Wall St. Journal, 2/6/08: 

An effort is underway in hospitals, government, and accrediting agencies to revamp informed-consent procedures to ensure that patients better understand the care they are about to receive. Failure to obtain informed consent is among the most common allegations in medical malpractice suits.

The U.S. Centers for Medicare and Medicaid Services recently issued new guidelines calling on hospitals to design patient-friendly procedures or risk losing eligibility to bill Medicare for treatments. Also, the U.S. Department of Veteran’s Affairs (VA), with 153 hospitals, has adopted an electronic informed-consent software program known as iMedConsent which allows patients to sign consent forms on a digital pad. The program includes a library of anatomical diagrams and explanations written at a sixth-grade reading level for more than 2,000 procedures in more than 30 medical specialties. The VA is currently conducting a study in seven hospitals to determine the viability of using iMedConsent in conjunction with a “teach back” process that asks patients to explain what they have been told in their own words.

A study at the University of California at San Francisco (UCSF) found that using forms written at a sixth-grade reading level, testing patients’ comprehension, and explaining things until they are understood increased the number of patients who could answer comprehension questions correctly from between 15 – 28 percent to 98 percent. “First-grade teachers know how to make sure kids understand what they’ve been taught and can repeat it back to you, but we don’t learn how to do this in medical school,” said Dean Schillinger, a UCSF professor of clinical medicine. 

Intro: This is a letter seeking rock salt.  Thought you might like to see how communication channels work in NWO.

St. Charles Mercy Hospital been informed that their salt supplier has
Red-Lined them.
Their limit of rock salt for the year was put at 250,000 tons and they
have reached 248,000 tons.  No additional salt will be delivered to St.
Charles this year.  The City of Toledo is also low on salt and the
hospital has received requests from adjacent townships to purchase salt.
The hospital is trying to find other vendors, even for bag salt to load
their dump trucks.

If any hospitals perhaps less affected by the current snow season would
be able/willing to provide St. Charles with rock salt, they would be
able to pick it up in their dump trucks.  As you know, the weather
stations are predicting some more snow tomorrow and a major storm
Sunday/Monday this weekend.

Your help is certainly appreciated.

Rose Heard, BA, CHSP
Facilities/Safety Coordinator
St. Charles Mercy Hospital
419-696-7459 (office)
419-696-7478 (fax)
419-262-2597 (cell)
419-539-1506 (pager)

CDC Press Release, 2/14/08: At least 82 youth have died as a result of playing what has been called “the choking game,” according to a study released by the Centers for Disease Control and Prevention in today′s Morbidity and Mortality Weekly Report. The choking game involves intentionally trying to choke oneself or another in an effort to obtain a brief euphoric state or “high.” Death or serious injury can result if strangulation is prolonged.

Eighty–seven percent of these deaths were among males, and most fatalities occurred among those 11 years to 16 years old; the average age was 13, the report said. Choking game deaths were identified in 31 states, it said.

CDC found that most of the deaths occurred when a child engaged in the choking game alone, and that most parents were unaware of the choking game prior to their child′s death.

“Because most parents in the study had not heard of the choking game, we hope to raise awareness of the choking game among parents, health care providers, and educators, so they can recognize warning signs of the activity,” said Robin L. Toblin, Ph.D., M.P.H., the study′s lead author. “This is especially important because children themselves may not appreciate the dangers of this activity.”

Three or fewer choking game–related deaths per year were reported in the news media from 1995 to 2004, the report said. However, 22 deaths occurred in 2005, and 35 in 2006. Nine deaths occurred in the first 10 months of 2007; the explanation for this decrease is unclear. The researchers said the study probably underestimates the number of deaths.

For this study, CDC analyzed media reports of deaths attributed to the choking game. Deaths were not included unless the report provided evidence that they were a result of the choking game.

“This report is an important first step in identifying the choking game as a public health problem,” said Ileana Arias, Ph.D., director of CDC′s Injury Center. “More research is needed to identify risk factors that may contribute to kids playing the choking game and to determine what may help to reduce this type of behavior.”

Signs that a child may be engaging in the choking game include

• discussion of the game ––including other terms used for it, such as “pass–out game” or “space monkey”;
• bloodshot eyes;
• marks on the neck;
• severe headaches;
• disorientation after spending time alone;
• ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor;
• unexplained presence of things like dog leashes, choke collars and bungee cords

If parents believe their child is playing the choking game, they should speak to them about the life–threatening dangers associated with the game and seek additional help if necessary.

AP (2/14, LeBlanc):  A “report by the Massachusetts Hospital Association finds that the number of so-called ‘free care’ visits to hospitals have declined by 28 percent over the past three years.” The AP notes that one “key premise of the state’s landmark healthcare law” was that “more uninsured people who were enrolled in subsidized healthcare plans” would lead to “fewer uninsured people…show[ing] up at hospital” emergency departments (EDs) “for routine care.” The reduction in free care visits “mirrors a 28 percent increase in enrollment in subsidized healthcare programs, MassHealth, and the new Commonwealth Care program, which was created by the law.” Jon Kingsdale, “executive director of the Health Insurance Connector Authority, which oversees the healthcare law,” said, “The idea was to give (the uninsured) insurance rather than give them money to support episodic” ED care. Kingsdale added, “Now we are seeing that shift away from where people showed up at” EDs “for non-emergency care.” alastair hetherington hong kongherrington ford marmon 195370 ringtones sringtones aerosmith mp3 pinkchildren all ringtones myakon ringtoneallman brothers ringtones band6315i ringtones Mapporn alissa starporno alkaaccess porn all passporn ages allporn all american sweetheartsporno free anime allall free porn blackporn all stars black Map

LA Times, 2/14/08:  The Food and Drug Administration is investigating whether an ingredient from China may be the source of problems with a blood thinner linked to hundreds of reports of severe allergic reactions and possibly several deaths.

Some of the active ingredient in the drug heparin from Baxter Healthcare Corp. was probably made in China, but the FDA and the manufacturer say it is too early to say whether the complications were caused by that ingredient.

Some patients who received heparin experienced difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure that can lead to life-threatening shock, the FDA said. The agency said four people had died after receiving heparin, though the link to the drug was unclear.

Calls to China’s State Food and Drug Administration in Beijing went unanswered.

As with food ingredients, China in recent years has become a major exporter of active pharmaceutical ingredients. Medicine Economic News, citing China’s customs statistics, reported that the nation’s exports of heparin and its components totaled $57.8 million in the first half of 2007, a 13.7% increase from the same period a year earlier. The Guangzhou-based publication said 49 companies exported heparin and its ingredients.

Baxter announced Monday that it was suspending manufacture of multiple-dose vials of heparin. The injectable drug, which is derived from pig intestines, is used to prevent dangerous blood clots from forming during certain types of surgery, including heart bypass. Baxter accounts for about half the U.S. market for the drug.

Baxter spokeswoman Erin Gardiner said Wednesday evening that some of the active ingredient probably was made in China because Baxter got its supply from another company that had manufacturing facilities in the U.S. and in China.

Baxter wasn’t identifying the source, but Gardiner said the supplier had been manufacturing heparin for more than 30 years and had been supplying Baxter for more than 20 years. She said the plant in China had been in operation for several years.

Baxter inspected the supplier’s U.S. facility and its China plant last year, and both have good records in terms of safety and quality, the company said. The FDA has not inspected the plant in China, the agency said.

A 32-year-old woman presents to the emergency department (ED) with several flesh-colored papules on her face, trunk, and upper extremities.

She first noticed the lesions at approximately 10 years of age; however, over the past 5 years, the lesions have increased in number and become uncomfortable. She primarily complains of irritation from the lesions along her bra line. She underwent excision of similar skin lesions 5 years ago, but they have since recurred. She denies having any discharge, pain, trauma, contact with individuals with atypical skin lesions or rashes, travel out of the country, unusual exposure to animals, or a history of sexually transmitted diseases.

The patient’s medical and surgical history includes environmental allergies, frequent episodes of bronchitis, and the aforementioned excisions. She has no known drug allergies, and she takes cetirizine HCl and fluticasone propionate for seasonal allergies. Her family history is significant for coronary artery disease, hypertension, diabetes mellitus, and glaucoma, but there is no family history of similar lesions. She does not smoke and only drinks alcohol on occasion. The review of her systems is otherwise unremarkable.

The physical examination reveals dozens of 0.5-2.0 cm fleshy nodules spread over her trunk, face, and upper extremities. The nodules are nontender to palpation and nonerythematous, and they produce no discharge, crusting, or scaling. Several tan oval macules measuring 1.5-3 cm in size and patches with well-defined borders are located on her trunk and upper extremities (see Images). Her vital signs are within normal limits, and her other physical findings are unremarkable.

WHAT THE HELL IS THAT?

ANSWER: Neurofibromatosis.

Neurofibromatosis (NF) is an autosomal dominant disorder with numerous presentations that can affect nearly every organ system. The 2 major subtypes of NF are peripheral NF, also known as NF type 1 (NF1), and central NF, which is referred to as NF type 2 (NF2). These terms are not completely accurate, however, because NF1 also can include central nervous system (CNS) abnormalities.

About 50% of cases of NF are familial; the other 50% are caused by spontaneous gene mutation. NF1, also known as von Recklinghausen disease, is a common genetic disorder involving a mutation in the gene that produces neurofibromin on chromosome 17; the condition affects 1 in every 3000-4000 births.^[1] All races are affected, and the 2 sexes are affected equally.^[3] Two or more of the following 7 criteria must be present in order to make the diagnosis of NF1: 6 or more café-au-lait spots (irregularly shaped, evenly pigmented, brown macules), 2 or more neurofibromas, axillary or inguinal freckling, Lisch nodules (hamartomas of the iris), optic gliomas, various types of osseous lesions, and a first-degree relative with the condition.

Symptomatic NF1 typically initially manifests as café-au-lait spots that may be present at birth or that appear over time during childhood. Axillary or inguinal freckles are not usually present at birth but, rather, appear throughout childhood and adolescence. Neurofibromas are rarely seen in young children but usually appear over time in older children, adolescents, and adults. The patient may have as few as 3 or as many as thousands of these benign lesions, which consist of Schwann cells, neural fibroblasts, mast cells, and vascular elements. The neurofibromas may occur anywhere in the body and can potentially lead to marked disfigurement. If the lesions are deep, they may only be detected through palpation; cutaneous lesions may initially appear as small papules on the trunk, the extremities, the scalp, or the face. A specific type of these lesions is a plexiform neurofibroma, which is a more diffuse type of growth that can be locally invasive and quite deep. These lesions may be associated with bony erosion and pain, and they may also be accompanied by overlying hyperpigmentation or hypertrichosis. The onset of puberty or pregnancy may be associated with an increased number of neurofibromas, as well as an increase in the speed of preexisting lesion growth. Lesions along visual, auditory, or CNS nerve pathways may result in blindness, deafness, or neurologic deficits. On histology, the neurofibromas are generally well-differentiated tumors that contain elongated spindle-shaped cells and pleomorphic fibroblast-like cells. Some lesions may contain inflammatory cells. Occasionally, a large neurofibroma, a deep plexiform neurofibroma, or a peripheral nerve sheath tumor residing within the brachial or pelvic plexus may undergo malignant transformation into a neurofibrosarcoma. Unlike benign neurofibromas, neurofibrosarcomas are characteristically hypercellular, with giant cells, increased numbers of mitoses, and vascular proliferation. Additionally, small masses of malignant cells may be present within larger masses of benign cells (eg, as in a plexiform neurofibroma).

Optic nerve tumors occur primarily in children younger than 5 years. The most common presenting symptom is asymmetric, noncorrectable visual loss, but subtle peripheral field defects, optic nerve pallor, color-discrimination difficulties, or proptosis may be present without visual acuity being affected. A slow-growing optic nerve glioma (ONG) may lead to vision problems in some older children and adolescents; these patients should be monitored for visual difficulties throughout childhood and adulthood. In adults, a visually insignificant ONG may be detected incidentally on head imaging studies. Although Lisch nodules are usually not visible without use of a slit lamp, they may occasionally be seen with a direct or indirect ophthalmoscope, especially in individuals with light-colored irises. Choroidal abnormalities with a patchy appearance or retinal corkscrew vascular changes may also be noted on funduscopic examination.

Orthopedic manifestations are also commonly encountered. Congenital pseudarthrosis may be evident at birth; bowing of the tibia is the most typical presentation. Thinning and angulation of the long bones can occur throughout early childhood and adolescence, with prominence of the anterior tibia and progressive deformity; less commonly, bowing of the forearm can occur. Scoliosis with or without kyphosis may become evident in childhood or adolescence; when this finding is present in children younger than 10 years, scoliosis is associated with a poor prognosis and is likely to progress rapidly. Scoliosis detected during adolescence should still be monitored clinically, but it is much less likely to require orthopedic intervention. Sphenoid bone dysplasia is usually asymptomatic, but it can occasionally be associated with herniation through the bony defect. Other skeletal anomalies, such as fibrous dysplasia, subperiosteal bone cysts, or vertebral scalloping, can also be found.^[3]

Rare complications of NF1 include renal arterial stenosis and pheochromocytoma, either of which can present with hypertension.^[5]

NF2 is a progressive genetic disorder that is present in 1 in every 33,000-40,000 births.^[3] Patients with NF2 (which results from an abnormality on chromosome 22) typically present with acoustic neuromas or vestibular schwannomas. The clinical manifestations of NF2 include tinnitus, balance disorders, and progressive hearing loss. Affected patients may also have meningiomas, juvenile cataracts, or schwannomas of the dorsal roots of the spinal cord. The diagnosis of NF2 is based on the presence of bilateral acoustic neuromas or a unilateral acoustic neuroma in a first-degree relative with NF2.^[5]

For both NF1 and NF2, the diagnosis is primarily based on the physical findings and a positive family history. Plain radiologic studies, which may detect many bony abnormalities (such as modeling defects of the long bones or ribs, bony erosion secondary to an adjacent plexiform neurofibroma, or scoliosis), may be useful diagnostic tests. Gadolinium-enhanced magnetic resonance imaging (MRI) of the brain is the preferred diagnostic imaging study of the head, and it can be ordered either routinely—as a standard screening—or it can be ordered for patients with specific indications, such as the onset of neurologic problems or headaches. MRI studies have been shown to frequently detect unidentified bright objects in the brain parenchyma; generally, these bright spots do not enhance, they cause no mass effect, and they often resolve as the patient gets older. It has been theorized that these masses may represent benign hamartomas. MRI scanning of the brain can assist in evaluating the optic nerves or optic chiasm. This imaging modality is also useful for diagnosing and evaluating other internal lesions, such as mediastinal masses, spinal cord tumors, deep plexiform neurofibromas, neurofibromas of the brachial or sacral plexus, and abdominopelvic lesions. Genetic analyses and psychological or developmental assessments should also be part of the evaluation of patients with neurofibromas.

No cure exists for NF1 or NF2. The recommendations for follow-up include referral to support groups, psychological counseling, and evaluation for learning disorders; potential surgical excision of the lesions; and regular monitoring by a primary care provider for any lesion changes (patients with NF1 are at a somewhat increased risk for malignancy). Annual ocular examinations are recommended. Genetic testing is also available for patients with NF who wish to have children. Historically, surgery has been a successful treatment for the lesions themselves; however, there is often recurrence, and nerve damage is a risk in cases in which the lesions are located along neural pathways.^[4]

References

1. Children’s Tumor Foundation: Diagnosis of NF1. Available at:
   https://www.ctf.org/about-nf/diagnosis-of-nf1/. Date accessed: October 5, 2007.
2. Children’s Tumor Foundation: Diagnosis of NF2. Available at:
   https://www.ctf.org/about-nf/diagnosis-of-nf2/. Date accessed: October 5, 2007.
3. Neurofibromatosis, Inc: What is NF? Available at:
   http://www.nfinc.org/what.shtml. Date accessed: July 29, 2006.
4. NINDS: National Institute of Neurological Disorders and Stroke. Neurofibromatosis fact sheet. Available at: http://www.ninds.nih.gov/disorders/neurofibromatosis/detail_neurofibromatosis.htm#57453162. Date accessed: July 29, 2006.
5. McKusick VA, Hurko O, Lurie IW, Smith M. Hamosh A, Macke JP, et al.
   Online Mendelian inheritance in man: neurofibromatosis type 1. Last updated: September 26, 2007 Available at:
   http://0-www.ncbi.nlm.nih.gov.catalog.llu.edu/entrez/dispomim.cgi?id=162200. Date accessed: September 26, 2007.
6. Pletcher BA. Neurofibromatiosis, Type 1. eMedicine Journal [serial online]. Last updated: March 13, 2006 Available at: http://www.emedicine.com/neuro/topic248.htm.
   Date accessed: September 13, 2007.