January 31st, 2008 by Dr. Val Jones in News
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Tonight (Jan 31, 2008) the CBS evening news will be airing a segment about a tragic case of a young Marine who died of melanoma. According to the news transcript, an unusual mole was diagnosed as a melanoma in 1997, but no follow up was scheduled, and no explanation given to the young man about his diagnosis or treatment plan. Eight years later in Iraq he complained to medical personnel of the mole growing larger and he was told it was a wart which would be treated once he returned to US soil. He slipped through the cracks somehow, and tragically died in 2008 of stage IV melanoma.
One interesting issue raised in the segment is that the Marine was not eligible to to sue for negligence in his case. There is a law, the Feres Doctrine, that denies military personnel the right to sue the government in cases of perceived or real medical malpractice. The rule was established in 1950 after a case was brought to the U.S. Supreme Court (Feres v. United States) in which servicemen who picked up highly radioactive weapons fragments from a crashed airplane were not permitted to recover damages from the government.
While I do understand (in theory) the purpose of this law – if every battle injury allowed soldiers to sue the government, we’d bankrupt our country in the span of a year – it does seem to be over-reaching in this case. The Marine was not injured in battle, but his life was indeed compromised by sloppy medical follow up. In my opinion, the doctor who correctly diagnosed him in 1997 should be held accountable for lack of follow up (if that’s indeed what happened). As for the military personnel who thought the Marine’s advanced melanoma was a wart, that is a tragic misdiagnosis, but hard to say that there was malpractice at play. With limited access to diagnostic pathology services, it is difficult (in the field) to be sure of the diagnosis of a skin lesion. And yes, I can imagine that an advanced melanoma could look wart-like. This is a tragic shame, but since the young man had the melanoma for 8 years prior to the misdiagnosis of the “wart,” in the end I doubt that a correct diagnosis at that point would have changed his terminal outcome.
But I wonder if the Feres Doctrine should be modified to allow for more accountability amongst military physicians in caring for diseases and conditions unrelated to military service? Although I am not pro-lawsuit, it does seem unfair that this Marine was denied the opportunity to pursue justice in his case. What do you think? Check out the segment with Katie Couric tonight and let’s discuss.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 23rd, 2008 by Dr. Val Jones in News
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I was shocked and saddened to hear of the sudden and unexpected death of actor Heath Ledger. As fate would have it, I had watched his movie, “Candy” on the weekend prior to his death. Candy is the sad story of a young Australian couple who get involved in the drug culture, begin shooting heroin, and end up as junkies, prostituting themselves to afford their habits.
While the cause of Heath’s death is not yet known, a drug overdose is suspected and autopsy results will not be available for up to two weeks. A coworker asked me why the results would take so long, and what’s involved in an autopsy. I found a good article on the subject and will excerpt it here:
- Before the actual autopsy, as much information as possible is gathered about the person who died and the events that led to the death. Other information may be gathered by investigating the area where the person died, and studying the circumstances surrounding the death.
- Procedures done during the autopsy may vary depending on the circumstances surrounding the death, whether the medical examiner or coroner is involved, and what specific issues are being evaluated during the autopsy.
- The autopsy begins with a careful examination of the external part of the body. Photographs may be taken of the entire body and of specific body parts. X-rays may be taken to evaluate skeletal or other abnormalities, confirm injuries, locate bullets or other objects, or to help establish identity. The body is weighed and measured. Clothing and valuables are identified and recorded. The location and description of identifying marks, such as scars, tattoos, birthmarks, and other significant findings (injuries, wounds, bruises, cuts), are recorded on a body diagram.
- A complete internal examination includes removal of and dissection of the chest, abdominal, and pelvic organs and the brain. The examination of the trunk requires an incision from the chest to the abdomen. The removal of the brain requires an incision over the top of the head. The body organs are examined before removal, then removed and examined in detail.
- In some cases, organs may be placed in a preservative called formalin for days to weeks prior to dissection. This is particularly important in the examination of the brain for certain types of diseases or injuries. Tissue samples are taken from some or all of the organs for examination under a microscope.
- Completion of the autopsy may require examination of tissues under a microscope, further investigation of the circumstances of death, or specialized tests (such as genetic or toxicology tests). The tests performed may vary based on the findings at the autopsy dissection, the circumstances of death, the questions asked about the death, and the condition of the tissues and body fluids obtained at autopsy. A written report describes the autopsy findings. This report may address the cause of death and may help answer any questions from the deceased person’s doctor and family.
So it makes sense that autopsy results take as long as they do. A thorough investigation requires everything from documenting items from the scene of the death, to a careful analysis of blood toxins, to preserving tissues in formalin before viewing them under a microscope. All of the clues must be carefully weighed (Is there any evidence of a heart attack? Was there a blot clot in the lungs? Was there a brain hemorrhage?) to get the full picture and to be sure of the exact cause of death. All things considered, it’s amazing that the pathologists can render an opinion so quickly.
My heart goes out to Heath’s family as they await closure on the cause of his death.
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See also:
Mira Kirshenbaum discusses depression, suicide, and a healthy way to handle stressful life circumstances
.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 25th, 2007 by Dr. Val Jones in Expert Interviews
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My former mentor, Dr. Richard Robb, is Director of the Biomedical Imaging Resource Center at the Mayo Clinic, Rochester, Minnesota. I first met Dr. Robb as a Summer Undergraduate Research Fellow (SURF) in the Department of Biophysics at Mayo in 1994. Behind his reserved exterior is a man who is bursting with enthusiasm about the amazing technological advances that are making it possible for us to see cells, tissues, and organs in ways barely conceived of several decades ago. Dr. Robb admits that his passion for improving the quality of anatomical visualization is a response to a challenge once given him by a neurosurgeon colleague: “If I can see it, I can fix it.” Dr. Robb’s life’s work is to enable physicians and surgeons to be more effective healers through direct visualization of anatomy and physiology.
I caught up with Dr. Robb (at the Society for Women’s Health Research briefing on imaging and women’s health) and asked him a few questions about the future of medical imaging. Here are some excerpts from our interview:
Dr. Val: What is micro CT and what information does it give doctors?
Dr. Robb: Micro CT is a specialized kind of scanner that works on the same principles as regular CT scanners but it can capture images at much higher resolution. Structures as small as 5-10 microns in size can be seen. Although this is an emerging technology used primarily for research purposes, it has tremendous potential and implications for the future. With such resolution, we’ll be able to do “virtual biopsies” of suspicious tissue that we find with a regular CT and then zoom in with the Micro CT to get a close look at microscopic detail without having to do a biopsy to study them.
Dr. Val: What is SISCOM and who benefits from it?
Dr. Robb: SISCOM is an acronym for “Subtraction Interictal Spect COregistered to Mri.” It is used to pinpoint small parts of the brain that cause epileptic seizures, so that surgeons can effectively remove the diseased tissue. SISCOM uses radioactive tags that are absorbed by the parts of the brain that are over-active during a seizure, and they glow like a lightbulb on SPECT brain scans that are subtracted and registered onto MRI scans. The radiologist can pinpoint the exact focus of the abnormal epileptic discharges and then show the surgeons exactly where they need to resect the tissue. This technique allows surgeons to cure many patients who suffer from seizures that don’t respond to medications.
Dr. Val: What is the most exciting new imaging technology under development and how will it impact health?
Dr. Robb: The most exciting future technologies will allow us to visualize tissue functions at a chemical level. In the next 10 years we’ll see major advancements in image resolution and micro imaging techniques, and eventually we’ll be able to see individual molecules. This technology could actually eliminate the need for surgical biopsies, replacing them with “virtual or digital biopsies”, including close up images of cells and chemical reactions, such as diffusion, all in the context of surrounding macro-sized structures. The effect of the chemical actions and reactions will be expressed visually at the organ function level.
Also, in the next 10-20 years the development and clinical use of “nanobots”, or tiny robotic elements, that can be ingested or injected into the body will become manifest. These may be used with special biomarkers – substances that preferentially label tissue types and pathology within the body. These traveling nanobots can, for example, either go to the biomarkers or expore intelligently certain anatomic domains, taking pictures inside GI tracts, pulmonary airways, or even blood vessels. They will then analyze these images for detection and characterization of abnormalities (like a polyp) followed by administering treatment to the abnormality (e.g., remove it by ablation or radiation or chemicals). The nanobot will remain in the body until it has removed or repaired the targeted pathology or trauma, then it will exit through natural means or “self-destruct” in a safe way. Nanobots could reduce the need for more invasive surgeries, and dramatically improve clinical outcomes with very low risk and morbidity.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 30th, 2007 by Dr. Val Jones in Opinion
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You may remember the horrifying story of a young French woman who passed out after taking some sedatives, and her dog tried to wake her up by gnawing on her face. She was the first recipient of a face transplant, and is on immunosuppressant therapy to this day to prevent rejection of the donor tissue. This immunosuppression puts her at greater risk for cancer and infections and raises the issue of whether the benefits (a closer approximation of a normal appearance than reconstruction of her face from her own body tissue) outweigh the risks (a shortened lifespan and potential hospitalizations for infections, eventual tissue rejection, and perhaps cancer.)
Many people suffer severe facial disfigurement from accidents and burns every year. Face transplants could give them a chance at a relatively normal appearance – but American doctors are unwilling to put them at risk for what is in essence a cosmetic procedure. However, Harvard physicians are now offering face transplants to those who are already on immunosuppressants for organ transplants they’ve previously received. As you may imagine, the number of people who qualify for face transplants is rather small – as you’d have to have had an organ transplant and then coincidentally sustained severe trauma and tissue loss to the face.
The Boston Globe ran an interesting story on a man who was severely disfigured by facial burns and could have been eligible for a face transplant in France. He chose to undergo reconstruction from his own tissues, which requires no immunosuppression. He says that he is glad that his body is healthy, that he requires no medications, and that the risks of a face transplant are not worth the benefits, though he remains severely disfigured.
I think it’s interesting that the French took a different stand on this issue – allowing people to choose to have a cosmetic procedure at the expense of general health, longevity, and risk for life-threatening illness.
I have known patients who decline limb amputations for fear of disfigurement – even though the gangrene in the limb is sure to result in sepsis and eventual death. A person’s appearance and personal identity are sometimes inextricably linked – so that some would choose death over disfigurement (even of a limb). Is this choice pathological, or is it their right to choose? Given the choice between disfigurement or death, I’d choose disfigurement. I’d also not choose a face transplant over reconstruction from my own tissues, even if the aesthetic outcome is inferior. Still, I’m hesitant to say that those who’d rather live a shorter, less healthy life with a more natural face are unilaterally making the wrong choice for them. For the time being, though, people who wish to make that choice will need to do so outside of the US.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 26th, 2007 by Dr. Val Jones in Opinion
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-Continued from previous post–
In contradistinction to these patients exposed to tumor cells who did not develop malignancies, other studies have shown that normal cells can become malignant in an environment where a malignancy had developed. One study, for example, followed two leukemia patients whose bone marrows were eradicated with radiotherapy and who subsequently received bone marrow transplants from normal donors. Two to four months following the procedure, the transplanted bone marrow donor cells were found to have become leukemic.(11)
Clearly, cellular environment plays a critical role in cancer development. Malignant cells infused into a normal environment may not produce a tumor while normal cells placed into an environment that had previously harbored a tumor can become malignant. We are no longer even sure from what cell type a particular cancer develops. Stomach cancer in mice has been shown to originate not from the lining cells of the stomach, as we had thought, but from bone marrow cells responding to experimentally-induced stomach inflammation.(12) The problem may be the environment not the “malignant” cell.(13)
Are we at least able to recognize clinically significant cancer? Can we confidently say, as one judge did when defining pornography, “I know it when I see it.?” Apparently not.
Autopsies on people who died of non-malignant causes have caused us to re-examine our definition of cancer. Patients with previously treated Hodgkins disease—showing no clinical evidence of tumor and thought to have been cured, who died of unrelated causes—were found on autopsy to have residual foci of the disease.(14) Although thyroid cancer is diagnosed in only 1 in 1000 adults between the ages of 50 and 70, on autopsy it has been found in 1 of 3 adults.(15) The prevalence of clinically apparent prostate cancer in men 60 to 70 years of age is about 1%; nevertheless, over 40% of men in their 60s with normal rectal examinations have been found to have histologic evidence of the disease,(16) and autopsy studies have found evidence of prostate cancer in 1 out of 3 men by age 50(17), a finding which rises to 7 out of 10 men by age 80.(18) Similarly, clinical breast cancer is diagnosed in 1 out of 100 women between the ages of 40 and 50;(19) on autopsy it was found in a startling 1 out of 2.5 women in this age group. Moreover, over 45% of the autopsied women had more than one focus of breast cancer and 40% had bilateral breast cancer.(20)
What, then, is cancer? What is responsible for the clinical behavior of cancer, sometimes lying dormant and undiagnosed because it causes no symptoms, sometimes progressing inexorably to death?
For the present, we don’t know the answers to these questions. We have developed treatment programs that offer the best current options for cure, but we should, and do, remain unsatisfied with these approaches. First, because they don’t always work and, second, because with rare exception, they are based on trial and error, not on an understanding of the disease process we are treating.
Once we identify the processes responsible for the accumulation of cells into tumors, we can treat these conditions more effectively, reduce or eliminate the side effects associated with many of our current “best practice” treatments, and remove the terror currently shadowing cancer the way terror used to shadow diseases like syphilis, tuberculosis, and pernicious anemia before we learned how they were caused and developed treatments directed at those causes. We are making progress. Stay tuned.
REFERENCES
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This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
