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    Tuesday, June 30, 2009

    Circumcision Prevents Sexual Transmitted Diseases (STDs)

    Is there a reason why Catholic nuns and Jewish women have a decreased incidence of cervical cancer and the opposite applies to groups such as blacks and Hispanics, where rates of HIV, herpes, and cervical cancer are disproportionately high?

    Johns Hopkins scientists, along with researchers in Uganda, are saying that "circumcision significantly reduces the risk of contracting herpes (HSV-2) and human papillomavirus (HPV)," contributing more hard data to a pool of "growing scientific evidence that the procedure helps stem the spread of some sexually transmitted diseases." A little "over half of male newborns in the US get circumcised, according to research published earlier this year in the American Journal of Public Health." It’s ironic that apparently, that "percentage has declined over the past decade, in part because the American Academy of Pediatrics said in 1999 that the evidence is 'not sufficient to recommend routine neonatal circumcision.'" But, pathologist and Hopkins' team member Aaron Tobian, MD, PhD, said, "The scientific evidence for the public-health benefits of male circumcision is overwhelming now."

    For example, "landmark studies from three African countries, including Uganda, previously found circumcision lowered men's chance of catching the AIDS virus by up to 60 percent. The new work "stems from the Uganda research and looked at protection against three other STDs" -- herpes, HPV, and syphilis.

    The research teams set up two parallel, but independent, trials comprised of "a total of 5,534 uncircumcised men between the ages of 15 and 49 who were negative for the AIDS virus. Then, "1,684 of the 3,393 men who tested negative for herpes were circumcised immediately, and the others received a medical circumcision after 24 months." In addition, "352 men in the circumcised group and 345 in the delayed circumcision group were evaluated for HPV at the start of the trial and at 24 months."

    Two years later, investigators noted that "circumcised volunteers were one-fourth less likely to have genital herpes and one-third less apt to carry a type of HPV that causes cervical cancer, compared with the still-uncircumcised males." Even "when all HPV types were assessed, including those causing genital warts, the circumcised volunteers were still nearly one-third less likely to carry one of the types.”

    There are "several reasons that removing the foreskin of the penis might help reduce transmission of certain infections. The foreskin, has two different sides," with the outside being very much like "regular skin cells," but "the inside is mucosal, similar to a woman's vagina." And, "during intercourse, the skin side is pulled back and the mucosal side is open and exposed." One researcher opines that "it's likely that there are viral receptors on that mucosal side that make it easier for a virus to get into the cells." Moreover, "if a woman has passed along viral cells, they're now trapped inside the foreskin, in a moist environment that's conducive for the virus to replicate."

    The study authors say their findings "should guide public health policies for neonatal, adolescent, and adult male circumcision programs," according to MedPage Today (3/25/09, Smith), particularly since "circumcision rates in the US are falling, especially among groups such as blacks and Hispanics, where rates of HIV, herpes, and cervical cancer are 'disproportionately high.'"

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    * Tune in tomorrow for Part I of IV, Believing in Treatments that don't work

    Deepen your understanding of How to Be an Effective Medical Expert

    Monday, June 29, 2009


    “This time media overkill and sudden death have come together to create a perfect storm, a storybook ending to public fascination: The end of one entertainer’s lifelong struggles and a never-ending media chase all in the same scene. It is, however, still not safe to go back to the news.”

    No. I’m not referring to Michael Jackson.

    This was the heading of a new story about Anna Nicole Smith’s death who died suddenly at a hotel in Florida. This was also the way Marilyn Monroe, died of drugs and barbiturates. The medical examiner in the Smith case said the cause of death was "combined drug intoxication" with the sleeping medications as the major factor in combination with therapeutic levels of other drugs used to treat pain. Drug associated sudden death was also the way Smith’s son died five months earlier.

    Smith was taking a lengthy list of other medications, including methadone for pain, Valium, anti-anxiety and anti-depression drugs. She had also recently taken longevity medications, B12 and growth hormone.

    Bacterial infection from injecting drugs into her buttocks were contributory causes in her death. Some of the medications Smith was taking were prescribed to her, some to other aliases she used or to other people, but all of the drugs she was on were intended for her."Miss Smith had a long history of prescription drug use and over-self medicating. It can become very toxic if you mix it with any other central nervous system depressant drugs. You could get profound sedation leading up to coma and respiratory arrest."

    There was no evidence of suicide. There was no suicide note. Smith also suffered stress from the various lawsuits she was involved in.
    Does all this sound familiar?

    Michael Jackson, age 50, was pronounced at the UCLA Medical Center, after being found unconscious and without respiration at a rented home in Los Angeles.
    At approximately 1:14 p.m., a team of doctors including emergency physicians and cardiologists attempted to resuscitate him for a period of more than one hour, and they were unsuccessful," Jackson's brother Jermaine Jackson said during a Thursday press conference. A cadiologist at Indiana University in Indianapolis, opined that cardiac arrest was "the first thing that came to mind" after hearing of the singer's sudden death, and also pointed out that 30% to 50% of such events occur in people with no preceding history.

    In this case also drugs, prescription and otherwise- and even some heroin use probably played a major role. There was also a lot of morphine. A lot of different drugs, say British newspapers including The Sun and the Times of London, citing an anonymous hospital worker and another source, who reported that Jackson received an injection of meperidine (Demerol) shortly before collapsing in his home. Jackson's health appeared to be worsening in recent years. In 2005,Jackson just like his predecessor Anna Nicole Smith was also hospitalized due to "dehydration with the flu."

    Jackson himself had admitted to a painkiller addiction in 1993. He claimed that his addiction stemmed from an injury he sustained in 1984, when a special effects explosion during the filming for a Pepsi commercial badly burned his head. He also claimed that the mental stress of child-molestation allegations fueled his need for medication.

    Jackson also reportedly suffered from back pain -- a condition that took the spotlight during his much-publicized trial in 2005 for allegedly molesting a young boy. Jackson failed to show up for a court appointment, ostensibly because his back pain became so severe that he had to go to the hospital instead The chief suspected cause of Jackson's death continues to be cardiac arrest.

    Is there anyone left that does not know that cardiac arrest or sudden death is the chief manifestation of drug abuse?

    I doubt it.

    We’re going to be faced with months of reporting on this—about drugs—about who will take care of his children—about his debts and most of all his accruing income to his estate ala’ Elvis. I have a request. Let’s stop the news cycle now and just remember Jackson as we do Elvis as great and innovative entertainers who gave us a lot of pleasure during the years we were lucky to know them.

    Please remember, as with all our articles we provide information, not medical advice.

    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    TOP 10 Laws and Rules Every Physician Should Know

    The following information is being provided as a resource to remind you of important laws and rules that affect your medical practice, but is not all inclusive. Although this applies to my state of Florida it is still your responsibility to read and become familiar with the laws and rules of your state.

    Florida Law and/or Rule

    1. You must update your Practitioner Profile within 15 days


    s. 456.042, F.S. This includes changes in –
    • Address
    • Staff privileges
    • Medical malpractice history
    • Financial responsibility
    • Board certification
    • Education
    • Disciplinary/criminal history

    Florida Law and/or Rule
    2. Before you move to a new practice, notify the Board


    s. 456.035, F.S.; s. 458.319(3), F.S.; s. 458.327(2)(e), F.S. No current address on file? Here is what can happen:
    • crisis at renewal time
    • late renewal may mean practicing on an inactive license
    • practice on inactive license = criminal offense

    Florida Law and/or Rule

    3. Do not pre-sign prescriptions

    s. 458.331(1)(aa), F.S. Board of Medicine Disciplinary Guidelines provide a maximum penalty of -
    • Reprimand
    • $5,000 fine
    • 2 years probation

    Florida Law and/or Rule
    4. At license renewal, read the fine print before you renew

    s. 458.319, F.S. • It is your license on the line, not your office manager’s!
    • CME and Financial Responsibility requirements are audited
    • Maintain copies of your CME certificates for at least 2 biennium
    • DIDN’T RECEIVE YOUR RENEWAL POSTCARD? Call (850) 488-0595 extension #3
    • The Preventing of Medical Errors course has specific requirements including a study of root cause analysis, error reduction, prevention and patient safety, and the 5 most mis-diagnosed medical conditions which are:
    • cancer
    • cardiac
    • acute abdomen
    • timely diagnosis of surgical complications
    • stroke and related cranial conditions

    • CME providers may be located on the Internet by typing “continuing medical education” in the search field, or by contacting the American Medical Association at (312) 464-4952.

    Florida Law and/or Rule
    5. You must keep charts on the family, employees and friends that you treat

    s. 458.331(1)(r), F.S. and s. 458.331(1)(m), F.S. • A prescription creates the physician/patient relationship
    • Records are required even for family
    • Spouses/friends may become adverse parties
    • Cannot self-prescribe controlled substances

    Florida Law and/or Rule
    6. Patient Boundaries

    S. 458.329, F.S. and s. 458.331(1)(j), F.S. State Boards of Medicine should have a zero tolerance policy on physician/patient sexual misconduct
    • Typical penalty is suspension/revocation
    • Remember: A prescription creates a physician/patient relationship

    Florida Law and/or Rule
    7. Pause before you make the incision on the correct site of the correct patient

    s. 458.331(1)(t), F.S.; s. 456.072, F.S.; and Rule 64B8-9.007, F.A.C. • The “pause” before the procedure must be in the patient chart
    • If you make the mistake, inform the patient and/or the patient’s representative and document it or the Board will increase the penalty.
    • Read the rule at 64B8-9.007 Standards of Practice.

    Florida Law and/or Rule
    8. Internet Prescribing

    s. 458.331(1)(t), F.S. and Rule 64B8-9.014, FAC • Prescribing without a history and physical is both a standard of care violation and a violation of Board rule
    • Physician have been disciplined for this with penalties ranging from revocation to suspension, reprimands and fines

    Florida Law and/or Rule

    9. Relocating Practice?

    Rule 64B8-10.002, FAC You are responsible to:
    • hold patient records for 5 years
    • notify patients in letters or by sign as to where to pick up records
    • place a notice in newspapers and notify the Board of Medicine 30 days before you move
    • complete your hospital charts if leaving the area!

    Florida Law and/or Rule
    10. Help for impaired practitioners

    s. 456.076, F.S. Do you know a colleague with drug, alcohol, or psychiatric problems?
    • You can get them help without subjecting them to disciplinary action
    • Most state Boards have an excellent evaluation and rehabilitation programs that is a phone call away: Call your state’s Professional Resource Network
    • For most practitioners, this is and remains a confidential process that offers help to those willing to change
    • This program was recently expanded to include medical students as well

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    * Tune in tomorrow for Circumcision Prevents Sexual Transmitted Diseases (STDs)

    Deepen your understanding of How to Be an Effective Medical Expert

    Sunday, June 28, 2009


    I was surfing through some medical blogs the other day and found this Emergency Physicians Monthly - White Coats Call Room – A blog from inside the emergency department

    The doctor writes that “During a recent ED shift, just for the heck of it, I started taking notes as I went from room to room treating patients. I wanted to try to show myself whether or not “defensive medicine” was a figment of my imagination. It isn’t a figment of my imagination.”The ED doctor gives these examples which do not serve his purpose of showing up “defensive medicine as bad.” In fact if f I were judging by this doctor’s examples I would defend the indefensible. I would defend defensive medicine.
    See if you agree.

    His Example 1.
    A patient in her 60s fell and hit her head 5 days ago. She was having a headache. I couldn’t find a mark on her and was inclined to send her home with pain medications. But she was on Coumadin which put her at risk of bleeding. So I did a CT scan of her head to “make sure” that she didn’t have a bleed. She didn’t.

    But she could have! Couldn’t she? Remember the late Catherine Graham owner of the Washington Post who died post fall cerebral bleed. And how about the beautiful actress daughter of the famous Redgrave clan - Natasha Richardson--mother of 2 children who also died post a skiing accident of a subdural hematoma—even without Coumadin to precipitate and prolong the bleeding inside her head.. The only way to help these patients is early diagnosis by x-ray. When clinical findings occur it’s usually too late-- which this doctor, seems to disregard.

    Example 2 given by this ED doctor as defensive medicine.
    An out of town patient in her 40’s who had a long history of smoking and a history of COPD came in for coughing and shortness of breath. She was at a baby shower and had forgotten her albuterol inhaler. Her oxygen saturation was 92% on room air. Her heart rate was 105. She got a couple of treatments and steroids and was marginally improved. Her symptoms were most likely explained by her underlying COPD. I was inclined to discharge her with a prescription for steroids and another inhaler. Instead, I did a CT scan of her chest to “make sure” that she didn’t have a pulmonary embolism. She didn’t. She went home on steroids and an inhaler. We made sure to recommend that she stop smoking so that we wouldn’t get dinged by CMS for failing to meet a “quality indicator.”

    This patient could very well have a pulmonary embolus kicking in a bout of SOB.

    His third Example.
    A patient dropped a TV on his foot. There was only a little red mark on the back of his foot, but the patient stated that he could not bear weight on his foot. I was inclined to wrap him up and send him home with pain medication and crutches, but I did an x-ray of his foot to “make sure” that there was no fracture. There wasn’t.
    Only a little red mark of his foot-but he could not bear weight on his foot? Sounds like an x-ray certainly is indicated here.

    Example 4.
    A 94 year old demented lady was brought in because she was not “acting right.” Her daughter tried to wake her from sleep and had a more difficult time than usual waking the patient up. The daughter stated that the patient was “acting different,” even though nurses who had seen the patient before and the nursing home staff stated that the patient was not acting different. The patient got a bunch of labs and a head CT just to “make sure” that the allegedly incremental increase in her dementia wasn’t caused by a metabolic problem or a spontaneous bleed in her brain. It wasn’t. She was discharged back to the nursing home to finish her nap.

    The most common causes of sudden dementia or worsening of dementia in the elderly are medication problems, metabolic causes and infections. This lady certainly deserved these “defensive medical tests.”

    Example 5.
    Then there was the suicidal patient. She was drinking, became upset with her boyfriend, and used a piece of broken glass to cut her wrists. Her alcohol level was in the mid-200s. She was drunk and she “was going to f***ing die.” But no psychiatric institution would accept her in transfer until she had a complete laboratory and toxicological workup, including an EKG and a urinalysis just to “make sure” that a whacked out chloride level or a raging UTI wasn’t really behind her suicidal tendencies.

    That’s right. How many “psychiatric” patients die in the psychiatric unit not from psychiatric but because of drugs and metabolic causes? Too many.

    This particular ED doctor obvious from his remarks, thought that he had to do all the “extra” studies because of “defensive medicine.”

    “Why,” he asks, “was I ordering all of these things when my clinical judgment led me to believe that they would “probably” not lead to any changes in the patient’s management?

    Hello! Clinical judgment is great where indicated. These examples however do not prove this doctor’s point. In fact the opposite.

    The answer, he gives is that “because in our culture, “probably” doesn’t cut the mustard any more. Clinical medical judgment has been supplanted, he says, by the demand that physicians disprove the improbable. Society has made it so that physicians are more concerned with proving that unlikely diagnoses with the possibility of a “bad outcome” don’t exist and with maintaining good Press - Ganey scores. Many physicians are afraid to practice rational medicine based upon clinical judgment and physical examination skills. No one wants to face the liability. For those who would assert that I was practicing inappropriate medicine for ordering all of the “unnecessary tests” above, tell me which conditions that it would have been acceptable to “fail to diagnose” on the possibility that my clinical examination alone missed an unlikely disease process. That, my friends, is defensive medicine at work.”

    Doctor, your case would be better made with better examples.

    And doctor, I would further reply ---how about this case?

    40 yr old indigent street guppy shows up to the ER with altered level of consciousness. Blood alcohol was .3 (almost 4 times the normal intoxication limit 0.08). ER Doc runs CBC, metabolic panel that shows only elevated liver enzymes, no surprise for chronic alcoholism. ER Doc decides to wait it out, and discharges patient after almost a full shift, alert and oriented. (No discharge blood alcohol done). Said patient returns 1 hr later, again altered LOC. Being a bounce back, this time he gets the full work-up. Blood alcohol 0.12, CT shows subdural hematoma.

    What really is defensive medicine? Defensive medicine eludes easy definition

    Definitions include:
    “Medical practices designed to avert the future possibility of malpractice suits.”
    “ In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient.”
    “Doctors order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability.”

    “Medical practices designed to avert the future possibility of malpractice suits.”
    Some defensive medicine, however, presumably helps patients. Some paradoxically puts the patients in harm's way (the more you do, the more you are likely to "break something.")

    As the blog complained, many believe that sound clinical judgment has been supplanted by disproving the improbable. Failure to diagnose, no matter how improbable, can, and often does, evolve into a multi-year odyssey narrated by "a plaintiff's attorney telling everyone how the patient's injury is an example of why [the physician] is a bad doctor and why clinical examination alone is simply not good enough." But the problem with the definitions are that defensive” medicine - ie medicine done to avoid the risk of liability, remains undefinable, because you don’t know if your liability is actually reduced by each “unnecessary” test you order.

    If I were judging by this doctor’s examples I would defend the indefensible. I would defend defensive medicine.

    Please remember, as with all our articles we provide information, not medical advice.

    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    * Tune in tomorrow for TOP 10 Laws and Rules Every Physician Should Know

    Deepen your understanding of How to Be an Effective Medical Expert

    Saturday, June 27, 2009

    HHS says researcher fabricated, falsified data on sleep apnea in severely obese patients

    In the Wall Street Journal (4/10/09) Health Blog, Sarah Rubenstein wrote that, according to the Office of Research Integrity at the Health and Human Services Department, "Robert Fogel, a former assistant professor at Harvard Medical School, fabricated and falsified data in a study of sleep apnea in severely obese patients." The office said that Fogel "changed or falsified nearly half of the sleep data "so that those data would better conform to his hypothesis." He is also accused of fabricating "about 20 percent of anatomic data that supposedly came from CT scans."

    The study, titled "Anatomic and Physiologic Predictors of Apnea Severity in Morbidly Obese Subjects," has since been retracted from the journal Sleep. Commenting on the false data, Fogel said "What I did was obviously horrendously wrong," but that "this was the only paper on which he'd done this." Fogel’s fabrications don’t appear as widespread as those of a Massachusetts doctor who allegedly faked data in 21 published studies. Specifically, PHS found that for the data reported in the Sleep paper, the Respondent:

    • Changed/falsified roughly half of the physiologic data
    • Fabricated roughly 20% of the anatomic data that were supposedly obtained from Computed Tomography (CT) images
    • Changed/falsified 50 to 80 percent of the other anatomic data
    • Changed/falsified roughly 40 to 50 percent of the sleep data so that those data would better conform to his hypothesis.

    A New Low in Drug Research: 21 Fabricated Studies

    We’ve written about plenty of controversies around drug trials, from ghostwriting to keeping quiet about unflattering results.

    But the latest news is particularly eye-popping: A prominent Massachusetts anesthesiologist allegedly fabricated 21 medical studies involving major drugs. Baystate Medical Center in Springfield, Mass., has asked several anesthesiology journals to retract the studies, which appeared between 1996 and 2008. The hospital says its former chief of acute pain, Scott S. Reuben, faked data used in the studies.

    Some of the studies reported favorable results from use of Pfizer’s Bextra and Merck’s Vioxx, both painkillers that have since been pulled from the market. Others offered good news about Pfizer’s pain drugs Lyrica and Celebrex and Wyeth’s antidepressant Effexor XR. Doctors said Reuben’s work was particularly influential in pain treatment and that they were shocked by the news.

    “We are left with a large hole in our understanding of this field,” said the editor-in-chief of Anesthesia and Analgesia, which first reported on the retractions. “There are substantial tendrils from this body of work that reach throughout the discipline of postoperative pain management.”Pfizer had funded some of Reuben’s research and had also paid him to speak on behalf of its medicines.

    And another horror story:

    A medical device company and four of its executives have been indicted on charges of conducting unapproved clinical trials in which three patients died, according to the U.S. Department of Justice.

    The company, Norian Corporation, of Cupertino, Calif., faces 52 felony counts, including conspiracy to impede the lawful functions of the FDA, seven counts of making false statements, and 44 counts of shipping an adulterated product. Its parent company, Synthes, of Switzerland and West Chester, Pa., faces 44 misdemeanor counts of shipping an adulterated product

    The indictment charges that, from May 2002 to fall 2004, Norian conspired with parent company Synthes and four top executives to use Norian XR and Norian SRS to surgically treat vertebral compression fractures of the spine Norian SRS, in vertebral compression fracture procedures as part of a test market, according to the Department of Justice. Ultimately, 52 surgeons were trained on use of the product in such procedures.

    The surgeries were performed despite a warning on the FDA approved label for Norian XR against such use -- preliminary studies had found that the cement reacted chemically with human blood, resulting in clotting. Animal studies had shown that the blood clots became lodged in the lungs, according to the Department of Justice.

    Norian conducted three of the training sessions, canceling others after three patients in whom Norian XR was used died on the operating table. The company did not recall the product from the market -- doing so would have required a disclosure about the deaths to the FDA.

    Instead, the Department of Justice charges that the company carried out a cover-up in which they lied to the FDA during inspections in May and June 2004.

    * Tune in tomorrow for In defense of Defensive medicine.

    Deepen your understanding of How to Be an Effective Medical Expert

    Friday, June 26, 2009

    Recommendations on Managing Infection Passed from Pets to Humans via Bite Injuries

    Life-threatening pathogens including the very dangerous MRSA can be transmitted from cats and dogs to humans via bite wounds — and such injuries should prompt careful clinical consideration.

    Among the pet-related pathogens are Pasteurella, Capnocytophaga, Streptococcus, and Staphylococcus species — with methicillin-resistant Staphylococcus aureus on the rise. Given the potential for severe complications, the authors offer a wound management strategy. Steps include:

    • Culture for aerobes and anaerobes if the patient has an abscess, severe cellulitis, devitalized tissue, or sepsis.

    • Irrigate the wound with saline solution.

    • Order radiographs in case of fracture or bone penetration; MRI or CT may also be indicated.

    • Prescribe prophylactic antibiotics as necessary. If MRSA is suspected, first-line antibiotics include trimethoprim-sulfamethoxazole, doxycycline, minocycline, and clindamycin.

    • Hospitalize the patient if there is fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function, or if the patient is immunocompromised or likely to be nonadherent.

    * Tune in tomorrow for falsified data on sleep apnea in severely obese patients.

    Deepen your understanding of How to Be an Effective Medical Expert

    Thursday, June 25, 2009


    “Never events are now the going payment standard of care as far as hospital re-imbursement. But that means to many a never event will probably also be viewed as representing “below standard medical care.” Thus "the mere designation of never events will likely result in both more numerous and more valuable plaintiffs’ verdicts nationwide,” says Charles Brown.

    In an op-ed in the New York Times Philip K. Howard, chairman of Common Good, a legal reform coalition, writes that currently, "fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures." This practice, known as "defensive medicine," is now "so prevalent that it has become part of standard protocol," Howard notes.

    And, "under instructions from lawyers," physicians "don't apologize or offer explanations when things go wrong." As a result, "patients, sensing distrust, demand second opinions." "it would be relatively easy to create a new [health] system of reliable justice, one that could support broader reforms to contain costs." But, with "special health courts aimed...delivering fair and reliable decisions," patients and physicians would have "expedited proceedings with knowledgeable staff."

    He also points out that "one benefit" of a "quicker, streamlined system would" be "drastically lower legal costs." Howard concludes that "restoring trust in law," an "essential reform, can be accomplished with the creation of reliable courts." Restoring a foundation of trust requires a new system of medical justice, says Howard. Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments. Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.

    America needs special health courts aimed not at stopping lawsuits but at delivering fair and reliable decisions. A special court would provide expedited proceedings with knowledgeable staff that would work to settle claims quickly. Trials would be conducted before a judge who is advised by a neutral expert, with written rulings on standards of care.

    All information about each incident, including details learned in settlements, would be compiled and disseminated so that doctors and hospitals could learn from their errors.

    Proponents of special health courts have estimated that the total cost of such a new liability system would be about the same as the existing system — less than 2 percent of America’s total health care costs. One benefit would be that the quicker, streamlined system would compensate far more people, with drastically lower legal costs. Most important, it would restore faith in the reliability of medical justice. This country has a long tradition of courts and tribunals to deal with issues like bankruptcy that require special expertise. Nowhere is that expertise, along with the stability and trust it would bring, more needed than in health care.

    Several prominent hospitals, including New York Presbyterian, have said they are interested in being part of a health court pilot project. Some large consumer and patient safety groups support the idea. The fastest way to do this would be for Congress to authorize and finance pilot courts around the country. These ideas already have some bipartisan support: Bills for alternative medical justice systems have been introduced in Congress.

    Cutting back on the notorious inefficiency of American health care is essential to achieve universal care, as well as make the American economy more competitive.
    Part of the solution — overhauling the reimbursement model so that doctors get paid only for what is needed — is unavoidably complex.
    But restoring trust in law, the other essential reform, can be accomplished with the creation of reliable courts.

    * Tune in tomorrow for Recommendations on Managing Infection Passed from Pets to Humans via Bite Injuries

    Deepen your understanding of How to Be an Effective Medical Expert

    Wednesday, June 24, 2009

    Do Not Eat Nestle Toll House Prepackaged Cookie Dough

    Nestle Toll House prepackaged refrigerated products were recalled on June 19, 2009, over concerns about E. coli contamination, with the FDA advising consumers to throw away any dough they may have already purchased. (Cooking the dough is not recommended, as the bacterium could contaminate one's hands or cooking surfaces.)

    Since March, E. coli infections potentially linked to the dough have been reported in 66 people in 28 states, according to the FDA. There have been 25 hospitalizations —
    some with hemolytic uremic syndrome — and no deaths.The U.S. Food and Drug Administration and the Centers for Disease Control and Prevention are warning consumers not to eat any varieties of prepackaged Nestle Toll House refrigerated cookie dough due to the risk of contamination with E. coli O157:H7 (a bacterium that causes food borne illness).

    The FDA advises that if consumers have any prepackaged, refrigerated Nestle Toll House cookie dough products in their home that they throw them away. Cooking the dough is not recommended because consumers might get the bacteria on their hands and on other cooking surfaces. Retailers, restaurateurs, and personnel at other food-service operations should not sell or serve any Nestle Toll House prepackaged, refrigerated cookie dough products subject to the recall. Since March 2009 there have been 66 reports of illness across 28 states. Twenty-five persons were hospitalized; 7 with a severe complication called Hemolytic Uremic Syndrome (HUS). No one has died.

    Because the appearance of E. coli 0157 in cookie dough is so unusual, investigators are looking at a broad range of possible factors, analyzing the ingredients, the plant's equipment and interior, the health of workers and whether the facility is located near cattle. Federal officials are also considering whether the dough might have been intentionally contaminated. E. coli O157:H7 causes abdominal cramping, vomiting and a diarrheal illness, often with bloody stools. Most healthy adults can recover completely within a week. Young children and the elderly are at highest risk for developing HUS, which can lead to serious kidney damage and even death. E. coli refers to many kinds of bacteria, most of which are harmless or even beneficial. But certain types, including E. coli 0157, produce a toxin that can cause severe illness and even death in humans. The E. coli 0157 bacterium lives in the intestines of cows and other animals -- goats, sheep, deer and elk -- and is found most often in ground beef. But over the past decade, a number of E. coli 0157 illness outbreaks have been associated with green, leafy produce, such as spinach

    For more information on safe food handling practices, go to

    State health officials first noticed cases of E. coli 0157 emerging in March. Initially, they suspected ground beef or strawberries. But after interviewing victims, state officials and the CDC compared notes during a conference call Tuesday and settled on the refrigerated cookie dough as the prime suspect.

    The risk usually associated with cookie dough is salmonella, a bacteria that can be found in raw eggs contained in the dough. Nestlé's cookie dough is packaged with labels warning consumers not to eat it raw. But people tend to disregard the warning -- 39 percent of consumers eat raw cookie dough, according to Consumer Reports. It has become such a popular snack that many ice cream makers have developed a cookie dough flavor.

    * Tune in tomorrow for A Great Idea-- Specialized Health Care Courts

    Deepen your understanding of How to Be an Effective Medical Expert

    Tuesday, June 23, 2009

    America's other drug problem

    The National Council on Patient Information and Education has termed medication nonadherence "America's other drug problem.”

    Approaches to improve adherence can be complex and labor intensive. The problem of medication nonadherence poses an even greater risk among elderly patients in the United States, among whom poor medication adherence is common, morbid, costly, and difficult to treat. And it is among the elderly, that polypharmacy, which is the use of multiple medications resulting in complicated drug regimens, is an important barrier to medication adherence. Of 4053 patients aged 65 years or older prescribed medications for hypertension and hyperlipidemia, the adherence to both classes of medication decreased rapidly to 40.5% at the 3-month interval, and then to 32.7% at 6 months.

    • The adherence rate for medical treatments [ or non-compliance rate] averages in some studies about 50%, with a range that extends from 0% to 100% .
    • A Physicians' estimates of their own patients' adherence have no better than “chance accuracy”.
    • Thus the problem of low adherence can be almost invisible to the individual practitioner dealing with a specific patient. This is true even for patients whom physicians feel they know well.
    • Thus, part of the problem of detecting low adherence is that clinicians often think they know a poor or good complier when they see one, perhaps cueing on such characteristics as age, gender, education, and intelligence—none of which have been shown to have any consistent relationship to adherence.
    • Adherence to chronic pharmacological therapies is poor.
    • This often leads to worsening disease severity and increased costs associated with higher hospital admission rates.
    • Barriers to medication adherence are numerous,and are particularly prevalent among the elderly population, placing them at increased risk for medication nonadherence.
    J. K. Lee et al noted that poor medication adherence diminishes the health benefits of pharmacotherapies, especially in elderly patients with coronary risk factors who frequently require treatment with multiple medications, placing them at increased risk for nonadherence.

    Of a total of 200 elderly patients, a pharmacy care program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP, whereas discontinuation of the program was associated with decreased medication adherence and persistence.

    “Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol A Randomized Controlled Trial” published in JAMA. 2006;296: (doi:10.1001/jama.296.21.joc60162)
    Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147-1152.

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    Monday, June 22, 2009

    Hospitals Should Aim for 'As Soon As Possible' Standard for Door-to-Balloon Time

    Hospitals Should Aim for 'As Soon As Possible' Standard for Door-to-Balloon Time
    Balloon time is measured in minutes from the time the patient arrives at the hospital with a heart attack [myocardial infarction] to the time appropriate coronary artery intervention is performed, usually with balloon dilation of the obstructed coronary artery via primary percutaneous coronary intervention, [PCI].

    Any delay in door-to-balloon time is associated with higher mortality rates in patients undergoing PCI. Therefore hospitals should strive for times well under the recommended 90-minute benchmark, according to a thorough BMJ study. Using a national registry, researchers examined outcomes among nearly 44,000 patients who underwent PCI for ST-segment-elevation myocardial infarction. In particular, they looked at time from hospital arrival to first balloon inflation or device deployment, as well as mortality rates.

    The median door-to-balloon time was 83 minutes. Patients who underwent PCI by 30 minutes had an adjusted mortality rate of 3.0%, while those with door-to-balloon times of 240 minutes had a mortality rate of 10.3%. The recommended 90-minute time yielded a mortality rate of 4.3%.The authors conclude that their data "support calls for an 'as soon as possible' standard for patients undergoing primary percutaneous coronary intervention."

    The authors stated that any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes Clinical guidelines recommend that hospitals providing primary percutaneous coronary intervention to patients with ST segment elevation myocardial infarction should treat patients within 90 minutes of contact with the medical system or admission to hospital.

    What is already known on this topic
    Clinical guidelines recommend that hospitals providing primary percutaneous coronary intervention to patients with ST segment elevation myocardial infarction treat within 90 minutes of contact with the medical system or admission to hospital
    The specific shape of the relation between mortality risk and time to treatment, and the incremental benefit of reductions in door-to-balloon times beyond 90 minutes, is unclear

    What this study adds
    Any delay in door-to-balloon time for patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention is associated with higher mortality, even among patients treated within 90 minutes of admission
    Reducing door-to-balloon time to the greatest extent possible for all patient, including those currently treated within 90 minutes of admission, might reduce mortality

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    Sunday, June 21, 2009


    Two Delaware patients died after taking heparin, a widely used blood thinner made by Baxter International Inc. In addition, a third patient suffered medical problems. Indeed "all three were using heparin," however, "there was no specific evidence tying heparin to the illness.

    At Beebe Medical Center in Lewes, DE, where the deaths occurred, heparin use was suspended. The new complications involve premixed intravenous bags of heparin. Because of its ability to repress clotting and coagulation, the drug can cause serious side effects if administered in too high a dose. The company, however, said on 5/15 after testing that results of forensic and analytical tests verified that the heparin used at Beebe was of the proper purity and potency, "All tests on samples obtained from the hospital, retained samples from the same lot, and samples produced before and after the lot in question confirmed that the product's formulation was within specifications and met all requirements."

    Medical evaluations of the patients indicated that "the intracranial bleeding was related to underlying medical conditions and risk factors that increase the relative risks involved in using a particular drug," the statement said. "The unfortunate patient events that occurred at Beebe Medical Center were isolated, institution-specific issues. The FDA spokeswoman said agency investigators inspected Baxter's facilities and tested heparin products there as well as samples collected at Beebe and said the findings thus far confirmed Baxter's account.

    This incident sparked concerns about a repeat of fatal heparin contamination in 2008.

    The manufacturer of the heparin involved in the Beebe cases, Baxter Healthcare Corp., recalled batches of the drug in 2008 after the Food and Drug Administration found it was contaminated with a chemical that caused serious allergic reactions and low blood pressure in patients who received high doses. Imports from a Chinese manufacturer of an ingredient in heparin have been banned in connection with that contamination.

    In the 2008 heparin deaths, however, the bulk material came from China.

    In those incidents, FDA officials and Baxter believed a substance known as oversulfated chondroitin sulfate was intentionally put into the product from suppliers in China.
    No Chinese suppliers are involved in the latest incidents.

    What to do to help curtail Heparin problems: Multiple Dose Heparin Vials Risky for Patients
    According to The Institute for Safe Medication Practices (ISMP), a non-profit organization devoted to medication error prevention and safe medication,, multiple dose Heparin vials have potentially confusing labels that can lead to dangerous overdoses.
    The overdoses may cause serious injury to patients and even death. (Heparin is used to prevent blood clots.)
    The problem with the vials is that although they contain 4 mL of Heparin solution, they are labeled “10,000 USP units/1 mL,” with the “10,000″ in extra large print. This labeling may cause a healthcare professional to assume that the entire vial contains 10,000 units and as a result, the professional may administer a dose of Heparin that is four times more than a patient should receive. This problem may not have been the case @ Beebe Hospital since it appears that the heparin came from premixed bags.
    But, in light of this danger, the ISMP is urging hospitals, doctors, nurses, and all other healthcare professionals to carefully read the label on vials of Heparin before administering the drug to patients and is advising hospitals to consider whether they should stock any Heparin vials that contain more than 10,000 units per vial.

    If you are hospitalized and Heparin has been prescribed for you, keep yourself safer by requesting that the drug be administered from a single dose, not a double dose, vial.

    Please remember, as with all our articles we provide information, not medical advice.

    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    Saturday, June 20, 2009


    It’s been reported that, "Hospital rapid response teams, created to prevent cardiac arrest and deaths in critically ill patients, do not seem to work," according to a study published in the Dec. 3,2008 issue of the Journal of the American Medical Association. Normally, rapid response teams are "made up of doctors, nurses and respiratory therapists, whose primary role is to care for patients in the intensive care unit (ICU)." The teams may also "help evaluate patients who are not in the ICU."

    For the study, investigators analyzed "the use of rapid-response teams consisting of intensive-care unit nurses and respiratory therapists at 404-bed St. Luke's Hospital of Kansas City (Mo.), and their association with lower hospitalwide cardiopulmonary arrest and hospital mortality rates,"

    It is also noted that the study revealed a four percent decline in mortality rates "after rapid-response teams were introduced in late 2005," and a 33 percent decline in "mean rates for hospital-wide cardiopulmonary arrest codes." But, "after accounting for other changes occurring in the same time frame, including hospital quality-improvement programs and improved technologies, the adjusted odds ratio of 0.76 failed to reach statistical significance."

    A rapid response team, also known as a medical emergency team, is a multidisciplinary team of intensive care unit (ICU) personnel charged with the evaluation, triage, and treatment of non-ICU patients with signs of clinical deterioration to reduce the rates of in-hospital cardiopulmonary arrests (codes) and their attendant morbidity and mortality. Several studies have shown that rates of non-ICU codes decrease after rapid response team implementation,7-11 but these studies, which have focused on cardiopulmonary arrests outside of the ICU, may lead to a favorable bias for rapid response teams because cardiac arrests that occurred after transferring patients with physiological decline to the ICU were not included.

    In-hospital cardiac arrests are common and delays in treatment are associated with lower survival and worse neurological outcomes. Prior studies have reported that adult patients often exhibit physiological deterioration hours before cardiopulmonary arrest. As a result, the Institute for Healthcare Improvement recommended in their 100 000 Lives Campaign that hospitals implement rapid response teams as 1 of 6 strategies to reduce preventable in-hospital deaths. In response, hundreds of hospitals around the country have invested significant financial and personnel resources in implementing rapid response teams, despite the fact that limited published data support their

    The authors found no differences in length of hospital stay (ie, median exposure time to codes) was seen across the study years. We found that implementation of a rapid response team was not associated with lower hospital-wide code rates. Similarly, rapid response team intervention was not associated with improvements in the clinically meaningful outcome of hospital-wide mortality. Importantly, only a small percentage of deaths after rapid response team intervention and cardiopulmonary arrests were categorized as potential rapid response team undertreatment or underuse and would not have plausibly altered these findings. We believe that this study provides important new insights regarding the effectiveness and limitations of rapid response team intervention and raises critical questions about whether recommendations to disseminate rapid response teams nationally are warranted without a demonstrable mortality benefit.

    Implementation of a rapid response team in the author’s tertiary care adult hospital was not associated with lower rates of either hospital-wide cardiopulmonary arrests or mortality.

    Because of the lack of robust outcomes after the rapid response team intervention, well-designed multicenter adequately powered randomized controlled trials with sufficiently long follow-up should be considered to rigorously evaluate the efficacy of rapid response teams prior to endorsing their widespread implementation.

    Paul S. Chan et al. Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team. JAMA. 2008;300(21):2506-2513.

    Friday, June 19, 2009


    It is estimated that over 11,000 women will be diagnosed with cervical cancer and nearly 4000 women will die of cancer of the cervix this year. A high percentage of women will develop abnormal cervical pathology-a precursor to cervical cancer. Guidelines recommend Pap screening at least every 3 years for all women and annual screening for women greater than 30 years of age.

    According to a study published in Clinical Gastroenterology and Hepatology, women with IBD like ulcerative colitis and Crohns disease have a high incidence of abnormal cervical cytology. However they are tested for cervical abnormalities at suboptimal rates.

    Using the PharMetrics Patient-Centric Database (1996 to 2005), doctors identified cases of IBD and matched controls via a validated algorithm. With logistic regression, they compared utilization of cervical testing with IBD case status, patients' age, use of immunosuppressive medications, Medicaid insurance status and use of primary care services.

    Although Cervical malignancy is largely preventable through proper screening half of all women –especially those with IBD who receive the diagnosis of cervical cancer have never been screened. This has to be changed through proper education. Quality improvement initiatives are needed to improve disease prevention services for women with IBD.

    Clinical Gastroenterology and Hepatology; 2009: 7(5): 549-553

    Thursday, June 18, 2009


    Reporting of Mistakes by Hospitals Is Faulted

    A.Hatocollis reports that at least in one city--New York City-- hospitals are the least reliable in the state at reporting preventable mistakes and adverse incidents for patients like heart attacks, blood clots, hospital infections and medication errors, according to a new report by the office of City Comptroller.

    The comptroller also expressed concern that the New York City data on medication errors appear to run counter to the national trend, citing estimates by the Institute of Medicine of the National Academies that at least 400,000 hospital patients are harmed and 7,000 killed by medication errors annually. In contrast, the report said, from 2004 through 2007, city hospitals rarely reported medication errors: 37 that resulted in death, near death or permanent harm to patients, with 22 hospitals, including four very large ones, reporting none.

    The lack of accurate reporting makes it virtually impossible for consumers to judge accurately the quality of a hospital or for the hospital to compare itself with its peers and make improvements, the comptroller’s office argues, saying the consequences include longer hospital stays and higher health-care costs. “Without the fullest possible reporting, hospitals cannot identify areas where systematic improvement may be needed,” reads the report. “Weak enforcement and flagging commitment to a broad-based effort has compromised the whole program.”

    NewYork-Presbyterian/Weill Cornell Medical Center one of New York City’s major academic medical centers, reported only about 20 adverse incidents per 10,000 patient discharges, while a comparable institution outside the city, which was not named, reported about 166 incidents per 10,000, a rate more than eight times higher.

    Within New York City’s 60-plus hospitals, there was great range: 17 reported no heart attacks unrelated to a cardiac procedure while one had more than 40; six hospitals reported 2 blood clots or acute pulmonary embolisms per 10,000 patient discharges while two others had more than 60 per 10,000; one major academic medical center reported 3.6 post-operative infections per 10,000 discharges and a similar hospital had 32 per 10,000. None of these hospitals were named in the report.

    The report, which looks at data from 2004 through 2006, with some additional data from 2007, echoes a state Health Department study in 2001 that similarly concluded that New York City underreported adverse incidents, with 6 of the 11 city-run public hospitals among the 25 lowest reporters. The new analysis faulted the state for not being more aggressive in enforcing penalties such as fines against hospitals with lax reporting, and cited “enormous and inexplicable disparities among individual hospitals.”

    A hospital’s size and the type of procedures it performs do not seem to explain the differences in reporting rates.

    The report does not name individual hospitals, but the comptroller’s office separately released a list of the 12 lowest reporters in the city based on 2006 data. The top three — St. Vincent’s Midtown and Cabrini Medical Center in Manhattan, and Mary Immaculate in Jamaica, Queens — have all since closed.

    The others include some of New York’s biggest and most prestigious hospitals: Lenox Hill, on the Upper East Side (No. 7); Bellevue, the flagship hospital of the city’s Health and Hospitals Corporation (10); Weill-Cornell (11); and Mount Sinai (12).

    It’s not difficult to believe that NYC is not an isolated city. I believe that hospital statistics reported from other cities will have to also be investigated—with severe sanctions applied to violaters.

    Wednesday, June 17, 2009



    Guy Clifton, a neurosurgery professor at the University of Texas Health Science Center in Houston, argues in his book Flatlined: Resuscitating American Medicine that there are two ways to control healthcare costs: price controls with rationing (used by most industrialized nations and abhorred in the U.S.) or increased efficiency. Clifton points out that the cost of healthcare is so high that it is affordable only if someone else is paying for it, such as government or employers. The "haves" consume the healthcare of the "have nots," to the detriment of both. An estimated 30,000 patients die each year from overtreatment. He estimates that 50 percent of healthcare is a waste, if you factor in excessive medical care and patient health behavior.

    In The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will), cardiologist Michael Ozner claims that the annual 1.5 million U.S. angioplasties and coronary bypass surgeries, for which the price tag is $60 billion, neither save lives nor prevent heart attacks. He cites Harvard research that 70 to 90 percent of those procedures are unnecessary.

    The U.S. is the only industrialized nation not to guarantee healthcare to its citizens. We spend more than twice as much per capita as any other country, yet if longevity is the criteria comparatively we do not live longer lives. Medical professor Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America, says healthcare interventions rarely, if ever, improve longevity. He defines two types of medical malpractice. Type I malpractice: Doing something medically necessary unacceptably poorly. Type II malpractice: Doing something unnecessary very well.

    Journalist Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, gives partial credit of overtreatment to Americans’ blind faith in technology and science. About 34 percent agreed with the statement in a Harvard survey that modern medicine can cure almost any illness with the right technology. However, Brownlee points out that 25 to 40 percent of autopsies show that patients were being treated for the wrong diagnosis, which is virtually unchanged from 1910.

    Physician Dennis Gottfried, who wrote Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care, wants to ban direct-to-consumer advertising for medications and aggressive promotion of pharmaceuticals to physicians because both result in prescription of more expensive, less effective drugs. About 31 percent of patients who see these advertisements ask about the drug, and a significant portion of them want it even though they are clueless to its effects. Unfortunately, he says,a significant percentage of doctors comply because they do not want to lose a fully insured patient.

    Tuesday, June 16, 2009

    June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections

    June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections.:

    This is Sybil Tonkonogy with a little laryngitis this morning. I do not know where it came from and wish it would go back to wherever it came from, but anyway, we are going to continue and you, I hope that you remember that I had a very pleasant voice, but here this morning, very, very laryngitisy. So, maybe it will just go away. I would like to present our guest this morning who is Dr. Perry Hookman, who is an Associate Professor of Medicine at the University of Miami - Miller School of Medicine. What we are going to be talking about this morning is a thing called C. difficile and if I said it wrong, Dr. Hookman, please correct me. Hello?

    Dr. Perry Hookman: You got it right. You got it right. It is called C. difficile infection.

    Sybil Tonkonogy: Difficile.

    Dr. Perry Hookman: Or C. difficile, it does not matter.

    Sybil Tonkonogy: Difficile, we will call it. Tell us what it is.

    Dr. Perry Hookman: Well, C. difficile infection is a very vicious type of infection, which attacks people when they are most vulnerable and that is in the hospital. It is a hospital-acquired infection and it is starting to make a tremendous impact. We know that there is a total of over a 12-year period, there has been a total of two million hospital discharges, which has doubled from a similar period in 2001 to 2005. Before that, the rate was 301,000 and we know now that there is 100% increase in the past four years of this infection. This infection gives patients with a very vicious type of diarrhea in which in many if it is hit by a virulent drug means that their colon has to come out. Basically, it is called C. difficile diarrhea and it is the technical name for pseudomembranous colitis.

    Sybil Tonkonogy: Now, perhaps we can talk about it. This is particularly from antibiotics.

    Dr. Perry Hookman: Well, that is right. What happens is that the bugs are evolving over a period of time as antibiotics evolve. So, every time we use a stronger antibiotic or different antibiotic and use it on a mass basis, the drugs go through an evolutionary process in which the Darwinian selection takes place and the fetus of the bacteria, or the strongest of the bacteria, able to survive in that environment of the new antibiotic takes hold. The more sensitive ones to the antibiotic die off, but those bacteria that develop through their genes, a different type of gene, which makes it more resistant to that antibiotic take over. This most vicious virulent type of C. difficile we are seeing now is called NAP1, B1, 027, which is the full name for it, talking about the way we type it in the gel-field electrophoresis and endonucleus analysis and a polymerase chain reaction, 027. So, technically, all technical terms aside, we will call this a NAP1 virulent epidemic type of C. difficile, which has evolved on the basis of an antibiotic resistance to the fluoroquinolones like Cipro and other type of antibiotics, which because they are being used more frequently and some would say for unnecessary reasons are making these bacteria much stronger.

    Sybil Tonkonogy: Now, are we as doctors, and I am not one, but eye doctors and nurses and medical people in hospitals, using more antibiotics, and let us say they did, in the 1900s?

    Dr. Perry Hookman: They certainly are using more antibiotics and up until a short time ago, before committees are formed in the hospitals, they realized that these massive use of antibiotics, some of which may be unnecessary, have to be curtailed and controlled. There are many hospital committees now, which watch what the doctors are prescribing and are trying to prevent the most egregious of these practices from taking place.

    Sybil Tonkonogy: As you said before, there are definitely special kinds of antibiotics that have caused this.

    Dr. Perry Hookman: Yeah. Actually, all antibiotics will cause the evolution of the more fit bacteria. So, for example, if you use penicillin a lot, we now know that you can get penicillin-resistant bacteria. When we use methicillin a lot, we now know that we can get methicillin-resistant bacteria. Those are called MRSA infections. These MRSA infections are merciless in that there are very few ways to handle them and some of them we may call them flesh-eating bacteria because when they get involved into the human skin and flesh, they can actually cause a tremendous amount of necrosis. So, it is not just one antibiotic, but all antibiotics when used extensively will cause the bacteria to evolve into a more fitter bacteria, which can actually surmount the antibiotic defenses, which we can mount. So, it is a race between the bacteria, which are becoming stronger and more virulent and the bacteria which we try to keep making stronger and stronger so that it could kill the bacteria that are already becoming selected to survive through the bacterial crises that they face.

    Sybil Tonkonogy: Now, how about if you are not in a hospital and you are taking an antibiotic? Could this happen in a home?

    Dr. Perry Hookman: Yes. Actually, now we are beginning to see these bacterial resistant organisms, which used to be seen mostly in hospitals and not only hospitals, but long-term care centers have these problems. For example, there are certain populations that increase risk for C. difficile. The patients who are taking, of course, drugs, antibiotics, even patients who are taking proton pump inhibitors, you know, these are pills, which will cut down acid in people with heartburn who take the strong PPIs like the purple pill Nexium or the other type of heartburn pills, they also are susceptible to getting these infections. Patients who have IBD, which include Crohn's disease and ulcerative colitis have a tendency to get these infections even outside the hospitals as do patients who have serious underlying illnesses or what we call co-morbidities, that is, being sick with more than one disease. We are seeing patients who have had even outpatient surgery get more tendencies to have this disease. Elderly patients have increased tendency for this disease. We are seeing these in immune-compromised conditions, people in whom their immune system are compromised either by disease or by medications they are taking like cortisone. We are even seeing these in the peripartum patient, the people who are pregnant both during the pregnancy and after the pregnancy, but chiefly, we are seeing this healthcare settings, in patients who have prolonged stays in these hospitals and in the long-term care facilities, but in answer to your question are people outside the hospitals getting it, the answer is a definite yes.

    Sybil Tonkonogy: Now, you mentioned something like Nexium and, of course, I immediately jumped on that one because I have been taking it for years. I have been taking Nexium so that I am not having heartburn and is the longer I take it, does that have anything to do with it?

    Dr. Perry Hookman: Well, we do not know that. We do know that among all people taking Nexium or other such drugs, PPIs, or proton pump inhibitors, which cut down acid in the stomach, we know that an increased percentage of these people are more susceptible to this disease. Now, there are a lot of speculations as to why. People will speculate that the acid in the stomach is a natural barrier to bacteria and C. difficile and if you take a drug to decrease the acid, you are decreasing the natural barrier to the bacteria and, therefore, are more susceptible. We do not know exactly why yet, but we do know that people taking PPIs are increasingly susceptible.

    Sybil Tonkonogy: Even advise people not to take that particular type of medication?

    Dr. Perry Hookman: Well, no. You cannot advise people not to take a medication that is useful for them, but as with all medications, even aspirin, it is your doctor that has to weigh the risks between the benefits derived from the medicine and the dangers that the medicines cause. So, what I am saying is you should not just buy PPI over-the-counter without a doctor knowing about it and simply buy the drug either in Costco or it is now over-the-counter in many places and in drugstores. You do not buy it for yourself as with any medication until you talk with the doctor and let him help you weigh the risks or, what we say in medicine, do a risk-benefit analysis. Each patient is different and some patients, you have to take it and have to suffer the risk of increasing susceptibility.

    Sybil Tonkonogy: Okay. We are going to take a message break at this point to listen to our sponsor. We will be right back with Dr. Hookman in just one moment, so do not go away because we are going to continue our discussion.


    Sybil Tonkonogy: Welcome back to 1550 Today. This is Sybil Tonkonogy and on the line with us is Dr. Perry Hookman who have had over 30 years experience of internal medicine and gastroenterology, is a Voluntary Associate Professor of Medicine at the University of Miami - Miller School of Medicine, and on the teaching staff of Mount Sinai Hospital in Miami, Florida, and we are talking about a disease called C. difficile and we are talking about how it has developed more and more over the several past years. Dr. Hookman, perhaps you could tell me, is more C. difficile happening because we are using more medications?

    Dr. Perry Hookman: Well, in a way, yes. We are using antibiotics on a greater scale than we ever have and because of this, there is an evolution of so-called resistant bugs, we just call them bugs. The bugs become resistant to the antibiotics, not because they look up a book and find out what they can do to become resistant to the antibiotic and develop a technology, but because of evolution. What happens is that the antibiotic designed to kill the bugs do kill the bugs, but some bugs develop a genetic mutation and the ones with the genetic mutation that provides the bug with survival skills in the face of that antibiotic begins to survive more than the bugs that are being killed, which are sensitive to the antibiotic and after a while, the resistant bugs are the ones that populate the human intestinal track. So, for example, if you have a C. difficile sensitive to a common antibiotic, the common antibiotic will kill it, but if you have a resistant bug and you get resistant bugs simply by touching the walls or touching a bed or touching the toilet of a previous patient who has been a carrier of C. difficile, then you have problems. So, the bugs evolve and become much more resistant to the very drugs that we try to kill them with.

    Sybil Tonkonogy: Now, doesn't the hospitals when a person has this particular disease, don't they clean it up and sterilize everything that they touched in the hospital?

    Dr. Perry Hookman: Yes, they do try and as we are learning more and more about these bugs, if you remember, if you have looked at the review article we wrote for the World Journal of Gastroenterology, which by the way anybody can download on the Internet, just go to the World Journal of Gastroenterology, and this is the April 7, 2009 article, it will tell you most everything you want to know about C. difficile and the way you get and the way it is treated. But yes, the hospitals do know, but it is a very difficult, very difficult organism to eliminate. For example, C. difficile can remain dormant in a hospital room for many weeks and it does so by becoming a spore. A spore is an organism that circles itself in a protective round body and the spore formation of these C. difficiles will go on skin and on doctors' ties and on doctors' shoes and on patients' clothes and anybody who touches these patients, of course, can spread the disease and we are learning that it is very difficult, not even alcohol wipes will take care and eliminate these spores of C. difficile. The important point to remember is that only mechanically getting them off your hands like washing your hands thoroughly with soap and water multiple times will do this, will get of these spores. Only by cleaning the walls and the bathrooms of these patients and any patient, of course, may have it in their room, especially those with diarrhea, previously been there with diarrhea, the wall should be cleaned with a Clorox-type bleach, which is the only thing we find now that can do this. I, for one, advise patients who go into a hospital as a patient to actually initiate the conversation with the nurse to find out whether the walls and the bathrooms have been cleaned by housekeeping with Clorox bleach. That is really the only way that you can be sure that there are no more C. difficile spores lying around the room.

    Sybil Tonkonogy: Is it accumulation of let us say how long you take these medications?

    Dr. Perry Hookman: Actually, one day or one week or one month of taking the medication has shown the same result. You can see C. difficile infections coming even after one day of taking antibiotics. Everybody is different. Everybody has a different sensitivity. What the antibiotics appear to do is to kill off the good bacteria in the colon, and everybody has very good bacteria, and the bad bacteria take over. When that happens, that is when the C. difficile infection occurs. The C. difficile infection produces huge amounts of toxin and the toxin is what changes the pattern in the disease to make the patient have a lot more diarrhea and a lot more intestinal necrosis. Just to give you an example, before 2002, the average C. difficile bug produced just very low amounts of toxins. We call them toxin A and B and also now, there is another one, a third one, but since then the bug has evolved so the ones especially that are resistant to fluoroquinolones have developed higher degrees of producing the toxins and caused much more damage than they used to.

    Sybil Tonkonogy: Is there any way of telling what patient is going to have a reaction? I mean is there any way of telling before the patient takes the medication that maybe that type of [unintelligible]?

    Dr. Perry Hookman: Yes. The risk factors are the ones that I mentioned, the patients with those special risk factors. The risk factors for relapses occur in those who have prolonged antibiotic usage and those with prolonged hospitalization and those over age 65 and those who have diverticulosis and in those who have co-morbid medical conditions, that is, a lot of other medical conditions than just one, for example, diabetes and coronary disease and hypertension and various other type of diseases. Now, it is very important that doctors understand that severe C. difficile disease occurs in certain patients with certain characteristics, so you would want to measure and protect these patients with tremendous care and those are older patients, greater than 65 years old; again, the presence of co-morbid conditions; immune-compromising conditions; an organ failure of any type, kidney, lung, or shock; people who have increased white blood counts; renal failure; those that have low serum albumin, that is a certain protein; and various complications of the disease like ileus and toxic megacolon. In patients that develop those kinds of severe disease, the standard of care now is to not wait too long for surgery. Surgery and colectomy is probably the only way to go now rather than to wait around trying to find out if the medications we have will work.

    Sybil Tonkonogy: If people who take medications like antibiotics, etc., who are not hospitalized, is there any difference in how they can catch it or is there any lesser frequency of it?

    Dr. Perry Hookman: Well, the only difference between being hospitalized now and not being hospitalized is the extent of the disease in terms of populations. In other words, more people will get the disease in the hospitals, or as before 2001, these diseases were very rare outside the hospital, now they are becoming more common. So, you can get this disease both inside the hospital and outside the hospital.

    Sybil Tonkonogy: Is there a great deal of study being done on what can be done eventually?

    Dr. Perry Hookman: In what way?

    Sybil Tonkonogy: How we can somehow lower the levels of C. difficile?

    Dr. Perry Hookman: I think the main way to do this is to cut down on the amount of antibiotics being given. That is crucial, especially cut down on the amount of antibiotics being used in hospitals and now every good hospital has a committee in which all the antibiotics that is being given are being studied and trying to eliminate unnecessary administration of antibiotics and at least the unnecessary administration of the fluoroquinolones, which are the antibiotics that have shown to cause increasing resistance of C. difficile infections.

    Sybil Tonkonogy: Well, Dr. Hookman, I want to thank you so very much for joining us. I think this has been most interesting and I think at least these people are aware of it. They can take some of the suggestions that you have given them and really think about them and hopefully wash their hands and that seems to be the cure for many, many things and I really believe it. So, I thank you so very much for joining us and it is very important for us to bring this type of information to people.

    Dr. Perry Hookman: You are welcome.

    Sybil Tonkonogy: Thank you and everybody else, you have a nice day. Be good to yourself. Be good to each other. Drive carefully and I will talk to you next time. Bye-bye.

    Monday, June 15, 2009

    PART II OF II. The Key to Reducing Medical Malpractice in the U.S.

    Stopping Repeat Offenders: Five Percent Of The Doctors In The United States Are Responsible For Half The Malpractice Claims.

    In reality, states a report in Public Citizen only a small percentage of doctors are responsible for the bulk of malpractice in the United States. Public Citizen’s analysis of the National Practitioner Data Bank, which covers malpractice judgments and settlements since September 1990, found that about five percent of the doctors in the United States are responsible for half the malpractice.

    Specifically, 4.8 percent of doctors (40,118) have paid two or more malpractice awards to patients. These doctors are responsible for 51 percent of all the reports made to the Data Bank, and have paid out nearly $21 billion in damages, more than 53 percent of the total damages paid. In addition, 14,293 doctors, representing 1.7 percent of the doctors in the U.S., have made three or more payments, totaling $11 billion. These doctors are thus responsible for 27.5 percent of all malpractice awards.

    This distribution very much resembles the pattern of drunk driving recidivism says Public Citizen. There are over 6,000 doctors in the U.S. who have paid four or more malpractice claims, amounting to more than $6 billion.

    Number of Medical Malpractice Payments and Amounts Paid by Doctors

    Number of Payment Reports Number of Doctors Percent/Total Doctors in US Total Number of Payments Total Amount of Payments Percent of Total Number of


    All 147,378 17.6% 219,272 $38,993,664,850 100%
    1 107,260 12.8% 107,260 $18,131,973,750 48.9%
    2 or more 40,118 4.8% 112,012 $20,861,691,100 51.1%
    3 or more 14,293 1.7% 60,362 $11,084,300,850 27.5%
    4 or more 6,193 0.7% 36,063 $6,481,629,350 16.5%
    5 or more 3,071 0.4% 23,576 $4,073,749,100 10.8%

    Redacted records from the National Practitioner Data Bank demonstrate the following examples.

    • Physician Number 94358, licensed in New Jersey, settled or lost 33 medical malpractice suits involving improper diagnosis or treatment between 1988 and 1993, inflicting over $400,000 in disability costs to his patients.

    • Physician Number 64625, licensed in Pennsylvania, paid 24 medical malpractice claims involving improper performance of surgery between 1989 and 2001. Damages to this doctor’s patients exceeded $370,000.

    • Physician Number 125457, while licensed in Nevada, paid 5 malpractice claims involving improper performance of surgery between 1995 and 1997, with damages totalling $2.3 million. Recent news accounts have reported that doctors are fleeing from Las Vegas to other states to avoid high malpractice insurance premiums. Physician 125457 was ahead of the curve in moving his practice to California. There he paid another 8 malpractice claims with damages exceeding $7.5 million.

    • Physician Number 37949, licensed in Texas, settled or lost 13 medical malpractice suits involving improper treatment or improper performance of surgery between 1990 and 1997. Two of the suits involved the same allegation—a foreign body left in the patient during surgery. Damages to this doctor’s patients exceeded $2 million.
    How about these stories?

    • Surgeon Hits Double Digits in Medical Malpractice Complaints is a headline in an Illinois paper-A surgeon had a 15th medical malpractice complaint filed against him after international exposure for allegedly leaving a Russian teen brain dead. This last complaint was filed in civil court and the attorney was mum to details. Among the complaints, the surgeon is a defendant in a litigation involving “wrongful death.”

    • A negligent surgeon barred in another state linked to deaths in a VA hospital. A patient hemorrhaged after routine surgery at a VA Hospital The surgeon, was barred from practicing in another state because he had previously been accused of causing life-threatening complications and deaths by providing "grossly substandard care" and making repeated errors in a series of inpatient surgeries shortly associated with post-surgical deaths. The hospital was responsible for a mortality rate over four times the normal amount. The barred surgeon was involved in all of them. The same surgeon had been linked to deaths all over the country.

    • A Pennsylvania doctor with 27 malpractice suits no longer has operating privileges in any hospital which fortunately has prevented him from performing further surgeries. He said in December 2008 that he would be on “medical administrative leave" for "several months" but would return to his practice.” Yet despite his record of 27 malpractice lawsuits and settlements, the Pennsylvania Board of Medicine renewed this doctor’s license to practice in December 2008 which is valid through the end of 2010.


    Good Ideas:
    1. Institute experience rating.
    Doctors should be rated on performance for malpractice premiums. Doctors with numerous malpractice claims must be reviewed and higher premiums imposed so that they are discouraged from practicing and competent doctors do not subsidize them.
    2. Empower Patients with More Information
    Public Citizen has long sought greater consumer access to information about doctors, and there have been recent improvements in making that information available. Most state medical boards now provide some physician information on the Internet, but the information about disciplinary actions varies greatly, is often inadequate and can be difficult for people to access. To read Public Citizen’s survey of state medical board Web sites, go to:
    3. Legislate More Information Out to the Public

    One state bill that would allow residents to have full access to a physician’s history was approved. The bill was named after a patient who died at age 25 due to when he underwent unnecessary brain surgery after a misdiagnosis of a brain cyst. His neurosurgeon had many previous medical malpractice lawsuits in multiple states. The bill requires the state Board of Medical Examiners to collect information on physicians’ history of disciplinary action, malpractice and license probation, their criminal records, limits on their hospital privileges and their ownership and employment affiliation. This information would then be made public.

    Bad Idea
    4. Open the National Practitioner Data Bank. Information about doctor discipline, including state sanctions, hospital disciplinary actions and medical malpractice awards is now contained in the National Practitioner Data Bank. HMOs, hospitals and medical boards can look at the National Practitioner Data Bank. The names of physicians in the database are kept secret from the public. Public citizen wants Congress should allow people to get the information they need from this source on the Internet.

    This is a bad idea because it will lead to vital information going underground and out of reach of any agencies. It will also weaken those agencies now delegated to deal with these problems in an orderly manner and with due process instead of with a populist witch hunt.

    It will make matters worse, because it will force underground what should be reported to the National Data bank-although some critics say it can’t get much worse than this.

    A May 27, 2009 Report suggests hospitals not reporting discipline against physicians.

    More than a third of Michigan hospitals have never reported a single doctor disciplinary action against a physician in 17 years of a national database, according to the report by a Washington, D.C., health watchdog organization and "nearly half of all hospitals" in the US "failed to report actions against doctors to the National Practitioner Data Bank between Sept. 1, 1990, when the database began, through December 2007." Although "federal law requires hospitals to report physicians who have had their admitting privileges revoked or restricted for more than 30 days," the group "charged that hospitals use loopholes in the law, avoiding filing requirements by putting doctors on leave, or disciplining them for less than 30 days." Public Citizen "sent a letter and recommendations on the issue to HHS secretary including a proposal to "tie a hospital's Medicare reimbursement with its participation in the data bank."

    Even doctors with more than two disciplinary actions weren’t reported to the database.

    In all, U.S. hospitals filed 11,221 reports to the data bank in its first 17 years, significantly less than the 10,000 a year expected by industry leaders and 5,000 a year the government estimated before beginning the system.It is run by the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services
    The report and recommendations are at

    Sloan et al, "Medical Malpractice Experience of Physicians: Predictable or Haphazard?" 262 JAMA 3291 (1989) undisciplined.aspx?googleid=261504
    Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
    For author information visit; for book purchase visit

    Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
    (Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit; for book purchase visit

    Sunday, June 14, 2009

    PART I OF II. What is Medical malpractice?

    Medical malpractice claims and lawsuits can arise when people are injured by acts of a doctor, nurse, psychiatrist, dentist, chiropractor, podiatrist, hospital, or other healthcare provider which was a “deviation of the standard of medical care.” In legal theory when one’s actions cause an injury to another person (but the actions do not rise to the level of a crime), they are said to be a "tort," or civil wrong, which can provide the basis for a lawsuit. When someone is determined to be legally responsible for injuring someone else, they are liable for the injury, and may be made to pay the injured person compensatory damages.

    Terms definition:
    Compensatory damages attempt to put an injured person back in the position he or she was in before being injured. In some cases, punitive damages are also awarded in these lawsuits.

    Punitive damages are intended to punish wrongdoers and prevent them from harming others.

    Specifically medical negligence & malpractice can include
    • Missed diagnosis; Mis-diagnosis ; Delayed diagnosis
    • Lack of informed consent
    • Other Doctor, hospital & healthcare provider deviations in the standard of medical care.
    • HMO misconduct
    • Adverse drug reactions and their mis-handling
    • Improperly prescribed, dispensed or filled medication
    The common denominator in all the above is a deviation from the medical standard of care.

    This is usually interpreted to be a deviation from what a prudent physician or other healthcare professional of similar training would do or not do in similar circumstances.
    It is because of that definition that a medical expert of the same training is called upon to testify on his opinion whether or not the standard of medical care had been met or not.

    What is Wrongful Death?
    Wrongful death as a legal term is a death that has been caused by the fault of another person. For example, deaths caused by drunk driving, the manufacture of a defective or dangerous product, the construction of an unsound structure or building, or failing to diagnose a fatal disease may be considered under the law as "wrongful deaths".

    • Wrongful death lawsuits or claims are generally filed by family members or beneficiaries of the decedent. In some instances, these claims are filed in order to obtain monetary damages to cover the earnings the deceased person would have provided.

    Preventable Adverse Events
    The National Quality Forum created a list of adverse malpractice issues.
    This list contains serious medical malpractice events with dire consequences. They should not happen because they are so easily preventable.

    These listed issues are:

    • Switching donor eggs or sperm, resulting in paternity mixups
    • Leaving of sponges or instruments inside a surgery patient.
    • Disappearance of a patient from a facility.
    • Medication errors (wrong drug, wrong patient, wrong dose, etc.)
    • Giving wrong blood type.
    • Electric shock to a patient.
    • Fall of a patient.
    • Surgery performed on the wrong body side or organ or on the wrong patient.
    • Death during or after surgery on a healthy patient under anesthesia.
    • Contaminated drugs or medical devices.
    • Medical device malfunction or improper use.
    • Air embolisms.
    • Babies discharged to wrong parents.
    • Patient suicide.
    • Death or injury to a mother during low-risk pregnancy.
    • patient developing hypoglycemia.
    • Failing to identify high bilirubin in infants leading to death.
    • Advanced pressure sores.
    • Death or injury in spine manipulative therapy.
    • Oxygen or other gas lines being switched or contaminated.
    • Burn of a patient.
    • Injury or death from restraints.
    • Impersonation of a health care worker.
    • Kidnapping of a patient.
    • Assault of a patient or Assault or battery between staffers.

    How successful are plaintiffs in medical malpractice litigation?
    Using North Carolina data, Neil Vidmar, Russell M. Robinson II Professor of Law at Duke University Law School, and author of Medical Malpractice and the American Jury: Confronting the Myths About Jury Incompetence, Deep Pockets and Outrageous Damage Awards (1995), concludes that most claims grow from serious injuries. Minor or emotional injuries accounted for less than 5 percent of claims. Most claims are based on disability, or death. Just 17 out of 895 cases got anything at all. Among the 895 North Carolina cases Vidmar examined, just eighty-four reached the stage of trial by jury. Plaintiffs prevailed on the issue of liability in seventeen of the cases. There were three awards of at least $1 million, along with one for $750,000 and two for $300,000.

    The remainder of the trials, though, resulted in much more modest sums, down to $4,000. "The most striking impression from these verdict statistics is that plaintiffs did not do well with juries," writes Vidmar. "They won less than one case in five. When they did receive an award, the amount was usually low."

    Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
    For author information visit; for book purchase visit

    Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
    (Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit; for book purchase visit

    Saturday, June 13, 2009


    In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidental) without clinical symptoms or suspicion. It is a common problem with the current rate of imaging and is the name given to a lesion found by accident when doing x-rays or other imaging procedures for something else. These lesions or masses are found on the adrenal gland which sits on top of the kidney.

    Up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland, which is detected when diagnostic imaging is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan may have abnormal findings that need further evaluation.

    When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Other tests are required to determine the exact nature of an incidentaloma.

    What are the facts about adrenal masses discovered during imaging for non-adrenal related causes?
    • It is the commonest adrenal 'disorder'
    • Found during 1-5% of abdominal CT scans
    • 5-10% patients have non-functioning adrenal masses found at postmortem examination
    • Male to female ratio is equal
    • Most incidentalomas are benign and hormonally inactive
    • Few patients require adrenalectomy
    • Diagnostic assessment needs to evaluate:
    o Is the lesion hormonally active
    o Is the lesion malignant

    Tom Cawood states that evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant and it’s time for a re-think of the whole matter. Cawood suggests that we-re-assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.

    Cawood performed a literature review of electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.

    • The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%).
    • The development of functionality or malignancy during follow-up was rare (<1% style="font-weight: bold;">Bottom Line:
    This argues for a review of current guidelines.

    Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates.
    The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant.

    Please remember, as with all our articles we provide information, not medical advice.

    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.