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Tips to Prevent Medical Errors – AHRQ

Posted on 06. Oct, 2011 by .

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The largely ineffective Agency for Healthcare Research and Quality (AHRQ) has a list of 20 Tips to Help Prevent Medical Errors  http://www.ahrq.gov/consumer/20tips.htm

Number 20 on the list is

 “Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.”

It then suggests to ask your doctor if the treatment is based on the latest evidence. The way this is presented it seems to say that doctors and nurses often do not always present treatment options based on the latest evidence.

As argued by Shannon Brownlee, http://www.washingtonmonthly.com/features/2007/0710.brownlee.html the U.S. is clearly in need of an

“… independant agency that would fund systematic reviews of the medical literature, as well as clinical trials to test the comparative effectiveness of everything from drugs to treatments”

Unfortunately the current AHRQ is not performing this service as it was rendered somewhat ineffective thanks to Newt Gingrich and Congress in 1996 over the issue of spinal fusion surgery.

The Agency for Health Care Policy and Research (AHCPR) was created in 1989 to produce evidence-based, clinical-practice guidelines. What ended up happening was the AHCPR panel concluded that there was little evidence to support surgery as a first line treatment for low back pain and that nonsurgical interventions should first be used. The medical device industry and several doctors organizations opposed governmental control over the research and evaluation of new technologies including The American Society of Cataract Surgery, the American Board of Ophthalmologists, and the North American Spine Society.

Sensing a threat to their livelihoods, many surgeons bombarded Congress with letters contending that the agency’s panel was biased and found a sympathetic ear with Newt Gingrich and the Republican House majority.  The AHCPR had a budget that became crippled and it’s mission shifted and it became the Agency for Healthcare Research and Quality (AHRQ). As a result, numerous spinal fusion surgeries continue to be performed.

Currently today the American health system is based on scientific evidence as long as the evidence supports commercial interests; but all too often when the science conflicts with commercial interests, science gets nudged aside.

Sources:

1) Overdosed America: The Broken Promise of American Medicine (P.S.) Tips to Prevent Medical Errors   AHRQ
John Abramson. Harper Collins Publishers. 2004.

2) Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer Tips to Prevent Medical Errors   AHRQ Shannon Brownlee.Bloomsbury USA. 2007.

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The truthiness of extracting wisdom teeth: James R. Carey

Posted on 04. Oct, 2011 by .

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An excellent article was written yesterday October 3, 2011, titled “The truthiness of extracting wisdom teeth” by James R. Carey who is a Professor of Entomology at UC Davis  http://entomology.ucdavis.edu/faculty/facpage.cfm?id=carey

The article is located at http://www.davisenterprise.com/opinion/opinion-columns/the-truthiness-of-extracting-wisdom-teeth/ and I think it is well worth a read for anyone considering wisdom teeth removal.

He opens the article with

In this age of evidence-based health care, I was astonished to discover that the oral surgeon’s recommendation for removal of my 21-year-old daughter’s impacted wisdom teeth was not based on evidence, theory, logic or facts but rather on truthiness — the quality of being considered to be true because of what he wished.

He goes on to say

“Yet it is considered by dentists, oral surgeons and the majority of the public as “standard of care.” Neither I nor any family members or friends were aware that evidence is lacking on the benefits of wisdom tooth extraction in young adults.”

I discovered this after leaving the oral surgeon’s office and researching the topic online. One of the most insightful articles I read was by Los Angeles dentist Jay W. Friedman, recipient of the 2009 Author of the Year award from the American Journal of Public Health, in which he noted that all of the arguments used by dentists for extraction of wisdom teeth are myths.”

He then goes on to say

So why was I not only oblivious of the lack of benefits from wisdom teeth extraction, but also unaware of the potential health risks? Probably for two reasons. The first is that there is a substantial financial incentive for my daughter’s oral surgeon and others in his profession to recommend extraction to their patients by telling us their “truthiness” story as though it is deep principle. …The second is that early extraction resonates as a prevention concept in the same way that tonsillectomies resonated with my parents in the 1960s as preventative.”

Dr. Carey goes on to suggest that medical and veterinary schools should make changes to their curriculum to educate their patients and evaluate research literature evidence.

He concludes

“A new concept of health care can then begin to emerge in which caregivers and their patients create a close, mutually beneficial partnership of information sharing and decision-making.”

I am not sure if Dr. Carey visited my website, but I echo many of his thoughts and observations.

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Long Term Effects of Trigeminal Nerve Injuries from Dental Care

Posted on 03. Oct, 2011 by .

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A study was published in the Journal of Oral and Maxillofacial Surgery titled “Long-Term Outcome of Trigeminal Nerve Injuries Related to Dental Treatment” by M. Anthony Pogrel, Ryan Jergensen, Eric Burgon, and Daniel Hulme. (vol. 69, pages 2284-2288, 2011) that looked at long-term effects of those who suffer from permanent nerve injury from dental treatment particularly involving the third molars or wisdom teeth.

A total of 145 patients with 95 female and 50 male patients were involved in the study who had suffered a trigeminal nerve injury affecting either the inferior alveolar nerve or lingual nerve and in 8 cases both nerves. Nineteen patients (13.1 %) reported that their employment was affected, while 21  patients (14.5%)  reported problems with their relationship, 53  patients (36. 6%) reported depression, 55  patients (38%) reported problems speaking and pronouncing words correctly, 63  patients (43.5%) reported problems eating, and 1 patient reported a significant change in his appearance. Twelve patients (8.2%) were reported to have gone on to make a late full recovery.

Some of the coping mechanisms the patients used include getting used to it (64), prayer and mediation (7), ice and heat packs (3), pressure on teeth (3), exercise and yoga (3), antidepressants (2), chewing gum (2), relation and acupuncture (2), and other methods included keeping a journal, alcohol, massage, and herbal medicines.

The authors state:

“In this study, the encouraging news is that in general terms, patients did tend to improve with time, with over 8% going on to full recovery, although it is unclear in some cases whether this recovery was a true neurological improvement or the development of coping mechanisms.”

It is not clear from the results if the improvement in symptoms in a few of these patients was due to and an actual improvement or just the better ability to cope. I agree that I think this is hard to say.

The authors also mention the ability for surgical exploration which did not occur in all these patients but is a possibility within 9 months after injury to the trigeminal nerve following a wisdom tooth extraction

  • Patients with a witnessed transection
  • Patients who are still totally anesthetic at 8 weeks postinjury, with no signs of recovery
  • Patients with severe dysesthesia at 8 weeks postinjury, who are showing no improvement
  • Patients at 4 months postinjury, who have less than 30% return of function (or do not have protective reflexes), or have severe dysesthesia

For the patients in the study who did have surgery some were helped but none fully recovered.

Consequently many of these patients suffered from a permanent decrease in their quality of life.

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Periodontal disease (gum disease) might increase the time it takes to become pregnant

Posted on 01. Oct, 2011 by .

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Research presented at the the European Society of Human Reproduction and Embryology earlier this year showed that periodontal disease (gum disease) might increase the length of time it takes for a woman to become pregnant. Periodontal disease has been linked to many different types of systemic disease. Periodontal disease can lead to inflammation and bleeding around the gums which can lead to spaces called periodontal pockets.

The research was led by Roger Hart who is a Professor of Reproductive Medicine and is also Medical Director of Fertility Specialists of the University of Western Australia. A total of 3737 pregnant women in the study were followed and outcomes of pregnancy were looked at for 3416 of the 3737 pregnant women. It was found that women who had periodontal disease (gum disease) took around 7 months to become pregnant while those women who did not have periodontal disease took roughly 5 months to become pregnant.

Professor Hart said

“Our data suggest that the presence of periodontal disease is a modifiable risk factor, which can increase a woman’s time to conception, particularly for non-Caucasians. It exerts a negative influence on fertility that is of the same order of magnitude as obesity.”

The reason why non-Caucasians have longer time’s to conception while having periodontal disease may be due to a higher level of inflammatory response.

More information on periodontal disease and how it is a risk of keeping wisdom teeth is found on the risks of keeping wisdom teeth page on this site.  Due to the link of periodontal disease with many different types of systemic disease it has received much attention from researchers lately and is often a reason given for why healthy wisdom teeth should be extracted at a young age.  Even so there is a lot of controversy on whether or not healthy wisdom teeth should be extracted as discussed on the wisdom teeth controversy page of this site.

Source: European Society of Human Reproduction and Embryology. Gum disease can increase the time it takes to become pregnant. July 5, 2011. http://www.eshre.eu/membership/page.aspx/1355

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How to Really Know if Wisdom Teeth Really Need to be Removed

Posted on 29. Sep, 2011 by .

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Earlier today a article appeared in the Huffington Post titled “How To Know If Wisdom Teeth Really Need To Be Removed.”

The author attempts to discuss some of the ongoing debate regarding extracting wisdom teeth.

He talks about how doctors are fair and responsible.

However, the American Association of Oral and Maxillofacial Surgeons (AAOMS) continues to say on their webpage on wisdom teeth http://www.aaoms.org/wisdom_teeth.php

It isn’t wise to wait until your wisdom teeth start to bother you.

I would think a fair and responsible doctor would agree that the current scientific evidence should be presented to the patient of an elective procedure of teenagers and young adults such as described here http://www.teethremoval.com/controversy.html

The author then refers to a study and says:

“Interestingly, early removal of wisdom teeth (when the teeth have hardly any of the roots formed) has been shown to result in very predictable and successful outcomes, with hardly any gum pockets, dry sockets, nerve injury or infections developing post-operatively.”

In fact when I had my wisdom teeth extracted I was never told of the scientific evidence, that wisdom teeth are not extracted that are healthy in the U.K due to the risk of harm., nor was I told of many of the complications.

I was left with a 24/7 headache as a result of the extractions after just having turned 20. I received no compensation for my injuries. I don’t see any evidence to suggest that oral surgeons and dentists are adequately disclosing to their patients such serious life alternating injuries in the informed consent process.

In fact numerous physicians groups such as AAOMS and the AMA are advocating for a caps on possible non-economic damage caps be to reduced to $250,000 at the national level http://blog.teethremoval.com/the-war-on-healthcare-patients-who-hate-doctors/

Young teenagers and adults who go to have their disease free healthy teeth removed can in on occasions suffer a life alternating complication such as a lasting headache.

If doctors were fair and responsible they would be advocating for fair compensation or some sort of insurance to be provided for those unfortunate people who fall in this category where the current legal system is of no use for them. See http://www.teethremoval.com/legal_system_medical_malpractice.html for more information.

I don’t see how it is reasonable to advocate for a surgical procedure that can cause major harm in a small number of instances to a young and healthy individual when they had no symptoms and problems present prior to the surgery and then not be able to receive any compensation for some of those injuries that may occur. See this page http://www.teethremoval.com/wisdomteeth.html for some of the guidelines on wisdom teeth and reasons for their removal.

The article in the Huffington Post concludes

“While all patients do not need to have their wisdom teeth extracted, there are clear indications that warrant removal of wisdom teeth. The age of the patient, the presence of gum disease, the potential for dental crowding and the long-term health of the second molars are all factors that must be considered when deciding if the wisdom teeth need to be extracted. “

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