Category Archives: Orthopedic Surgery

A New Weapon Against Concussion

Sports-related concussions are a growing concern in scholastic and professional athletics, as more studies have shown lasting effects from even a single blow to the head.  Concussions have also become a major concern for physicians, who are often pressured to clear athletes to return to play.

Courtesy Wikimedia Commons user Patrick J. Lynch/Creative Commons

Earlier today, I heard a little about what is increasingly being deployed as a new weapon in the quest to learn more about sports-related concussions: the accelerometer.  Dr. Dan Garza, an emergency and sports medicine physician at Stanford Hospital and Clinics, and medical director for the San Francisco 49ers, discussed Stanford’s use of accelerometers in the helmets of football players and of female lacrosse and field hockey players. (Virginia Tech announced a similar program back in 2007.)

The goal: to get real-time data on what kind of hits these players are taking. During practices and games, the players wear mouthpieces outfitted with accelerometers and gyrometers “that measure the linear and rotational force of head impacts,” according to the Stanford news story on the just-initiated program.

It’s also rimmed with microchips that transmit the accelerational force (known as G force) data to coaches on the sidelines. Dr. Garza said the mouthpieces are a bit eery with their red glow. “They look like Christmas trees out there,” he told his audience, attendees at the American College of Emergency Physicians Scientific Assembly in San Francisco.

Dr. Garza shared a game film from the Stanford Cardinals’ contest against Washington State on Oct. 15 in which wide receiver Chris Owusu received what looked to be a helmet-to-helmet hit (story here). He dropped to the ground and lay there for a bit. On the sidelines, Dr. Garza and his crew received the data from Mr. Owusu’s mouthpiece. They determined that the force of impact was equal to 184 Gs.

That type of accelerational force is considered deadly (for more on G forces, see here and here). For comparison purposes, astronauts only sustain up to 40 Gs at launch and an Indy race car driver might pull 3 Gs in a tight corner. Forces over 100 are usually only encountered in motor vehicle accidents.

Dr. Garza and his colleagues will use the data in a wider study. In the Stanford release, Dr. Garza said the study  “will build toward establishing clinically relevant head-impact correlations and thresholds to allow for a better understanding of the biomechanics of brain injuries.” It may also help with diagnosis and subsequent management of concussions.

Stanford’s football program is being especially closely watched these days, as its quarterback, Andrew Luck, is considered to be a potential number one pick in the NFL draft next year.

The NFL recently announced that it would restart a long, broad look at concussion among its players.  The league has also bankrolled a head-injury program overseen by the Boston University Center for the Study of Traumatic Encephalopathy.

As more attention has been focused on sports-related traumatic brain injury, Congress has gotten involved also. The Senate Commerce, Science and Transportation Committee is having a hearing this Wednesday on companies marketing supposed anti-concussion equipment.

—Alicia Ault (on Twitter @aliciaault)

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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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Drug Companies Do-Si-Do at Diabetes Meeting

I don’t really walk around with antennae out trying to detect pharmaceutical company influence on physicians, despite this being my second blog post on the topic in the past month. (See the earlier one here.) But I couldn’t help thinking about it when I arrived at the American Diabetes Association 2011 scientific meeting and found that the registration packet included a 40-page booklet produced by the ADA but focused on “Corporate Events.”

Cover of a book in the ADA attendee materials. (Photo by Sherry Boschert)

Most large medical conferences will have satellite symposia driven by drug companies, but I don’t think I’ve ever seen them given the same packaging treatment as the scientific sessions.

Why does this bother me? Well, the day after I returned from that meeting, the media widely reported on a study and several papers in The Spine Journal questioning the validity of years of industry-sponsored research that had led doctors to believe that a bone growth protein often used in spinal fusion surgeries was safe. The review led by Stanford University researchers concluded that bone morphogenetic protein may cause a variety of complications, even permanent or potentially fatal ones, at rates 10-50 times higher than reported. After the news coverage, the authors called out what they considered deceptive back-pedaling by the companies and a doctor who profited from it all.

Granted, that’s not the diabetes world, but having such an apparently cozy relationship between industry and the ADA probably isn’t a good thing in the end. Except that I imagine it might have helped pay for the truly delicious, healthy food they fed us in the press room.

On the other hand, there are signs of potential progress in disclosing drug company influence on the practice of medicine. Nearly all medical conferences I cover now religiously require speakers to list disclosures of conflicts of interest and make these accessible in printed form for all conference attendees. That’s a big improvement over the days when I’d have to request the information and spend a couple of hours flipping through the single three-ring binder containing disclosures.

And back at the American Diabetes Association meeting, I saw something else unusual that I had seen only once before, at the 2011 American Psychiatric Association meeting. In the Exhibit Hall, one of the pharmaceutical giants was giving away free fruit smoothies — nothing unusual in that. But the smoothie stand featured a sign saying the following:

“The cost of any refreshments, meals or educational items provided to U.S. licensed Healthcare Professionals attending this [company] Exhibit will be subject to public disclosure on [the company's Website] as part of [the company's] Healthcare Professional Disclosure policies, and may also be subject to disclosure by state governmental authorities pursuant to your state law. In order to comply with these requirements, please make your badge available to be scanned by an attendant as requested.

“If you hold a Healthcare Professional license in Minnesota, we are prohibited from providing you any refreshments or items of value due to your state limitations and ask that you do not partake in the hospitality provided.”

No need to feel sorry for Minnesota physicians, though. No such signs tried to dissuade them from filling up on coffee and lattes from numerous other company booths in the Exhibit Hall. Apparently smoothies may cross a “hospitality” threshold for disclosure that java does not.

–Sherry Boschert (@sherryboschert on Twitter)

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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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Surgeons Sound, Heed Call to Serve

As president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dr. Jo Buyske has made it her mission to develop a “more humanitarian SAGES,” she said at the organization’s annual meeting last week in San Antonio, Texas.

Dr. Jo Buyske challenged her SAGES colleagues to share their gifts with those in need. Photo by Diana Mahoney

Toward this end, the University of Pennsylvania adjunct professor and associate executive director of the American Board of Surgery spearheaded a series of initiatives that debuted at the conference. On Thursday, a group of meeting attendees boarded a bus to a Habitat for Humanity construction site where they swapped their surgical scrubs and scalpels for hard hats and hammers to help build a new home for a low-income family. The following day, SAGES sponsored an on-site donor blood bank and a bone marrow testing station at the convention center – both of which were well utilized between sessions – and a number of SAGES surgeons offered to mentor local high school students with an interest in medicine who had been invited to the meeting for the day.

Throughout the week, attendees dropped off used medical text books for medical schools in China and old medical instruments and supplies that for shipment (via Medwish) to the Albert Schweitzer Hospital in Haiti. During the course of the week, SAGES members also gathered information about international volunteerism from the several medical volunteers’ desks located near the SAGES membership booth and Dr. Buyske announced the formation of a SAGES humanitarian task force, charged with identifying new service opportunities and resources for its SAGES members.

Dr. Buyske volunteering with Aloha Medical Missions in Bohol, Philippines. Image courtesy of SAGES.

The very vocal call to arms is more than just lip service for Dr. Buyske. In her presidential address, aptly titled, “To Whom Much is Given, Much is Required” [Luke 12:48], she described her own humbling experiences as a surgical volunteer in remote villages of Chiapas, Mexico; Bohol, Phillipines; and in the Republic of Mozambique, where access to sufficient water and electricity was erratic, at best, and where all of the niceties of surgery in this country, such as having assistants to help scrub, glove, and gown, as well as prepare and handle instruments, were non-existent. “I was not prepared for things as simple as having to pick up and unwrap my own instruments and choosing which sutures to use and which size needle. I was used to having everything handed right to me. It takes a different part of you brain to think about these things.”

Despite at various times having to pull anesthesia tubing from the trash to reuse it, having such poor lighting that she had to wait until the afternoon sun was just right in to perform cesarean sections, and having to use water from the local stream to scrub, Dr. Buyske said that each of the volunteer experiences made her a better person, and a better surgeon,. “You begin to think hard about what you use and why; you become more flexible; and you become more frugal. You revisit surgery in a way you might not have since medical school or residency. And though you’ll be exhausted, you will also be refreshed.”

As surgeons, “we have the great good fortune of doing work that allows us to go to bed every night knowing that just by doing our jobs, by our livelihoods, we have taken care of people; we have improved lives; we have done good. We should pause for a minute and savor the great good fortune, the luck, the wisdom, the hard work that went into a profession that is so fulfilling. but we should also be good stewards of our skills and our good fortune and take advantage of opportunities to be of service,” Dr. Buyske stressed. “As our Japanese friends and colleagues can tell us, our fortune and status can’t be taken for granted. There is no guarantee that it will be with us, even tomorrow.”

Thoracic surgeon Dr. Cameron Wright is a Colonel in the Medical Corps of the US Army Reserve. Image courtesy of MGH.

Dr. Buyske’s pledge to service was echoed by Dr. Cameron Wright, during the meeting’s Gerald Marks Lecture. A respected thoracic surgeon at Boston’s Massachusetts General Hospital, Dr. Wright is also a colonel in the Medical Corps of the US Army reserve, which he joined in 2007, “for many reasons,” including the obvious need for qualified surgeons to deal with the many casualties of the wars in Iraq and Afghanistan, and the opportunity to experience war surgery, he said. The most important reason, however, was the fact that his son, a heavy weapons specialist in the US Marine Corps “had skin in the game, and I decided I should put my skin in the game as well.”

In a moving slide presentation, Dr. Wright told his story through dramatic pictures, both of the soldiers with whom he served with and those to whom he ministered. Evident in all of the pictures are the camaraderie and sense of shared purpose that pervades military deployments, but also the human destruction that begs for the hands of a skilled surgeon.

— Diana Mahoney

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With Diabetes, the Hands Aren’t Free

You’ve got to hand it to diabetes for leaving few parts of the body unscathed, including the hands. While far less common than foot problems, hand complications that are more common in people with diabetes – including tenosynovitis (aka “trigger finger”), Carpal tunnel syndrome, Dupuytren’s contracture, De Quervain syndrome, and limited joint mobility – can be equally crippling.

“Hand problems, although not usually life-threatening, can certainly be livelihood threatening,” according to Dr. Leo Rozmaryn, an orthopedic hand surgeon in Rockville, Md.

Although vascular complications can occur in the hands, diabetes-related hand problems more often involve the tendons, nerves, and/or joints. The exact mechanisms aren’t well understood, and the complications can occur even in diabetes patients who are well-controlled, particularly in those with type 1 diabetes.

The most common is “trigger finger,” which occurs when the sheath surrounding the flexor tendon in the finger becomes inflamed and thickened, causing stiffness and pain and impairing movement. Instead of gliding smoothly when the fingers bends, the tendon gets caught and “snaps” back.

Photo by Miriam E. Tucker

Dr. Rozmaryn says that he sees about 7-8 patients a day with trigger fingers, and of those about a quarter to a third have diabetes. But diabetics make up about 70% of patients who present with multiple trigger fingers, as I did. I’ve had trigger “release” operations – in which the tendon is cut in order to widen the space within the sheath – on 8 fingers, including a thumb.

Cortisone shots are a temporary fix for some cases of trigger finger. But Dr. Rozmaryn says that he doesn’t like to give those to patients with diabetes, because the steroid can drastically raise blood sugar levels. “I’m very hesitant to give diabetics shots of cortisone unless they’re very well controlled and can monitor themselves and adjust their insulin doses.”

Most studies on diabetic hand complications are published in orthopedic and rheumatologic literature, rather than in endocrinology or primary care journals. As a result, diabetic hands aren’t often on the radar screen, Dr. Rozmaryn says.

“With diabetes, you’re worrying about the eyes, kidneys, the heart, and so many other things. But still, if you’re a physician who’s treating diabetics, my advice is don’t ignore the hands.”

—Miriam E. Tucker (@MiriamETucker on Twitter)

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Now tell me where ELSE it hurts…

When it comes to managing chronic pain, have physicians been looking in the wrong places? Physical findings in peripheral tissues rarely match up with patients’ reports of pain, or vice versa. Yet, clinicians typically examine only the area where the patient reports the pain, rather than looking at the whole body and considering that the patient’s perception of persistent pain may have a more central origin, according to pain expert Dr. Daniel J. Clauw.

Image by Kira.Belle via Flickr Creative Commons

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” Dr. Clauw said at last week at a 2-day scientific workshop on pain and musculoskeletal disorders, sponsored by the University of Michigan and held on the Bethesda, Md., campus of the National Institutes of Health.

That narrow focus has led many medical professionals to assume that when there is a disparity between peripheral findings and pain, the pain must be caused primarily by psychological factors. A prime example is fibromyalgia, still a somewhat controversial diagnosis. But as the first chronic pain syndrome identified as NOT being caused by peripheral inflammation or damage, fibromyalgia is “a metaphor for the centrality of chronic pain,” Dr. Clauw said.

So what should clinicians do differently? First, look beyond the immediate area the patient is complaining about. Has the patient had pain in other parts of the body? Experience frequent headaches? Have irritable bowel? Previous chronic neck pain, and now pain in the hip? “To me as a pain researcher, this is a blinking neon light that the person has a problem with pain processing. It may be that the particular symptom they’re coming in with is due to increased volume control setting rather than a pathologic problem in that part of the body,” Dr. Clauw told me.

And treatment? Ensuring adequate exercise and sleep and reducing stress are important yet underemphasized. Cognitive behavior therapy also has been shown to help. Pharmacologic therapy that acts centrally, rather than peripherally, may also be effective. The antidepressant duloxetine (Cymbalta), for example, is a serotonin/norepinephrine reuptake inhibitor that has been recently approved to treat osteoarthritis of the hip and low back pain, in addition to fibromyalgia and diabetic peripheral nerve pain.

A major challenge, Dr. Clauw believes, might be in getting clinicians to change their approach to pain. “It takes a long time for people trained in one way of thinking to think differently. This isn’t just a new drug or a new device. It’s a major paradigm shift.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Osteoarthritis Pain Assessment Poses Challenges

  What is pain, and how much is too much?

Patients with painful hip or knee osteoarthritis say they know how much pain they should have to make joint replacement surgery necessary, and that their physicians are largely in the dark about their pain. Patients use the Supreme Court’s famous approach to identifying pain that warrants knee surgery: I know it when I feel it.

courtesy Flickr user GlobinMedChiro

To get the perspective of osteoarthritis patients, Dr. Gillian Hawker, a Toronto rheumatologist, and her associates put 58 local patients with moderately severe hip or knee osteoarthritis in focus groups, including 36 veterans of total joint replacement surgery. They discussed joint surgery appropriateness, and the point when appropriateness and their willingness to have the surgery intersect. The major determinant was their pain: their ability to cope with it, and its impact on their quality of life.

Patients “evaluated their pain against some invisible marker,” and despite having what they called high levels of pain they often said it was not bad enough to justify surgery, Dr. Hawker reported last month at the World Congress on Osteoarthritis. As one focus-group patient put it, “I don’t feel I’m ready.” But when their pain became bad enough, they said it trumped all other considerations of whether or not to have joint surgery. Most patients in the focus groups also said their pain had been “inadequately evaluated” by their physicians.

Other study results reported at the Congress also highlighted the highly subjective and variable nature of knee pain. Dr. Tuhina Neogi from Boston University measured central sensitization in knee osteoarthritis patients, and saw that both increased disease severity and duration significantly boosted the incidence of central sensitization, a neurologic process that alters the nervous system and potentially increases pain sensitivity.

Dr. Neogi and her associates found the only way to reliably measure central sensitization was by comparing pain in a patient’s knee affected by osteoarthritis and in the patient’s second, unaffected knee. Comparisons between different patients involved too much variable noise to show a significant link between osteoarthritis and central sensitization. Comparing knees within individual patients cut away the effects of genetics, and psychosocial and cultural factors, allowing each patient to apply their own unique, personal criteria for judging pain severity. 

—Mitchel Zoler (on Twitter @mitchelzoler)

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Treating Knee Injury Like a Myocardial Infarction

  When a skier skids on an icy patch, torques her knee, and gets a sudden ligament tear, is it the orthopedic equivalent of a myocardial infarction? Can rapid medical treatment in the knee damp down the resulting inflammatory, pathologic cascade and help preserve the knee’s long-term health, the same way that rapid restoration of coronary blood flow limits the extent of a myocardial infarct and long-term loss of cardiac function?

image courtesy Flickir user Dance Party Duo

 It’s an intriguing concept, and forms the rationale behind a new approach to acute management of traumatically injured knees that is starting clinical testing.

 “The early phase of acute joint injury represents a window of opportunity to promote healing and prevent a subsequent cascade of joint destructive processes,” said Duke rheumatologist Virginia Byers Kraus last week at the World Congress on Osteoarthritis in Brussels.

 “We think of osteoarthritis as a slow, chronic disease,” but that’s when it appears years after a traumatic knee injury, she said. “This is a curable type of osteoarthritis because you know when it starts. We should start to treat joint injury emergently, like an acute myocardial infarction.”

 At the Congress, she presented early evidence supporting this approach. A single, knee-joint injection of a potent anti-inflammatory drug, the interleukin 1 receptor antagonist anakinra, produced dramatic improvements in short-term pain and function when administered roughly 2 weeks after traumatic injury in a pilot controlled study with 11 patients. The next step is to look at more patients, and to push the time of treatment even earlier, within a few hours after injury, Dr. Kraus said.

 The time seems ripe for finding new ways to manage knee injuries, as middle-aged and elderly Americans are experiencing an epidemic of knee osteoarthritis that needs the ultimate treatment, total knee replacement. A second report at the Congress documented that the rate of total knee replacement surgeries soared during the decade ending in 2007. The number of knee replacements in Americans aged 45-64 tripled in that period, reaching 221,000 in 2007, with all U.S. knee replacements in 2007 reaching an all-time, 1-year high of 550,000.

 —Mitchel Zoler (on Twitter @mitchelzoler)

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Video of the Week: Olympic Trauma Care

 

Trauma care at the Olympic Games focuses on getting the athletes back in the games.  That’s what Dr. Jay Doucet told our Doug Brunk at a critical care meeting sponsored by the University of California in San Diego.

Dr. Doucet—director of the Surgical Intensive Care Unit at the university—was one of the clinicians who provided trauma care at the 2010 Winter Olympic Games in Vancouver. In fact, he provided care at Whistler Mountain, where many of the high-speed events—-such as luge and bobsled—took place. “We did see quite a few injuries from that.  Luckily most were not serious or career-ending,” he said.

“The Olympics is a pretty rare event, and the opportunity to do well at the Olympics is something that these athletes really strive for.  You have to be totally focused on what they need. What they don’t need is more time off work or more narcotics. What they need is to get better.”

For more great videos and the latest medical news, check out our new Internal Medicine News Web site.

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