February 17th, 2011 by Peggy Polaneczky, M.D. in Health Tips, Research
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Bioadhesives are a reasonable alternative to sutures for repair of perineal lacerations sustained during childbirth, according to a poster presentation at last week’s annual meeting of the Society for Maternal-Fetal Medicine.
Researchers at the Hadassah Hebrew University Medical Center in Jerusalem randomized women with first degree perineal tears to either 2-octyl cyanoacrylate (Dermabond) adhesive glue or suture for wound closure. While healing and incisional pain was similar, women who received the adhesive closure were more satisfied than those who were sutured.
In Portugal, bioadhesives have been studied for closure of the top skin layer of an episiotomy repair, and found to shorten the duration of the procedure with similar outcomes to suture in terms of pain, healing, and infection.
Biologic adhesives are chemically related to Super Glue, which is ethyl-cyanoacrylate. Midwives have been using Super Glue for perineal wound repair for some time, according to Anne Frye, who has authored a book on wound closure for midwives, and who gives instructions for its use in repair of perineal lacerations. Apparently Super Glue was also used by the military during Vietnam for wound closure.
A PubMed search on Dermabond finds multiple studies of its use, from plastic surgery to mastectomy, surgical wound closure, retinal surgery, lung and gastric leak closure, and even on esophageal varices. RL Bates mentions Dermabond as an option to repair skin tears in elderly patients. This stuff is turning into the duct tape of the medical profession.
It’s important to remember that adhesives are only for superficial skin closure, as use in deeper layers can cause irritation and burning of tissues. Side effects of their use include irritation and allergic reactions and of course wound infections, and pain can always occur no matter how one closes a wound.
*This blog post was originally published at The Blog That Ate Manhattan*
February 15th, 2011 by KevinMD in Better Health Network, Opinion
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Abdominal pain is the bane of many emergency physicians. Recently, I wrote how CT scans are on the rise in the ER. Much of those scans look for potential causes of abdominal pain.
In an essay from Time, Dr. Zachary Meisel discusses why abdominal pain, in his words, is the doctor’s “booby prize.” And when you consider that there are 7 million visits annually by people who report abdominal pain, that’s a lot of proverbial prizes.
One reason is the myriad of causes that lead bring a patient to the hospital clutching his abdomen. It can range from something as relatively benign as viral gastroenteritis where a patient be safely discharged home, to any number of “acute” abdominal problems necessitating surgery.
But more importantly, we need to consider how limited doctors actually are in the ER. Consider the ubiquitous CT scan, which is being ordered with increasing regularity:
The pros: CT scans are readily available, able to look at every organ in the abdomen and pelvis, and very good for ruling out many of the immediately life-threatening causes of belly pain. CT scans can also reduce the need for exploratory surgery. The cons: Often, CTs can’t diagnose the actual cause of ER patients’ abdominal pain. Worse, CTs deliver significant doses of radiation to a patient’s abdomen and pelvis (equivalent to between 100 and 250 chest X-rays). Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors.
Add that to the fact that patients expect a definitive diagnosis when visiting the hospital — one that doctors can’t always give when it comes to abdominal pain. Read more »
*This blog post was originally published at KevinMD.com*
February 9th, 2011 by GruntDoc in Better Health Network, News
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From an AP article in the Dallas-Fort Worth Star-Telegram:
AUSTIN — Texas medical regulators on Friday placed on probation a West Texas doctor involved in the unsuccessful prosecution of two nurses who complained anonymously that the physician was unethical and risking patients’ health.
The Texas Medical Board technically suspended Dr. Rolando G. Arafiles Jr. but allowed him to continue to practice medicine while on probation for four years if he completes additional training.
The board also said Arafiles must be monitored by another physician and submit patient medical and billing records for review. The monitor will report his or her findings to the board.
In the mediated order signed in Austin, the board concluded that Arafiles failed to treat emergency room patients properly, did not apply hormone therapy to a female patient appropriately and failed to document patient diagnoses and treatment plans.
The board also found that Arafiles improperly tried to intimidate two nurses who reported him to the medical board for unethical behavior.
Ugh.
*This blog post was originally published at GruntDoc*
February 5th, 2011 by Veronica Sikka, M.D., Ph.D. in Health Policy, Opinion
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In 1986, when Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals and ambulance services were mandated by law to stabilize anyone needing emergency healthcare services regardless of citizenship, legal status, and/or insurance status.
This was instituted at the time to prevent the prevalent practice of “dumping” — refusing to treat patients because of insufficient insurance or transferring or discharging patients on the basis of anticipating high diagnosis and treatment costs. While the implications of this law are indeed very noble in providing undifferentiated care to all patients based solely on healthcare needs and not financial status, it has unfortunately led to many patients presenting to the emergency department (ED) for primary care issues.
The misconception is that the care in the ED is similar if not better (because of increased access to consult services and imaging) and quicker than waiting to see your primary care physician (PCP). A 2010 study published in Health Affairs found that 14 percent to 27 percent of visits to hospital EDs are nonemergent, such as minor infections, strains, fractures, and lacerations. The study found that all of these cases could have been appropriately triaged in urgent care centers or retails clinics.
England has a model that may be a potential solution. The healthcare goal of the National Health Services (NHS) is to “treat the right patients in the right place at the right time.” The NHS employs nurses and paramedics to handle 999 (their equivalent of our 911) triage calls with more appropriate triaging of patients based on acuity. Read more »
February 2nd, 2011 by Edwin Leap, M.D. in Better Health Network, Opinion
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My partners and I have long struggled with the lack of specialty back-up at our hospital. Semi-rural hospitals, out of the way facilities, just can’t always attract specialists. So, we’re happy to have cardiologists every night, but understand that we only have an ENT every third night. We’re thankful to have neurologists, even if they don’t admit anyone. We’re glad to have radiologists, even if they don’t read plain films after 5PM on weekdays.
Still, I continue to scratch my head about why only three of seven community pediatricians take call, such that family physicians have to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation when their offices were close by the hospital. (In the same year they were called in roughly three times per neurologist for urgent stroke evaluation.) That problem was resolved, thank goodness.
Now, I find that the problem has returned and grown. We will, very soon, have no ophthalmologist on call, despite the fact that we have three in the community and that they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on the weekend. And the pediatric problem remains.
Of course, I’m using my local experience to highlight something that isn’t a local problem at all. It’s a national problem. All over America, specialists are relinquishing their hospital priveleges and staying in the office. Proceduralists are opening surgery centers that are free from the burdens of indigent care. Primary care physicians are allowing hospitalists to do all of their admissions.
In the process, not only are patients losing out, but referral centers are being absolutely overwhelmed. The cities and counties that lie around teaching hospitals are sending steady streams of patients, since they have fewer and fewer specialists. Those referral and teaching centers want patients, but they can’t take all of the non-paying patients, all of the complicated, or even all of the mundane patients with no local coverage. Those facilities, for all their shiny billboards and “center of excellence” marketing, will collapse. Read more »
*This blog post was originally published at edwinleap.com*
