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Breast Cancer Mis-Diagnosis and Late Diagnosis

Robert Blanchard — Fri, 22 Dec 2006 12:22:30 GMT

An international panel updated their standards on the diagnosis and treatment of breast cancer, as reported in the October 2006 issue of the Journal of the American College of Surgeons (JACS).

According to the American Cancer Society, invasive breast cancer will be diagnosed in 211,240 women and will cause more than 40,000 deaths in 2005. The updated statement reflects the conclusions of a panel of 23 expert surgeons, radiologists, pathologists, and oncologists based on their own research, clinical experiences, familiarity with the professional literature, and points of consensus reached through discussion at a conference. However, the panel cautions that their conclusions should not be considered inclusive of all appropriate treatments or exclusive of other treatments reasonably directed at achieving the same results or of interventions performed in the context of clinical trials.

The overall focus of the statement is that physicians should attempt to replace traditional, invasive procedures for diagnosing breast cancer with proven, less-invasive diagnostic methods, such as minimally invasive needle biopsies of the breasts and sentinel node biopsies.

Summary of Recommendations
Mammography is the only imaging modality that should be used routinely to screen women for breast cancer. However, MRI may be used to screen younger women with a high risk of breast cancer because of a strong family history or BRCA mutation. MRI findings should be combined with other imaging data or histologic results prior to surgical planning. Diagnostic ultrasonography can be helpful in characterizing known breast masses, as it is more sensitive than mammography in evaluating tumor size.
The panel agreed that minimally invasive breast biopsy is the optimal initial method for tissue acquisition for image-detected breast lesions, in large part because the determination of cancer prior to surgery improves outcomes of breast-conserving therapy. For microcalcifications without an obvious mass, the authors recommend vacuum-assisted devices with needle sizes of 11 gauge or larger. Fine- needle aspiration is suitable for lymph-node evaluation but less so for evaluation of breast lesions.
Biopsy specimens should be labeled by surgeons to preserve three-dimensional orientation. Radiography or ultrasonography of the surgical specimen can be useful in determining whether the target lesion was successfully removed. Two views should be used for specimen radiography.
Pathologic breast specimens should be evaluated using the Nottingham Combined Histologic Grade, which accounts for glandular differentiation, mitotic count, and nuclear grade. Ideally, these findings are combined with radiologic data at a treatment conference involving pathologists, radiologists, and surgeons.
Pathologists should read both prognostic size, determined by the extent of the largest invasive component of the tumor and helpful in predicting survival and distant metastasis, as well as the overall size of the breast tumor.
Intraoperative ultrasonography and bracketing localization wires can aid in defining the limits of resection in breast-conserving surgery, as can preoperative MRI and ultrasonography.
Sentinel lymph node biopsy is the preferred means of pathologic axillary nodal staging. However, patients should be made aware of the possibility of a false- negative result with such testing. When the sentinel lymph node reveals minimal involvement of 0.2 mm or smaller, complete axillary dissection is not necessarily indicated.
Regarding treatment of DCIS, adjunctive radiation therapy has been demonstrated to reduce rates of local failure but may not improve survival. Older age, smaller, widely excised DCIS, and low- or intermediate-grade histology mitigate against using radiation therapy following surgery for DCIS. The use of adjunctive tamoxifen for patients with DCIS is controversial, but it seems to be more helpful among patients with receptor-positive DCIS. Sentinel lymph node biopsy generally has no role in the staging of DCIS, but it should be performed in women receiving mastectomy for DCIS.
Hormonal therapy should be offered to all women with hormone-receptor-positive tumors, and the minimum period of treatment is 5 years. Patients receiving other chemotherapy should receive both an anthracycline and a taxane. However, chemotherapy in addition to hormonal therapy is less likely to provide an overall clinical benefit for women older than 60 years of age with hormone-receptor-positive tumors or for those older than the 70 years with any breast cancer.

Originally posted at InjuryBoard by Robert Blanchard

Old Surgeons Not a Problem

Robert Blanchard — Mon, 04 Dec 2006 10:05:47 GMT

When you need complex cardiovascular or cancer surgery, you have to choose a surgeon and many patients may select an older physician, assuming his experience may be needed. New research says they are right - experience helps. A study designed to address this issue used approximately 461,000 Medicare records to assess the association between age of the listed operator and surgical mortality. For some operations, such as pancreatectomy, coronary artery surgery, and carotid endarterectomy, surgeons aged 60 or older had higher mortality rates than younger surgeons. However, for other equally complex operations, such as esophagectomy, effects of the age of the surgeon were not observed. Surgical volume must also be taken into account when considering the impact of the age of the surgeon.
The conclusion of the study is that the age of the surgeon is not a major factor to surgical complications. It is unusual that an age effect was observed for a few difficult procedures but not for others of equal complexity. However, if you have to chooose a surgeon, the conclusions are reassuring: The results after surgery performed by an older surgeon are comparable to outcomes of similar procedures performed by a younger surgeon.

But, older surgeons - those over age 60 - who do not maintain a high surgical volume as they age are more likely to have high patient mortality rate than younger surgeons.
The researchers at the University of Michigan Health System say patients should be less concerned about the age of their surgeon and more focused on other factors that really count - like surgical volume.
These findings, published in the September issue of the Annals of Surgery, reveal that for some complex cardiovascular and cancer surgical procedures, older surgeons who continued to maintain higher surgical case loads were found to have comparable outcomes to peers ages 41 to 50.
The study also dispels the belief that younger, less experienced surgeons are more likely to have poor surgical outcomes. Instead, the researchers say young surgeons, ages 40 and under, had similar patient mortality rates to those of their more experienced peers for the eight surgical procedures studied.
"This study's results should be very encouraging not only for patients, but also for younger and older surgeons whose operative skills may previously have been the subject of scrutiny," says lead author Jennifer F. Waljee, M.D., M.P.H., general surgery resident in the Department of Surgery at the U-M Medical School.
"The bottom line is that for most procedures the age of the surgeon is not an important predictor of operative risk for a patient. The effect of surgeon age was largely limited to those surgeons with lower procedure volumes."
Previous studies that focused on primary care have suggested an inverse relationship between a surgeon's age and his or her clinical performance. They've found that older physicians are less likely to know about new treatments and medications, and tend to perform poorly on recertification exams.
Based on these recent studies, Waljee and her colleagues wondered if some of the common mental and physical affects of aging might affect older surgeons' performance in the operating room, as well.
Using data from the National Medicare Inpatient Files, the team reviewed eight major cardiovascular procedures and cancer surgical resections that were performed from 1998 to 1999 on patients between the ages 65 to 99.
For the study, surgeons were placed into three age groups: 40 years and younger, ages 41-50, and 60 years and older.
A total of 460,738 Medicare patients who underwent one of the eight surgical procedures - coronary artery bypass grafting; elective abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy, pancreatectomy, esophagectomy, lung resection and cystectomy - were used for this study. These procedures were chosen because they are some of the more commonly-performed procedures among Medicare patients, says Waljee.
Patient operative mortality - death before discharge or within 30 days of surgery - was reviewed for each patient. Additionally, factors such as surgeon procedure volume, hospital surgery volume and the hospital's teaching status were evaluated.
Overall, surgeons over age 60 were found to have higher patient mortality rates when compared against the rates of surgeons ages 41-50, for three of the eight procedures: pancreatectomy, coronary artery bypass grafting, and carotid endarterectomy. Surgeon age was not related to mortality for elective abdominal aortic aneurysm repair, aortic valve replacement, exophagectomy, lung resection or cystectomy.
More surprising to researchers, however, was that the younger surgeons - those under age 40 - had comparable mortality to surgeons between the ages of 41 and 50, for all eight procedures.
"We expected to see a significant difference in patient mortality at the extremes of surgeon age, but instead found very little variation among younger and older surgeons," says Waljee, a Robert Wood Johnson Clinical Scholar. "Based on these finding, we'd encourage patients not to focus on age when selecting a surgeon. Instead, other characteristics of the provider and practice setting, such as operative volume, are likely better predictors of patient outcome than surgeon age."
Waljee hopes to further explore this topic through future research to determine if specific mechanisms of aging (physical and mental stamina, vision and motor skills) affect low-volume surgeons' performance in the OR.

Originally posted at InjuryBoard by Robert Blanchard

Doctors Need to Be Aware of Possible Condition

Robert Blanchard — Wed, 29 Nov 2006 12:42:30 GMT

With the rise in obesity, there is also expected to be a rise in obesity related medical conditions. Many such conditions only require long term management, but some require instant identification and appropriate medical intervention. Such is the case with the condition known as Pseudotumor Cerebris. Overweight women of childbearing age are at risk and the condition causes and increase in pressure inside the brain which can lead to blindness. If not properly identified, serious injury can result and there is the question of whether medical negligence led to the permanent injury.

Pseudotumor Cerebri, otherwise known as, Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology. It affects predominantly obese women of childbearing age. The primary problem is chronically elevated intracranial pressure (ICP), and the most important neurological manifestation is papilledema, which may lead to progressive optic atrophy and blindness. Although it is not a common disorder, clinicians must be familiar with its presentation so that it can be diagnosed and treated in a timely manner. Delay in treatment will result in a catastrophic outcome.

Symptoms of elevated ICP include headache that is nonspecific and varies in type, location, and frequency, pulsatile tinnitus - a rhythmic sound, heard in one or both ears, with pulsing synchronous rhythm that may be exacerbated by the supine or bending position, and horizontal diplopia - A symptom of a false-localizing sixth cranial nerve palsy.
Symptoms of papilledema include transient visual obscurations (e.g.: dimming or blackout of vision in one or both eyes lasting for a few seconds) which may be predominantly or uniformly orthostatic (i.e.: after bending over), progressive loss of peripheral vision in one or both of the eyes, most often starting in the nasal inferior quadrant, followed by loss of central visual field (possibly affecting visual acuity) and, lastly, loss of color vision, and blurring and distortion (i.e.: metamorphopsia) of central vision caused by macular wrinkling and subretinal fluid spreading from the swollen optic disc. Sudden visual loss is due to intraocular hemorrhage secondary to peripapillary subretinal neovascularization related to chronic papilledema.

Visual loss in one or both eyes can evolve rapidly despite the best efforts to arrest the process. Litigation centers on the delay of maximum medical and surgical management beyond what has to be considered ideal and standard practice in the United States for patients who present with rapidly declining vision.
The exact time window within which vision loss can be reversed after symptomatic decline is not known. Opinions among experts in the field vary as to how rapidly and aggressively any given patient should have been treated. Usually erring on the side of rapid intervention (hours to days) in such patients is better. This is a dramatic opportunity to save vision that can be easily lost. A major medicolegal pitfall is created when poor outcome is coupled with the perception of delayed treatment.
One of the standard teachings has been that pregnancy exacerbates or triggers the onset of symptomatic IIH. However, at present little statistical evidence exists of a causal association between the two conditions, beyond the fact that both events are common in the age group and gender that is predominantly affected by the disease.

Originally posted at InjuryBoard by Robert Blanchard

VA Gives Veteran Bad Care - One Horror Story

Robert Blanchard — Fri, 21 Apr 2006 11:35:30 GMT

My firm handles cases of Stevens Johnson Syndrome, which is one of the most painful and often fatal conditions anyone can suffer through. It is like being slowly burnt alive from the inside out. Keep that in mind and read this account I just received of how the VA treated one of our veterans:
Dear Sir,
I want to tell you about my husband. In 2004, he developed Avascualr necrosis of his right hip, the doctors gave him Celebrex. He took it religiously, it seemed to be a wonder drug, let him move, walk and continue to work. This was in late April. By June, he had to stop work, which cancelled his insurance. So he had to go to the VA hospital for treatment. In July he developed a skin rash, on his hands at first, but quickly spreading all over his body. The doctors didn't know what it was, so they ignored it, told him to use 1% cortizone on it. By August, we were i the emergency room, his whole body was filled with fluid, he couldn't breathe, I thought he was dying. They gave him Lasix (frusemide) and sent him home. He passed 10 gallons of fluid in the next 3 days, I was scared to leave him alone for any time. I still had to work though. He was leaking fluid out of every lesion on his body, and believe me he was totally covered with lesions. The lesions started a s red bumps, quickly turning into blister-like rounds with a red circle around them, my husband is black, so to me his lesions looked just very black and very dark. the blisters would spread and become the shape of the lesion, not round any more, then they would grow together and form thick pad like areas which would leak fluids and then become crusty and hard and very itchy. He found that he couldn't use hot water any more to wash as it "burned" his skin, he would constantly complain of his whole body burning. Then, he got lesions on his lips and the inside of his mouth and couldn't eat or drink anything warm. He was passing black stools, which usually means blood in the stool, but the doctors at the VA wouldn't do any tests to find out what was wrong with his skin. They gave him an appointment ...

with a dermatologist who did an inspection of his skin via video link! This didn't amount to anything and he was given 1% cortizone again to treat this extremely out of control skin reaction.
We got past this horrendous time by putting vaseline on his lesions to stop them drying and cracking, and then wrapping them in strips of pure cotton material. The cotton soaked up most of the fluid which was oozing out of his whole body and I guess stopped infection getting in to the lesions. Last year, he broke out with the rash again, but nowhere near as severe. I have him covered on my medical now, so we were able to go to a dermatologist. They took a biopsy of a lesion and told us that it was an allergic reaction....

Originally posted at InjuryBoard by Robert Blanchard

Juror Bias Affects Trial Outcomes

Robert Blanchard — Wed, 11 Jan 2006 10:25:18 GMT

Many clients think that simply being on the right side of the case means they will win their case in front of a jury. What many don't realize is that every juror brings to trial their on bias and preferences which have nothing to do with the facts of the case. If a juror goes into trial believing that doctors are honest, benevolent, highly trained and competent, this juror will almost certainly justify plaintiffâ€™s evidence of malpractice in a manner favorable for the doctor. To this juror, it is more likely that the evidence was taken out of context, has a reasonable explanation, or is the result of an honest mistake than convincing evidence of malpractice.

Trial is ultimately about jurors making choices between the versions of the evidence offered by the plaintiff and the defense. Although the justice system demands that jurors make these choices based solely on an objective view of the evidence presented, psychologist and experienced trial lawyers understand that this is impossible; in interpreting information and making judgments and decision, jurors are forced to rely on their subjective framing of the case to make these choices, and the jurorsâ€™ framework of the case colors their interpretation of the evidence to fit their preconceived ideas.

Originally posted at InjuryBoard by Robert Blanchard

Keep Close eye on Malpractice Legislation

Robert Blanchard — Tue, 21 Feb 2006 10:26:57 GMT

Under an agreement on medical-malpractice laws in Washington State, which expected to be enacted into law, doctors would be able to apologize for a medical mistake without it being used against them in court. Mediation would be mandatory before a lawsuit could proceed, and if it went forward, both sides could agree to binding arbitration to avoid costly litigation. Juries also would be able to hear for the first time if a patient suing a doctor has previously received money for the claim from an insurance company. Still to be decided, however, is the doctors' demand for limits on the amount of damages a jury could award in a malpractice case. If history is any judge, their efforts to limit damages for malpractice will continue.

Originally posted at InjuryBoard by Robert Blanchard

Uterine Cancer Diagnosis

Robert Blanchard — Mon, 30 Oct 2006 12:27:56 GMT

As with any cancer, early detection is the key to succesful treatment of uterine cancer. In the context of medical malpractice, a problem arises when the cancer because the doctor does not follow up apropriately on anobvious warning sign. For uterine cancer, the most likely warning sign is bleeding in post-menopausal women.
Approximately 40,880 women developed this form of malignancy in 2005 in the United States. After doubling in the early 1970s, the incidence of uterine cancer has remained fairly constant. In 2005, there were more than 7,000 deaths from endometrial cancer.
Endometrial cancer is primarily a disease of postmenopausal women. The average age at diagnosis is approximately 60 years. Women diagnosed with endometrial cancer when they are younger than 40 years make up only 5% of the total cases. These women invariably have specific risk factors such as morbid obesity, chronic anovulation, and hereditary syndromes. Endometrial cancer is more common in white women when compared to black women.

Invasive neoplasms of the female pelvic organs account for almost 15% of all cancers in women. In 2005, approximately 80,000 women in the United States were predicted to receive a diagnosis of pelvic gynecologic malignancy.
The most common of these malignancies is uterine cancer, specifically, endometrial cancer. Endometrial cancer is the fourth most common cancer in women, following breast, lung, and colorectal cancer, in that order. However, it is only the eighth most common cause of cancer deaths because it is usually detected in early stages.
Of the 40,880 cases of uterine cancer predicted for 2005, only 7,310 cancer deaths were predicted for the year. Ovarian cancer accounts for the largest number and highest frequency of cancer deaths from pelvic gynecologic malignancies, with 22,220 new cases and 16,210 deaths predicted for 2006.

Originally posted at InjuryBoard by Robert Blanchard

Testing for Adverse Reactions

Robert Blanchard — Mon, 11 Sep 2006 10:13:10 GMT

When it comes time for anesthesia, it sure would be reassuring if a test could be given to make sure you don't have an adverse reaction to the anesthesia medication. It will take sometime to sort out what is feasible, but a recent study shows that more people are at risk than normally assumed.

Allergy to Anesthesia Drugs Not Rare in Surgical Patients
Nearly 5% of surgical patients have a positive prick test to one or more anesthetic drugs, according to a brief report by anesthesiologists in Spain.
"Allergy tests on anesthetizing are indicated only among those patients who have a history of an adverse reaction" to these drugs," Dr. E. Tamayo and colleagues, from the Valladolid University Hospital in Spain, note.
Until now, however, it was unclear how often prick tests are conducted and how often they are positive among surgical patients without a history of drug allergies, they point out in the August issue of Allergy.
To investigate, Dr. Tamayo's group conducted a prospective study, between September 1, 2003 and July 30, 2004, with 424 randomly selected surgical patients who underwent prick testing to 30 agents commonly used in the OR setting.
Overall, 4.7% of patients had at least one positive prick test, most commonly to a neuromuscular blocking drug. On multivariate analysis, a history of drug allergy was the only factor that predicted a positive result, raising the likelihood by 6.13-fold.

Originally posted at InjuryBoard by Robert Blanchard

Pregnancy - hemorrhage and preterm delivery

Robert Blanchard — Mon, 24 Apr 2006 10:42:40 GMT

I just read an article on placenta previa. This is a condition where the pacenta is in position in the uterus lower down than the baby and thus in in position to come out first during delivery. This condition is a leading cause of death from pregnancy, but it can be discovered by sonogram and medically managed. The primary risk is massive hemorrhage and preterm delivery. Might be a good idea in later preganancy to ask the doctor if the placenta appears to be in the right position, so a potential problem won't simply be missed.

A baseline CBC count with a platelet count is useful. Prothrombin time, activated partial thromboplastin time, fibrinogen, and fibrin split products may also be helpful because retroplacental bleeding has been associated with consumptive coagulopathy.
The most useful and least expensive imaging study is ultrasonography. Transabdominal ultrasonography has 95% accuracy. Transvaginal ultrasonography provides 100% accuracy in identifying placenta previa. An important caveat is the phenomenon termed placental migration. This occurs when placenta previa is identified early in pregnancy and resolves as the pregnancy proceeds. For example, ultrasonograms performed early in the second trimester identify placenta previa in 5-15% of patients, with 90% of these resolving by term. Similarly, 26% of the total cases of placenta previa and only 2.5% of the cases of partial or marginal placenta previa diagnosed in the second trimester persist into the third trimester. This does not represent true migration of the implantation site but, rather, differential growth of the placenta and distention of the myometrial cavity away from the os.
Other tests include: fetal monitoring, Rh testing (patients who are Rh negative and unsensitized and who present with painless vaginal bleeding require Rh-immune globulin), and a Kleihauer- Betke test to detect excessive fetomaternal hemorrhage (>30 mL) that would necessitate additional Rh-immune globulin therapy.

Originally posted at InjuryBoard by Robert Blanchard

Insurance Costs Not Affected by Malpractice Lawsuits

Robert Blanchard — Mon, 14 Nov 2005 10:43:14 GMT

Yet another study has been published showing the the amount doctors are paying for their medical malpractice insurance is not related to payouts on liablility claims. See the full article. There have been so many reports and studies by so many independent groups for so many years, all showing that the "lawsuit crises" over medical malpractice is a hoax, that everyone should by now realize that politicians perpetuating this big lie have another agenda. Their agenda is to take away accountabilty and responsibilty for patient injuries so insurance companies can make more more. When will the doctors learn that it won't bring down their insurance premiums?

The truth is that there is a medical malpractice crisis facing our nation. It has its origins in the operating room, not the courtroom. According to an Institute of Medicine study published a few years ago, between 44,000 and 98,000 Americans die in hospitals every year due to preventable medical errors. Additionally, a recent study of just a sample of Pennsylvania hospitals found that hospital-acquired infections in that state alone are taking a staggering toll on patients and the cost of health care, resulting in nearly 1,800 additional deaths, increased costs of $2 billion, and 205,000 additional days spent in the hospital by patients contracting largely preventable infections.
In many instances, health care institutions could greatly reduce the number of preventable injuries and infections by simply increasing staffing levels. Deliberate short staffing is literally injuring or killing thousands of patients every year. Staffing is often the largest component of many health care institutionsâ€™ budgets. While decreasing staffing increases profits, the practice takes a horrible toll in patient lives and safety, and it should be stopped.

Originally posted at InjuryBoard by Robert Blanchard