July 9th, 2009 by DrRob in Better Health Network, True Stories
Tags: Acetaminophen, Coma, Family Medicine, Hepatology, Internal Medicine, Liver Failure, Liver Transplant, Pediatrics, Psychiatry, Suicide, Toxicology, Tylenol
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My worst night as a doctor was during my residency. I was working the pediatric ICU and admitted a young teenager who had tried to kill herself. Well, she didn’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.
On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning. We did everything we could to keep her alive, but without a liver there is no chance of survival.
Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests. I told the ER doctor to check an acetaminophen level and, sadly, it was elevated. She too had taken a handful of acetaminophen at an earlier time. She too was lucid and scared at the start of the evening. The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant. I got the call later that next day with the bad news: she died.
The saddest thing about both of these kids is that they both thought they were safe. The handful of pills was a gesture, not meant to harm themselves. They were like most people; they didn’t know that this medication that is ubiquitous and reportedly safe can be so deadly. But when they finally learned this, it was too late. They are both dead. Suicides? Technically, but not in reality.
For these children the problem was that symptoms of toxicity may not show up until it is too late. People often get nausea and vomiting with acute overdose, but if the treatment isn’t initiated within 8-10 hours, the risk of going to liver failure is high. Once enough time passes, it is rare that the person can be cured without liver transplant.
Acetaminophen overdose is the #1 cause of liver failure in the US. According to a Reuters article, there are 1600 cases of liver failure from this drug per year (2007). This is a huge number. In comparison consider that the cholesterol drug Cerivastatin (Baycol) was withdrawn from the market when there were 31 deaths from rhabdomyalysis (severe muscle break-down, which is far more common than liver failure in these drugs). These happened mainly when the drug was used in combination with another cholesterol drug.
Should the drug be pulled from the market? No, it is safe when used properly. The toxic dose is generally 10 times the therapeutic dose. My complaint is not that they have dangerous drugs available; ALL drugs should be considered dangerous. Aspirin, decongestants, anti-inflammatories, and even antacids can be toxic if taken in high dose. The problems with acetaminophen stem from several factors:
- Most people don’t realize the danger.
- There has been very little public education and no significant warning labels on the packages.
- The drug is often hidden in combination with other drugs, including prescription narcotics and over-the-counter cold medications. This means that a person can take excess medication without knowing it.
I would advocate putting warning labels on medications containing this drug. I am sure this doesn’t thrill the drug manufacturers, but the goal is not to make them happy. I have thought this since that terrible night during residency. If there was such a warning, perhaps she wouldn’t have died.
It seems a bit silly that this action by the FDA is coming after their pulling of children’s cough/cold medications. Those drugs have very small numbers of true harmful overdoses. The reason they were pulled was probably more that they didn’t do anything over the fact that they were dangerous. Acetaminophen, on the other hand, can be deadly.
Just ask the parents of my two patients.
*This blog post was originally published at Musings of a Distractible Mind*
July 9th, 2009 by Berci in Better Health Network, News
Tags: Britain, Communication, Hospital, Notificator, Twitter
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If you are a hospital, healthcare facility or parent system considering social media, please take the time to learn what is happening in the “Twittersphere”, and do pay attention to the evolving “agreements” of Twitter-etiquette.
*This blog post was originally published at ScienceRoll*
July 9th, 2009 by Harriet Hall, M.D. in Better Health Network
Tags: Costs, Expense, False Positive, Finance, Harm, Screening Tests
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It’s easy to think of medical tests as black and white. If the test is positive, you have the disease; if it’s negative, you don’t. Even good clinicians sometimes fall into that trap. Based on the pre-test probability of the disease, a positive test result only increases the probability by a variable amount. An example: if the probability that a patient has a pulmonary embolus (based on symptoms and physical findings) is 10% and you do a D-dimer test, a positive result raises the probability of PE to 17% and a negative result lowers it to 0.2%.
Even something as simple as a throat culture for strep throat can be misleading. It’s possible to have a positive culture because you happen to be an asymptomatic strep carrier, while your current symptoms of fever and sore throat are actually due to a virus. Not to mention all the things that might have gone wrong in the lab: a mix-up of specimens, contamination, inaccurate recording…
Mammography is widely used to screen for breast cancer. Most patients and even some doctors think that if you have a positive mammogram you almost certainly have breast cancer. Not true. A positive result actually means the patient has about a 10% chance of cancer. 9 out of 10 positives are false positives.
But women don’t just get one mammogram. They get them every year or two. After 3 mammograms, 18% of women will have had a false positive. After ten exams, the rate rises to 49.1%. In a study of 2400 women who had an average of 4 mammograms over a 10 year period, the false positive tests led to 870 outpatient appointments, 539 diagnostic mammograms, 186 ultrasound examinations, 188 biopsies, and 1 hospitalization. There are also concerns about changes in behavior and psychological wellbeing following false positives.
Until recently, no one had looked at the cumulative incidence of false positives from other cancer screening tests. A new study in the Annals of Family Medicine has done just that.
They took advantage of the ongoing Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial to gather their data. In this large controlled trial (over 150,000 subjects), men randomized to screening were offered chest x-rays, flexible sigmoidoscopies, digital rectal examinations and PSA blood tests. Women were offered CA-125 blood tests for cancer antigen, transvaginal sonograms, chest x-rays, and flexible sigmoidoscopies. During the 3-year study period, a total of 14 screening tests were possible for each sex. The subjects didn’t all get every test.
By the 4th screening test, the risk of false positives was 37% for men and 26% for women. By the 14th screening test, 60% of men and 49% of women had had false positives. This led to invasive diagnostic procedures in 29% of men and 22% of women. 3% were minimally invasive (like endoscopy), 15.8% were moderately invasive (like biopsy) and 1.6% involved major surgical procedures (like hysterectomy). The rate of invasive procedures varied by screening test: 3% of screened women underwent a major surgical procedure for false-positive findings on a transvaginal sonogram.
These numbers do not include non-invasive diagnostic procedures, imaging studies, office visits. They do not address the psychological impact of false positives. And they do not address the cost of further testing.
These data should not be over-interpreted. They don’t represent the average patient undergoing typical cancer screening in the typical clinic. But they do serve as a wake-up call. Screening tests should be chosen to maximize benefit and minimize harm. Organizations like the U.S. Preventive Services Task Force try to do just that; they frequently re-evaluate any new evidence and offer new recommendations. Data like these on cumulative false positive risks will help them make better decisions than they could make based on previously available single-test false positive rates.
“In a post earlier this year, I discussed the pros and cons of PSA screening. Last year, I discussed screening ultrasound exams offered direct to the public to bypass medical judgment). If you do 20 lab tests on a normal person, statistically one will come back false positive just because of the way normal lab results are determined. Figuring out which tests to do on a given patient, either for screening or for diagnosis, is far from straightforward.
This new information doesn’t mean we should abandon cancer screening tests. It does mean we should use them judiciously and be careful not to mislead our patients into thinking they offer more certainty and less risk than they really do.
*This blog post was originally published at Science-Based Medicine*
July 8th, 2009 by Nancy Brown, Ph.D. in Better Health Network
Tags: Birds And Bees, Conversation, Dating, HIV, Parenting, Pediatrics, Psychology, sex, STDs, teens
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Just a friendly reminder to parents that dating does not equal sex. I cannot tell you how many teens have shared with me that the first lecture they got from their parents when they started dating was about sexually transmitted infections, including HIV and unwanted pregnancy. Their reactions were “what?”
When young teens start dating it is because they have found themselves twitterpated (which is apparently not a real word), and attracted to someone. Chances are good it is more of an emotional attraction than a sexual one, and one that will wax and wane, usually end with tears, but not kill them.
It is easy to understand why parents panic and worry about sexuality and the risks associated with that sexuality – we live in an extremely over-sexualized culture that can make us believe that everyone is having sex – which is not true. Please remember that only half of teens start being sexual before they are 18, but most fall in love at least once before leaving high school.
Dating is about learning how to be in a relationship, and you will be doing your children a great service if you talk with them about relationships, not sex. It is a good idea to make the difference really clear for them, and make your expectations very clear, too! If you expect your teen to not become sexual, tell them that, and why. Ask them to tell you what there limits and expectations about relationships and sex are. Here are some topic suggestions:
- What do they think dating includes?
- What does sexual pressure look and feel like?
- How would your child resist sexual pressure?
- How long do they think people should date before the topic of sex even comes up?
- How will they know if someone is the “one?”
- What would have to happen before they did think about sexual behavior?
If the possibility exists that they will be sexual, then, you can have the conversation about sex – but not if they tell you they will not be swayed and are not interested – you have to trust them.
Many teens are afraid of dating or choose not to date because a partner may expect sex, so they find a friend or pseudo partner to attend events with and protect them from having to resist sexual pressure – which is a great strategy, but keeps them from trying on relationships.
Oh the conversations that we might have … keep talking and make sure they know you are open to talking – even about things that make you squirm.
This post, Teen Dating Does Not Mean They’re Having Sex, was originally published on
Healthine.com by Nancy Brown, Ph.D..
July 8th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Health Tips
Tags: Academics, Achievement, kids, Kids Need A Break, Parenting, Pediatrics, Pressure, Summer School
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I used to feel guilty when I would say “no thanks” but not any more. I no longer by the line: “Ok…but you do know she might get behind…many of the other kids do continue for the summer.”
I’m ok with it…and so are my kids. And, you know what, not once have they “fallen behind” in any of their activities, even the ones they are at the top of their game on, in sports or in the arts.
It’s a myth that the sports world is the only world with year ‘round pressure. The music and arts worlds have it, too. Those worlds, in fact, can be more insidious about it because it’s done under the guise of “enrichment” and “culture”. The 24/7 wear and tear on our kids bodies, minds, and souls is, nonetheless, the same as with a ‘year round sport and it’s time music, dance and other fine arts parents recognize that their kids, too, need an off season.
The way to look at it is that any school year after school activity that occupies a great deal of time and focus and goes on for most of the school year, or more than 1 celestial season, requires an off season. The model is in the pro worlds. Pro athletes get off seasons and professional dancers and musicians do take breaks from the intense rigor of their professional season.
Our children have 1 childhood and only so much time in it to explore themselves and pursue activities that interest them. Given how much of the school year’s schedule is dictated by adults, the summer is the best time to hand over the reins to our kids and find out what they want to do and make it happen. The summer is the most perfect time to spread wings and try on something new, something that they may have had to shelve by necessity during the school year.
So, don’t buy into the “she’ll get behind” line – in sports or in the arts. Give your kids the off season this summer they deserve. Just like the off season in the pro worlds, kids use the time so productively that by the time they return to their beloved passions, they have a new found energy, zeal and focus. The rust will come off amazingly quickly and they’ll surge ahead again as if the summer never occurred.
Why not just keep on going, you ask? You could…but you may end up turning an activity your kids love into a complete grind and burn them out entirely. Plus, injury rates increase dramatically in sports and the arts when kids don’t have a break. Musicians and dancers put wear and tear on their bodies just like athletes, but with different muscle groups. Those areas of their bodies need to rest and rehab, in addition to their minds and souls having a chance to not focus so intensely for a while.
Childhood isn’t about specialization, it’s about variety. We’ve forgotten that along the way, and our kids’ bodies and spirits are paying a steep price.
*This blog post was originally published at Dr. Gwenn Is In*
