Category Archives: Anesthesia and Analgesia

“Turning the Tide” on HIV/AIDS

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

Everyone is urged to sign the Declaration.

It calls for:

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington.  It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs  in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

Plenaries and other conference sessions will be webcast at http://globalhealth.kff.org/aids2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Adolescent Misuse of Prescription Pain Medicine Starts Early

In stark contrast to most research that suggests senior year in high school or later is the peak time for misuse of prescription pain relievers, it is younger 16-year-olds who are the mostly likely to report their first use of these agents outside their intended prescription within the previous year, a new study finds.

Courtesy Wikimedia Creative Commons/Kandy Talbot

The time for physicians to identify risk and intervene is the young to middle teenage years, Elizabeth A. Meier, Ph.D., and her associates at Michigan State University in East Lansing reported.

“With peak risk at age 16 years and a notable acceleration in risk between ages 13 and 14 years, any strict focus on college students or 12th graders might be an example of too little too late in the clinical practice sector and in public health work,” they wrote in the Archives of Pediatrics & Adolescent Medicine, published online May 7, 2012.

“We suspect that many physicians, other prescribing clinicians, and public health professionals will share our surprise that for youth in the United States, the peak risk of starting extramedical use of prescription pain relievers occurs before the final year of high school [and] not during the post-secondary school years,” the authors wrote.

Another reason to screen your young adolescent patients is the risk of hazardous consequences associated with prescription pain misuse, which is greatest during early adolescence, Dr. Meier and her colleagues noted.

They assessed self-reported extramedical prescription pain reliever use among 119,877 U.S. teens and young adults (ages 12-21 years) using 2004-2008 data from the National Survey on Drug Use and Health (NSDUH).

They calculated the highest risk estimate, 2.8%, at 16 years of age. This is an increase from 0.5% at 12 years; 0.7% at 13 years; 1.6% at 14 years; and 2.2% at 15 years. After the peak in mid-adolescence, risk dropped steadily by 0.3% or 0.4% each year, down to 1.1% among 21-year-olds.

Reliance on self-reported misuse of prescription pain killers is a limitation of the study. A strong point of the research, however, was including adolescents and young adults regardless of whether they were still in school.

Earlier and stronger school-based prevention and outreach programs are warranted, according to the researchers. There also is a distinct role and reason for pediatricians, dentists, and other clinicians to work toward misuse prevention in their practices, they added: roughly 15% of the youths surveyed were not in school during the peak time of risk.

–Damian McNamara

@MedReporter on twitter

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Real World Full of Medical Ethics Challenges

There’s the ideal world, and then there’s the real world. Humans have a wonderful hubris in forever trying to get the twain to meet, and a necessary humility in examining ways that they don’t. That’s as true in medicine as anywhere else.

The Charter on Medical Professionalism, endorsed by the U.S. Accreditation Council on Graduate Medical Education and more than 130 professional groups worldwide, contains three fundamental principles: the primacy of patient welfare; respect for patient autonomy, and promotion of social justice. Who wouldn’t want that? A physician’s professional responsibility as spelled out in the charter entails honesty (including disclosure of medical error), patient confidentiality, maintaining trust by managing conflicts of interest, and much more.

Ben A. Rich, J.D., Ph.D. (SHERRY BOSCHERT/IMNG Medical Media)

Yet, more than 10% of 1,891 practicing U.S. physicians surveyed recently in seven specialities said that they had told adult patients or a minor’s parent or guardian something that was not true, Ben A. Rich, J.D., Ph.D. noted during a session on ethics at the annual meeting of the American Academy of Pain Medicine.

Results of the survey of physicians in internal medicine, family practice, pediatrics, cardiology, general surgery, psychiatry, and anesthesiology also showed that 20% of physicians had not fully disclosed mistakes to patients out of fear of malpractice litigation.

More than 33% said they do not agree that physicians necessarily must disclose all serious medical errors to affected patients, or that it’s important to disclose to patients any financial relationships with drug and device manufacturers (Health Affairs 2012;31:383-391).

More than 25% of the physicians said they had revealed unauthorized information about a patient. More than 50% had described a prognosis to a patient more positively than the clinical facts warranted.

Women were more likely than men to practice consistently within the Charter on Medical Professionalism, as were physicians from racial and ethnic minorities, the survey found.

It’s comforting to note that a majority of physicians seem to adhere to the professional principles, and perhaps we shouldn’t be too hard on those who admit their actions sometimes diverge from the ideals, said Dr. Rich, professor of medicine and director of the Bioethics Program at the University of California, Davis. The “messy facts” of real cases show the challenges that physicians face in trying to help patients while also respecting their autonomy while also being honest, etc.

One example: A published case of a 45-year-old licensed practical nurse whose license had been suspended due to her medical problems. She was being treated for migraine headaches by a psychiatric neurologist and was on gabapentin, topirimate, propranolol for prophylaxis, oxycodone for breakthrough headaches, and IM injections of meperidine and hydroxyzine for breakthrough pain. She signed a contract with her physician saying she would only take narcotic medications that he prescribed and would not seek painkillers from emergency departments (Nursing Journal 2007;29:35-40).

“She violated that contract repeatedly and with impunity and was becoming a `frequent flyer’ in the local E.D.s.,” Dr. Rich said. Her physician persuaded her to get inpatient treatment, but afterward she relapsed and continued E.D.-hopping in pursuit of pain meds. One local E.D. suggested to her physician that he be notified whenever she turned up in an E.D. Her physician suggested instead that the E.D. do what he had resorted to doing — injecting her with saline and telling her it’s meperidine.

Some E.D. physicians gave her medications just to get her out the door. Others refused to give her any narcotics for her pain because of her addiction and violations of her contract. All the healthcare providers in the medical group of one emergency department signed a letter to the patient telling her that if she came there for treatment, she would be evaluated and treated with non-narcotic medications recommended by her treating neurologist but she would no longer be given narcotics.

Which, if any, of these approaches pass ethical scrutiny? What would you do if you were her neurologist or saw her in pain in the emergency department?

The group that sent her a joint letter was “at least trying a collaborative approach and putting her on notice about how she would be treated if she continued to present there,” Dr. Rich said.

The lengthy Ethics Charter of the American Academy of Pain Medicine lists many physician duties, including this “intriguing” one, he noted: Any reports to law enforcement of attempts to acquire pain medications illegally should be based on confirmed firsthand information.

“Some of my colleagues at UC Davis are working on a manuscript right now where we’re finding it’s not as clear as one might hope” when deciding whether you have a duty to report a patient to law enforcement or a duty not to report to law enforcement because reporting the patient may infringe upon patient confidentially, not to mention potentially violating the Health Insurance Portability and Accountability Act (HIPAA), he said.

The messiness of real life doesn’t diminish the importance of standards, it just reinforces the need for ideals to guide us as we muddle our way through the real world.

Dr. Rich has been a consultant to KOL, L.L.C.

–Sherry Boschert (@sherryboschert on Twitter)

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U.S. Military Gets Modern Pain Management

When Col. Chester “Trip” Buckenmaier III, MC, USA, first went to Afghanistan as an anesthesiologist with the U.S. Army, the only pain medicine at his disposal was morphine. If wounded soldiers got morphine but were still in pain, they’d get “more phine,” he said. Those were the options for pain control. No spinal or epidural analgesia.

It’s better than downing a glass of whiskey and biting on a bullet, I suppose, but you’d think that in an age when satellites can pinpoint an enemy from space and unmanned drones conduct precise bombing raids, the military might have better ways of easing the agony of injured human fighters.

Col. Chester "Trip" Buckenmaier III, M.D. (Sherry Boschert/Elsevier Global Medical News)

By 2006-2007, the military was beginning to see a link between increasing rates of soldier and veteran suicides and pain issues. They noticed that symptoms in troops with chronic pain were the same symptoms associated with posttraumatic stress disorder and traumatic brain injury. “How could we really diagnose those very important issues if we didn’t have a good handle on pain?” he said.

The military was ripe for new ideas for acute pain control, and in 2009, Dr. Buckenmaier became part of a task force to create a comprehensive pain-management strategy. “We were using words like ‘holistic” and ‘multidisciplinary’ and ‘multimodal’ and not snickering. That was a big change. Just a few years ago if you used the word ‘holistic’ in military medicine, people would kind of smile at you and then you would sit alone in the lunch room. That’s not the case any more,” he said at the annual meeting of the American Academy of Pain Medicine.

The task force report in 2010 established guidelines for state-of-the-art acute pain medicine services in combat zones prior to air evacuation of casualties to their countries of origin, a document that the U.S. military had never had before, he said. Before this, pain was always thought of as something else — the consequence of having a leg blown off, perhaps — and the military approach was to try and fix that other medical issue and assume that the pain would then take care of itself. Today, there is greater understanding that pain itself “is a disease process and that acute pain, if not managed well, can lead to the devastating disease process of chronic pain,” Dr. Buckenmaier said.

An Acute Pain Medicine Service in Afghanistan seems to have made a drastic difference in the war zone, he reported. Data from April to July 2009 showed that 160 of 392 surgical trauma patients (including 61 Afghans) were managed by the Acute Pain Service (41%). Another 40% were too wounded — paralyzed, sedated, or on a ventilator — for the service to be useful, and the rest were soldiers with minor problems that didn’t need the service, such as ankle sprains and basketball injuries.

When first seen by the Acute Pain Service, the patients rated their pain level as 5  (severe pain) on a Visual Analog Scale. Within 24 hours, the average rating dropped to 0.7, Dr. Buckenmaier reported.

In a survey of 64 military health professionals including 26 physicians and 32 nurses who were asked to rate the Acute Pain Service on a scale of 0 (not at all helpful) to 10 (extremely helpful), respondents gave the Service an 8 for satisfaction, an 8 for being beneficial, and 8.5 for the importance of deploying the Acute Pain Service.

Seventy-four percent of respondents said that patients got greater levels of pain relief from the Acute Pain Service, and 65% said the patients reported decreased levels of pain. Overall, 74% said the Acute Pain Service had a significant impact on patient outcomes.

The military personnel needed for Acute Pain Services already exist in other roles and can be tasked with becoming the medical officer, chief nurse, and ward pain nurse champions that make up an Acute Pain Service, Dr. Buckenmaier said.

That way, there may be more outcomes like that of a British soldier who got his left foot blown off. A tourniquet was not well placed, and he had bled out by the time Dr. Buckenmaier saw him as the trauma anesthesiologist. As he put the soldier under, Dr. Buckenmaier told him, “Don’t worry. When you wake up, you’ll be pain free.” After surgery and transfusions and Dr. Buckenmaier’s ministrations wearing his Acute Pain Service hat, Dr. Buckenmaier looked in on the soldier later in the recovery room.

The young man was sitting up, talking on the phone. “Mum, I had to give ‘em a foot,” he said, “but I’m okay and I’ll see you in a few weeks.”

Dr. Buckenmaier thought, ‘That’s the standard that we should be achieving.”

He reported having no financial disclosures.

–Sherry Boschert (@sherryboschert on Twitter)

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Recycle to Reduce Drug Overdoses

Recycling and prescription drug overdoses have something in common.

Recycling has become second nature in many parts of America. Bins and containers to collect excess paper, bottles and cans are ubiquitous. Yet, only a few a few decades ago, recycling seemed foreign, was not convenient, and took some effort and resolve on an individual’s part.

Keith N. Humphreys, Ph.D. (Sherry Boschert/Elsevier Global Medical News)

That same evolution has to happen in the way that we handle leftover medications, Keith N. Humphreys, Ph.D., told physicians at the American Academy of Pain Medicine annual meeting. There’s an epidemic of opioid overdose deaths in the United States, and the most common source of misused opioids is leftover medications obtained from friends and family.

He’s talking about a huge cultural shift – with consumers going from saving and sharing costly medications that can be hard to come by in the current health system to recognizing their potential for harm and routinely returning leftover drugs on “take-back days” organized by law enforcement or even depositing them in specialized “recycling” bins.

The number of opioid prescriptions dispensed by U.S. retail pharmacies increased from 76 million in 1991 to 210 million in 2010, according to a report by the National Institute on Drug Abuse. And since 1990, the rate of drug overdoses has tripled, increasing approximately from 4 per 100,000 people to 12 per 100,000 people, the Centers for Disease Control and Prevention report.

As someone who worked in hospices for a decade, Dr. Humphries knows the valuable role that opioids can play in relieving pain. So, how do we make opioids available but reduce the risk of addiction, abuse and accidental overdose?

There is no policy framework that will eliminate the tension between these two goals, but some policies will help avoid it, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He recently served as senior policy adviser at the White House Office of National Drug Control Policy, and  reports having no financial conflicts of interest on this issue.

Here, he said, are five emerging public policies, codes of practice, and cultural norms that “most people can agree on” while working toward harder-to-implement options like expanding addiction treatment programs:

1) Build prescription monitoring programs (PMPs). The idea is that physicians could check to see if a patient has received another opioid prescription recently before handing over a new prescription, to prevent drug-seeking patients from “doctor-shopping” to get more opioids. Thirty-six states have PMPs, though most are early versions that are slow, clunky and virtually worthless. Fourteen states and the District of Columbia have enacted legislation to create PMPs, and two states have no PMP plans.

PMPs “may be resisted and resented by many professionals, but they’re inevitable” and deserve support to quickly improve, Dr. Humphreys said. Plus, there’s a bonus for prescribers: In some states, checking with the PMP before prescribing an opioid gives physicians presumptive immunity from legal liability.

2) Lock doctor shoppers into one prescriber. Every week, a West Virginian dies of a drug overdose while holding prescriptions from five or more health care providers. Public and private insurers could tell patients who have opioid prescriptions from multiple providers that they must get all prescriptions from a single provider if they want their insurance to cover costs.

Recycling bins at the Palm Springs (Calif.) Convention Center, where the AAPM met. (Sherry Boschert/Elsevier Global Medical News)

3) Make prescription “recycling” a cultural norm. Legally, opioid narcotics can be returned to any Drug Enforcement Agency law enforcer, though some states also allow pharmacies to take back leftover drugs. When sheriffs in one small Arkansas town (population 20,000) organized a drug take-back day, residents brought in 25,000 pills, Dr. Humphreys said. A physician at the meeting from Santa Maria, Calif., said a drug take-back day organized by sheriffs there was so successful that they installed a permanent drop-off box outside the sheriff’s office. Dr. Humphreys urged physicians to promote drug take-back days in their communities.

4) Make abuse-resistant medication approvals easier. Currently, developing an abuse-resistant version of an addictive medication requires a new drug application, engendering a lengthy approval process and potentially hundreds of millions of dollars in costs. Government regulators should find a way to ease this massive disincentive for pharmaceutical companies to develop safer pain medicines, he said.

5) Change opioid-related medical practice. A potpourri of short- and long-term strategies could improve practice, he suggested. Patients should be told that sharing opioids is dangerous and illegal. Both patients and physicians need to learn that opioids are not the only response to pain. Emergency physicians should break their habit of automatically writing prescriptions for 30 days’ worth of a drug, and write for shorter time lengths when appropriate. Health care workers need to get better at recognizing addiction, and more attention should go toward ways of preventing “iatrogenic” addiction caused by the health care system itself.

Physicians need to lead the way in these efforts. “Who else?” he asked.

–Sherry Boschert (@sherryboschert on Twitter)

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Hypnosis Takes the Bite Out of MRI Anxiety

I’d rather have an MRI.

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America  meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that  nine out of ten patients are probably already muttering something under their breath during their MRI.

—Patrice Wendling

Images by Patrice Wendling/Elsevier Global Medical News

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What Fuels the Athlete With Type 1 Diabetes?

A phenomenon that was virtually impossible just a couple of decades ago is now becoming increasingly commonplace: Athletes with type 1 diabetes are not only competing at elite levels in just about every sport, but in many cases are actually beating nondiabetic competitors. Gary Hall Jr. won three Olympic Gold medals in swimming after his diagnosis in 1999. Natalie Strand, an anesthesiologist, won the TV extreme-sport reality show Amazing Race with her partner last December. And bicycle racers Team Type 1 won the Race Across America in 2009 and 2010.

Of course, exercise is encouraged for people with both type 1 and type 2 diabetes as a way of improving glycemic control, cardiovascular health, and quality of life. But in competitive sports, milliseconds count and physical perturbations of any kind can mean the difference between winning and losing. With type 1 diabetes, aerobic exercise can result in hypoglycemia, while anaerobic exercise can cause glucose levels to rise. Many sports involve a combination of the two. The athlete with type 1 diabetes must perform frequent glucose checks and eat or take insulin as needed to maintain normal or near-normal glucose, while at the same time performing the athletic feat itself. It seems nearly impossible, yet they do it … with the help of both new technology and devoted health care professionals.

“I take each athlete, learn their sport and find solutions,” said Dr. Anne Peters, the endocrinologist who managed Gary Hall Jr.’s diabetes regimen during the Olympics and is now doing the same for professional racecar driver Charlie Kimball. “Each athlete is unique and requires individualized care.”

Javier Megias of Team Type 1 checks his blood sugar while warming up for a time trial at a race in Italy. Photo courtesy of Team Type 1

New research is aimed at understanding the physiology of these athletes better in order to improve that care. Team Type 1, sponsored by Sanofi, is funding a study in which data are being collected on about 10 bike racers with and 10 without type 1 diabetes. The athletes are being evaluated before, during, and after races using continuous glucose monitors and devices placed on the bicycles that measure variables such as power, heart rate, energy expenditure, speed, and altitude. Data on the athletes’ diet, insulin doses, and other variables are also being collected in a total of five major cycling events, each of which includes 4-8 individual races. “Bottom line, it’s a lot of data,” said Team Type 1 director of research Dr. Juan Frias.

Interestingly, blood glucose values of up to 200 mg/dL - far above “normal” – have been recorded in the nondiabetic riders during very intense portions of races. This “stress hormone” effect had been seen previously in the lab and in some hospitalized patients, but has not been well documented in field-based, real-world studies of healthy people. “Ultimately we hope that this feasibility study will provide data that will help us begin to better understand the optimal glucose concentrations needed to maximize athletic performance, Dr. Frias said.

Findings from the TT1 study will likely be announced at scientific conferences during 2012 and ultimately published, he told me.

Another research project, led by Nate Heintzman, Ph.D., of the University of California, San Diego, is studying athletes who are part of Insulindependence, an organization that promotes physical fitness and sport for people with type 1 diabetes. One of Insulindependence’s recreation-specific clubs, Triabetes, trains people with type diabetes to compete in triathalons. The UCSD-supported project, called the Diabetes Management Integrated Technology Research Initiative (DMITRI), is looking at many of the same variables as in the TT1 study, but is also collecting other data, including behavioral and cognitive information and biospecimens for DNA sequencing.

Insulindependence Captains starting their track workout at UCSD in June. Every person in this photo has type 1 diabetes. Courtesy of Nate Heintzman, Ph.D.

“The idea is to use emerging wireless and device technology as well as genetics and genomics to understand more about the personalized basis of blood glucose management. I think we’ll uncover trends to help tailor therapeutic regimens, and also develop technology on a personal level,” Dr. Heintzman said.

The DMITRI project began in June, and data will begin to emerge in the coming months. In the meantime, if you’re a health care provider or person with diabetes interested in learning more, Dr. Peters recommends Sheri Colberg-Ochs Ph.D.’s Diabetic Athlete’s Handbook. And if you’re seeking inspiration, you can follow Team Type 1 founder and CEO Phil Southerland’s efforts to enter the team in the 2012 Tour de France, professional cycling’s most elite event.

Bottom line, according to Dr. Peters, “The truly gifted athletes I have known seem to be born with an ability that compels them to compete, diabetes or not.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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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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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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Another Side to Guidelines

What makes for quality guidelines? This remains an open question, based on the packed room for a discussion on the importance of quality guidelines at the annual meeting of the American Academy of Pain Medicine.

courtesy of flickr user Steve Kay (creative commons)

Two speakers at the meeting  shared their views on the development of guidelines in general and the American Pain Society guidelines for low back pain in particular.

Dr. Richard Rosenquist of the University of Iowa in Iowa City, acknowledged that reviewing the literature in pursuit of quality guidelines can be challenging at best. “You can’t find the data to support what you believe,” he said. But he added that guidelines have a role to play in quality care, and that as a specialty, pain medicine physicians need to develop widely accepted outcome measures.

Dr. Laxmaiah Manchikanti of the Pain Management Center in Paducah, Ky., took a more provocative stance, suggesting that clinical guidelines lack accountability. And they are expensive. Dr. Manchikanti said that, based on his research into the subject, a systematic review of guidelines costs hundreds of thousands of dollars, and “the actual impact on quality of care is impossible to determine,” he said.

Disclosing funding for guidelines is an important part of accountability, Dr. Manchikanti emphasized. He noted that most clinicians never know what organizations paid their guideline-writing peers for their work, and that information should be available.

What do you think? Should authors of guidelines disclose when they have been compensated by the organizations that are promoting the guidelines?

–Heidi Splete (on twitter @hsplete)

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