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Medical Error: The Third Leading Cause of Death in the U.S.

by jmiller on May 5, 2016

In the news, (BMJ, May 3) .  The article explains that the 1999 Institute of Medicine (IOM report is limited and outdated.  The results were contested by Leape in 1993, a chief  investigator of the 1984 Harvard study which published an article arguing that the study’s estimate was too low, contending that 78% rather than 51% of the 180,000 iatrogenic deaths were preventable. Similarly,  the Inspector General of the USDHHS Office examining the health records of hospital inpatients in 2008, reported that 180,000 deaths due to medical error a year among Medicare beneficiaries alone, a rate of 1.13%.  If this rate is applied to all registered US hospital admissions in 2013, it translates to over 400,000 deaths a year, more than four times the IOM estimate.  The ICD-10 coding system has limited ability to capture most types of medical error.  At best, there are only a few codes where the role of error can be inferred, such as the code for anticoagulation causing adverse effects and the code for overdose.  When a medical error results in death, both the physiologic cause of the death and the related problem with deliver of care should be captured.  Data should be shared nationally and internationally to improve safety, much in the way scientists share data about disease.  Click here to read full-text.

Which oral anticoagulant for atrial fibrillation?

by jmiller on April 21, 2016

Direct-to-consumer advertisements continue to urge patients who take warfarin for atrial fibrillation to ask their doctors about the benefits of one or another of the newer anticoagulants.  This review  (Medical Letter, April 11) addresses the efficacy, bleeding and reversibility of direct oral anticoagulants.  The article concludes that “the direct oral anticoagulants dabigatran (Pradaxa), apixaban (Eliquis), eoxaban (Savaysa, and rivaroxaban (Zarelto) have been at least as effective as warfarin (Coumadin, and others) in preventing stroke or systemic embolism in patients with nonvalvular atrial fibrillation, and they may appear to be safer.  Patients well-controlled on warfarin (INR stable in the therapeutic range) could stay on it.  For all others, one of the direct oral anticoagulants might be a better choice.  Head-to-head comparisons of the new drugs are lacking.”  Click here to read full text.

Zika Virus and Pregnancy – Online First – NEJM

by jmiller on April 14, 2016

In a series of “online first” articles, and also reported in this weeks news, the NEJM has made the following articles available:  Zika virus infection in pregnant women in Rio de Janeiro – preliminary report; Zika virus and birth defects – Reviewing the evidence for causality; Zika virus infection with prolonged maternal viremia and fetal brain abnormalities; Zika virus and microcephaly; Evidence of sexual transmission of Zika virus ; Zika virus associated with microcephaly.  Click here to read this compendium of articles.

Zika Virus

by jmiller on April 14, 2016

In an “online first” series from the NEJM this week, this segment includes general information:  Zika Virus; The Zika Challenge; Zika Virus in the Americas: Yet another arbovirus threat.  Click here to read full text.

Zika virus as a cause of neurologic disorders

by jmiller on April 14, 2016

In a series of “online first: articles published in the NEJM this week, the focus is on Zika virus in the United States.  The articles in this set include:  Zika virus as a cause of neurologic disorders and Zika virus associated with meningoencephalitis.  Click here to read full text.

Mediterranean diet and fracture risk in postmenopausal women

by jmiller on March 29, 2016

This early online article and editorial (JAMA Intern Med) concludes, “Higher adherence to a Mediterranean diet is associated with a lower risk for hip fractures.  These results support that a healthy dietary pattern may play a role in maintaining bone health in postmenopausal women.”  Click here to read article and editorial.

Effect of mindfulness-based stress reduction vs. cognitive behavioral therapy or usual care on back pain

by jmiller on March 22, 2016

From this week’s JAMA (Mar 22/29), article concludes, “Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT.  These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.”  Click here to read full text.

CDC guideline for prescribing opioids for chronic pain: United States, 2016: A proactive response to prescription opioid abuse

by jmiller on March 17, 2016

The CDC guidelines, with accompanying editorials attached (JAMA, March 15) and the FDA’s response (NEJM, Feb 4 early online), provide a blueprint for opioid prescribing for primary care clinicians treating adult patients with chronic pain “outside of active cancer treatment, palliative care and end-of-life care.”  “There are 12 recommendations. Of primary importance, non-opioid therapy is preferred for treatment of chronic pain. “Opioids should be used only when benefits for pain and function are expected to outweigh risks. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every three months or more frequently. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.” The FDA supports the CDC guidelines and has crafted its own responses for addressing these issues by refining these goals and “ensuring that all available effective tools are brought to bear on this epidemic,” and that “the evidence base for proper pain management and appropriate opioid use is optimized and translated into practice.” Of note (and addressed in an editorial attached), this guideline does not adequately address children. Click here to read the full text.

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