Because the commonly used drug propofol can cause low blood pressure, prolonged sleepiness and decreased breathing, this study’s results can help anesthesiologists safely treat a common type of surgical patient that is often misunderstood.

“Little information is available to assist anesthesiologists in determining the right dose of medication to give to an obese child,” said Dr. Olutoyin A. Olutoye, of Texas Children’s Hospital in Houston, and lead author of the study.

Companies that make these medications do not specifically study their effects in this group of children before the drug is released for general use,  researchers say.

Anesthesiologists now must decide whether anesthetic drug doses should be based on a child’s actual weight or lean body weight. In obese children, 75 percent of their excess body weight is comprised of fat tissue, which alters drug distribution.

“Obese adults often need a smaller dose of propofol than normal weight adults, but a correlation to children isn’t guaranteed since adults and kids handle medications differently,” said Dr. Olutoye in a news release.

For this study, 40 obese and 40 non-obese children were observed using a process called the biased coin design. This process requires fewer patients and provides greater accuracy in the calculation of dose requirements than other techniques.

After measuring each child’s response 20 seconds after the propofol was administered, researchers discovered obese children needed 2 mg/kg of propofol to bring about unconsciousness at the beginning of surgery, compared to the normal weight children who needed 50-60 percent more propofol (3.2mg/kg).

“When providing care for obese children with propofol, 95 percent of children will likely need only a smaller dose of propofol to initiate anesthesia for surgical procedures,” said Dr. Olutoye, commenting on the study‘s results.

This study is important, Dr. Olutove said,  because propofol can cause low blood pressure, which can be worsened if larger-than-needed amounts are given.

Researchers say more pediatric studies are needed to determine if there are other differences in medication responses for obese and non-obese children in clinical practice.

For more on child medical safety issues, see the library of articles by Daytona Beach child injury attorney.

And those most affected are African Americans, poor, uninsured and rural residents.

Researchers from the University of California, San Francisco examined changes in driving time to trauma centers, which have increasingly been shuttered in recent years. They found that by 2007, 69 million Americans — nearly one in four — had to travel farther to the nearest trauma center than they traveled in 2001.

“Trauma centers aren’t just for ‘certain’ people — if you sustain a serious injury from a car accident or fall off your roof, you need a trauma center,’’ said lead author Dr. Renee Y. Hsia, an assistant professor of emergency medicine at UCSF. She is also an attending physician in the emergency department at San Francisco General Hospital & Trauma Center and a Robert Wood Johnson Foundation Physician Faculty Scholar.

“We found evidence that vulnerable communities have less geographic access to trauma care, adding to their health disparities,’’ Hsia said in a news release. “This study will help us better understand how trauma center closures are affecting people.’’

Hsia’s research centers on illustrating inequalities in accessing trauma care as well as the decline of emergency care in the United States. She has documented that tens of millions of Americans do not have ready access to a certified trauma center, and that nearly a third of urban and suburban emergency rooms have closed in the last two decades.

Trauma services are not, as commonly believed, available in all hospitals. They are hospitals with emergency departments that provide specialty care for injured patients, regardless of ability to pay. As a result, trauma centers face greater financial jeopardy depending on the surrounding patient population.

For their new study, the researchers analyzed 31,475 ZIP codes in the United States, covering some 283 million people, nearly the entire nation.

Overall, nearly three-quarters of the U.S. lives within 10 miles of a trauma center. Of the remainder, 14 percent live more than 30 miles from a trauma center.

Communities with a higher number of residents under the federal poverty level, black residents, uninsured residents and rural residents faced longer drives compared to communities with a low share of these vulnerable populations.

For nearly 16 million people, the extra driving time amounts to about 30 minutes — a critical period for people facing life-threatening injuries such as stroke and gunshot wounds.

In 1990 there were 1,125 trauma centers in the United States; by 2005, about 30 percent of them had closed primarily because of the high costs and fewer patients able to pay the bills. The majority of closures took place in urban areas but rural communities have also been affected.

The authors recommend policy makers should subsidize trauma centers that treat a large number of African American, uninsured or poor people. In rural areas, they recommend that hospitals establish agreements with nearby trauma centers to ease transfers of seriously injured patients.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

“The good news is that over the last ten years hospital palliative care teams have more than doubled,” said Dr. Diane E. Meier, director of the Center and co-author of the study, in a news release. “The bad news is that despite its enormous benefits to patients and care givers, millions of seriously ill Americans still do not have access to palliative care. Given the will of Congress to assure patients receive high quality care while reducing costs, it seems that palliative care should be a natural part of that prescription.”

Palliative care is a medical specialty that helps people facing serious and chronic illness more comfortable by alleviating pain, treating a host of other symptoms and focusing on their quality of life. It is appropriate at any age and any stage of a serious illness and can be provided along with curative treatment.

Approximately 90 million Americans are living with serious and chronic illnesses, such as cancer, heart disease, diabetes, Parkinson’s, stroke, and Alzheimer’s.

The Report Card demonstrates considerable improvement in the growth of palliative care. (Out of a total of 2,489 hospitals nationwide who participated in this survey, about 1,500 provide palliative care services.) This number is expected to grow significantly over the next five years, but barriers continue to exist in three key areas: Workforce, Research and Access.

Of course, you can’t get palliative care from a hospital that does not offer it.
Meier and colleagues graded states on the percentage of hospitals that have palliative care teams. They counted only hospitals with 50 or more beds, as palliative care savings may not offset costs for very small hospitals.

States got an A for having palliative care teams in 83 percent or more of their hospitals, a B for 61 to 80 percent of hospitals, a C for 42 to 60 percent of hospitals, a D for 28 to 38 percent of hospitals, and an F for 0 to 20 percent of hospitals.

The report gives seven states plus the District of Columbia an A: Maryland, Minnesota, Nebraska, Oregon, Rhode Island, Vermont and Washington. Only three states, Vermont, Montana and New Hampshire, received an A in 2008.

More than half of the fifty states received a grade of B, including Florida. Seven states improved from a D to a C (Georgia, Kentucky, New Mexico, Texas, South Carolina, Louisiana and Wyoming).

Nevada saw dramatic gains, rising from a D to a B grade. Only two states – Delaware and Mississippi – got an F. Oklahoma, Alabama and Arkansas improved from an F in the last report card to a D in 2011.

Findings from a separate 2011 Public Opinion Strategies survey found that most Americans believe palliative care should be made available at all hospitals. Once informed about it, 92 percent of respondents said they would consider it for a seriously ill loved one.

“America’s hospitals have a strong history of caring for patients and families during the most difficult of times,” said Rich Umbdenstock, President and CEO of the American Hospital Association. “Hospitals and other health care organizations are taking the lead in ensuring health care is patient-centered, reflecting patient’s desires including palliative care assistance.”

“Studies suggest that in states with more hospital-based palliative care programs, patients are less likely to die in the hospital, are likely to spend fewer days in the ICU, have better pain management and higher satisfaction with their healthcare,” said Dr. Sean Morrison, director of the National Palliative Care Research Center and the study’s lead author. “Some studies have reported that palliative care may also prolong life. And beyond patient benefits, the overall cost savings to hospitals have been well documented.”

For more on patient safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

An analysis of Medicare data showed a higher death risk if the stent was inserted by a doctor who performed less than six procedures a year, or if the procedure was conducted early in the physician’s career.

Carotid stenting is increasingly being used to treat severe carotid atherosclerosis, an important cause of ischemic stroke. Since approval of the first carotid stent system by the U.S. Food and Drug Administration in 2004, use of carotid stenting has more than doubled in Medicare beneficiaries.

Despite the promise of this procedure, its increasing use has raised potential concerns.

“Carotid stenting is a technically demanding procedure and earlier studies have demonstrated a substantial learning curve with it,” says lead study author Dr. Brahmajee K. Nallamothu, cardiologist at the University of Michigan Cardiovascular Center, in a news release. “The total number of operators currently performing carotid stenting in routine clinical practice and their overall experiences and outcomes with the procedure remain largely unknown.

Nallamothu and colleagues at the U-M Health System, Mayo Clinic, Dartmouth-Hitchcock Medical Center, and Yale University School of Medicine conducted a study to examine recent patterns of utilization and outcomes for carotid stenting in the U.S. among elderly patients.

The researchers used administrative data from fee-for-service Medicare beneficiaries ages 65 years or older who underwent carotid stenting between 2005 and 2007. Among the outcomes the researchers measured were 30-day mortality and treatment early vs. late during an operator’s experience.

Analysis of the data identified 24,701 patients who underwent carotid stenting by 2,339 operators. Average age of the patients in the study was 76.2 years.

Compared with patients treated by operators performing 24 or more procedures per year, those treated by operators performing less than six procedures per year were nearly twice as likely to die within 30 days of the stent placement, the study showed.

The authors found higher 30-day mortality in patients treated early vs. late during a new operator’s experience (2.3 percent vs. 1.4 percent, respectively). Compared with patients who were their operator’s 12th procedure or higher, those who were among their operator’s first 11 procedures had a 1.7 times higher odds of dying within 30 days of the procedure.

“In conclusion, many physicians have begun performing carotid stenting in Medicare beneficiaries during recent years, although most operators appear to have developed limited experience with the procedure over time, “ study authors write. “This finding is important since adjusted outcomes following the procedure are worse among very low-volume operators and early during an operator’s experience. Given limitations of these data, caution should be exerted when using our findings to set specific targets for operator experience.”

Collecting more detailed data about operator experience during the early dissemination of new procedures, like carotid stenting, may help optimize outcomes, according to the researchers.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Although most patients would allow residents and medical students to be involved in their operation, researchers say the rates of consent vary depending on the type of surgery and the trainee’s level of participation

Dr. Christopher R. Porta and colleagues from Madigan Army Health System, Tacoma, Wash., conducted an anonymous questionnaire at a tertiary-level U.S. Army hospital and referral center, to evaluate patient perceptions and willingness to participate in surgical resident education and training programs.

“Currently, no widely accepted guidelines or policies exist for providing information regarding the role of surgical trainees to the patient during the informed consent process,” the authors write. “The accepted standard is to provide information that ‘a reasonable patient’ would want and would need to know to make an informed decision, but this counseling may vary widely by health care professional, setting, and type of surgical procedure.”

The authors distributed 500 surveys, 316 (63.2 percent) of which were returned and included in the study. Most patients indicated no preference for a private hospital versus a teaching hospital, however of those who did, more preferred a teaching hospital to a private facility for overall care (24.9 percent vs. 8.8 percent) and minor surgical procedures (28.2 percent vs. 12 percent), but hospital preference for major surgical procedures was similar (24.7 percent vs. 26.6 percent).

Additionally, 91.2 percent of those patients who indicated a facility preference reported that their care in a teaching hospital would be equivalent to or better than that of a private hospital.

Patients also indicated they overwhelmingly preferred to be informed of resident participation in their surgical procedure, regardless of whether it was a major procedure (95.7 percent) or a minor surgery (87.5 percent).

A total of 94 percent of respondents indicated they would consent to involvement of a surgical resident, however this decreased to 85 percent for a surgical intern and 79.9 percent for medical student involvement.

When provided with specific scenarios involving trainee participation, 57.6 percent of patients consented to having a junior resident act as the first assistant, 25.6 percent consented to the resident acting as the operation surgeon with direct staff observation, and 18.2 percent consented to resident participation without direct staff observation.

“Although most patients express an overall willingness to participate in surgical education, wide variations can be observed in the actual consent rates for specific training situations, “ the authors said. “This decreased willingness to consent and the potential effect on training programs must be considered when discussing policy initiatives aimed at improving informed consent.”

For more on medical safety issues, see the library of  articles by Daytona Beach medical malpractice attorney.

Approval from the U.S. Food and Drug Administration (FDA) does not necessarily ensure that a drug has a large or important benefit, or that all serious adverse effects of the drug are known, according to the report published in the September issue of Archives of Internal Medicine.

“Uncertainties are greatest in the first few years after approval and for drugs approved solely on the basis of a surrogate outcome,” the authors note.

Researchers point out that the cholesterol-lowering drugs Zetia and Vytorin reached $1.8 billion in sales in 2007 before a study found no clinical benefit from these drugs, and that the anti-inflammatory medication Vioxx reached $2.4 billion in sales by 2003 before being withdrawn from the market due to its association with myocardial infarctions (heart attacks) and strokes.

“The FDA has never required advertisements to acknowledge uncertainties inherent in all new drugs,” write the authors. “Enthusiasm for Zetia and Vioxx might have been dampened had consumers known to look for drugs approved based on patient outcomes or drugs with a longer safety record.”

Dr. Lisa Schwartz  and Dr. Steven Woloshin, from the VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt., and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., conducted an Internet-based, randomized, controlled trial of U.S. adults’ beliefs and choices regarding prescription drug uncertainties.

The 2,944 participants were randomized to three explanations about a pair of cholesterol drugs, one that was approved because of a surrogate outcome (lower cholesterol) and another that was approved because of a patient outcome (reduced myocardial infarctions).

Participants in the control group received no explanation, those in the nondirective group were told that surrogate outcomes do not always translate into patient outcomes and those in the directive group received the same explanation as well as advice to “Ask for a drug shown to reduce heart attacks.”

In a second randomization, participants received one of three explanations about a pair of heartburn drugs, one that was newly approved and another that was approved eight years earlier. Participants in the control group received no explanation, those in the nondirective group were told “It takes time to establish the safety of new drugs” and those in the directive group were advised to “Ask for a drug with a longer track record.”

The primary outcome was choice of the drug for which there was less uncertainty. In the cholesterol drug example, the better choice would be the drug that had a beneficial effect on patient outcome (reducing myocardial infarction) instead of surrogate outcome (lowering cholesterol).

In the heartburn drug example, the better choice would be the drug that was approved eight years earlier instead of the recently approved drug.

Researchers also asked participants, “What would you do if your doctor recommended the drug with the surrogate outcome? Do you think new — or old — drugs are safer?” and assessed their understanding of FDA approval with four true/false questions.

One-quarter of participants mistakenly believed that the FDA approves only drugs without serious side effects, and more than one-third mistakenly believed that the FDA approves only “extremely effective” drugs.

Equal percentages of participants in the directive and nondirective groups (71 percent in the cholesterol drug example and 53 percent in the heartburn drug example) chose the drug for which there was less uncertainty. In both examples, choice of the drug for which there was less uncertainty was lowest among the control group (59 percent and 34 percent, respectively).

When asked what they would do if their physician recommended the drug approved for a surrogate outcome, 61 percent, 58 percent and 49 percent of participants in the directive, nondirective and control groups, respectively, said they would request the drug approved for a patient outcome.

When asked which of the heartburn drugs was safer, 46 percent, 45 percent and 31 percent of the directive, nondirective and control groups, respectively, selected the older drug. The proportion of participants who chose the older heartburn drug and said it was safer was 40 percent, 41 percent and 26 percent, respectively. One limitation the authors note is “participants were making hypothetical choices between drugs.”

“There are important gaps in what people know about prescription drugs — gaps that undoubtedly contribute to the rapid uptake of drugs despite uncertainty about benefit and harm,” write the authors. “Our findings show that simple explanations (ones that are brief enough even for television advertisements) help consumers make better decisions.”

Researchers recommend that the FDA more effectively communicate what it knows and does not know about how well drugs work.

For more on medication safety, see the library of articles by Daytona Beach medical malpractice attorney.

Researchers analyzed data from the Nationwide Inpatient Sample — a national database of hospital discharge records — from 1993-2008 and found a significant increase in infections related to cardiac electrophysiological devices or CIED.

Their analysis found that the annual incidence of CIED-related infection increased by 210 percent over the 16-year period studied. 

Further analysis showed a jump in infections after 2004, directly correlating with an increase in four major comorbidities or other medical conditions: renal failure, respiratory failure, heart failure and diabetes.

“We believe the growing number of clinical comorbidities in this patient population plays a large role in the increase in infections associated with CIEDs,” said Dr. Arnold J. Greenspon, professor of medicine at Jefferson Medical College of Thomas Jefferson University, director of Cardiac Electrophysiology at Thomas Jefferson University Hospital, and lead author of the study. “The patients are sicker, which may place them at higher risk for infection.”

Pacemakers and implantable cardioverter-defibrillators or ICDs are important in regulating the electrical signaling to the heart. Pacemakers help to speed up a slow heart rhythm (bradycardia) whereas ICDs help to slow down rapid heart rhythm (tachycardia), a potentially life-threatening condition.

The study showed a 96 percent increase in CIED implantation, mostly due to a marked increase in the use of ICDs.

“The expanding indications for ICD implantation may have contributed to the rise in infections since many of these patients have multiple medical co-morbidities,” said Dr. Greenspon. The highest infection rates occurred in white males over 65.

“The number of Americans receiving pacemakers and defibrillators has dramatically increased. This analysis shows that the infection risk associated with these devices has, unfortunately, increased as well,” said Greenspon. “A better understanding of the risk factors for infection will improve patient care and, hopefully, reduce the prolonged hospital stays that often result.”

Rising CIED infection rates also have economic implications for hospitals, as these patients require prolonged hospital stays which are associated with increased costs.

Researchers say further investigation into the risk factors that predict CIED infection or therapies to mitigate this issue is warranted.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

There are many different types of Staphylococci bacteria, which cause skin infections, pneumonia, food and blood infections (blood poisoning). Staphylococcus aureus or “Staph” is a very common germ that about 1 out of every 3 people have on their skin or in their nose. This germ does not cause any problems for most people who have it on their skin. But sometimes it can cause serious infections such as skin or wound infections, pneumonia, or infections of the blood.

While some S.aureus infections are treated easily with antibiotics, others are resistant (MRSA) to commonly prescribed antibiotics such as penicillin and amoxicillin.

The KeyPath MRSA/MSSA Blood Culture Test determines whether bacteria growing in a patient’s positive blood culture sample are MRSA or MSSA within about five hours after any bacterial growth is first detected in the sample. Aside from blood culture equipment, the test does not require any specific instruments to get results, which makes it useful in any laboratory.

“Clearing this test gives health care professionals a test that can confirm S.aureus and then identify whether the bacteria is MRSA or MSSA,” said Alberto Gutierrez, Ph.D., director of the Office of In Vitro Diagnostics Device Evaluation and Safety in the FDA’s Center for Devices and Radiological Health, in a news release.

MRSA infections can occur anywhere; however, infections appearing in health care settings are usually more severe and potentially life-threatening given patients being treated in those facilities may have weakened immune systems and frequently undergo procedures such as surgery, which allows an easier spread of bacteria directly into the body.

It is estimated that in 2005, the staph bug caused severe infections in nearly 95,000 Americans and killed more than 18,500 of them. However, in 2010 results from a CDC study showed that invasive (life-threatening) MRSA infections that began in hospitals declined 28% from 2005 through 2008. The study also showed a 17 percent drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.

Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be:

• Red
• Swollen
• Painful
• Warm to the touch
• Full of pus or other drainage
• Accompanied by a fever

The FDA based its clearance on a clinical study of 1,116 blood samples evaluated at four major U.S. hospital centers. Within the organisms determined to be S.aureus, the MRSA determination was 98.9 percent accurate (178/180) and the MSSA determination was 99.4 percent accurate (153/154).

“This not only saves time in diagnosing potentially life-threatening infections but also allows health care professionals to optimize treatment and start appropriate contact precautions to prevent the spread of the organism,” Gutierrez said.

For more on medical issues, see the library of articles by Daytona Beach nursing home injury attorney.

According to researchers, thyroidectomy is a common operation, but it can be associated with serious complications: paralysis of the recurrent laryngeal nerve (RLN, a nerve that transmits motor function and sensation to the larynx, or voice box) and hypoparathyroidism (caused by injury to the parathyroid glands, which make a hormone that controls calcium levels).

Unintentional damage to the RLN by this surgery is reported to cause nerve paralysis in one percent to two percent of cases. Extensive searching for the RLN during thyroid surgery may cause temporary or permanent hypoparathyroidism.

The authors note two methods of identifying the RLN: one approach locates the nerve where it enters the larynx (superior-inferior direction), and the other approach locates the nerve in the trachea-esophageal groove, and traces it in the superior direction (inferior-superior direction).

Dr. Bayram Veyseller, from Bezmialem Vakif University, Istanbul, Turkey, and colleagues conducted a study to compare both techniques. They studied patients undergoing partial or total thyroidectomy between January 2006 and August 2009.

In 67 patients, the superior-inferior RLN identification technique was used, and in 128 patients, the inferior-superior method was used, according to the attending surgeon’s preference.

Researchers evaluated patients’ vocal cord function and blood calcium levels on the first day after the surgery. Follow-up was conducted every three months until patients’ calcium levels improved, for an average of 26 months.

If at the one-year mark blood calcium levels were still low (a sign of hypoparathyroidism) or RLN paralysis did not improve, the conditions were considered permanent.

Permanent paralysis of the RLN occurred in two patients in the inferior-superior group, and none in the other group. Hypoparathyroidism among the superior-inferior group patients was temporary in four and permanent in none; among the inferior-superior group patients, 14 experienced temporary hyperthyroidism and four experienced permanent hypoparathyroidism.

Overall, significantly fewer complications were found in terms of RLN paralysis and hypoparathyroidism in the superior-inferior group, which is when surgeons locate the nerve where it enters the larynx.

“Significantly lower rates of RLN paralysis and hypoparathyroidism were observed in thyroidectomies using a superior-inferior approach,” the authors concluded. They added that more studies should be conducted to corroborate these results.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

The term Sepsis Belt might be a new one, though. Sepsis, a severe illness in which the bloodstream is overwhelmed by bacteria, also appears to have a belt of its own.

According to University of Alabama at Birmingham emergency physician Henry Wang, M.D., the death rate for sepsis is much higher in one geographic region of the United States — the same region in which stroke is most prevalent. The Stroke Belt spans 11 states from Louisiana to Virginia, but does not include Florida.

“In 2010, we examined death rates from sepsis across the United States,” said Wang, associate professor and vice chair for research in the UAB Department of Emergency Medicine, in a news release. “Laying it out on a map, we saw that the states with highest sepsis mortality formed a cluster in the Southeast United States, closely mirroring the appearance of the Stroke Belt.”

Wang says sepsis is responsible for 750,000 hospitalizations and some 200,000 deaths in the United States each year, about the same as for heart attack and breast cancer. Sepsis is triggered by infections such as meningitis or bacterial pneumonia, and can lead to shock, organ failure and death.

“There are a host of possible causes for this geographic cluster,” said Wang. “Possibilities include pre-existing medical conditions, health behaviors, diet, genetics and even the environment and air pollution.”

Wang will use data from REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, a large, long-term study of the Stroke Belt, funded by the federal government and based at UAB.

“We’ll be able to make extensive use of the REGARDS infrastructure, with access to information from the more than 30,000 people enrolled in that project,” said Wang. “With that wealth of information, we will be able to identify the characteristics of persons most likely to be hospitalized for sepsis. This information will may lead to strategies to prevent its onset.”

“Sepsis treatment is complex, dealing with disruption of blood flow, organs shutting down and shock,” he said. “Our current best course of action is to prevent sepsis from occurring in the first place. We hope our new research endeavor will lead to novel ways to prevent this disease and its effects.”

For more on medical issues, see the library  of articles by Daytona Beach medical malpractice attorney.