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The patient should have no serious medical problems that increase the risk associated with the biopsy. The facility in which the biopsy is performed should have an approved laboratory, a blood-banking unit, an easily accessible inpatient bed, and personnel to monitor the patient for at least 6 hours after the biopsy. The patient should be hospitalized after the biopsy is performed if there is evidence of bleeding, a bile leak, pneumothorax air or gas in the pleural space ; , or other organ puncture, or if the patients pain requires more than one dose of analgesics in the first 4 hours after the biopsy. Liver biopsy is a safe procedure when performed by experienced operators. Froehlich et al. noted a lower complication rate for physicians who performed more than 50 biopsies a year. Prior localization of the biopsy site via ultrasound may decrease the rate of complications for physicians who perform liver biopsies infrequently. Blind liver biopsies i.e., without the aid of prior ultrasound localization ; should be performed by experienced gastroenterologists, hepatologists, or transplantation surgeons and not by general internists. Although the liver has a rich vascular supply, complications associated with percutaneous liver biopsy are rare. Sixty percent of complications occur within 2 hours and 96 percent within 24 hours after the procedure. Approximately 1 to 3 percent of patients requires hospitalization for complications after a liver biopsy.
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Events versus patients There is no doubt that the inclusion of PPS Number on HIPE would greatly enhance the range of potential uses for these data. Use of PPS Number is, however, currently confined to specified agencies within the public sector and any further extension of its use requires legislative provision and consultation with the Department of Social and Family Affairs.9 In the Health Information Strategy there is, however, a commitment to the introduction of a system for unique identification within the health sector using PPS Number.9 Delivery on this commitment will, of course, have to ensure that the necessary safeguards are in place to protect patient privacy. Socio-economic group variable When the HIPE system was originally introduced in the 1970s, a data variable for occupation was included. Prior to the ESRI taking management responsibility for HIPE, this variable was regrettably dropped in the 1980s due to the very low level of response achieved. There is an annual review of the data elements collected within HIPE and the inclusion of a variable to enable the assignment of socio-economic group has been considered on a number of occasions. When data changes to the HIPE system are considered, however, a number of factors have to be taken into account. Firstly, data can only be collected for the HIPE system if they are collected initially by hospitals. Where a number of changes to the system are being considered, priorities must be assigned to determine which changes are considered more urgent or important. Finally, there is a cost to each change to the HIPE system both in terms of the workload generated for those collecting and inputing the data and also because of software changes that have to be made locally and nationally. While the inclusion of a variable to facilitate improved measures of socio-economic status remains an objective for the HIPE system, the inclusion of information on public private status and medical card status should facilitate an assessment of equity issues within the system as currently structured and toprol.
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15 July Reuters reported despite warnings from the government, health groups and doctors, more than 70 percent of Americans still eat too much meat and fat and too few vegetables. They published a survey showing 72 percent of Americans still centered their meals on animal fats, leaving little room for the vegetables that prevent not only cancer but heart disease and perhaps a range of other diseases, too. A survey of 1, 000 adults asked what they had eaten the night before and how much. The survey, with a margin of error of three points, showed that only 27 percent were eating the recommended proportion of plant food to animal food. Even when the people surveyed ate vegetables, they had too few and often the least nutritious kinds. Only 6 percent said they had eaten a salad the night before. Of those, 19 percent ate salads loaded with meat and cheese. View Article and
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STUDY OBJECTIVES: To determine the relationship between diagnosed and treated COPD and the incidence of cardiovascular disease CVD ; hospitalization and mortality. DESIGN: Retrospective matched cohort study. SETTING : Northern California Kaiser Permanente Medical Care Program KPNC ; , a comprehensive prepaid integrated health care system. PATIENTS OR PARTICIPANTS: Case patients n 45, 966 ; were all KPNC members with COPD who were identified during a four-year period from January 1996 through December 1999. An equal number of control subjects without COPD were selected from KPNC membership and were matched for gender, year of birth, and length of KPNC membership. MEASUREMENTS AND RESULTS: Follow-up conducted for hospitalization and mortality from CVD end points through December 31, 2000. CVD study end points included cardiac arrhythmias, angina pectoris, acute myocardial infarction, congestive heart failure CHF ; , stroke, pulmonary embolism, all of the aforementioned study end points combined, other CVD, and all CVD end points. The mean follow-up time was 2.75 years for case patients and 2.99 years for control subjects. The risk of and
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OBJECTIF : Uniformiser la prise en charge des enfants avec cancer de la thyrode, qui est sujette controverse. MTHODE : Nous avons rvis les cas de nodules thyrodiens 0-18 ans ; hospitaliss au CHUL de 1980 2000. RSULTATS : Dix-neuf patients retracs. Age moyen : 12, 9 ans. Ratio fille garon : 2 : Aucun antcdent d'irradiation. Diagnostics finaux : 1 MEN IIa, 1 MEN IIb, 5 carcinomes papillaires, 9 adnomes, 2 kystes, 1 thyrodite d'Hashimoto. Tous les patients cancreux taient euthyrodiens. 12 19 ont subi une chographie. Cancers retrouvs dans les lsions nodulaires 2 ; et lsions mixtes 2 ; . Patient avec MEN IIb : chographie normale. 16 19 ont subi une scintigraphie. Cancers dans les catgories nodule froid 3 ; et captation normale 3 ; . 10 ont subi une cytoponction, classifies comme insuffisante 2 ; , suspecte 2 ; , cancer 2 ; et bnigne 4 ; . Aucun cancer manqu la cytoponction. Parmi les cancers : 6 ont subi une thyrodectomie totale et 1 patient a subi une thyrodectomie sub-totale avec chantillonnage ganglionnaire ; . 80% des cancers papillaires taient mtastatiques. Les patients avec MEN II a et souffraient d'un cancer mdullaire mtastatique. 3 5 des cancers papillaires ont subi une ablation l'131 et 5 furent supprims la LT4. Parmi ces patients : 1 rcidive locale, aucun dcs aprs suivi moyen de 6, 5 ans. La patiente avec MEN IIa a subi 4 rcidives mais survit 14 ans post-chirurgie. La patiente avec MEN IIb n'a subi aucune rcidive 13 ans post-chirurgie. CONCLUSION : Nous proposons un algorithme dcisionnel bas sur la cytoponction et une suggestion de traitement et de suivi.
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Selection of hospitals This is a retrospective pre post-reform case study. The study was conducted in two public hospitals located in the capital city of Shandong Province, a provincial hospital one of the largest in the province, with over 1 million outpatient visits annually ; , and a municipal hospital. In China, public hospitals dominate the provision of medical services and generate a large proportion of drug expenditures. The hospitals were purposively selected to represent different hospital types. The provincial hospital is directly managed by the provincial Department of Health and is one of 10 model hospitals in China. Model hospitals are selected by the Ministry of Health as examples for administration and service quality. The municipal health authority directly manages the municipal hospital. Selection of a medical condition and patients' records Criteria for choosing a tracer diagnosis were that the condition should, in the Chinese context, be relatively intensive in consumption of drugs, with a wide range of types and substitutes; have inpatient care with a relatively long hospital stay; and have a stable composition of the case mix in a short time period. A panel of medical experts was organized to select the diagnosis. Cerebral infarction ICD-10 code I63 ; was selected as an appropriate tracer condition for drug expenditure. In both hospitals, the majority, but not all, cases were confirmed by computerized tomographic examinations. Because the numbers of patients with the sole diagnosis of cerebral infarction were limited, cases with the secondary diagnoses of hypertension essential hypertension ; ICD-10 code I10 ; or atherosclerotic heart disease coronary ; ICD-10 code I25.1 ; were also selected. Cases with additional complications were excluded, to reduce variation in disease severity between the two time periods. The drug retail price control policy was implemented in late 2000. Because drug expenditure might not yet have been affected in 2001, the cases were selected from the beginning of 2002 for the post-reform period and from the end of 2000 backwards for pre-reform cases. All cases meeting the diagnostic criteria after 1 January 2002 were selected. In the provincial hospital, records of 49 cerebral infarction cases were selected, and in the municipal hospital, 55 cases were selected. In the provincial hospital, 49 cases from prior to the implementation of the policy were selected, and in the municipal hospital, 60 such cases. A total of 213 medical records of cerebral infarction patients were reviewed. The study periods covered January to August 2002 post-reform ; , and May to December 2000 pre-reform.
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OBJECTIVE: The aim of this study was to evaluate fatigue in Australian Gulf War veterans and a military comparison group according to the 1994 chronic fatigue syndrome CFS ; definition and investigate the relation with exposures. METHODS: Comprehensive medical, psychological and reported exposure assessments of 1, 456 veterans and 1, 588 comparison group in a cross-sectional study. RESULTS: More Gulf War veterans had fatigue at all levels than did the military comparison group. The findings may be at least partly explained as an "active-deployment effect." The odds ratios increased with increasing clinical evaluation of the nature of the fatigue, even after adjustment for current psychiatric disorders in addition to other possible confounding factors. CONCLUSION: Medically unexplained chronic fatigue was more common, but not more disabling, in veterans than in the comparison group, but veterans with unexplained chronic fatigue had poorer health than veterans without. Within both populations, CFS is uncommon and at a similar level to the general community. Chronic fatigue syndrome CFS ; is a debilitating condition that has no known aetiology or pathophysiology. Recent investigations by other workers have suggested that individuals with CFS may have a hypercoagulable state. This study investigated various aspects of platelet activation and function in 17 patients with CFS and in 16 age-matched and sex-matched healthy controls. Platelet aggregation, platelet volume and coagulation tests were performed. Platelet aggregation was investigated by means of the photometric changes using citrated platelet-rich plasma, whole blood aggregation was calculated as the percentage fall in single platelet counts and the coagulation tests were performed on an automatic microcentrifugal analyser.A trend was observed for the patients to have lower aggregation results and a reduced mean platelet volume. However, this only reached statistical significance for one result; the rate of the aggregation slope by 1.0 microg ml collagen [CFS patients, 18 9-28 ; versus controls, 32.5 1936 Mann-Whitney U test, P 0.029]. No significant differences were found for any of the measurements of coagulation.These results are in contrast to previously reported findings. However, due to the heterogeneous nature of the disease, and the resulting lifestyles of the patients, caution should be taken when comparing one group of patients with another. Nevertheless, we certainly found no evidence of increased platelet activation or of a hypercoagulable state in patients with CFS and, on the basis of these results, anti-platelet or anti-coagulant therapy is not warranted. Chronic fatigue syndrome CFS ; is an illness characterised by disabling fatigue of at least 6 months.
By Barbara Rose, Senior Risk Management Representative The following closed claim study is based on an actual malpractice claim from TMLT. This case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician's defensibility. The ultimate goal in presenting this case is to help physicians practice safe medicine. An attempt has been made to make the material less easy to identify. If you recognize your own claim, please be assured it is presented solely to emphasize the issues of the case. Clinical presentation A 45-year-old woman came to the emergency department ED ; complaining of pain, blurry vision, and sensitivity to light in the left eye. Examination confirmed a corneal abrasion. The patient was given an antibiotic eye drop and instructions to follow up with the defendant ophthalmologist. She was seen the next day in the defendant's practice. At that time, the history revealed that the patient had not filled the oral antibiotic prescription. She also had not administered the topical antibiotics as instructed by the ED physician. Physician action Visual acuity was 20 200 in the left eye. A corneal ulcer with an infiltrate was diagnosed. The defendant started the patient on topical Tobradex, a combination antibiotic and corticosteroid medication. The patient was instructed to return the next day for repeat evaluation. At that visit, she reported less discomfort and improved vision. On examination, the visual acuity had improved to 20 80 and the infiltrate was still present but improved. Tobradex was continued as well as Ciloxan that had been prescribed by the ED physician. A return appointment was made in five days. On the appointment date, the patient came to the same ED and was instructed to see the defendant as scheduled. She did not keep this appointment, but was seen the next day. The patient reported an increasing foreign body sensation in the affected eye. Visual acuity had decreased to 20 200 and an infiltrate was still noted. A therapeutic bandage contact lens was inserted and the patient was advised to continue Ciloxan and Tobradex and return in two days. At this appointment the patient complained of increased pain and decreased vision in the left eye. She informed the physician that she thought a piece of asphalt had flown into her eye the first day she went to the ED. Visual acuity was 20 400 and the infiltrate was larger, involving the inferior cornea. The bandage contact lens was exchanged and Ancef and Atropine drops were added to the topical medications. The patient was seen the next two days Saturday and Sunday ; by the defendant. No improvement was noted. On Sunday, the patient was referred to a corneal specialist. The defendant paged the on-call specialist for the corneal group and that physician agreed to see the patient on Sunday at a medical center. The patient was examined in the ED and appropriate cultures were done. On Monday, the corneal specialist recorded a corneal abrasion 4mm by 6mm that had not increased from the earlier measurements. Two days later, the abrasion had decreased in size to 3mm by 5mm. The final results of the cultures were determined five days later April 16th ; , and were positive for a fungal corneal ulcer. Amphotericin B was started and Cosopt for increased intraocular pressure. A return visit with the corneal specialist on April 21st listed Amphotericin B, Vancomycin, Gentamycin, continued on page 2.
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