September 23rd, 2009 by David Kroll, Ph.D. in Better Health Network, News, True Stories
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From today’s article by the always-interesting Sarah Avery at the News & Observer:
After several failed attempts to extract the item, Manley was referred to another doctor, who suggested removing the entire left lung. “I said, no, I wouldn’t be doing that,” Manley says.
That’s when he decided to seek a second opinion at Duke University Medical Center.
We’ve heard of “hot tub lung” and “popcorn lung” but my chest hurts just thinking about “jagged, fast-food implement lung.”
If this case does not make it into the New England Journal of Medicine, I will be disappointed.
Photo credit: Duke Hospitals via the News & Observer
Title quote: courtesy of Dr Momen Wahidi, director of interventional pulmonology at Duke
*This blog post was originally published at Terra Sigillata*
September 16th, 2009 by DrRob in Better Health Network, Health Policy
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I got something in my e-mail this morning. It’s a press release aimed at helping with prostate cancer awareness month, and is supported by Lance Armstrong’s foundation.
SURVEY SHOWS AT-RISK MEN LACKING IN PROSTATE CANCER KNOWLEDGE
SUNNYVALE, CALIF.,– September 9, 2009 – Prostate cancer remains one of the most commonly diagnosed cancers in the United States. In fact, one in six men will develop prostate cancer. It is also the second-leading cause of cancer death in the United States. But a recent survey suggests that many men at risk for the cancer still aren’t aware of all available treatment options. The survey, conducted late last year, reveals that nearly 50% of men aged 40 and older are not aware of the most common approach to surgery for prostate cancer — robotic-assisted surgery to remove the prostate. “I had to do my own research and then self-admit myself to the [hospital],” says surgery patient Tim Propheter. “…. Most people are just told … ‘Sorry, you have to have surgery, and we’ll set you up for such and such day,’ and they don’t know any better until they run into someone like me,” he says. This lack of information persists despite the fact that prostate cancer treatment has changed dramatically in the last decade. For example, surgery — which remains the gold standard treatment for localized prostate cancer — has become much less invasive. According to the American Urologic Association, the major benefit of prostatectomy, or prostate removal, is a potential “cancer cure” in patients with localized or early stage cancer.
Guess who the press release was from? Guess who sponsored the survey? The following was at the bottom of the email:
About the survey
Data was collected from 1000 self-selected adult healthcare information seekers through an online panel available through Ztelligence.com, using an survey questionnaire. Fifty-four percent of those were male and 46 percent were female. The results reflect only the opinions of the healthcare seekers who chose to participate.
About Intuitive Surgical, Inc.
The survey was conducted by Intuitive Surgical, Inc. (NASDAQ: ISRG), the manufacturer of the da Vinci Surgical System, the world’s only commercially available system designed to allow physicians to provide a minimally invasive option for complex surgeries. Intuitive Surgical, headquartered in Sunnyvale, California, is the global technology leader in robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company’s mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Intuitive Surgical — Taking surgery beyond the limits of the human hand.™
Imagine that. A survey done by company that sells the da Vinci robotic surgical equipment shows that men have tragically no knowledge of the da Vinci robotic prostate surgery!
So let’s see what the evidence shows:
- Prostate cancer occurs in 186,000 men each year and kills nearly 29,000.
- In a well-known autopsy survey, over 1/3 of men over 80 were found to have cancer present in their prostate without evidence of significant disease. It is not clear how many of these men will progress to overt cancer, but it is very clear that this is the vast minority.
- PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates. It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.
From the reference uptodate.com:
The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up; however, 48 additional patients would need aggressive treatment to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments. Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after seven to ten years of follow-up. The crux of this screening dilemma was aptly stated by the urologist Willet Whitmore, who asked “is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?”
The most important line in this is at the end of the first sentence, stating that 48 patients would need aggressive treatment (including prostatectomy) to prevent one prostate cancer death. So how much does “aggressive treatment to prevent cancer death” cost?
From the Journal of Clinical Oncology:
For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P < .001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P < .001).
note: it was very hard to find numbers here. This is actually from Medicare claims from 1992 and 1993, so it is a huge underestimate from today’s numbers.
Which means that based on the 1992 numbers, you would spend $672,000 to save one life using radiation therapy and $1,084,000 if you used surgery. This does not take into account the consequences of surgery for the men who underwent the surgery.
What about robotic surgery? In a comparison of the cost of open prostatectomy to robot-assisted surgery, the cost is even higher.
Cost was the one area in which the older open surgery was the clear winner: Open radical prostatectomy costs $487 less a case than non-robotic laparoscopy and $1,726 less than robot-assisted prostatectomy.
According to the review, “Shorter operative time and decreased hospital stays associated with the robotic procedure did not make up for the cost of the additional equipment expenditure.” Estimated costs of the robotic system to a provider run about $1.2 million a year, with maintenance costs of $120,000 a year and one-time costs of $1,500 a case.
To summarize:
- Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.
- PSA Testing as greatly increased the number of men diagnosed with early stage cancers.
- Prostate cancer surgery or radiation therapy is recommended for men who have early stage cancers.
- Aggressive prostate cancer treatment has to be done 48 times to save one life.
- The most expensive treatment for prostate cancer is prostatectomy, or removal of the prostate.
- The robotic form of the surgery is a higher-cost procedure by a significant amount.
So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery. Why in the world is this being promoted at all?
Money. Here’s the homepage of one of our local hospitals. They have aggressively marketed da Vinci surgery on television, billboards, and the radio.
Why do you think they would pay as much money as they do for this device? It’s good business? Not so fast. Dr. Paul Levy stated back in 2007 about this very procedure:
Here you have it folks — the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the “state of the art”, so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?
No, hospitals are employing this just to keep pace. The real winner in this is Intuitive Surgical, Inc., who has been a darling of Wall Street, beating estimates in earnings with a Q2 net profit of $62.4 Million.
Why is the cost of healthcare going up while physician reimbursement goes down and hospitals go out of business?
It’s Intuitive.
God Bless America!
*This blog post was originally published at Musings of a Distractible Mind*
September 15th, 2009 by Bongi in Better Health Network, True Stories
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M and M was never fun. Sometimes I would walk out feeling I’d just escaped by the skin of my teeth. Sometimes I would feel like my teeth had had too close a shave. But once…just once, it could have been worse.
It was a pretty standard call. It was very busy. In the early evening I was called to casualties for a patient with severe abdominal pain. When I examined him it was clear there was something seriously wrong inside. He had a classical acute abdomen with board like rigidity. He clearly had a perforated peptic ulcer and needed surgery. I set my house doctor to work to get him admitted and on the list. Meanwhile I went back to theater to work through the number of equally critical patients already on the list.
Things then settled down into a rhythm. I was in theater with a student operating the cases one after the other while the house doctor separated the corn from the chaff in casualties. Finally it was time to do the laparotomy for the guy with the acute abdomen. I needed to shoot through casualties before we started so I decided to swing past the ward and make sure the guy was still ok.
The ward was dark. Pretty much everyone was asleep. Without wanting to wake the other patients I turned on the small bedside light of my patient. Even in that dim light I could see a bit of oral thrush. I was surprised. I was thinking to myself how the hell did I miss that in casualties. I felt his abdomen. It was no longer quite so tender. I turned to the student.
“See why it is important to make your decision before giving opioids?” I said with an air of authority. “Now he is actually not so tender but he definitely had an acute abdomen. We must go ahead with the operation.”
I quickly felt for lymph nodes. He had them everywhere. Once again I was quietly thinking that my clinical skills must be slipping because that I also didn’t pick up in casualties. I kept this new information to myself. Imagine the shock to the student if he realised I was not all knowing. i just didn’t want to be responsible for that level of devastation in his life. But I started considering other causes for his condition. It was clear he had AIDS and TB abdomen started looking like a possibility.
While we were still with the patient, the theater personnel arrived to take him to theater. I told them to get things going so long while I quickly shot down to casualties to evaluate a patient the house doctor was unsure about. And off I went at a brisk walk.
I walked into casualties. The house doctor led me to the patient in question, but as we approached his bed my blood went cold. In the exact bed where my acute abdomen had been lying about four hours previously was my acute abdomen still lying there!! I turned and ran back to theater. Fortunately I was in time.
Later I found out what had happened. Once we had admitted the acute abdomen, the porter had come in to take him to the ward. One of the patients lying in casualties was a guy that had just come in. His HIV had wreaked havoc in his life causing a number of unpleasant things, including AIDS dementia syndrome. The exchange went something like this;
“Timothy Mokoena? Is there a Timothy Mokoena here?” the porter called out.
“Here I am, but it’s not Mokoena. It’s Magagula.”
“Ok, Timothy Magagula, I’m going to take you to the ward.”
“Ok, but it’s not Timothy. It’s Michael.”
“Ok, Michael Magagula. Let’s go.”
And thus Michael Magagula, the AIDS dementia patient (not to be confused with Timothy Mokoena, the acute abdomen patient), thinking he had just jumped the queue to see a doctor was carted off to the ward and prepared for theater. He even signed for a laparotomy without even having seen a doctor.
In the end it all turned out well. Timothy got his operation and the hole in his stomach was patched. Michael was referred appropriately to the physicians. But I couldn’t help wondering how this could have looked in the next M and M meeting.
“Well, prof, the patient died on the table basically because I operated him unnecessarily.”
“And how is the other patient? The one you should have operated?”
“Well, he died too because I didn’t operate him.”
200% mortality for one operation. Not easy to achieve.
*This blog post was originally published at other things amanzi*
September 10th, 2009 by RamonaBatesMD in Better Health Network, Health Tips
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This past week I was once again asked about suture allergy. It has prompted me to revisit the issue which I have posted about twice now. (photo credit).
Sutures by their very nature of being foreign material will cause a reaction in the tissue. This tissue reactivity is NOT necessarily a suture allergy.
Many factors may contribute to suture reactivity.
- The length of time the sutures remain. The longer the sutures are in, the more reactivity occurs.
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The size of the sutures used. The larger the caliber of the suture, the more reactivity. The increase of one suture size results in a 2- to 3-fold increase in tissue reactivity.
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The type of suture material used. Synthetic or wire sutures are much less reactive than natural sutures (eg, silk, cotton, catgut). Monofilament suture is less reactive than a braided suture.
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The region of the body the suture is used affects tissue reactivity. The chest, back, extremities, and sebaceous areas of the face are more reactive.
In general, accepted time intervals for superficial suture removal vary by body site, 5-7 days for the face and the neck, 7-10 days for the scalp, 7-14 days for the trunk, and 14 days for the extremities and the buttocks. The deeper placed sutures will never be removed.
Sutures meant to dissolve (ie vicryl sutures) placed too high in the dermis (which happens often when the dermis is thin) can “spit” several weeks to several months after surgery. This is a reactive process, NOT a suture allergy. It usually presents as a noninflammatory papule (looks very much like a pimple) and progresses with extrusion of the suture through the skin. The suture material may be trimmed or removed if loose, and it is not needed for maintaining wound strength. Rarely does this affect the scar outcome.
The remaining portion is a “repost” about suture allergies:
Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.
Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.
MONOCRYL Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP(triclosan).
PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).
VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan). [In rechecking facts, I found that only Vicryl Plus has the triclosan, so simple vicryl or coated vicryl should be okay.]
Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.
Dermabond — Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.
SO WHAT IS LEFT TO USE
So what is left to use in a patient who may have or has a proven allergy to suture or closure material?
Silk, Dexon, Nylon (monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn’t react negatively.
The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.
The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.
REFERENCES
Allergic Suture Material Contact Dermatitis Induced by Ethylene Oxide: G. Dagregorio, G. Guillet; Allergy Net Article
Johnson and Johnson Product Information
Current Issues in the Prevention and Management of Surgical Site Infection – Part 2; MedScape Article
MECHANICS OF BIOMATERIALS: SUTURES AFTER THE SURGERY; Raúl De Persia, Alberto Guzmán, Lisandra Rivera and Jessika Vazquez
Materials for Wound Closure by Margaret Terhune, MD; eMedicine Article
Product Allergy Watch: Triclosan; MedScape Article by Lauren Campbell; Matthew J. Zirwas
New References
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Surgical Complications;
eMedicine Article, May 29, 2009; Natalie L Semchyshyn, MD, Roberta D Sengelmann, MD
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Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature.
Ann Allergy. Apr 1986;56(4):317-20.
[Medline].
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Fisher AA. Nylon allergy: nylon suture test.
Cutis. Jan 1994;53(1):17-8.
[Medline].
Related Posts
Allergies from Suture Material (September 7, 2007)
Suture Allergies Revisited (April 30, 2008)
Suture (June 7, 2007)
Basic Suture Techniques (June 8, 2007)
*This blog post was originally published at Suture for a Living*
August 27th, 2009 by Medgadget in Better Health Network, Humor
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Designer Olivier Trillon’s concepts make you wonder whether you’d prefer your post op morphine drip in a Yves Saint Laurent or a Chanel IV bag. Seeing how sexy medical gadgetry has been getting lately, perhaps this is a field for the fashion world to embrace with open arms.
More of Olivier Trillon’s works from Trend.Land…
(hat tip: Interior design room)
*This blog post was originally published at Medgadget*
From today’s article by the always-interesting Sarah Avery at the News & Observer:
