factors include obesity, dyslipidemia, inflammation, hypertension, smoking, physical inactivity, unhealthy diet, and insulin resistance. “Patients should understand that having diabetes means being at higher risk for CVD,”...
Malpractice Reform’s Effect on ED Care

Malpractice Reform’s Effect on ED Care

It is often claimed that “defensive medicine” is a major source of wasteful medical spending. One report estimated that $210 billion is spent each year on needless care that is motivated by fear of lawsuits. Despite this widespread belief, few previous studies have directly measured the effect of malpractice reform laws on clinical practice. Emergency care may be at particular risk for accruing high costs from defensive medicine practices. “Emergency physicians operate in an information-poor, high-risk environment that would seem to be as prone to defensive practice as any other,” says Daniel A. Waxman, MD, PhD. Most changes to tort law have focused on limiting the size of awards, such as putting a cap on noneconomic damages. ED care, however, has been a focus of a new kind of reform that might be expected to offer a stronger sense of protection to emergency physicians. About 10 years ago, Texas, Georgia, and South Carolina changed their malpractice standard for emergency care from the usual “deviation from the standard of customary practice” to “willful and wanton negligence” (in Texas) and “gross negligence” (in Georgia and South Carolina). Those two standards are essentially synonymous. The three states’ laws, which also have other provisions that apply outside the ED, are summarized in Table 1. “The gross negligence standard is widely acknowledged to be an incredibly high bar for plaintiffs to meet, and the laws therefore offer very strong protection to emergency physicians,” Dr. Waxman says. “For example, plaintiffs must prove ‘conscious indifference,’ meaning that a physician knew that an action would probably cause serious injury and then took the action anyway.” New Research...
APS 2015

APS 2015

New research was presented at APS 2015, the American Pain Society’s annual scientific meeting, from May 13 to 16 in Palm Springs, CA. The features below highlight some of the studies that emerged from the conference. Migraine Prevalent in Patients With Fibromyalgia The Particulars: Fibromyalgia has been shown in several studies to be highly prevalent in patients with migraine. However, few studies have explored the prevalence of migraines in patients with fibromyalgia. Data Breakdown: For a study, more than 1,000 patients with fibromyalgia completed a survey with questions about medical history, demographics, and migraine. More than half of respondents participating in the study met criteria for migraine headaches. Those who met the criteria were significantly more likely to report hypertension, asthma, IBS, chronic fatigue syndrome, depression, anxiety, and PTSD. Take Home Pearls: Migraines appear to be common among patients with fibromyalgia. Several additional medical and psychiatric comorbidities appear to be common in this patient population. Influences on Health Behavior Change in Chronic Pain The Particulars: Treatment non-adherence and dropout are common among patients who are prescribed behavioral therapy for pain. Assessing the influences of health behavior change in patients with chronic pain could help identify those at risk for treatment dropout. Data Breakdown: University of Florida investigators assessed the cognitive motivational influences on health behavior change among adults with chronic musculoskeletal pain who participated in a study. Patients expected that engaging in health behavior changes would improve their pain-related symptoms by 21% to 34% but reported they would require improvements of 45% to 52% in order to feel that it was worthwhile to practice these behaviors. Participants frequently endorsed...
Updated Guidelines for NSTE-ACS

Updated Guidelines for NSTE-ACS

Recently, the American College of Cardiology and American Heart Association (ACC/AHA) updated their guideline on the management of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). “This guideline is the first full revision of previous recommendations since 2007,” says Ezra A. Amsterdam, MD, FACC, who co-chaired the ACC/AHA writing committee. The other co-chair was Nanette Wenger, MD, of Emory University, and the writing group included 18 clinicians from multiple specialties involved in the care of patients with NSTE-ACS. “The ACC/AHA update offers a new name and terminology that reflects current ways of thinking about the condition,” says Dr. Amsterdam. “The terminology now emphasizes the pathophysiologic continuum of unstable angina and NSTEMI and their frequently indistinguishable clinical presentations.” The update incorporates both established and new evidence from published clinical trials and information from basic science and comprehensive review articles. Dr. Amsterdam notes that there have been major advances since 2007 with regard to enhancing the care of these patients. Although still extensive and comprehensive, the document is now more direct and succinct. Important Changes “A significant change in the guideline was to replace the term ‘initial conservative management’ with ‘ischemia-guided strategy,’” says Dr. Amsterdam. “This was done to more clearly convey the physiologic rationale of this approach.” When treating NSTE-ACS, the guideline notes that an early invasive strategy for those with high-risk coronary artery disease has been successful. However, low-risk patients can benefit substantially from guideline-directed medical therapy (GDMT), an approach that has not always been optimally used. Advances in cardiac troponin testing should help clinicians detect patients with NSTE-ACS, according to Dr. Amsterdam. “Advances in non-invasive assessment of prognostic risk...
ATS 2015

ATS 2015

New research was presented at ATS 2015, the American Thoracic Society’s annual meeting, from May 15 to 20 in Denver. The features below highlight some of the studies that emerged from the conference. Predicting COPD Exacerbation Readmissions The Particulars: Previous studies have found that the 30-day readmission rate following an acute exacerbation of COPD (AECOPD) can be as high as 23%. However, predictors of readmission after AECOPD have not been well established in clinical investigations. Data Breakdown: For a study, researchers used uni­variate analysis to identify predictors of 30-day readmission among patients hospitalized with a primary diagnosis of AECOPD. The authors found that low forced ejection fraction in 1 second (FEV1) and a history of depression independently predicted 30-day readmission. Take Home Pearl: Depression and low FEV1 appear to predict 30-day readmission following hospitalizations for AECOPD. E-Cigarette Use in Older Adults The Particulars: Elec­tronic cigarettes (e-cigar­ettes) are increasingly being used by smokers. However, data are lacking on the use of e-cigarettes in older Americans, those with smoking-related lung disease, or ethnic minorities. Data Breakdown: Researchers assessed e-cigarette use among more than 10,000 Caucasian and African-American current and former smokers with at least 10-pack years. Those who had tried e-cigarettes were significantly more likely to be current smokers, compared with those who had not. About 91% of e-cigarette users reported using them to cut down on tobacco cigarette use, but only 47% did so. COPD exacerbation and chronic bronchitis rates were similar among e-cigarette users and non-users. Take Home Pearl: E-cigarette use does not appear to reduce tobacco cigarette use or alter the progression of COPD. Detecting Lung Changes During...
An Update for Preventing MRSA

An Update for Preventing MRSA

In 2008, the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America—partnering with the American Hospital Association, Association for Professionals in Infection Control and Epidemiology, and the Joint Commission—published the “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals,” a collection of recommendations focused on common hospital-acquired infections. With new research emerging and the need for up-to-date information, the organizations recently released an update to the compendium. As part of the compendium, updated recommendations were made on the prevention of MRSA infection and transmission. Getting to the Basics Published in Infection Control and Hospital Epidemi-ology, the recently updated compendium recommendations provide a roadmap for prioritizing and implementing strategies to help prevent MRSA infection and transmission. These strategies are broken down into basic practices (Table 1) and special practices. “Based on evidence, expert opinion, and experience, the basic practices are recommended for all hospitals, regardless of the burden of MRSA,” explains lead author David P. Calfee, MD, MS. “These are good, basic infection control practices. Many would be useful in preventing a wide variety of healthcare-associated infections (HAIs) and preventing transmission of various pathogens, including MRSA.” When considering MRSA control practices, conducting a risk assessment is important. This should include an analysis of infection rates, the basic practices that have and have not been implemented already, and whether implemented practices are adhered to consistently, according to Dr. Calfee. “Writing a policy and making sure it’s actually being followed are two different things,” he adds. “A good understanding of the epidemiology of MRSA within your facility is really the first step.” He notes that all providers...
Heart Rhythm 2015

Heart Rhythm 2015

New research was presented at Heart Rhythm 2015, the Heart Rhythm Society’s annual scientific sessions, from May 13 to 16 in Boston. The features below highlight some of the studies that emerged from the conference. Physical Activity, AF, & Gender The Particulars: Results of previous studies on the impact of physical activity on the risk of atrial fibrillation (AF) have been inconclusive in many investigations. Few analyses have assessed the effect of intensity of physical activity on AF, particularly with regard to gender. Data Breakdown: Researchers performed a systematic review of 14 studies involving nearly 400,000 patients that reported on the relationship between physical activity and AF incidence. Among men, vigorous exercise increased the risk of AF, whereas moderate exercise lowered AF incidence. For women, moderate and high intensity physical activity both reduced subsequent risks of AF. Take Home Pearls: Moderate exercise appears to reduce the risk of AF in men and women. However, vigorous exercise appears to reduce the risk of AF in women but increase this risk in men. Measuring Activity in Patients With ICDs The Particulars: Implantable cardioverter defibrillators (ICDs) automatically collect physical activity data in order to provide quantifiable and easily accessible measures of functional status. However, few studies have assessed the relationship of these measures with survival in this patient population. Data Breakdown: More than 98,000 patients with ICDs were followed in a study to examine the association between survival and increments of 30 minutes of physical activity per day. After 4 years, the survival rate was about 90% among the most active patients when assessed at baseline, compared with a rate of 50%...
CME: An Update on Managing IBS & Chronic Idiopathic Constipation

CME: An Update on Managing IBS & Chronic Idiopathic Constipation

IBS and chronic idiopathic constipation (CIC) are among the most common functional gastrointestinal (GI) disorders, with studies estimating that between 5% and 15% of the general population experiences IBS symptoms, whereas CIC symptoms occur in about 14% of people. Recently, the American College of Gastroenterology (ACG) released a monograph—published in the American Journal of Gastroenterology—that updated prior monographs on approaches to treating IBS and CIC. To develop the monograph, the ACG’s Institute for Clinical Research & Education conducted a systematic review and meta-analysis of randomized clinical trials that assessed several types of interventions for IBS and CIC. “We looked back at previous monographs from recent years,” explains Eamonn M.M. Quigley, MD, FACG, a co-author of the update. “The last monograph on constipation came out in 2005, whereas the last one on IBS was released in 2009. Since then, there have been significant developments that warranted an update.” Diet & Fiber An important addition to the ACG guidelines is new information on the relationship between diet and IBS (Table 1). “Research has shown that diet has emerged as a major issue, especially for patients with IBS,” says Dr. Quigley. “This isn’t new for patients because they’ve known for years about certain foods upsetting their GI tract. For clinicians, however, we now have good evidence that diet is a major factor in the precipitation of IBS attacks.” The guidelines note that specialized diets may improve IBS symptoms for some, but the recommendation was labeled as weak because of a low quality of evidence. Current data show that gluten-free diets and diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—also known as...
CME: Updating Pneumococcal Vaccine Recommendations

CME: Updating Pneumococcal Vaccine Recommendations

Pneumococcal disease is an infection caused by Streptococcus pneumoniae bacteria (also referred to as pneumococcus). These bacteria can cause many types of illnesses, including pneumonia, meningitis, and ear, sinus, and bloodstream infections. Pneumococcus is spread when people cough, sneeze, and/or are in close contact with others who are infected. Symptoms depend on the part of the body that is infected. They can include fever, cough, shortness of breath, chest pain, stiff neck, and confusion and disorientation. Symptoms may also include sensitivity to light, joint pain, chills, ear pain, sleeplessness, and irritability. In severe cases, pneumococcal disease can cause hearing loss, brain damage, and death. Pneumococcal disease is a leading infectious cause of serious illness among older adults in the United States. Studies have identified certain patient groups that are more likely to become ill with pneumococcal disease. These high-risk groups include adults aged 65 and older and children younger than 2 years of age. People with weakened immune systems (eg, those with HIV/AIDS), those with chronic illnesses (eg, diabetes, heart disease, and asthma), and individuals who smoke cigarettes are at increased risk for getting pneumococcal disease. Vaccines Have Helped The incidence of pneumococcal infections among children and adults in the U.S. has dropped since a 7-valent pneumococcal conjugate vaccine (PCV7) was initiated for routine use among infants in 2000 and was later replaced by the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010. “For decades, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for use in adults aged 65 and older for the prevention of pneumococcal infections,” explains Tamara Pilishvili, MPH. More recently, the FDA approved PCV13 for use...

Woman Refuses Episiotomy, Gets One Anyway

A woman in California is suing her obstetrician because he performed an episiotomy that she had specifically requested not be done. A relative of the patient shot a video of the entire delivery, ShowerHacks.com reports. The portion of the video embedded below begins after the mother had been pushing for about an hour. You can judge for yourself about the bedside manner of the obstetrician. [Emphatically NSFW] Articles on Yahoo! News and The Daily Beast provide some background to the story. The incident brings up some issues. According to Yahoo, more than 80 lawyers turned down the case before a civil rights attorney agreed to handle it. People who commented cited this as proof that the patient did not have a strong case for malpractice. The reason it is not a good malpractice case has nothing to do with whether the doctor was negligent or wrong. In order to successfully sue for malpractice, there must also be damages. In this case, the episiotomy apparently did not cause harm. Therefore, a malpractice lawyer would decline the case because, absent damages, there is no money to be made. This case is not about malpractice. It is about the right of a patient to refuse an intervention. While the doctor stood with scissors in hand, the patient can clearly be heard saying, “Don’t cut me.” Many other comments centered on the misconception that episiotomies lead to better outcomes of deliveries. To quote The Daily Beast, “Though episiotomies were once common in the U.S.—in 1979 they were performed in 61 percent of vaginal deliveries compared to 14 percent today—the American College of Obstetricians...
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