more_vertNot only can Leo Martinez work opponents on the chess board—he began playing aged 8 and reached national level—he’s also a talented scientist who was awarded the 2017 Stephen Lawn TB-HIV Research Leadership Prize for his contributions to reducing the burden of tuberculosis (TB) and HIV/AIDS in Africa. “Leo has done outstanding innovative research on reducing the childhood TB burden—a much needed and underappreciated area”, says Professor Heather Zar, Chair of the Department of Paediatrics and Director of the MRC Unit on Child & Adolescent Health at the University of Cape Town in South Africa.
Preference: Law
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[Editorial] The scars of violence on children
In the first 11 weeks of 2018, there have been 12 school shootings. Although shootings on school campuses only make up a tiny fraction of gun injuries and deaths annually, a March report from the Giffords Law Center focuses on the deep impact of gun violence on children in the USA, elaborating on how it extends far beyond the classroom.
How common is misdiagnosis?
In the news this week has been the horrific case of Magdalena Malec, 31, who, despite showing all the classic signs of sepsis, went undiagnosed as she lay in a UK hospital recovering from an operation. Admitted following an ectopic pregnancy, Ms Malec had a raised temperature and a number of other red flags for sepsis, following her surgery. She later developed extensive limb ischaemia and eventually had to have both of her legs, her right arm and the fingers of her left hand amputated, and she also needed a kidney transplant.
“The catastrophic chain of events which led to Magdalena’s near death and horrendous injuries were completely avoidable if the hospital had followed its own sepsis protocol,” her lawyer said. The hospital has since apologised.
Cases like that of Magdalena Malec put a human face on the very real problem of diagnostic error. More publicity tends to surround cases of wrong-site surgery or drug errors, but the research shows that misdiagnosis is a far more common – and more intractable – issue.
One recent attempt at putting a figure to the problem found that patients were misdiagnosed around 10-15% of the time. And an Australian systematic review of diagnostic error in older patients found rates of over 10% for COPD, dementia, Parkinson’s, heart failure, stroke and MI.
But it’s not easy to nail down figures, as many hospitals and practices don’t keep count and there can be strong motivations for doctors not to report a wrong diagnosis. On top of that, misdiagnosed patients may also follow up with another doctor who makes the correct diagnosis, with the first doctor never realising their mistake.
There are various methods researchers use to try and quantify diagnostic error. The gold standard is said to be autopsy studies, which consistently identify diagnostic discrepancies in 10-20% of cases. Of course, not all deaths are subject to autopsy, and those that are may already be cases where the diagnosis is unclear.
Another, if subjective, method is patient surveys, which show that around a third of patients have been the subject of a misdiagnosis or have had a family member of close friend who has been misdiagnosed. ‘Secret shopper’ studies have also been carried out, where real or simulated patients with classic symptoms of a condition present to a doctor or hospital. In these studies, doctors misdiagnose the patient in around 13% of cases.
Second reviews offer yet another opportunity to quantify diagnostic error. These have shown that 10-30% of breast cancers are missed on mammography, and 1-2% of cancers overall are misread on biopsy samples.
Misdiagnosis and delayed diagnosis are also far and away the greatest cause of malpractice suits, which point to how common they are. Of course, not every misdiagnosis is actionable: under Australian law, diagnostic error is only considered negligent if it falls short of Australian medical standards and is the result of the doctor failing to take “reasonable care” in diagnosing the condition.
Misdiagnosis is “the hidden part of the iceberg of medical errors that dwarfs other kinds of mistakes,” says Dr David Newman-Toker of the Johns Hopkins School of Medicine, who has extensively studied the problem.
In a survey, the top reasons doctors gave for cancer misdiagnosis were “fragmented or missing information across medical information systems”, along with “inadequate diagnostic resources”. But Dr Newman-Toker says they more typically result from flawed ways of thinking, sometimes coupled with negligence.
He says drug errors and wrong-site surgery are not only less common but more amenable to solutions such as color-coded labelling or preoperative checklists. But there is no such easy or obvious fix for diagnostic error, he says.
New studies give greater understanding on menopause
One year of hormone replacement therapy may be able to prevent development of depressive symptoms in women who are in the menopause transition, a study published online in JAMA Psychiatry has shown.
The double-blind, randomised controlled trial, conducted by University of North Carolina (UNC) School of Medicine found certain women would be more likely to experience the greatest mood benefit of hormone replacement therapy during the menopause transition, which are women early in the transition and women with a greater number of recent stressful life events.
Women are two to four times more likely to develop clinically significant depressive symptoms during the menopause transition, according to the study.
“We know that midlife for women, particularly in the transition to menopause, is a time of substantial elevations in risk for depression,” said Professor Susan Girdler, who helped lead the research.
“During the menopause transition, our risk for depression actually increases two to four times. And that’s true even for women who haven’t had a history of depression early in life.”
The participants were randomly selected and put into two separate groups. Over the course of a year, one group received transdermal estradiol on a daily basis, the other a placebo.
The study found more than 30 percent of the placebo group developed clinically significant depression. However, only 17 percent of women who received estradiol developed the same depression symptoms.
Other research published by The University of Illinois (UI) in the journal Sleep Medicine suggests addressing menopausal symptoms of hot flushes and depression may also address sleep disruptions.
The UI study also gives women hope that their sleep symptoms may not last past the menopausal transition, said Professor Rebecca Smith, from the Pathobiology Department at the University of Illinois. Professor Smith conducted the study with Professors Jodi Flaws and Megan Mahoney.
“Poor sleep is one of the major issues that menopausal women seek treatment for from their doctors,” Professor Mahoney said.
“It’s a huge health care burden, and it’s a huge burden on the women’s quality of life. Investigating what’s underlying this is very important.”
The study used data from the Midlife Women’s Health Study, which followed 776 women aged 45-54 in the greater Baltimore area for up to seven years.
The study found no correlation between the likelihood of reporting poor sleep before menopause, during menopause and after menopause. Meaning, for many women in the study, their reported sleep problems changed as they transitioned to different stages of menopause. For example, women who had insomnia during menopause were not more likely to have insomnia after menopause.
“That’s a hopeful thing for women who feel like their sleep has gone downhill since they hit the menopause transition: It might not be bad forever,” Professor Smith said.
“Your sleep does change, but the change may not be permanent.”
The researchers found that hot flushes and depression were strongly correlated with poor sleep across all stages of menopause.
Those two risk factors vary in reported frequency across menopausal stages, which might help explain why poor sleep also varies across the stages, the researchers said.
Professor Smith believes that the study has shown sleep disturbances in menopause are part of a bigger picture that doctors should be looking at.
“It indicates that when dealing with sleep problems, physicians should be asking about other symptoms related to menopause, especially looking for signs of depression and asking about hot flushes,” Professor Smith said.
MEREDITH HORNE
[Editorial] Examining humanitarian principles in changing warfare
Violence in war must have a limit. Those who are not participating in the hostilities should be protected to prevent war from sinking into barbarity. Today, this is safeguarded by international humanitarian law (IHL), of which the cornerstones are the four Geneva Conventions of 1949 and its Additional Protocols. IHL provides for the wounded and sick to be collected and cared for by the warring faction that has them in their power, and for them to receive timely medical care. Traditionally, those entering into conflict could be expected to uphold these laws.
Is your practice ready for the new privacy laws?
According to a recent survey, the overwhelming majority of Australian doctors are unaware or unprepared for new privacy laws which will directly affect their medical practices, and which come into force on 22nd February. These laws introduce a mandatory data breach notification requirement, meaning that doctors and medical practices will have a legal obligation to notify both the people affected by any data breach as well as the Office of the Australian Information Commissioner.
The requirement applies to breaches where “a reasonable person would conclude that there is a likely risk of serious harm to any of the affected individuals as a result of the unauthorised access or unauthorised disclosure”.
Each notification must contain a description of the breach, the type of information involved, and how the patients should deal with the data breach. Failing to notify patients of the breach can lead to fines of up to $360,000 for individual doctors and up to $1.8 million for organisations.
It’s important to note that data breaches can come in many forms and aren’t limited to criminal cyber attacks. They could also be the result of a stolen laptop containing patient information, for example, or accidental disclosure of patient records to a third party.
But it’s also true that healthcare providers have been the particular target of ransomware attacks, which encrypt a computer’s information and then ask for a ransom fee to unlock it. In the United States, around 88% of ransomware attacks have targeted healthcare providers, according to recent research. And Australian institutions have not been spared: just last year, a Queensland hospital suffered a massive loss of patient data due to a ransomware attack.
But do not assume that just because you are a small practice you are immune from cyber attack. Patient records including names, birthdates, Medicare numbers and billing information can provide a rich source of data for criminals and are readily sold on the black market.
Here are some tips for mitigating exposure to unintended data breaches in your practice:
- Ensure that you properly understand your obligations under the newly amended legislation;
- Check with your insurer that you are adequately covered for any unintentional privacy breaches in relation to your provision of healthcare;
- Review your IT systems for collecting, storing and backing up patient information and document where the information is stored and who has access to it;
- Ensure your software is up to date and that cyberscurity software is installed;
- Ensure you have an emergency response plan to deal with any data breach and that you and your staff are fully aware of what to do in case of such an emergency.
- Make sure you document your plan and regularly test it.
Source: Avant
Collision avoidance technology
BY DR CLIVE FRASER
As we anxiously enter the age of driverless vehicles I’m aghast to see how many driverless cars already seem to be on Australian roads.
When I’m travelling I notice every day other motorists staring into their laps at their smart phones and not looking straight ahead at where they are going.
They are usually in cars that to the best of my knowledge aren’t fitted with adaptive cruise control, lane guidance or autopilot collision avoidance systems.
So I can only assume that there is some sort of app on their smart phone which will alert them if necessary to the need to look up if driver input is required.
I’d say that any car being driven by someone distracted by a smart phone is in my opinion technically “driver-less”.
In my practice I see people every week who have been terribly injured by being impacted from someone texting, Facebooking, Tweeting or Instagraming etc.
I’m also very pleased to see how vigorously law enforcement officers breach distracted drivers for doing so.
With so much inattention on our roads it’s great to see how much technology is already out there to augment rather than replace driver awareness.
My first experience of this was about five years ago in the car park of my local Volvo dealership to test the laser-based City Safety feature in a Volvo XC70.
The salesman told me to drive straight into a large cardboard box in the carpark.
Hard as I tried, the XC70 just would not let me hit it as sensors mounted alongside the rear vision mirror detected an object in front of the vehicle and braked accordingly.
The system works to avoid collisions at speeds of up to 50 km/h.
Thereafter I’ve seen radar-based Adaptive Cruise Control appearing in many more affordable models such as Hyundai’s i30 Elite.
The technology relies on the Doppler effect and the fact that radio-waves reflect from solid objects.
The vehicle will then adjust its speed +/- apply the brakes depending on the closing distance of another vehicle.
More recently a colleague proudly showed me his new Mercedes GLC 250d SUV which comes standard with Collision Prevention Assist.
In his first week of ownership the GLC’s collision avoidance technology successfully helped him to avoid hitting a feral pig which suddenly darted across the road in front of him at mid-night.
But the collision avoidance system proved not to be infallible when he collided with a kangaroo at dusk one week later.
I think Mercedes can be forgiven if their technology works most reliably with pedestrians and walking beasts (cows, horses, sheep, goats etc).
Kangaroos and other hopping animals generally aren’t encountered on German autobahns and the software may require some further tweaking.
Whilst all of this technology arguably makes driving safer, none of it should ever replace driver attention.
Safe motoring,
Doctor Clive Fraser
[Department of Error] Department of Error
Honigsbaum M. Flawed hero. Lancet 2017; 389: 1874—In this Perspective, the third and fourth sentences in the penultimate paragraph should have read “However, it is in his justification for his action and what he did next that the story becomes fraught. Wadman allows the reader to draw their own conclusions about his fall from grace.” This correction has been made to the online version as of Feb 1, 2018.
[Editorial] Turkish Medical Association—detained for peace
“We acted as we always do as doctors. We have focused on human life and health. We will continue to act as doctors in every setting we are in. We do not accept the charges”, said Turkish Medical Association (TTB) chairman Raşit Tükel, as cited by his lawyer. In a letter to The Lancet, Caghan Kizil reports that Tükel and ten other senior members of the TTB were detained and accused of treason by President Recep Tayyip Erdoğan following a published statement in response to Turkey’s military incursion in northern Syria.
[Editorial] The health of a president: an unnecessary distraction
The respected New York Times physician-journalist, Lawrence K Altman, often wrote about the personal health of US presidential candidates and other elected leaders in high office. He argued that the medical records of each president should be made publicly available and that the public have a right to know that their president is fit to fulfil the role. Last week, the health of President Donald Trump became the subject of sometimes wild political speculation after the release of his first physical examination results since he took office.