Study Of 80,000 Birthing Moms Suggests Epidurals Safer Than Thought

(archibald jude via Compfight)

(archibald jude via Compfight)

I subscribe to the dentistry school of birthing babies. That is, I wouldn’t want to get a tooth filled without Novocaine, and I wouldn’t want to have a baby without an epidural.

I know that opinions — strong ones — vary on this, but for those of my ilk who’d like yet another data point to support the pain-relief side, here it is: A national study, one of the biggest yet, of complications from epidurals has just been presented at the annual conference of the American Society of Anesthesiologists now under way in New Orleans. And it suggests that epidurals are even safer than previously thought, with rates of the most-feared complications well under 1 percent.

Dr. Samir Jani, a senior resident in anesthesiology at Beth Israel Deaconess Medical Center, presented the findings, gleaned from a giant national database of anesthesiology cases, the National Anesthesia Clinical Outcomes Registry.

He found that among more than 80,000 cases of anesthesia during labor and delivery, 2,223 involved complications, for an overall rate of 2.78 percent. But most of those concerned medication errors — over-dosing, under-dosing, or use of expired drugs.

The rate of the complications that many women fear most — nerve damage or an excruciating “spinal headache” — were even lower than previously estimated, Dr. Jani said: .2 percent — that’s 2/10 of one percent — for the headache; .002 percent for spinal nerve damage and .14 percent for damage to other nerves.

“So it’s well under 1 percent for the kinds of complications that I think a lot of women worry about,” he said, not the 1-2 percent that he’s been quoting his patients based on textbook teachings.

An awkward question: But don’t anesthesiologists tend to be pretty pro-anesthesia? Mightn’t that bias the results?

“Actually,” Dr. Jani said, “Whenever I talk to all my patients, I tell them, ‘I’m not here to sell you an epidural. it’s your ultimate decision.’ And I think that that’s the mentality that almost all of us have. We aren’t ever going to force on a patient what they don’t want. But in that informed consent process, it’s important we quote not only possible complications but the rates to the best of our knowledge. At the end of the day, it’s good to be able to tell your patient that this is a safe and efficient method to be able to control labor pain.”

And what about the common belief that getting an epidural can hinder the pushing process in labor? Continue reading

8 Things You Need To Know About Ebola

Cpl. Zachary Wicker shows the use of a germ-protective gear in Fort Bliss, Texas, Tuesday, Oct. 14, 2014. About 500 Fort Bliss soldiers are preparing for deployment to West Africa where they will provide support in a military effort to contain the Ebola outbreak. /Juan Carlos Llorca/AP)

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

Ebola has been dominating the headlines lately, raising concern about the disease potentially spreading to Massachusetts. And after two recent Ebola scares in Boston, local authorities are also trying to reassure the public.

Here’s what you need to know about Ebola:

Continue reading

Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

Mass. Officials Try To Quell Ebola Fear

A Braintree cop places police tape around a Harvard Vanguard Medical Associates sign on Sunday. A patient there complained of Ebola-like symptoms, briefly closing the center. (Steven Senne/AP)

A Braintree cop places police tape around a Harvard Vanguard Medical Associates sign on Sunday. A patient there complained of Ebola-like symptoms, briefly closing the center. (Steven Senne/AP)

At this moment, in Massachusetts, the fear of Ebola may be more troubling than preparing for the possible cases.

Gov. Deval Patrick and Boston Mayor Marty Walsh pulled their top health, police, fire and transportation leaders into a briefing Tuesday morning and then addressed the public from Logan Airport. Their message: We’re ready, don’t worry.

Sometime Sunday afternoon, as word spread that a Braintree patient was being screened for Ebola, the fear factor in Boston spiked. Could this virus that’s killed 4,447 people as of early Tuesday in West Africa be in our midst? I heard from moms who were disinfecting playground equipment, from colleagues whose parents called with worry, and Walsh says his phone was ringing off the hook.

“I know this weekend was very fearful for a lot of people,” Walsh said, “but in the case of an Ebola case, we were prepared for it.”

Ebola has been ruled out in all of the scares this weekend — that Braintree patient and the five sick travelers who landed at Logan Airport from Dubai. Patrick says there have been several dozen cases in Massachusetts where doctors or nurses suspected Ebola and took precautions.

“I want to make clear that there have been no confirmed cases of Ebola in Massachusetts,” he said. “Each of the individuals that I referred to have been examined and Ebola has been ruled out.”
Continue reading

What The Boston Marathon Response Can Teach Us About Ebola: 5 Lessons

By Leonard Marcus, Ph.D, Barry Dorn, M.D., Richard Serino and Eric J. McNulty, M.A.

The massive and growing Ebola outbreak in West Africa is tragic both in the suffering and deaths among the affected population and in the difficulty of mounting a sufficient response. The number of cases is rising exponentially. We have had the first death in the U.S., the first case of someone contracting the disease in this country and the first case of transmission in Europe. Over the weekend, a man who had recently traveled to Liberia was taken to Beth Israel Deaconess Medical Center to be evaluated for possible Ebola.

Fear and anxiety are rising.

This has the potential to be the defining public health crisis of the 21st century. Boston has stepped up by sending doctors and other health care professionals with extensive experience and expertise. There is, however, something more that Boston has to share: the leadership lessons from the Boston Marathon bombing response.

(Ebola in Guinea/European Commission HG ECHO/flickr)

(Ebola in Guinea/European Commission HG ECHO/flickr)

After the Marathon, we saw federal, state and local agencies, as well as organizations in the private and non-profit sectors, came together as an integrated enterprise that can serve as a model for the Ebola response. While the two events are quite different, the principles for leadership effectiveness are actually similar.

There are five key interrelated lessons from Boston that can be useful as the world confronts Ebola:

Build A United Effort

An effective Ebola response requires linking and leveraging many organizations into a collaborative, cooperative enterprise, much like we saw in Boston after the bombing. Continue reading

Boston Patient Not At High Risk For Ebola, Health Officials Say

Beth Israel Deaconess Medical Center in Boston (Steven Senne/AP)

Beth Israel Deaconess Medical Center in Boston (Steven Senne/AP)

A man who travels frequently to Liberia caused a stir Sunday afternoon when he arrived at a Braintree clinic with Ebola-like symptoms. But doctors and public health officials say that the man is not considered at high risk for the often deadly virus. His case did, however, give us the first public look at how nurses, EMTs, hospital staff and others have prepared to respond when there is an Ebola alert.

WBUR’s Martha Bebinger spoke with WBUR’s Bob Oakes on Monday with more on the story.

Bob Oakes: How did this man, who has not been identified, become the focus of police escorts, press conferences and numerous statements on Sunday?

Martha Bebinger: The man called his primary care practice, Harvard Vanguard, in Braintree Sunday morning, complaining of a headache, muscle aches and some other problems. He was given an appointment in the afternoon. The man went to the Harvard Vanguard pharmacy to pick up a prescription for something else, then left.

But after that first call, Harvard Vanguard reviewed his medical record and noticed that the man traveled frequently to Liberia. The office staff then called the patient and “intercepted” him as he was coming in. They asked him to wait in his car while they called for an ambulance. The Harvard Vanguard office was closed for a period of time, while they disinfected surfaces in the pharmacy they believe he touched, and then reopened.

The man waited, cooperatively, we’re told, in his car, sort of a self-quarantine, until an ambulance arrived. What kind of precautions were in place there?

Brewster ambulance completed their Ebola response training about a week ago. Brewster’s director of training, Jeff Jacobson, says the company was on the scene in 15 minutes with two ambulances, one that had been sealed inside with plastic and three EMTs wearing hazardous materials suits.

“Once the patient is removed from the ambulance and into the hospital, two more folks get into the level B suits and remove all the plastic, put in sealed containers, then the vehicle is disinfected, following the Centers for Disease Control recommendations,” Jacobson said.

In all, Jacobson estimates there were 40 responders, including police, firefighters, local public health and Harvard Vanguard personnel.

Forty personnel arrived? And were all of those responders trained in Ebola safety practices?

I heard both yes and no. Only people who may come in contact with the patient or his body fluids need to wear gloves and protective gear. But I also heard there was a call Sunday, after this incident, on which some participants felt the response was too much while others thought that a maximum effort is warranted as responders test and adjust their reaction to Ebola.

The ambulance took the patient to Beth Israel Deaconess Medical Center, where I imagine there were a few nervous staff members. Earlier Sunday, the CDC confirmed that a nurse who treated a man who died from Ebola in Dallas has come down with the virus. Continue reading

Project Louise: The Zombie Workout Adds Strength Training

Louise's new role model: Rob Zombie. Note the muscle tension achieved by the squat.

Louise’s new role model: Rob Zombie. Note the muscle tension achieved by the squat. (Alfred Nitsch via Wikimedia Commons)

Back to the gym at last! I’ve been working out, far too sporadically and half-heartedly, at home, mostly doing my zombie workout on the treadmill. But as the cooler temperatures have been reminding me that year’s (and Project’s) end draws ever nearer, I knew it was time to get serious. And that meant a call to Trainer Rick.

Rick DiScipio is a kind, patient trainer who always manages to push me without making me feel guilty for not having pushed myself. So, even though I’d been neglecting him for months, he happily scheduled a session and walked me through a simple routine. Because he knew I’ve managed to do some cardio on my own, we decided to focus on some very simple strength training.

The key this time is that it’s all something I can do at home – no more using “no time to get to the gym” as my excuse for not doing a real workout. And Rick suggested that I set a small goal for the first couple of weeks. “Just do it twice a week,” he said. “That’s all. Just twice a week. What you need is to develop the habit.”

What I also need, I’m discovering, is a sense of community – a sense that other people are on this journey with me. So here’s my routine. I hope you’ll join in (assuming your doctor wouldn’t object, of course). Just twice a week.

First, a couple of notes. I don’t know about you, but I have torn out pages of suggested workouts from magazines, bookmarked routines online, bought videos, picked up flyers … and never done any of them. So I am deliberately not making this fancy, because I don’t want you to bookmark it or print it out and then never do it.

Instead, I want you to read through it, realize how ridiculously simple it is, and then try it just once. Continue reading

Rethinking Cancer Research Through ‘Exceptional Responder’ Patients

Grace Silva and her oncologist, Jochen Lorch (Photo: Sam Ogden, Dana-Farber Cancer Institute.)

Grace Silva and her oncologist, Jochen Lorch (Photo: Sam Ogden, Dana-Farber Cancer Institute.)

By Richard Knox

By all odds, Grace Silva should have died more than three years ago. Instead, this 58-year-old grandmother is helping scientists rethink cancer treatment and research.

Silva’s case, detailed in this week’s New England Journal of Medicine, is one of only three recently published accounts of what cancer doctors call “exceptional responses” to a drug called everolimus (brand name Afinitor).

It was approved two years ago to treat certain breast cancers and is also used against some kidney and pancreas tumors. A couple of months after Silva started taking the drug, her thyroid tumors, which had spread to her lungs, melted away to nearly nothing. That basically never happens with this aggressive tumor, known as anaplastic thyroid cancer. “It was a near-complete response,” says her oncologist at Dana-Farber Cancer Institute, Dr. Jochen Lorch. “That in itself is exceptional. When we saw it, it was one of the better days around here.”

Studying The Exceptions

More remarkable still, Silva’s tumor stopped growing for 18 months. We’ll come back to what happened after that. But first, you should understand this story isn’t about everolimus or any particular cancer drug. It’s about how cancer specialists are learning how cancer works at the most basic level — by studying exceptional responders like Grace Silva.

And to appreciate why her case is important, you need to know how researchers figured out why she was an exceptional responder. It’s partly due to a five-year-old technology called next generation sequencing. It’s a cheap and rapid way of spelling out the genetic code of, in this case, individual patients’ tumors. Researchers can then look for gene mutations that are driving the uncontrolled growth that is cancer.

Continue reading

Singing And Dancing The Flu Vaccine Lecture

You’d never call Dr. Lester Hartman and his associates at Westwood-Mansfield Pediatrics shy, but this musical version of the “get your flu shot” lecture takes the video oeuvre of this practice to new heights.

Challenge to other doctors and nurses: can you top this?  How far are you going this season to persuade patients to get vaccinated against influenza?

Research News Flash: Scientists Grow Cells For Possible Diabetes Cure

Human Stem Cell Beta Cells/Photo Courtesy Doug Melton, Harvard University

Human Stem Cell Beta Cells/Photo Courtesy Doug Melton, Harvard University

In what is being called a major advance on the road toward more effective diabetes treatment, Harvard researchers report that they’ve been able to grow large quantities of human, insulin-producing pancreatic “beta cells” from human embryonic stem cells. Why is this important?

As the leader of this massive, years-long effort, Doug Melton, the superstar Harvard stem cell researcher said in a news conference Tuesday: “This finding provides a kind of unprecedented cell source that could be used both for drug discovery and cell transplantation therapy in diabetes.” And as NPR’s Rob Stein put it: “The long-sought advance could eventually lead to new ways to help millions of people with diabetes.”

Reporter Karen Weintraub, writing for National Geographic, describes why the research, conducted in diabetic mice, has taken so long, with so many twists and turns:

The researchers started with cells taken from a days-old human embryo. At that point, the cells are capable of turning into any cell in the body. Others have tried to make beta cells from these human embryonic stem cells, but never fully succeeded. Melton’s team spent a decade testing hundreds of combinations before finally coaxing the stem cells into becoming beta cells.

“If you were going to make a fancy kind of raspberry chocolate cake with vanilla frosting, you’d pretty much know all the components you have to add, but it’s the way you add them and the order and the timing, how long you cook it” that makes the difference, Melton, also a Howard Hughes Medical Institute investigator, said at [the] news conference. “The solution took a long time.”

Here’s (a lot) more detail from the Harvard news release, written by B.D. Colen:

Harvard stem cell researchers today announced that they have made a giant leap forward in the quest to find a truly effective treatment for type 1 diabetes, a condition that affects an estimated three million Americans at a cost of about $15 billion annually.

With human embryonic stem cells as a starting point, the scientists are for the first time able to produce, in the kind of massive quantities needed for cell transplantation and pharmaceutical purposes, human insulin-producing beta cells equivalent in most every way to normally functioning beta cells.

Doug Melton, who led the work and who twenty-three years ago, when his then infant son Sam was diagnosed with type 1 diabetes, dedicated his career to finding a cure for the disease, said he hopes to have human transplantation trials using the cells to be underway within a few years.

“We are now just one pre-clinical step away from the finish line,” said Melton, whose daughter Emma also has type 1 diabetes.

A report on the new work has today been published by the journal Cell. Continue reading