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Fixing the Breakdown in Patient Satisfaction Print E-mail
Written by Kevin Haselhorst, MD | KevinMD   
Thursday, 11 August 2016 00:00

Ruth was a spry, but frail 98-year-old woman who was stiff and sore following the 6-hour drive from California to Arizona. She had suffered a recent wrist injury and was not recovering well after spending three weeks in a rehabilitation center. She was in the midst of upheaval and discontent - in the throes of relocation to an assisted-living residence closer to her son. The facility's coordinator had begun to evaluate Ruth's aptitude and appropriateness for assisted living, but thought it best to have Ruth seen in the emergency department.

Ruth was hungry, but did not wish to eat. She felt like her bowels needed to move, but did not wish to use the bedside commode. While still engaging, Ruth wished to be left alone. Ruth had explained that she used to be able to tell herself not to be sick, but her higher power seemed to be failing her now. When a patient feels abandoned by a higher power, what hope is there for patient satisfaction? When patients are uncertain of what is in their best interest, how can physicians succeed at meeting their expectations? Does it become the physician's duty to tell Ruth that she is not doing well and further deflate her self-image?

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The BVS Disappearing Stent: Promise, Hype and the Tension Between Progress and Safety Print E-mail
Written by Dr. John M   
Tuesday, 02 August 2016 17:06

Medicine does not stand still. You want innovation; you want progress. But you also want safety.

Millions of patients have coronary stents placed in the arteries supplying blood to the heart. It's big business.

Metal cages placed in the setting of a heart attack can be life saving. In other settings, however, the strongest quality evidence says metal cages perform no better than medicines.

One of the two main reasons stents don't improve long-term outcomes for patients with stable coronary disease are that they trade improved blood flow (good) for the presence of a metal cage in the artery (bad). The metal cage can stimulate inflammation and cause the artery to lay down more blockage (neo-atherosclerosis). Also, the exposed metal can attract platelets and form clots (really bad).

But what if you could design a stent that dissolved over time? It opens the blockage, improves blood flow, stabilizes the vessel, and then disappears.

This is the promise of Abbott Vascular's Absorb GT1 bioresorbable vascular scaffold (BVS) system. It's been used in Europe since 2011 and was just approved by the FDA.

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A Failed Transition of Care Print E-mail
Written by A Country Doctor Writes   
Thursday, 28 July 2016 00:00

Alvion Barr had a four month delay in his diagnosis.

He is technically a patient of my colleague, Dr. Laura McDonald. But he had drifted between two of our regular doctors and a locum tenens physician we hired to work during March, when both Laura and Dr. Wilford Brown were on vacation.

I saw him late Thursday afternoon for a rash, but he also asked what he could do about his heartburn.

"Tell me more about your heartburn", I said.

What followed was a near classic description of angina pectoris.

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We were promised death panels Print E-mail
Written by FHI's Week in Review   
Monday, 25 July 2016 00:00

An anesthesiologist describes his participation in an emergent exploratory laparotomy in a 7.18.16 KevinMD post:

The patient is returned to the ICU with a breathing tube in place, but with better numbers and better color than she had an hour earlier. With some serious teamwork, we did what was necessary. It was not easy, and I relied on our nurses, nurse anesthetist, surgeon, scrub tech, and others to contribute and help me keep her alive. We did a great job. 

But did we?

Hours later, family convened, and the reality of the situation was presented. Her condition was more or less incompatible with life, and she wouldn't have a heartbeat if not for earlier and ongoing Herculean efforts. The family chose to withdraw care, and she passed away shortly thereafter.

According to the author: 

While we may not need death panels, and we certainly don't need care rationed by governmental bodies as the term suggests, we could certainly benefit from further discussion and consideration of what we want done to our bodies when we are facing near-certain mortality. As a society, we should recognize the importance of having a plan in place, and as physicians, we need to help our patients face these uncomfortable questions before the answers become necessary. 

...When we fail to address end-of-life issues, we rob people of the ability to die with dignity. 

...We did what we had to do for her; I wish we could have done less.

Read more in the current issue of Week in Review>>

Last Updated on Tuesday, 26 July 2016 18:06
The health care system that failed Prince needs an immediate intervention Print E-mail
Written by FHI's Week in Review   
Monday, 11 July 2016 00:00

Shruti Kulkarni, JD, in a 7/4/16 KevinMD post, writes:
It has now been confirmed that Prince's untimely death resulted from an overdose of the drug fentanyl.
It is unclear whether the lethal dose of fentanyl was a prescription medication or a counterfeit "analog" drug from the illicit market. Regardless, the facts are now clear enough to know that the U.S. health care system failed Prince in the same ways it is failing the 78 Americans who die every day from overdoses involving prescription opioids, heroin, and analog drugs.
The author points out that:

On April 15 of this year, a plane with Prince onboard made an unscheduled landing in Moline, Illinois, to take Prince to an emergency room, where he was administered the opioid-overdose reversal medication naloxone. Three hours later, Prince left the hospital and flew home to Minneapolis.
...On April 21, just six days after his non-fatal overdose, Prince overdosed again and died.
The prince of pop and king of style was one of a kind in his life but not in his death. According to the Palm Beach County sheriff's department, one in four individuals who die of an overdose in the U.S. previously suffered a non-fatal overdose. This can't keep happening.

Read more in the current issue of Week in Review>>
The Opioid Crisis: Stop Criminalizing the Doctors Print E-mail
Written by Cindy Perlin, LCSW | KevinMD   
Tuesday, 05 July 2016 00:00

It's an unmitigated disaster. One hundred million pain patients. Millions addicted to opioids, hundreds of thousands dead. Pain patients abruptly cut off medication they've depended on, sometimes for decades, and offered nothing to replace it. Doctors, fearful of prosecution for overprescribing, dropping pain patients like hot potatoes. Pain patients unable to find any doctor that will treat them. Patients turning to heroin when they can't get their prescription painkillers. Articles in prestigious medical journals suggesting that doctors stop asking patients about pain or offer them placebos. Reported suicides by pain patients who found life intolerable without their meds and threats by pain patients of more suicides.
How did we get to this terrible place? And how do we get out of it?

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Closest Thing to a Wonder Drug? Print E-mail
Written by Aaron Carroll, MD, MS   
Monday, 20 June 2016 00:00

After I wrote last year that diet, not exercise, was the key to weight loss, I was troubled by how some readers took this to mean that exercise therefore had no value.
Nothing could be further from the truth. Of all the things we as physicians can recommend for health, few provide as much benefit as physical activity.
In 2015, the Academy of Medical Royal Colleges put out a report calling exercise a "miracle cure." This isn't a conclusion based simply on some cohort or case-control studies. There are many, many randomized controlled trials. A huge meta-analysis examined the effect of exercise therapy on outcomes in people with chronic diseases.
Let's start with musculoskeletal diseases.

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Last Updated on Friday, 24 June 2016 13:07
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