Archive for the ‘Medical Procedures’ Category

Ovarian Cancer – The Smear Test Won’t Tell You Much

February 28, 2010

According to an article published by the UK Press Association, a UK study revealed that one in three women mistakenly believe that a smear test can diagnose ovarian cancer. The test is also known as Papanicolaou test, Pap smear, Pap test, or cervical smear.

[The smear test] is a screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix. … In taking a Pap smear, a tool is used to gather cells from the outer opening of the cervix (Latin for “neck”) of the uterus and the endocervix. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by sexually transmitted human papillomaviruses (HPVs). The test remains an effective, widely used method for early detection of pre-cancer and cervical cancer. The test may also detect infections and abnormalities in the endocervix and endometrium.

While the smear test is customarily used to diagnose cervical cancer, it is not very helpful in diagnosing ovarian cancer. Cervical cancer and ovarian cancer are distinct medical conditions with distinct symptoms. Cervical cancer refers to malignant tissue developing in the cervix – the organ, which connects the uterus and the vagina. Last year, there were about 4,070 deaths associates with cervical cancer. The smear test is effective in diagnosing cervical cancer.

Ovarian cancer refers to malignant tissue in one or both of the ovaries. Last year, there were about 14,600 deaths associated with ovarian cancer – a much higher mortality rate when compared to that of cervical cancer. Symptoms of ovarian cancer include, but are not limited to : abdominal pressure, abdominal distention, urinary urgency, abdominal pain and discomfort, indigestion, constipation, changes in menstruation, lethargy, and pain during intercourse.

According to the article,

Almost one in three women (29%) mistakenly believe a smear test will pick up signs of ovarian cancer. …  Only 4% are confident they could spot symptoms of the disease themselves and many believe it is less common than cervical cancer. … The poll of more than 1,000 women found that twice as many (66%) had been given information about cervical cancer as those who had details on ovarian cancer (33%). Of women diagnosed with ovarian cancer, more than half (56%) did not know anything about the disease beforehand.

These numbers reveal a dangerous misconception about ovarian cancer. Many more women are diagnosed with ovarian cancer than cervical cancer. Moreover, many more women die as a result of ovarian cancer than as a result of cervical cancer. Early diagnosis is key in both instances. In this regard, being knowledgeable about these medical conditions can be a matter of life and death. Be mindful that a smear test is not helpful in diagnosing ovarian cancer.

Contributing author: Jon Stefanuca

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Expanding The Role Of Nurse Practitioners: Licence To Practice Medicine Without A License

February 27, 2010

An article published by NPR comments on the nationwide movement to expand the role of nurse practitioners in light of the growing deficit of primary care physicians. According to the article:

Nursing leaders say large numbers of [nurse practitioners] …will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.

A study published by the Center for Workforce Studies projects that, by 2025, there will be a nationwide shortage of about 124,000 physicians. Researchers note:

Under any set of plausible assumptions, the United States is likely to face a growing shortage of physicians. Due to population growth, aging and other factors, demand will outpace supply through at least 2025. Simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered and making better use of our physicians will also be needed.

Based on this rationale, a number nursing organizations, state level legislators, regulatory bodies, and various other national organizations and policy thinktanks advocate for an expanded role, particularly in the field of primary care, for nurse practitioners. According to the article, a number of states have already implemented or are presently considering legislation to expand the role of nurse practitioners. For example, a Colorado bill would enable nurse practitioners to issue orders in the same way as a physician. Practically speaking, this would mean that a nurse practitioner, in addition to being able to order medications, would also be able to issue orders directing the treatment of the patient (e.g., orders to admit the patient, CT/MRI orders, consultation orders, etc.)

While these proposed reforms may be practical and serve a utilitarian purpose, one can’t help but wonder if the quality of health care rendered to millions of Americans is going to be compromised as a consequence. The easy answer is not always the right answer. It may be true that there are more nurse practitioners in the U.S. than there are physicians (there are about 125,000 more nurse practitioners). If allowed, nurse practitioners could certainly fill the void. But, the critical inquiry remains: are nurse practitioners sufficiently qualified to serve as substitutes for physicians? For example,

The American Medical Association (AMA) and doctors’ groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised.

The AMA issued a report in which it questioned whether nurse practitioners are sufficiently qualified to render medical care in areas currently restricted to physicians.

“To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.”

The idea that nurse practitioners are qualified to serve as substitutes for physicians it truly worrisome. There is a reason why nurse practitioners are not physicians – they don’t have the same level of training and expertise. Surely, there are patients with fairly simple medical complaints, which probably could be addressed by nurse practitioners; however, what about the inevitable complex patient? Are nurse practitioners sufficiently trained to simultaneously recognize the interplay of multiple medical conditions, as well as determine the interplay of necessary medications, radiographic studies and necessary follow up care? I for one will make sure to be seen by a physician.

Contributing author: Jon Stefanuca

Debating the Unknowns in Obesity Surgery for Children – NYTimes.com

February 16, 2010

Bariatric surgery – commonly referred to as weight-loss surgery, is apparently on the rise in the pediatric population.  A New York Times article – Debating the Unknowns in Obesity Surgery for Children – NYTimes.com – reports that these surgeries are on the rise in the United States.      

“I honestly believe that in 5 to 10 years you’ll see as many children getting weight-loss procedures as adults,” said Dr. Evan Nadler, co-director of the Obesity Institute at Children’s National Medical Center in Washington.

For those who may not be familiar with exactly what a surgeon does to the intestinal tract, there are numerous videos available on the internet that provide a good overview of this surgery – for example, here is an example showing one form of such surgery known as a by-pass.   There are a number of types of bariatric surgery, including two of the most common – Roux-en-Y gastric bypass and gastric banding procedures.

While such surgeries of often medically necessary and truly constitute a life-saving measure for some, they are not just an alternative to diet and exercise – that is, they are not without substantial risks no matter what form of bariatric surgery is being considered.

Here’s a list of just some of the potential complications -depending on the type of surgery – that are recognized risks of this surgery:

  • Bleeding
  • Complications due to anesthesia and medications
  • Deep vein thrombosis
  • Dehiscence (wound breakdown)
  • Infections
  • Leaks from staple line breakdown
  • Marginal ulcers
  • Pulmonary (lung) problems
  • Spleen injury
  • malabsorption
  • nutritional complications
  • death (reported as less than one percent)

On the other side of the equation, there is no doubt that when indicated, this surgery can certainly provide much needed restoration of health and longevity to these juvenile patients:

Obese children can suffer from a long list of problems better known in adults: insulin resistance, high blood pressure, fatty liver, a thickening of the left side of the heart, and even depression.

So far, the studies have found that the body starts to repair itself as the weight falls. For example, two years after gastric bypass, the left side of the heart has started to return to normal in most adolescents, according to cardiologists at Cincinnati Children’s. Research also suggested that for at least as long as the children have been followed, the procedure appeared safe, and about 85 to 90 percent of adolescents maintained their initial weight loss, Dr.  (Thomas H.)Inge [director of the surgical weight loss program at Cincinnati Children’s] said.

Those on the other side of this significant debate are not so confident in the long-term effects/benefits of having children undergo weight-loss surgery:

Some physicians, including Dr. Edward Livingston, chairman of gastrointestinal and endocrine surgery at the University of Texas Southwestern Medical Center at Dallas, say advocates could be drawing conclusions too early. No one can say whether the changes will translate into a health advantage later on. Dr. Livingston noted that a third of the children in the Australian gastric-banding study had to go back to the operating room over concerns about the device — and that even the children in the group that did not have surgery showed respectable improvements in blood pressure, insulin resistance and other measures. With or without surgery, he said, “both groups got better.”

The NY Times article reports: “No one knows exactly how many adolescents are turning to surgery to get thinner. One of the few studies, published in 2007, reported that bariatric surgery in teenagers was relatively rare but rising fast: from 2000 to 2003 (the last year examined), the number of operations tripled, to about 800.”

In one article, it is estimated that 220,000 bariatric procedures were performed in 2008 with an estimated increase of approximately 20,000 in 2009.

There is also an ongoing debate as to which form of weight-loss surgery is indicated for adolescents – bypass or banding.

Nor do surgeons agree on which of the two procedures used most — banding or bypass — is more appropriate for youths. Dr. Nadler, of Children’s National Medical Center, prefers banding, saying it is less radical and can be more easily undone if need be. In November, in The Journal of the American College of Surgeons, he described a study finding that among 41 teenagers followed for two years after gastric banding, their excess body weight had dropped by about half, on average, and other measures of their health had improved.

There is no doubt the debates will rage on for years to come.  What is evident, however, to those of us who have litigated many cases involving bariatric surgery performed on adults, is that this is not to be considered a ‘quick fix’ for being overweight.  It is not a form of cosmetic surgery.  This is serious stuff and reasoned considerations must be made: (1) is it medically indicated?; (2) what are the alternatives?; (3) who are the surgeons skilled in these procedures?; (4) is the adolescent properly being screened and counseled before undergoing surgery?; (5) what post-operative follow-up is needed?; (6) is the facility where the procedure is to be performed truly recognized as being capable of dealing with such patients and potential post-operative complications?; and (7) does the child and his/her parent(s) truly understand the risks associated with such procedures? – just to name a few of the many issues that must be addressed.

Bill Clinton’s stent procedure – what it’s all about.

February 13, 2010
On February 4, 2010, former President Bill Clinton underwent a surgical procedure to restore blood flow to one of his coronary arteries. According to reports, he had been experiencing chest pain for several days prior to his admission to Presbyterian Hospital in New York. During the hospital admission, imaging studies revealed that one of Clinton’s bypass grafts was occluded. This bypass graft was created during Clinton’s quadruple bypass surgery back in 2004.

To restore blood flow to Clinton’s coronary artery, the surgeons performed a procedure called angioplasty. Angioplasty is a surgical technique used to mechanically widen or enlarge an occluded blood vessel. In cardiac angioplasties, surgeons use balloons catheters. These catheters have a balloon at the tip. During cardiac angioplasty, this catheter is guided into the body and then into the affected blood vessel until the tip of the catheter reaches the blocked area of the blood vessel. At such time, the tip of the catheter is inflated, causing the lumen or the interior diameter of the blood vessel to expand. As the blood vessel is expanded, any fatty deposits on the interior wall of the vessel are crushed and compressed. Then, the balloon is deflated and removed. As a result of this process, the vessel regains blood flow. Sometimes, the surgeon will also install a metal coil or a stent into the affected blood vessel to prevent future narrowing or blockage.

Clinton was diagnosed with a blockage in one of the bypass grafts, which was created during his quadruple bypass surgery back in 2004. This graft serves as a surrogate blood vessel to reroute blood around a blockage in the coronary artery. Clinton’s surgery involved the ballooning of the graft and the installation of two stents to provide for long-term blood vessel support.