Category Archives: Allergy and Immunology

Medical Errors Hurt Doctors, Too

Doctors and nurses make mistakes, some of which hurt patients. To err is human. In fact, that’s the name of a 2000 Institute of Medicine report aiming to decrease errors in health care.

Calcium chloride photo by Markus Brunner (Wikimedia Commons)

The Institute for Safe Medication Practices (ISMP), a non-profit that focuses the bulk of its work on improving patient safety, also recognizes that a patient injured by a medication error isn’t the only one hurting after the mistake. A recent newsletter and press release draw attention to the so-called “second victims” of medication errors — the healthcare workers who are involved in the error.

Healthcare workers may react with feelings of sadness, fear, anger, and shame, and be haunted by the incident. They may lose confidence, become depressed, and even develop PTSD-like symptoms.

A case in point: Kimberly Hiatt, a pediatric critical care nurse with 27 years of experience, made a mathematical error that resulted in an overdose of calcium chloride in a fragile infant. The baby died. Hiatt’s life went into a tailspin. She felt consumed by guilt. She lost her job and, despite obtaining extra training, she was unable to find work. Seven months later, she committed suicide in April 2011.

The ISMP says a culture of silence and lack of support surrounds medication errors in healthcare, and it points healthcare workers to resources to change that culture. For example, you can watch a free webinar about the second victims of medical error, produced by the Texas Medical Institute of Technology. A toolkit for building a support program for clinicians and staff is available from the Medically Induced Trauma Support Services.

If you’re a healthcare worker, what’s it like at your institution when medication errors happen? Does anyone ever hear about them? Are there mechanisms in place to learn from mistakes? Is there any structural support for healthcare workers who make a mistake?

Have you ever had to deal with a medication error or other medical error of your own? How did you cope?

Leave a comment and let us know.

—Sherry Boschert (on Twitter @sherryboschert)

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Dermatology: Just Don’t Get No Respect

Image courtesy of Flickr user Alan Light (CC)

Let’s face it — proctology aside — there’s probably no medical specialty that gets less respect than dermatology. Say the word “dermatology” to the average person on the street and you’ll hear about Botox, peels, fillers and treating some kid’s acne — and how every rash is dermatitis and it just needs some cream — and how most derms finish up their patient schedules in time to get out on the links. Dermatology is, in some ways, the Rodney Dangerfield of medicine.

Forget all that … well, forget a lot of that. There are many hardworking dermatologists out there, dealing with awful-looking skin conditions — some of which don’t even have names, much less effective treatments. Today at the annual meeting of the Society for Pediatric Dermatology, I listened to a series of talks, each detailing how the case dermatologists were able to identify cases of pseudoxanthoma elasticum with systemic involvement, poikiloderma with neutropenia, and limited Wegener’s granulomatosis presenting with pyoderma gangrenosum.

It was fascinating to hear how a dermatologist would notice one small mark or odd skin pattern and make the jump to consider that he or she might not be looking at a single skin condition but one with elements of different conditions. At the same time, they’re trouble-shooting treatment — adding and subtracting drugs to relieve different symptoms and comfort the patient.

I think it’s high time to put this old stereotype to bed. Dermatologists are among some of the hardest-working people in the business.  So, can we give ‘em a little respect; they’ve earned it.

Kerri Wachter

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At 25 Years, NIAMS Celebrates Progress, But Has a Long Way to Go

It’s been 25 years since the establishment of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and great strides have been made in diagnosis, treatment, and management of numerous conditions, “but you ain’t seen nothing yet,” said Dr. Francis Collins, director of the National Institutes of Health.

Opportunities for medical research have never been as great as they are today, said Dr. Collins, who gave the welcome address for NIAMS’ 25th anniversary at the NIH campus in Bethesda, Md.

Although prominent researchers in the field agreed that research has come a long way in the past 25 years, they stressed that there is still a long way to go. Currently, the molecular basis for 4,000 diseases is known, said Dr. Collins. “But we have effective treatment for only 200.”

In broad strokes, the day-long event touched on the past, present, and future of major diseases of bones, joints, muscles, and skin – including muscular dystrophies, osteoporosis, rheumatoid arthritis, and lupus – through panels and discussion involving prominent researchers, physicians, and patient advocates.

“These diseases are chronic, crippling, and common,” said Dr. Stephen Katz, director of NIAMS, in his opening address. “They affect every family in the United States.”

Among the attendees were many researchers and clinicians who said they felt loyalty and appreciation for receiving funding from NIAMS at some point in their career. For some, the progress in the past 2 decades was quite tangible.

“Public investment in osteoporosis research has really changed how we take care of the patients,” said Dr. Sundeep Khosla, president of the American Society for Bone and Mineral Research. Dr. Khosla, professor at the Mayo Medical School, Rochester, Minn., recalled a time more than 2 decades ago when calcium, vitamin D, and estrogen were the only options he could offer to patients with osteoporosis.

A few years later, bisphosphonates became available, then came anabolic drugs, and now more drugs are in the pipeline. Patient diagnosis also has advanced, he said. Although he agreed that the field still has a long way to go, he was optimistic about more progress. “Who knows what will happen in the next 25 years?” he asked.

There was talk of individualized therapy, balancing research and treatment, and a closer collaboration among scientists, all in the spirit of bringing better diagnosis and treatment to patients.

“We’re in a different world from when all we had was aspirin,” said Dr. Daniel Kastner, a scientific director at the National Human Genome Research Institute. “But what we really want is a cure. And we’re not there yet.”

Naseem S. Miller (@ReportingBack)

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Not This Life, Dear — I Have a Headache

A headache specialist's meeting doodle - is this picture worth a thousand words?

A headache is a mighty pain

That changes the defenseless brain,

It may go away.

It may come and stay.

Or rear again, again, and again.

Maybe not great poetry.

But certainly a statement – especially when we assume the author is a headache specialist.

I found this poem on a note pad left in a lecture room between sessions at the annual meeting of the American Headache Society, right after a talk on the genetics of migraine.

After a  lecture on the increased incidence of migraine in young soldiers with posttraumatic stress disorder, I found another note pad. This one depicted a stick-person, helplessly splayed across a tangled spider’s web.

Both, I think, represent the feeling of frustration that bonds headache specialists with their patients.

“We know what can turn it on, but how do we turn it off? That’s the question,” said Dr. Till Sprenger of the University of California, San Francisco. “We still don’t know.”

Headaches unremitting in the face of any treatment strategy are by no means a rarity. Medicines that benefit one may be useless to another. And drugs that can help can also hurt.

Almost anything used for a headache, from acetaminophen to opioids, can backfire if used often enough. Medication-overuse headaches are harder to treat and can start a cycle of using more and more drugs that become less and less effective. Triptans, the mainstay for many migraine patients, are most successful when used at the earliest signs of a headache. But they’re expensive, up to $32/dose, and most insurance companies impose a monthly limit. To save their pills for their worst moments, patients delay the dose, trying to figure out how bad the headache will be. The longer they wait, the less effective the medication.

The physicians at the American Headache Society know this. A number of speakers expressed frustration, not only at their inability to really help some patients but also at the still-rudimentary understanding of headache etiology – the only foundation upon which more effective treatments can grow.

The doctors at this meeting were a sympathetic lot or, perhaps more accurately, an empathetic lot. About half of the physicians I chatted with during breaks and in interviews said their own chronic headaches motivated them to specialize in treating others. They described their job as a mix of satisfaction and exasperation – because they know all too well the blessing of pain relief, the fear of impending pain, and the panic of unremitting pain.

Studies back up my very nonscientific observation of headaches among those who treat them. The most recent appeared in Headache, the American Headache Society’s own journal. It suggested that up to 40% of neurologists who treat headache suffer with their own.  Another 2010 study on migraine management noted that 48% of the  neurologists surveyed were themselves migraineurs.

While there no patients spoke at this meeting, Dr. Dawn Buse became their voice. Despite continuous evolution in headache medicine, her study showed that many continue to suffer.

“Forty percent have at least one unmet need regarding their headaches,” said Dr. Buse of the Montefiore Headache Center, New York.  The top reasons for continued problems? Dissatisfaction with current treatment. Continuing headache-related disability. Overuse of opioids or barbiturates. Other issues that presented in the survey were excessive visits to the emergency department or urgent care center and cardiovascular disorders, which can turn physicians off to the idea of a triptan-based migraine program.

The literature is replete with data confirming what headache physicians confront every day – migraine and other cephalgias worsen almost every quality of life measure.

A 2009 meta-analysis, coauthored by Dr. Buse and Dr. Richard Lipton, past president of the AHS, perfectly captured headache’s often all-consuming impact. Patients with a high headache burden “had higher lifetime rates of depressive disorders, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, specific phobias, and suicide attempts than controls, were more likely to have missed work in the preceding month, to assess their general health as ‘fair’ or ‘poor,’ and to use mental health services.”

The relationship between headache and mental disorders is a complex one, not entirely understood, Dr. Buse told me during an informal chat. She likened it to the famous chicken-or-egg conundrum. “There is some evidence of bidirectionality – that each one predisposes to the other,” she said. “But if you think about it, it makes intuitive sense. If you are afraid of your next headache, you’re likely to be anxious,” which makes a headache more likely and can increase its severity.

The same thing goes for depression, she said. The neurotransmitter dysfunction associated with depression may predispose to headache, but months – or years – of intermittent pain very probably increase the risk of becoming depressed.

It was easy to see the concern in her eyes, and the caring of everyone who spoke at the meeting. Many of them, I suspect, have seen the doodle come to life …  Caught in that spider’s web, knowing that something bad is coming, but having very little power to stop it.

– Michele G. Sullivan

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Rheumatology’s PR Problem

Overheard on the steps of the ExCeL London convention center on the last day of the annual European Congress of Rheumatology:

Attendee 1: “What is rheumatism?”

Attendee 2: “You know. Achy legs and such.”

Attendee 1: “Sounds dull.”

Attendee 2: “They’re probably saying that about us.”

Attendee 1: “Doubt it.”

In the interest of full disclosure, I should explain that not only was it the last day of this year’s EULAR congress, it was also the second day of the MCM Expo London Comic Con, which was taking place at the west end of the same convention center. The above discourse occurred between a giant insect and an anime character.

Photo by Diana Mahoney

It was impossible not to be amused by the unlikely juxtaposition of the two gatherings, particularly because the facility’s main entrance was on the building’s west side,. To get to the EULAR events, thousands of suited and serious rheumatologists had to weave in, out, and around the Comic Con crowd, all of whom were dressed as their favorite comic, manga, anime, film, game, and cult entertainment stars and were engaged in various modes of role play.

Despite the apparent incongruity, however, the above discourse seemed inherently relevant, as it came on the heels of a presentation that elucidated some persistent obstacles to the early diagnosis and optimal treatment of early rheumatologic disease, which I have come to think of as collective symptoms of rheumatology’s PR crisis.

In short, a lot of people don’t know what rheumatology is, and the opinions of those who have some vague sense of it continue to be colored by myths and misconceptions, including the belief that arthritis (or “rheumatism,” as per the arachnid quoted above) is a single entity and that there’s not much that can be done for it.

With respect to rheumatoid arthritis, in particular, this lack of awareness contributes to diagnostic and treatment delays that can have devastating consequences. While much effort has been spent recently on the development of early arthritis clinics within rheumatology centers as a way to streamline patient management, their success is limited. They can address the needs of only those patients who walk through the doors, not those of people who don’t seek treatment when their symptoms develop and persist or whose symptoms are inadequately assessed and managed initially by primary care physicians, according to session panelist Dr. Vivian Bykerk from Brigham and Women’s Hospital in Boston. “We have to remove all of the  roadblocks that are keeping very early inflammatory arthritis patients from getting to the rheumatologist,” she said.

Among the strategies recommended by Dr. Bykerk and co-panelist Dr. Paul Emery, EULAR president and head of musculoskeletal diseases at Chapel Allerton Hospital in the United Kingdom, were the possibility of prescreening referrals, the development of a specialized rheumatology referral form to help primary care physicians identify urgent referrals, the implementation of central triage clinics, and protocols for educating physicians and patients about the signs and symptoms of rheumatologic diseases and the value of early intervention. In other words, rheumatology needs better PR.

—Diana Mahoney

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Giving Nurses More Room in Rheumatology

At this year’s annual European Congress of Rheumatology (EULAR) in London, researchers presented data showing that an oral medication, tofacitinib, was more effective than a placebo for treating rheumatoid arthritis symptoms. The key word here is “oral.”

Read Sharon Worcester’s story for the details and an interview with investigator Dr. Joel Kremer. 

Some buzz around EULAR was that this drug, if it becomes widely used, might put some rheumatology nurses out of work if more patients opt out of infusion treatments.

courtesy of flickr user Shoreline (creative commons)

But never fear, nurses: the EULAR Nursing Task Force, a joint effort by rheumatologists, nurses, an occupational therapist, a psychologist, and epidemiologist, and patient representatives, is recommending ways to expand the role of nurses in arthritis care (no needles involved).

Ms. Yvonne van Eijk-Hustings of Maastricht University Medical Centre in the Netherlands emphasized that nurses can help in many other aspects of rheumatology care. For example, nurses in a rheumatology practice can serve as patient educators, and provide psychosocial support as well as disease management.  With that in mind, the recommendations call for improving access to training for rheum nurses so they can boost their knowledge and skills in these non-clinical areas.

Read my colleague Denise Napoli’s story on the Task Force recommendations.

What’s next for rheum nurses? They shouldn’t put away their needles just yet. More EULAR buzz suggests that the price of tofacitinib may be prohibitive for many patients for the immediate future. And in the meantime, the EULAR Nursing Task Force recommendations will be reviewed and disseminated, Ms. van Eijk-Hustings said.

Related News: Read Doug Brunk’s story on patients’ positive feedback after tofacitinib.

–Heidi Splete (on twitter @hsplete)

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Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor's] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

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Good News on Inhaled Corticosteroids in Children

Two new studies provide some comfort for physicians and parents who worry about the potential side effects in children from using inhaled corticosteroids for wheezing or asthma. 

Dr. Pederson (Photo by Sherry Boschert)

One long-term Danish study (the Scandinavians excel at longitudinal studies) found no bad eye effects, which previous less-rigorous studies had hinted at. Dr. Søren Pederson of the University of Southern Denmark and his associates followed 148 children using daily inhaled budesonide for chronic asthma from childhood into adulthood. They compared eye exam results in these patients 15-20 years after they began therapy to exam results in 53 of their siblings who did not have asthma and didn’t use budesonide. The ophthalmologist who evaluated all exam results did not know which exams came from the asthmatic kids and which came from healthy siblings.

They found that long-term daily budesonide use didn’t cause more cataracts or significantly change intraocular pressure or vision, Dr. Pederson reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology. AstraZeneca, which markets budesonide, funded the study. The investigators said they had no other potential conflicts of interest.

A separate study validated an alternative to daily inhaled corticosteroids in wheezing toddlers. Clinicians and parents worry about this recommended treatment strategy, because previous studies have shown that daily inhaled corticosteroids have a small but statistically significant class effect of reducing growth in preschool-aged children that only partially reverses if the corticosteroids are stopped, Dr. Leonard B. Bacharier said.

Dr. Bacharier (Photo by Sherry Boschert)

The multicenter, randomized, double-blind, placebo-controlled trial compared the recommended regimen for wheezing toddlers – daily low-dose budesonide – with an alternative regimen, intermittent high-dose budesonide. The intermittent budesonide group got daily placebo and received a 7-day course of high-dose budesonide only when they developed a respiratory tract illness.

Both treatment regimens proved effective, but the daily budesonide group was exposed to more than three times the cumulative amount of inhaled corticosteroid over a year’s time, compared with the intermittent group, Dr. Bacharier of Washington University and his associates reported. Read more in the full story.

Studies like these should help those who care for children with asthma breathe a little easier.

–Sherry Boschert (on Twitter @SherryBoschert)

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Doc: When Is It Safe for Me to Fly?

You may get this question from patients with respiratory compromise — from kids with cystic fibrosis to adults who have chronic obstructive pulmonary disease.

(Courtesy Mattes/WikiMedia public domain)

So what should you tell them? It depends. Ask where they are going, how long the flight(s) is, and about any previous air travel experiences.

Increased cabin pressure and susceptibilty to micro-organisms in re-circulated air are the two main clinical concerns, said Dr. Susan Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Michigan.

Ensure your patient passes a walk test. They will likely need this functional capacity to do some limited walking in the airport and to get through security screening (getting through screening is challenging enough, even without any pulmonary issues).

TSA rules for portable oxygen concentrator use are outlined in the agency’s recommendations for travelers with hidden disabilities.

Dr. Susan Millard (photo by D. McNamara)

“Cystic fibrosis patients will ask us to develop a letter, which is especially important if they are going through customs,” Dr. Millard said at a pediatric pulmonology seminar sponsored by the American College of Chest Physicians and the American Academy of Pediatrics in Fort Lauderdale, Fla. Include the patient’s contact information, insurance policy numbers, and physician or clinic telephone numbers. Some airlines require physicians complete a form in advance of the patient’s traveling, so advise your patient to check their airline requirements before ticket purchase, she added.

Waiting at least 6 weeks after lung surgery or major intervention is advised in Eurpoean recommendations on traveling with cystic fibrosis released in December 2010. This consensus statement addresses preparations for travel (e.g., vaccinations, packing medication); important considerations during travel; and issues specific to the immunocompromised. Absolute contraindications for travel also are outlined.

Scientists are looking for ways to reduce every traveler’s exposure to airborne pathogens, Dr. Millard said. For example, one study shows commercially-available biosensors are not sensitive enough to detect airborne biological contaminants, at least not in a meaningful way. You would have to be on a flight with at least seven infected passengers either coughing 20 times per hour or sneezing four times an hour to get the bacteria levels up to detectable levels. And no sensor in the study worked well with airborne viruses.

In the meantime, developing better sensors or screening individual passengers for infectious respiratory illness prior to boarding would be the best approaches, she said.

Also, don’t forget to fasten your seatbelt.

–Damian McNamara (@MedReporter on Twitter)

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Promising Technology Might Help Identify Asthma Earlier

It’s not ready for prime time, but a radiation-free MRI technique could eventually be used to predict which high-risk children will develop asthma, based on data presented by Dr. Daniel Jackson at a press conference at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, in San Francisco.

courtesy of flickr user kquedquest (creative commons)

MRI has been used to assess lung function in adults, but Dr. Daniel Jackson and his colleagues at the University of Wisconsin, Madison, hypothesized that they could obtain similar lung function data from children that could be used to predict asthma risk.

Using a technique developed by study co-author Sean Fain, Ph.D., 43 children aged 9-11 years underwent MRIs after inhaling hyperpolarized helium. The children were selected from the Childhood Origins of Asthma (COAST) project, a long-term observational study of a birth cohort of children at increased risk for asthma.

Using the technique, “we were able to look at the architecture of the lungs,” Dr. Jackson said at the press conference, as areas of the lungs that are not well-ventilated appear black on the MRI. The children’s lungs were assigned defect scores based on the MRI observations.

Children who already had asthma were significantly more likely to have defects than those who didn’t have asthma. But the more interesting finding was that girls were significantly more likely to have higher defect scores compared to boys, whether or not they had asthma.

What does this mean for disease expression? Dr. Jackson said that the next steps call for imaging the children again at age 12-13 years. Although the helium imaging technology is not ready for diagnostic use, it might serve as a biomarker for girls in particular who are at risk for developing persistent asthma after puberty, Dr. Jackson said.

For an excerpt from Dr. Jackson’s comments at the press conference,  click below.

–Heidi Splete (on twitter @hsplete)

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