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The CMG Voice

If you need kidney or rectal surgery, is robot-assisted surgery better?

Posted Friday, November 10, 2017 by Tyler Goldberg-Hoss

You may have heard by now: robot-assisted surgeries are a real thing. Since the early 2000s, hospitals have been buying these million dollar plus robots, such as the daVinci Surgical System, to assist surgeons in minimally invasive surgeries such as gallbladder removals. These robots use the same or similar access points as a laparoscopic surgery (small holes in the abdomen, through which cameras and other tools are inserted to do the surgery).

When surgeons use these robotic devices, instead of holding on to the tools themselves in a patient’s body (like in a traditional laparoscopic surgery), they manipulate controls outside of the patient’s body, and those controls correspond to movements of surgical tools in the body. While there have been critics of the use of these robots – citing the steep learning curve for surgeons, and the cost – it appears these robots are here to stay, at least in the short term.

Recently The Journal of the American Medical Association (JAMA) investigated the utility of robot-assisted surgeries in the context of both kidney surgery and rectal surgery. They were particularly looking at how the results differed from traditional laparoscopic techniques.

The study looking at kidney surgery found that, between 2003 and 2015 the use of robotic-assisted surgery surged from 1.5% to 27%. There was no significant difference from the perspective of patient safety (similar complication rates), robot-assisted procedures typically took longer and cost more.

Another study looked at the differences between the two approaches in rectal surgery, and in particular, whether there was a difference in the rates of times when surgeons needed to convert the minimally invasive procedure (using just the small holes) to a laparotomy (a large incision through the abdominal wall to gain access to the abdominal cavity).

There are many reasons that laparoscopic surgeries, including those with and without robotic-assistance, are favored in many cases. These reasons include less chance of bleeding, typically shortened recovery time, less scarring, and less postoperative pain.

In that context, all things being equal, surgeons (and patients) who initially start with a minimally invasive technique would prefer not to convert to a laparotomy if possible.

The study found that there was no difference between traditional laparoscopic surgeries and robot-assisted surgeries in the rate such surgeries convert to laparotomies.

These two studies indicate that, while there is potential for robot-assisted surgery to be beneficial to patients in the future, at present, at least in the context of kidney and rectal surgery, no benefit clearly exists.

You can read about the two studies here:

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer

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Can Herbal Supplements Damage Your Liver?

Posted Monday, November 6, 2017 by Gene Moen

The answer is yes, according to a presentation at the annual meeting of the American Association for the Study of Liver Diseases. Dr. Victor Navarro said at a press briefing that “herbal supplements are a common cause of liver injury.” He went on to say that “there are lots of products that are difficult to identify what they and what they’re used for.”

In a study of drug-induced liver injuries, it was found that 20% were caused by dietary supplements. Many of these products were sold as bodybuilding supplements or weight-loss supplements. There are two ways in which the products can be dangerous: they may include ingredients that are not listed on their labels, or they may be adulterated with additives on purpose (to support for purpose for which it is being marketed, such as for sexual enhancement).

In the study, people with drug-induced liver damage had used over 300 different dietary supplements. Chemical analysis of these products found some with hepatotoxins such as anabolic steroids or other pharmaceuticals, although the labels did not so indicate. One problem with using such “natural” or “herbal” products is that it is assumed there is nothing harmful in them. “Natural” in most people’s minds equates with “harmless.” But, unlike drugs, these supplements are not regulated or approved by the FDA. The companies that make these products often fail to list all of the ingredients or fail to test for toxicities or other problems that can arise from their use.

Physicians studying the causal relationship between the products and liver injuries found that identifying the problem often led to the product no longer being sold, but they are then replaced with a different product or at least one with changed labels. One positive outcome of the studies, according to Dr. Norah Turreault of the University of California San Francisco, is that “it highlights the fact that these herbal products contain ingredients that are unknown to the patients taking them.” The message to consumers is “don’t assume that a ‘natural’ or ‘herbal’ product can only help you — it can also cause serious damage.”

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The community decides what the standard of care in medicine is.

Posted Thursday, November 2, 2017 by Tyler Goldberg-Hoss

Every time I consider a potential new medical negligence case, or think about a case I am currently handling, it is in the context of how I think community members – jurors – will think about the care in question. The reason is, if I file a lawsuit on behalf of a client of mine, the end result will likely be a trial in front of 12 men and women in the county where care occurred.

The first question a jury will likely decide in such a case is whether the health care provider in question met, or fell below, the “standard of care.” This “standard of care”, in essence, is the health care provider’s duty to his or her patient to act reasonably carefully in caring for the patient. If the doctor met the standard of care, she is not negligent. If she fell below the standard of care, she is.

So how does a jury know what the “standard of care” is in a given situation?

Sometimes, it’s obvious. Sometimes the care is bad enough, and both sides know it. In those situations, the cases typically settle out of court.

Often times, though, there is not a particular authoritative text you can point to and say that a doctor or other healthcare provider clearly broke a particular rule.

In those situations, each side hires experts – physicians who practice in similar circumstances as the doctor who provided the care in question – who testify in court about what the “standard of care” is, and whether or not it was met this time. The jury listens to the experts, then deliberates and decides whether they agree with the experts for the patient or for the doctor.

This is an important point. To even get in front of a jury, the patient must offer sufficient expert testimony that the defendant doctor was negligent. However, once that threshold is met, the jury gets to listen to the testimony, and they get to make their own decision. That decision should not be made based on sympathy or bias, but it necessarily must be made on what the jury believes was the “standard of care” in the situation before them, and therefore what it should be in the community going forward.

You see, in Washington, the doctors don’t decide what the “standard of care” is, nor is the standard based on what care is expected by other doctors. It is decided based on what is expected by society – us, the community, and the representatives of it who sit on the jury.

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Early detection and treatment of melanoma critical for survival

Posted Monday, October 30, 2017 by Tyler Goldberg-Hoss

The results of a recent Cleveland Clinic study make clearer than ever that the sooner melanoma is detected and treated, the better.

Melanoma is the deadliest form of skin cancer. Rates of the disease are on the rise in the US, as an estimated 161,790 new cases will be diagnosed this year.

Previously, it was understood in the medical community that early detection is important to surviving melanoma. However, this recent study actually quantifies how much early detection can affect survival rates, particularly with respect to melanoma caught at Stage I.

The study looked at adult patients diagnosed with stage I-III melanoma from 2004-2012. It found, among other things, that the delay in surgery beyond 29 days negatively impacted overall survival for patients with stage I melanoma. Compared with those patients who were surgically treated within 30 days, those patients treated between 30-59 days were 5% more likely to die. Patients treated between 60-89 days were 16% more likely to die, patients treated between 91 and 120 days were 29% more likely to die, and when treated after 120 days, they were 41% more likely to die.

These findings are stark reminders that prompt diagnosis and surgical treatment can make the difference between surviving the disease and not. This includes so many front line providers, including family practice physicians, PAs and ARNPs fulfilling similar roles, as well as dermatologists, surgeons, oncologists, and others.

You can read a synopsis of the new study from the Cleveland Clinic itself here:

Cleveland Clinic Study: Timing of Melanoma Diagnosis, Treatment Critical to Survival

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Insurance rates play a big role in the difference in diagnosis and prognosis of breast cancer in black versus white women

Posted Thursday, October 26, 2017 by Tyler Goldberg-Hoss

The results of a recent study found that non-elderly black women were at greater risk of dying from breast cancer than non-elderly white women. One important reason was the racial disparities in insurance coverage.

The study, published in the Journal of Clinical Oncology, looked at white and black women ages 18-64 who were diagnosed with breast cancer between 2004 and 2013. The results show that four factors contributed to a significant increase in risk of death in black women versus white women: comorbidities, insurance, tumor characteristics, and treatment.

These factors accounted for 76.3% of the total excess risk of death in black women. Differences in insurance accounted for 37% of the total, nearly half of the disparity and by far the biggest single reason that black women were more likely to have larger and more serious tumors at the time of diagnosis.

With regard to the insurance coverage, black women were much more likely to be uninsured or insured through Medicaid than white women.

You can read the entire study here:

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013

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