Monday, March 12, 2007

CDC: Quadrivalent Human Papillomavirus Vaccine

Recommendations of the Advisory Committee on Immunization Practices (ACIP)

"Routine Vaccination of Females Aged 11--12 Years

ACIP recommends routine vaccination of females aged 11--12 years with 3 doses of quadrivalent HPV vaccine. The vaccination series can be started as young as age 9 years.

Catch-Up Vaccination of Females Aged 13--26 Years

Vaccination also is recommended for females aged 13--26 years who have not been previously vaccinated or who have not completed the full series. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact; however, females who might have already been exposed to HPV should be vaccinated. Sexually active females who have not been infected with any of the HPV vaccine types would receive full benefit from vaccination. Vaccination would provide less benefit to females if they have already been infected with one or more of the four vaccine HPV types. However, it is not possible for a clinician to assess the extent to which sexually active persons would benefit from vaccination, and the risk for HPV infection might continue as long as persons are sexually active. Pap testing and screening for HPV DNA or HPV antibody are not needed before vaccination at any age. "


Thursday, March 8, 2007

Why Are C-Section Rates Still Going Up?

csectionrate.gif

As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:

Cesarean Delivery and The Risk-Benefit Calculus

1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior

"At least one study found that physicians' malpractice premiums, the number of claims against physicians and hospitals, and the physician's preception of the risk fo being sued were all positively correlated with the likelihood of cesarean delivery. Many in the field defend the rising cesarean rates by citing concern about legal jeopardy, and indeed lawsuits often allege a failure to perform a timely cesarean delivery."

Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:

MEDICAL MALPRACTICE CASES
Another specialty Edwards developed was in medical malpractice cases involving problems during births of babies. According to the New York Times, after Edwards won a $6.5M verdict for a baby born with cerbral-palsy, he filed at least 20 similar lawsuits against doctors and hospitals in deliveries gone wrong, winning verdicts and settlements of more than $60M.
Case Summary of Facts Case Type Result
Griffin v. Teague, et al.
(Mecklenburg Co. Superior Ct., NC, 1997)		 Application of abdominal pressure and delay in performing c-section caused brain damage to infant and resulted in child having cerebral palsy and spastic quadriplegia. Verdict set record for malpractice award. Medical Malpractice $23.25M
verdict
Campbell v. Pitt County Memorial Hosp.

(Pitt County, NC, 1985)

 Infant born with cerebral palsy after breech birth via vaginal delivery, rather than cesarean. Established North Carolina precedent of physician and hospital liability for failing to determine if patient understood risks of particular procedure. Medical
Malpractice		 $5.75M
settlement
Wiggs v. Glover, et al. Plaintiff alleged infant's severe cerebral palsy was caused by negligent administration of pitocin, failure to use fetal monitor, or timely intervening in baby's fetal distress. Medical
Malpractice		 2.5M
settlement
Cooper v. Craven Regional Med. Ctr., et al. Infant suffered severe brain damage after obstetrician failed to moderate use of Picotin after baby displayed clear fetal distress. Medical
Malpractice		 $2.5M
settlement
Dixon v. Pitt County Memorial Hospital
(Pitt County, NC)		 Birth-related injuries including cerebral palsy and mental retardation allegedly caused by obstetrician's failure to diagnose fetal distress, including umbilical cord wrapped around baby's neck prior to delivery. Medical
Malpractice		 2.4M

settlement

Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...

Details On Why We Get Migraines

"A University of Iowa study may provide an explanation for why some people get migraine headaches while others do not. The researchers found that too much of a small protein called RAMP1 appears to "turn up the volume" of a nerve cell receptor's response to a neuropeptide thought to cause migraines.

"The neuropeptide is called CGRP (calcitonin gene-related peptide) and studies have shown that it plays a key role in migraine headaches. In particular, CGRP levels are elevated in the blood during migraine, and drugs that either reduce the levels of CGRP or block its action significantly reduce the pain of migraine headaches. Also, if CGRP is injected into people who are susceptible to migraines, they get a severe headache or a full migraine.

"We have shown that this RAMP protein is a key regulator for the action of CGRP," said Andrew Russo, Ph.D., UI professor of molecular physiology and biophysics. "Our study suggests that people who get migraines may have higher levels of RAMP1 than people who don't get migraines." "

The abstract is here.



Wednesday, March 7, 2007

Aspirin/NSAIDs For Colorectal Cancer Prevention Discouraged

"People who are at average risk for colorectal cancer, including those with a family history of the disease, should not take aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) to try to prevent the disease, according to a new recommendation from the U.S. Preventive Services Task Force. The recommendation is published in the March 6 issue of the Annals of Internal Medicine."

"USPSTF assessment: Overall, the USPSTF concluded that harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer."

[AHRQ]

AFP: Preparation of the Cardiac Patient for Noncardiac Surgery

Excellent Lee Fleisher article in American Family Physician [free full text] for any primary care physician who is asked to do pre-op medical evaluations (note I didn't use the word 'clearance').



Tuesday, February 27, 2007

JAMA: Prevalence of HPV Infection Among Females in the United States

Prevalence of HPV Infection Among Females in the United States [free full text]

"Our study provides the first national estimate of prevalent HPV infection among females aged 14 to 59 years in the United States. Overall, HPV prevalence was high (26.8%), and prevalence was highest among females aged 20 to 24 years [ed. where it was 44%]. Our data indicate that the burden of prevalent HPV infection among women was higher than previous estimates. However, the prevalence of HPV vaccine types was relatively low."

Remember, prevalence is the proportion of cases that are present at a single point in time.

For a background primer on HPV infection, see the excellent JAMA Patient Page.



Thursday, February 22, 2007

NIDA: Drugs, Brains, and Behavior - The Science of Addiction

The National Institute on Drug Abuse just published a booklet intended to help patients understand drug addiction titled The Science of Addiction.

"As a result of scientific research, we know that addiction is a disease that affects both brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities."


addiction.gif



Wednesday, February 21, 2007

JAMA: Off-Pump vs On-Pump CABG and Cognitive Decline

Five years after surgery, there is no difference in cognitive decline between on-pump and off-pump CABG.

Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery

"Results After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], –12.7% to 12.6%; P>.99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, –1.7%; 95% CI, –13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, –6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life.

Conclusion In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes."
[free full text]


Sunday, February 18, 2007

Keeping Patients Warm Means Generating Heat

Once anesthetized with a general anesthetic, patients are largely defenseless. The anesthesiologist is responsible for protecting the patient from their environment--an environment that can be increasingly hostile. One key facet of that environment is temperature, but control of it has never been more contested in the operating room than it is today.

My perspective may be skewed because I do so much anesthesia for orthopedic surgery--a surgery in which the surgeon is physically working hard under an OR gown, gloves, and hot lights. Certainly in pediatric rooms no one ever complains during times when we make the room hot. That's not true, actually. They complain, but they know full well that we are all there to keep the pediatric patient safe and keeping them warm is part of that. They don't expect us to drop the room temperature until we have the child anesthetized and covered.

But why does room temperature matter? It matters because it can affect patient body temperature, and patient body temperature matters for the following reasons:

  1. Mild hypothermia (1-3 deg. C) reduces resistance to surgical wound infection.
  2. Mild hypothermia prolongs hospital stay.
  3. Even mild hypothermia can cause shivering and be a very uncomfortable feeling after surgery.
  4. Shivering increases stress on the heart. In patients with heart disease this may cause ischemia.

Under anesthesia, our normal mechanisms for keeping warm are limited. Anesthetics significantly impair our ability to control blood flow to the skin. Although there are five mechanisms of heat loss from the body in the operating room, 90 percent occurs through the skin via radiation and convection

For those wanting a detailed review article and that have a NEJM subscription, see: Mild Perioperative Hypothermia by Daniel Sessler, M.D. in the Department of Anesthesia at UCSF.

I'm sure patients would be gratified to know that it's not the person with the most knowledge and training in patient temperature management that decides in most cases, but the person that whines the most (or is the sneakiest).

For example, last year I was scheduled to provide anesthesia for a 16 year old athlete having an ACL reconstruction. This was not the first case in that room, so the room was already as cold as a meat locker--64 degrees. I reset the room thermostat to 72 degrees, and placed a sticky note saying 'Please Do Not Change,' printed my name, and went to go see the patient.

When I came back to the room several minutes later, the note was gone and thermostat reset to 64 degrees. I replaced the note and reset the thermostat two more times. Both times the note was gone and thermostat reset. The final time there was a note from the charge nurse asking me to come see her.

What did I do? I did what any self-respecting anesthesiologist would do--I told the OR nurses the case was on hold until the room temperature came up and went to get some coffee. Not long after that the charge nurse paged me to discuss the issue. (Nothing gets management's attention more than a case delay.)

Why had she reset it? Because, she claimed, biomedical engineering (some guy with a Bachelor's Degree) said that bringing surgical instruments into a 72 degree room would cause them to sweat and possibly impair sterility. I thought back to my years of doing anesthesia for burn surgery in 85 degree operating rooms and found this explanation novel and fascinating. 'So', I asked her, 'you're taking the advice of a four year college graduate over that of a board certified anesthesiologist?'

Well, you can guess how the conversation went after that. These days, if someone in the OR is feeling hot they either turn the thermostat down themselves or ask the circulating nurse to do it. If all this done without asking me when I'm in the room, I point out to them that they should have asked me before making that decision and ask instead that the room temperature be increased several degrees. If they do ask me if they can turn the room temperature down, provided the patient is reasonably warm and covered, I'll oblige and say 'Thank for asking me. The patient appreciates it. You may set the room temperature to whatever you like.'

In days past everyone acknowledged room temperature was the anesthesiologists choice. These days I have to fight to control it, as I do for every other shred of professional respect. What I'm working on is to get a ruling from the OR committee that states room temperature is my bailiwick. With impending pay for performance measures that will include patient temperature on arrival to the recovery room, this issue has been forced to a head.



Friday, January 5, 2007

What Primary Care Physicians Really Do

From a recent JAMA section called A Piece of My Mind is an excerpt that gives a good summary of what primary care physicians spend a lot of time doing. The author describes what she will no longer be doing after moving to a new practice:

"No more primary care. No more forms to fill out for workers comp, disability, SSI, student loan forgiveness, longer-term-care insurance coverage, FMLA, or temporary suspension of billing for credit card or mortgage or rental furniture payments owing to customer illness.

No more forms for nebulizers, commodes, handrails, oxygen, home health nurses, adult diapers, wheelchairs, cock-up splints, lift chairs, physical therapy, or the dreaded power wheelchair/scooter doctoral dissertation.

No more forms to attest that someone can enter a nursing home, play soccer, work out at a gym, be in an assisted living facility, do chair exercise at the senior center, train to become a medical assistant, wrestle, teach school, or that he or she is, above all else, free from communicable diseases. "

The list of non-direct patient care tasks goes on for several more paragraphs, but you get the picture.

[JAMA]



Friday, November 24, 2006

Anesthesia is safer than ever (even in France)

Anesthesiology--Survey of Anesthesia-related Mortality in France.

" Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process."


Sunday, July 30, 2006

Risks of Epidural Analgesia for Labor

Anesthesiology has a nice article which attempt to quantify some of the less common risks of having an epidural during labor: epidural hematoma, infection, and neurologic injury.

Epidural hematoma 1 in 168,000 6 per million
Deep epidural infection 1 in 145,000 7 per million
Persistent neurologic injury 1 in 240,000 4 per million
Transient neurologic injury
[< 1 year]		 1 in 6,700 180 per million

It contains an interesting tidbit others might find interesting, too. There are 4 million births in the United States each year and 2.4 million involve epidural analgesia. Wow. That's three fifth of all live birth get an epidural! (And some call nights, it seems every single one does...)

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