April 27th, 2011 by Michael Kirsch, M.D. in Health Policy, News, Opinion
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Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.
What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?
This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.
Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes? Read more »
*This blog post was originally published at MD Whistleblower*
April 2nd, 2011 by Bongi in True Stories
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Surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. I remember one time that this turned out to be slightly humorous in a morbid sort of way.
I was in my vascular rotation which was not too much fun (except for a short moment). Generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. And there was pretty much nothing worse than an abdominal aorta aneurysm (AAA). Scratch that. A bleeding AAA was a lot worse than an AAA. So when casualties called and said they had a bleeding AAA my heart sank.
The patient was pale and clammy and his heart was racing. But the thing that struck me the most was his age. The man was 89 years old. The casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. So, in summary we had a man just this side of ninety with comorbidities and a condition that was known to kill most of its victims thirty years younger than him. The chances of him surviving the operation were dismal. I called my senior. Read more »
*This blog post was originally published at other things amanzi*
March 31st, 2011 by Mary Knudson in Expert Interviews, Health Tips
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I am saddened that Elizabeth Taylor died recently of heart failure. In his appreciation of her, film critic Roger Ebert said in the Chicago Sun-Times, “Of few deaths can it be said that they end an era, but hers does.”
She is a star that many of us felt we knew. She was a great actress and a woman of great beauty who was a hard working champion of people with AIDS and always seemed to be a determined person who knew herself. Yet she always had a vulnerable side. So many marriages, so many illnesses, so many, many surgeries, over 40, I’ve read. And then her heart problem developed. Which leads me to talk a little about that problem, mitral valve leakage.
The heart’s mitral valve
The heart has four chambers and four valves that open to let blood through to the next chamber of the heart and on out to the body and back. The valves, acting as gates, then immediately close to prevent the blood from running back where it just came from. The mitral valve looks like a mouth with leaflets that look like lips that open and close. When I saw it in action on an echocardiogram, a test that uses sound waves to show moving pictures of the heart, I thought it looked like a very sensuous mouth. Each of the valves looks different. But because it looks like a mouth, the mitral valve stands out. Blood has just left the lungs carrying oxygen and arrives at the left atrium of the heart. The mitral valve’s mouth opens to let the blood pour through into the left ventricle. As the left ventricle contracts, the mitral valve closes and the aortic valve opens to allow blood to leave the heart and get out to the body.
A mitral valve can start to leak. This can range anywhere from a condition that is minor and does not need treatment to a serious problem that leads to a weakened heart and heart failure. In Elizabeth Taylor’s case, it led to heart failure and her symptoms must have included difficulty breathing and fatigue.
I asked Edward K. Kasper, M.D., director of clinical cardiology at Johns Hopkins Hospital, to talk a little about what can go wrong with a mitral valve. I should mention for disclosure that Ed is my cardiologist and co-authored with me the book Living Well with Heart Failure, the Misnamed, Misunderstood Condition:
A leaky mitral valve – mitral regurgitation, is common and has many causes. Most people tolerate a leaky valve well, but some need surgery to correct the leak. Repair is preferred to replacement. The MitraClip (which was used for Elizabeth Taylor) is a new technique to try and fix mitral regurgitation in the cath lab rather than in the operating room. There are no long-term comparison studies of this technique compared to standard OR repair – that I know of. Repair is currently the gold standard for those who have severe mitral regurgitation and symptoms of heart failure. Outcomes are better including improvement in symptoms and survival in patients with repair rather than replacement.
What takes a person from a leaking mitral valve to heart failure?
The leakage back into the left atrium increases the pressure in the left atrium. This increased pressure in the left atrium is passed back to the lungs, causing fluid to leak into the lungs, leading to heart failure. With time, the demands of severe mitral regurgitation on the left ventricle will lead to a weakened left ventricle, a dilated cardiomyopathy (disease of the heart muscle). We try to prevent this by operating before it gets to that point.
Mitral regurgitation can also be a consequence of a dilated cardiomyopathy – the orifice of the mitral valve enlarges as the left ventricle enlarges. The leaflets of the mitral valve do not enlarge. Therefore, they no longer close correctly, leading to mitral regurgitation.
It’s easy to see why anyone would want to opt for the Evalve MitraClip over open heart surgery. The MitraClip is little different from a common test known as an angiogram in which a catheter is passed through the femoral vein in the groin up to the heart. In this repair procedure, however, the catheter guides a clip to the mitral valve where the metal clip covered with polyester fabric is positioned over the leakage and brought down below the open flaps and back up, fastening the valve’s open leaflets together. The manufacturer, Abbott, shows in a video here how blood still is able to pass through on either side of the fastening.
Elizabeth Taylor got her MitraClip repair a year and a half ago, so it must have worked for awhile. Then about six weeks ago she was hospitalized with heart failure at Cedars-Sinai Medical Center in Los Angeles where she died with her family at her bedside. For more on mitral regurgitation, see this NIH site.
Heart failure has many other causes. High blood pressure can damage the lining of blood vessels leading to deposits of cholesterol. Coronary artery disease causes heart attacks. A heart attack kills part of the heart muscle, forcing the rest of the heart to work harder and in doing so, get large and weak. Only about half the people who develop heart failure have a weak heart. In another cause of heart failure, the left ventricle becomes stiff and the heart does not fill properly. And in some heart failure, the heart itself is normal but connecting blood vessels are not or a valve may be too narrow. In all of these cases, a person is said to have heart failure because the heart and vascular system are not able to provide the body with the blood and oxygen it needs.
*This blog post was originally published at HeartSense*
March 29th, 2011 by AnneHansonMD in Opinion, Research
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I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I’d summarize the highlights for the blog. If you’d rather watch the recorded web seminar you can hear it here.
The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).
This is what they found:
- 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
- These findings support the conclusion that there should be strong integration of medical and mental health care Read more »
*This blog post was originally published at Shrink Rap*
March 28th, 2011 by PJSkerrett in Health Tips, News
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The condition that took Elizabeth Taylor’s life affects millions of Americans.
Reports of Elizabeth Taylor’s death focused, as they should, on her life, not on her death from heart failure. But given how common this condition is—the American Heart Association says nearly 6 million Americans are living with heart failure and it kills about 300,000 each year—a little attention to it might be a good idea.
What is heart failure?
The term “heart failure” is a scary one, conjuring up images of a heart that is suddenly unable to work. In truth, it represents a gradual decline in the heart’s ability to pump enough blood to meet the body’s needs. As the heart weakens, all parts of the body suffer the consequences. Read more »
*This blog post was originally published at Harvard Health Blog*
Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.
