News News News
NSAIDs INCREASE STROKE RISK 28 TO 86 PERCENT
Treatment with various types of non-steroidal anti-inflammatory drugs was linked with a significantly higher risk for strokes in a review of a million people from the Danish general population during 1997-2005; “Commonly used NSAIDs [non-steroidal anti-inflammatory drugs] such as diclofenac and ibuprofen were associated with an increased risk of hemorrhagic and ischemic stroke,” and the link showed a dose-response relationship, reported Dr. Gunnar H. Gislason.
The public needs “increased awareness about the cardiovascular risk of NSAIDs, even in healthy people,” said Dr. Gislason, a cardiologist at Gentofte Hospital in Hellerup, Denmark.
In a multivariate analysis that controlled for age, gender, co-morbidities, and concomitant medications, people treated with ibuprofen, diclofenac, rofecoxib, or celecoxib had a statistically significant, increased risk for fatal or non-fatal stroke. The increased risk ranged from about 30% higher among all ibuprofen users to about double in all diclofenac users. The two coxibs each linked with about an 80% increased risk. The only NSAID studied without a significantly linked risk was naproxen.
In general, the risk increased at higher dosages. For example, among ibuprofen users who averaged 1,200 mg/day or less had about a 20% increased risk for fatal or non-fatal stroke on the days they took the drug. People who took more than 1,200 mg a day had an average increased risk of about 80%. Both increases were statistically significant.
A second analysis showed significantly increased risks for ischemic stroke among ibuprofen and diclofenac users, but not among users of naproxen, rofecoxib, or celecoxib. Again, users of ibuprofen and diclofenac faced a greater risk when taking higher dosages, defined as being more than 1,200 mg/day of ibuprofen or at least 100 mg/day diclofenac.
THE PRESSURE FOR ELECTRONIC MEDICAL RECORDS CONTINUES…
Even though there is no assurance that the data will be kept private. The Connecticut attorney general has already collected $250.000.00 in a settlement with health insurer Health Net after they lost a disk drive with personal information on 500.000 subscribers. The state’s insurance department has fined the company an additional $375,000.00.
Of course this money will not prevent any misuse of the data, nor will it compensate any patients for any damages resulting from the security breach, who are being offered “free credit monitoring”. Huzzah! (American Medical News November 29th, p 47).
THE PRESSURE FOR ELECTRONIC MEDICAL RECORDS CONTINUES…
Even though a survey by the Healthcare Information and Management Systems Society suggests that at least 25% of practices and hospitals are not even assessing the risk that they may suffer a breach of computer security. (http://www.ama-assn.org/amednews/2010/11/22/bisc1122.htm).
A recent Harris poll found that 91% of adults would not return to a business if their personal information were stolen, but patients in the medical system have no alternative if their insurance company, their hospital, or a government agency such as the Veteran’s Administration fails to keep their medical information private, as in 2006 when more than 25 million veterans’ personal and family information was compromised. (http://www.securityfocus.com/news/11393).
THE PRESSURE FOR ELECTRONIC MEDICAL RECORDS CONTINUES…
Even though specialists cannot meet the bureaucratic requirements for “meaningful use” without exemptions.
One of the selling points for EMRs is that data that is presently obtained only when it is clinically relevant will be obtained by all primary practices. However, many specialists are not likely to hire personnel to collect irrelevant studies and services: For example, an ophthalmologist may not routinely enter blood pressure readings into their electronic medical records, so the Department of Health and Human Services is working on ways that requirements will be varied for each specialty so as to smooth the process of establishing a comprehensive medical database on every citizen.
These constantly changing regulations will require a new, expensive bureaucracy for rule making and enforcement, and compliance will divert more energy and time away from patients for busy clinicians.
CHINESE MEDICINE EFFECTIVE FOR CONSTIPATION
TCM interventions appear to be useful in the management of constipation, according to a systematic review from an Australian group.
One hundred and thirty-seven studies met the inclusion criteria, of which 21 were high-quality trials. Eighteen of the trials were of Chinese herbal medicine (CHM) and three were of acupuncture.
Significant positive results were found in 15 high-quality studies. CHM was more effective than conventional medicines in eight trials. Of the 10 remaining CHM trials, nine compared the CHM being studied with another CHM and the results were significant in four trials. The effective rate was significantly higher in the intervention group than in the placebo group in the last CHM study.
One of the three acupuncture trials compared acupuncture with conventional medicine; one compared it with Senna (Cassia angustifolia) and one with a deeper acupuncture technique.
The therapeutic effect in the treatment group was more effective than that in the control group in all three studies. The authors urge that the results should be interpreted cautiously due to heterogeneity in diagnostic procedures, interventions and outcome measures across the studies. (Efficacy of Traditional Chinese Medicine for the Management of Constipation: A Systematic Review. J Altern Complement Med. 2009 Dec 3. [Epub ahead of print]).
CHINESE HERBS CAN HELP PREVENT DIABETES
A Cochrane database systematic review carried out by Australian authors has assessed the effects and safety of Chinese herbal medicines for the treatment of people with impaired glucose tolerance (‘pre-diabetes’).
The researchers considered data from 16 clinical trials including 1391 people who received 15 different herbal formulations.
Meta-analysis of eight trials showed that those receiving Chinese herbal medicines combined with lifestyle modification were more than twice as likely to have their fasting plasma glucose levels return to normal levels compared to lifestyle modification alone. Those receiving Chinese herbs were less likely to progress to diabetes during the study period (one month to two years).
No adverse effects were reported in any of the trials. (Chinese herbal medicines for people with impaired glucose tolerance or impaired fasting blood glucose. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006690).
HERBAL MEDICINES SAY NO TO CIRCULATORY DISEASE
Research suggests that traditional Chinese herbal medicines (TCMs) used to treat cardiovascular disease may act by producing large amounts of nitric oxide (NO).
NO is a chemical messenger molecule that is crucial to the cardiovascular system because of its vasodilating action. It promotes blood flow through the heart and circulatory system, eliminates blood clots, lowers high blood pressure and reduces formation of atherosclerotic plaques. Many cardiovascular diseases are characterized by NO insufficiency.
The scientists tested a number of TCMs - including single herbs such as Dan Shen (Salvia miltiorrhizae Radix) and Gua Lou (Trichosanthis Fructus) as well as herbal formulae - for their ability to produce NO. All of the TCMs tested showed NO bioactivity through their nitrite and nitrate content and their ability to reduce nitrite to NO via the activity of the enzyme nitrite reductase.
Many of the TCMs were found to have nitrite reductase activity 1000 times greater than that of biological tissues, providing a natural system for generation of nitric oxide in the inner walls of blood vessels and thus accounting for some of their therapeutic effects. Each of the TCMs tested was also found to exert vasodilatation in an animal model. (Nitric oxide bioactivity of traditional Chinese medicines used for cardiovascular indications. Free Radic Biol Med. 2009 Sep 15;47(6):835-40).
OMEGA 3 FATS AND ATRIAL FIBRILLATION
Some data suggest that omega-3 fatty acids may be a safe and effective treatment option for patients with atrial fibrillation. In a randomized, placebo controlled, multicenter trial that enrolled patients with documented symptomatic paroxysmal or persistent AF and no structural heart disease, high dose (4 grams a day) of a prescription omega fatty acid (Lovaza) was not effective. Prior, smaller studies have suggested a protective benefit from consumption of fish and other fish oil preparations, so these results may reflect differences in populations studied, or limitations of the prescription preparation. (JAMA December 1, 2010 Vol 304:21 p 2363).
ACUPUNCTURE & DEPRESSION
Previous studies have shown acupuncture at depression specific points to be superior to acupuncture at points not specific to depression. In a recent study, however, it appears that the non specific acupuncture was superior to the specific acupuncture.
Study participants (151) were randomized to receive depression specific acupuncture, non-specific acupuncture or no treatment (waiting period) for eight weeks. All patients eventually underwent the depression specific acupuncture.
At the end of the first eight weeks, the effective response was 22%, 39% and 17% respectively in the three groups. By the end of the study around half of patients had responded to the treatment.
One notable factor is that while the depression-specific acupuncture was tailored to the individual patient at the first session, the study required those same points to be treated during the remainder of the study period. (Acupuncture for Depression: A Randomized Controlled Trial. Journal of Clinical Psychiatry 2006; 67: 11, 1665-1673).
ACUPUNCTURE & ALLERGIC ASTHMA
In a randomized controlled study, patients of 18 years or older with allergic asthma were assigned to routine care plus acupuncture (15 sessions over three months, 184 patients) or routine care alone (173 patients). Patients who did not consent to randomization also received acupuncture (1088 patients).
At three months, asthma specific quality of life and health-related general quality of life improved significantly in both acupuncture groups compared to controls. (Effectiveness of acupuncture in patients with allergic asthma – the Acupuncture in Routine Care (ARC) Study. Focus Altern Complement Ther 2006; 11: 06-7).
IRREGULAR WORK & PROSTATE CANCER
It is already known that shift workers are at a higher risk of developing some cancers, including breast and colorectal. Now a new study as uncovered a significant increased risk of prostate cancer among rotating shift-workers.
The researchers believe that the cause may be disturbance of melatonin secretion. (Am J Epidemiol 2006;164:549-555). Another study as identified two other risk factors for prostate cancer. One is height of greater than 1.7 meters (5’7”) at age 20, and the other is a long marriage (among men married only once and still married at interview). (Risk factors for prostate cancer: A national case-control study. Int J Cancer 2006;119:1690-1694).
"Is Anyone Thinking?" Department
DOCTORS BAFFLED BY SURGICAL ERRORS
"When the universal protocol was implemented it was thought "never events" would decrease. Not only did they not decrease, they increased." - Phillip F. Stabel M.D., Ph.D., Denver Health Medical Center
New evidence shows that the Joint Commission’s “universal protocol” to eliminate the possibility of wrong site surgery or surgery on the wrong patient has not only been ineffective in reversing the number of wrong procedures, but the numbers of these “never events” have peaked since the commission’s protocols were mandated in 2004 for all surgical procedures performed in the United States.
Supposedly, if surgeons and operating room staff use a written pre-procedure “checklist”, marks the area on the patient where the procedure is to be performed, and takes a “timeout” during the furious rush to create more cashflow for fat cats, obvious errors that should “never” happen will be prevented.
A study published in the October Archives of Surgery finds that one reason that errors have increased is that Joint Commission-required “timeouts” are skipped, rushed, or may take place without the surgeon present in the operating room.
The commission estimates that incorrect procedures happen about 40 times a week in the U.S., placing blame on poor communication and a “lack of physician leadership” according to Lamar McGinnis, M.D., immediate past president of the American College of Surgeons. He also serves as the College’s representative on the Joint Commission. (one would think this places him in a "leadership" role, no?)
The procedure problem is not limited to the operating room, as a quarter of the wrong patient cases reported in the study involved internists, and 32% of all the incorrect procedures involved nonsurgical specialists such as dermatologists. (American Medical News November 15, 2010 p 22)
The “universal protocol” solution illustrates another failure of a “top down” mentality when applied to the inexcusable failure of our medical system to ensure that a surgical procedure is performed on the correct organ, and on the correct patient.
So what is the brilliant advice from risk management consultant Michael S. Victoroff, M.D. to eliminate wrong site surgery? “Slow down — pause. Stop what you’re doing. Recalibrate. Step Back. Change the field of focus. Look around. Take a breath.”
Take a breath?
As mentioned in these pages before, the equally brilliant solution proposed by the Centers for Medicare and Medicaid in 2008?
“We won’t pay for procedures on the incorrect patient or site.”
Hard to believe that this powerful remedy also failed to work.
The only solution to this as well as many other failures of our medical system to function at a minimally acceptable level is to return to the “bottom up” model of medical care created by long term relationships between physicians and patients.
When I participated in a special clinical clerkship in anesthesia many years ago, I made it my business to know everything possible about the patient we would be operating on, and started days before the procedure began. And, we were administering anesthesia, which necessitated constant control of the patient's life functions.
There is no way that my preceptor or I would not be alert immediately if surgery was to go awry.
There will never be a situation where surgery is not an extremely dangerous proposition, and things can, and did, very quickly go bad on occasions. What saved the patient was the integration of skilled, self motivated professionals who knew why they were there and what they were doing.
It was rarely perfect, but I quickly understood the necessity for unified intent and integrated teamwork. No regulator or commission is going to find a rulebook that will create a culture of caring and good character for the members of the operating room team.
Every factor which interferes with the establishment and sustainability of these relationships contributes to an environment in which impersonal, unaccountable, poor quality medicine is accepted and eventually established as the standard.
The chickens of our government and employer-based third party payment and regulatory system have come home to roost, and no amount of feel-good regulation or "mandates" from outside bureaucrats will make any difference.
So, until it becomes fashionable for the medical profession to return to serving only one master instead of a panoply of social engineers, businessmen, and political opportunists, you must have a trusted friend watch over you during surgery.
Perhaps you must make your surgeon remove their mask before surgery so you can be sure that it is at least the correct surgeon.
It might also be wise to ask the surgeon to document in the chart right then in front of you what the procedure is and where it should be before you allow any anesthesia to be administered.
Perhaps everyone in the operating room should also be expected to sign this chart note as witnesses.
The proliferation of bureaucratic "solutions" such as universal protocols reflects the continuing deterioration of American medicine.