Revision surgery...PO DAY 257

Sometimes reverse total shoulder arthroplasty surgery needs surgical follow up. It's not that the original surgery was poorly done, it's  just the procedure is complicated and the outcome is not guaranteed. 

Four hundred forty one patients who were operated between 1999 and 2008 were followed. Of them, sixty seven had follow up surgical procedures. Reasons for additional surgery were identified and the first 37 patients were followed for two years.

Some patients needed only one additional surgery but 30 of them required a second procedure, 11 needed a third procedure and four had a fourth. 

The most common reason for additional treatment was instability of the new joint, 18%. Hematoma or Wound problems accounted for 15% of follow up surgery. And 12% experienced glenoid problems that required surgery. In spite of this unexpected complication, objective scoring of procedure results revealed that patients benefitted from the treatment in general and had improved comfort and use of the operated arm.

Other complications were scapular notching, infection and acromioal fractures. These were not treated surgically.

Two things to note: this study followed surgeries performed in the early years of this operation coming to the U.S. Experience has likely reduced the rate of complications.  And, in spite of requiring follow up surgical procedures (never what you want to hear recommended), follow up revealed improved and satisfied patients. 

Replacing body parts with prosthetic devices is big surgery and changing the configuration of the original joint and bone shaft is a major revision of nature. It's no surprise that there can be problems. It appears, statistically, that the end justifies the means and, in spite of requiring additional surgery, patients benefitted from the operation and had improved shoulder function and comfort. 

Hooray!

A rare pork dinner...PO Day 256

Dear son in law, who lives in Southern California, is here briefly to visit. So I wanted to cook a special dinner tonight. I chose a pork tenderloin recipe with a fennel and white wine sauce. But the recipe called for a slightly pink pork and I usually cremate pork so it turns out tough and dry. A little Google search taught me I have been doing it wrong.

In 2011 Consumer Reports published the latest from the FDA (Food and Drug Administration) on the subject of cooking the new pork. Pork is leaner thsn it used to be due to better feeding and breeding practices. The new pork is 16% leaner than what we knew years ago. Previously we were advised to cook pork to an internal temperature of 175, now it is recommended to cook it to 145, the same as beef, and allow it to rest for three minutes before serving.

The USDA’s recommendation for pork is now the same as for other whole cuts of meat including beef, veal and lamb. "With a single temperature for all whole cuts of meat and uniform three minute stand time, we believe it will be much easier for consumers to remember and result in safer food preparation,” said Under Secretary Elisabeth Hagen in a press release. "Now there will only be three numbers to remember: 145 for whole meats, 160 for ground meats and 165 for all poultry."

Everything changes! I don't know how to keep caught up on events and opinions. This was one little step towards being a modern cook.  Apparently restaurants have been cooking pork at lower finish temps for several years. Perhaps that's why their food is always so tender and good. If this is typical I am sold. The dish was easy and delicious.

Smoking v. Brain...PO Day 255

In the same issue of The Week there is a brief article about the effect of smoking on cognitive function. Researchers analyzed brain scans of over 500 smokers, non smokers and former smokers. Average age was 73 years old. The conclusion was that smoking may cause thinning of the cortex, the outer layer of the brain responsible for memory, language and perception. The more a person smoked the thinner the cortex became. Even quitting did not stop the continued decline in cognitive activity and memory, the effects which can continue for decades.

Thinning of the cortex can cause balance problems, Alzheimer's disease and schizophrenia.

People who stopped smoking did recover some cortical thickness although it did not appear to reverse the damage entirely.

Lead author of the article about the study was Dr. Sherif Karama of McGill University and the article was reported in the New York Daily News. If you are looking for ammunition to convince someone to stop smoking, this would be a good weapon in your armamentarium.

Meditation...PO Day 254

The latest issue of The Week magazine reports on a study at UCLA where researchers studied the effect of meditating on the aging brain. What is common is that as we age, even from age 20, our brains shrink in volume and weight eventually resulting in the loss of some functional ability. The study compared the brains of people who meditate with the brains of those who don't.

It was a small study, only fifty people who had meditated at least four years and fifty people who were not meditators. The research showed that the ones who meditated had less reduction in grey matter, the neuron containing tissue that processes information.  And it wasn't just certain areas, it involved almost the whole brain.

It could be coincidental. The ones who meditated may have other causative factors like diet or exercise. Or it could be the power of meditation.

Television anchor Dan Harris discovered meditation and used it to turn an anxious life around. He wrote  10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-Help That Actually Works. When his book came out I saw him interviewed several times. He certainly was convincing.

There are classes to help you get in the meditating groove. But it isn't necessary to have formal instruction. As they say, it's all in the breathing. A quiet room, no interruptions, and the ability to focus inwardly should get you started. A free activity that might help you maintain some cognitive function and doesn't make you sweat...what could be better?

Last word...PO DAY 253

At least I hope this is my last word on the superbug CRE.

Now reported is an outbreak of CRE in North Carolina of eighteen cases. The good news is that in this instance only three of the people were exposed in the hospital. The bad news is that the infection is active in the general population. It was not reported if there were fatalities.

But the North Carolina hospital involved has taken two approaches to the problem. First they have instituted a screening program looking for the infection as the patient is admitted and, if found, making appropriate arrangements to isolate the bug and patient. And they have changed to a gas sterilization process. It is, perhaps, a better method but the gas used, ethylene-oxide can be very toxic to hospital workers and patients. That may necessitate outsourcing the sterilization process, expensive and inconvenient. And no less toxic to the "outsourced" facility worker.

The CDC called this infection a "nightmare" bacteria. It certainly sounds like it is.

A demanding patient...PO Day 252

In the February 2015, 2015 issue of JAMA Oncology an editorial addresses the demanding patient. A study by  Gogineni and colleagues reports that the idea of the demanding patient, one who presents with unreasonable requests for scans and tests, is indeed a myth. Such demands are uncommon and, when issued, are generally warranted. 

The problem for the physician in the modern world is that patients are so well educated today. Between newspaper medical columns, uninhibited conversation about medical issues, and especially the Internet, the average patient is no longer dependent on their doctor for information. They usually come for their first appointment aware of their diagnosis, treatment options and prognosis. So when the patient asks for the latest scan, MRI or PET or ultrasound, it is usually part of the normal diagnostic work up. But, to the physician who is accustomed to being the one to initiate orders, the request often seems assertive. 

The author suggests ways the doctor can have better control of the situation and deal with the patient who is likely coming from a position of fear and insecurity. 

Perhaps we patients can help too by being open to our doctors' advice and counsel. I often hear from my doctors to not believe everything I read on the web. That has not kept me from doing my own research but I try not to pretend I am as knowledgable as my doctor. :)  They are right in a way, much of what is available on the web is not current, may even be information that is several years old.

Certainly, many of the articles on the web about reverse total shoulder replacement arthroplasty surgery date back ten years to when the surgery was first introduced in the U.S. The procedure was considered radical and unproven in that era. If you based your decision to have the surgery or not on those articles you'd probably opt out.

Now, our doctors just need to take the time to practice their communication skills and reassure us that they do know best. And maybe we can refrain from asking for the latest drug advertised on TV.

FDA warning....PO Day 251

In light of the recent outbreak of the CRE superbug at the California hospital the FDA has issued a warning regarding the use of the suspect endoscope which is used in the procedure that seems to be the source of the infection.

The hospital reports that as many as 179 patients may have been exposed during the exams that utilized the duodenoscopes. The exam is used on patients with digestive system problems, including gallstone and specific cancers. There have been two deaths reported by this hospital.

The FDA warning addresses proper methods of sterilizing the scopes. It also recommends discussing the risks of the procedure with the patient in light of recent events. Their recommendations are as follows:

• Inform patients of the benefits and risks associated with ERCP procedures.
• Discuss with your patients what they should expect following the ERCP procedure and what symptoms should prompt additional follow-up.
• Consider taking a duodenoscope out of service until it has been verified to be free of pathogens if a patient develops an infection with a multidrug-resistant organism following ERCP, and you suspect that there may be a link between the duodenoscope and the infection.
• Submit a report to the manufacturer and to the FDA via MedWatch if you suspect that problems with reprocessing a duodenoscope have led to patient infection.

There may also have been an outbreak of the superbug infection in a Philadelphia hospital last year where a total of eight patients were infected and two died. 

UCLA has addressed the sterilization techniques used and have  switched to a gas sterilization system to be used in the future. The FDA stresses that this infection is not a threat outside of the hospital setting. However, the spread of "superbugs" is a global concern and a British government report warns that these superbugs could "cause 10 million deaths a year and cost $100 trillion per year by 
2050, and called for a global innovation fund to power research and prevention, while President 
Barack Obama's recent budget proposal called for $1.2 billion to fight antibiotic superbugs."