ChiroView Presents - Some interesting stuff! From: Sigmund Miller, DC (http://www.ChiroViewPresents.com) Dean of Academic Affairs Texas Chiropractic College 281.998.6058 #1 Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation Haldeman S, et al. Manuelle Medizin. 2000; Vol. 38, Is. 1, pp. 3-16. Study Design: Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993. Objectives: To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized. Summary of background data: Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear. Methods - A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized. Results - The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3ą12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted. Conclusions - The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma. #2 Most Older Americans Report Daily Pain But Do Not Seek Treatment Westport, April 7th 2000 - Reuters Health More than half (55%) of Americans 65 years of age and older experience daily pain, and 69% of this group attribute their pain to arthritis, according to a survey released yesterday by the Arthritis Foundation in Atlanta, Georgia. "The frequency with which pain is identified is surprising," Dr. Jack Klippel, medical director of the Arthritis Foundation, told Reuters Health. The duration of pain reported by this group is 110 weeks. This shows that "these people are in chronic pain," Dr. Klippel said. The Gallup Organization survey of 2,002 adult Americans also shows that 23% of Americans age 18 years and older experience joint pain every few days or daily and 18% report having arthritis. Yet only 51% of those surveyed report visiting their doctor in the past 3 years for treatment of pain. In response to these findings the Arthritis Foundation and participating organizations announced a public education program. There is "a perception that getting older means increased pain and that there is no treatment for pain," Dr. Klippel said. Americans in pain need to be educated that "pain is not part of growing older and may be caused by arthritis, that arthritis can be treated, and that people in pain should talk to their doctors," Dr. Klippel said. #3 Doctors Shouldn't Have To 'Cheat' To Treat Patients Journal of the American Medical Association - April 12, 2000 A lot of doctors are willing to cheat when necessary in order to get HMOs and health plans to pay for better patient care. A survey of 720 physicians reveals that 39 percent have manipulated reimbursement rules in order to get coverage for services they perceive as necessary for a patient, according to a study in the Journal of the American Medical Association (JAMA). There are three different tactics physicians say they "sometimes" used during the last year. These are: 1. Exaggerating the severity of the patientsž condition; 2. Changing patientsž billing diagnoses; 3. Reporting signs or symptoms that patients did not have to help patients secure coverage for needed care. In other words, if a patient is worried and wants a colonoscopy, the doctor might report that the patient is bleeding, even if it isnžt true. Or, if an HMO wonžt pay for tests for minor gas pains, the doctor might exaggerate the symptoms as incredible pain being felt ten times a day. To my knowledge, reporting signs and symptoms that patients donžt actually have is done all the time in order to get the tests or procedures a doctor deems necessary to get to the root of a problem. Physicians today are caught between wanting to give the best quality care possible to patients and having to justify the costs of certain clinical services and tests to insurers that are pressuring doctors to save money by cutting out unnecessary procedures. The JAMA study shows that a sizeable minority of physicians will cheat, if necessary, because they feel their first commitment is to the patient, not the HMO. The problem is that if too many doctors manipulate the reimbursement rules, the HMOs may impose even more restrictions on what can or canžt be done for a patientžs condition. This in turn could result in more physician cheating to get services paid for and we get caught in a vicious cycle. No doctor wants to deceive an insurer, but patients are individuals and have individuals needs that doesnžt always fall into the approved "cookbook medicine" way of doing things. Physicians are trying to give the best care for the least amount of dollars and still maintain an ethical balance in their practices. It would be in the interest of HMOs to review their rules and procedures and work with physicians for the good of the patients so that reimbursement deception doesnžt become necessary. #4 The Importance Of Second Opinions HealthCentral.com - April 05, 2000 Pathologists are a critical component of medicine because they have to examine biopsy samples and decide if the sliver of tissue is benign or cancerous. When a sample turns up positive, you assume you have cancer, but pathologists do make mistakes. A study looking at biopsy slides of 6,171 patients at John Hopkins University found 86 wrong diagnoses that could have led to unnecessary or inappropriate treatment, according to a report on biopsy errors in the New York Times. This error rate of 1.4 percent might seem low, but it equals about one cancer patient a week ‚ and what if that patient was you? If the same error rate occurred nationally, the researchers say it would add up to more than 30,000 mistakes a year. Whatžs significant is that many patients sought a second opinion and were happy they did. For 20 patients, such a second opinion changed a diagnosis of malignant tissue to one of benign. In five cases, a growth thought to be benign turned out to be cancerous. Another six cases had mistaken the type of cancer reported by a pathologist. Another study at the University of Texas Southwestern Medical Center found major errors in two percent of the cases of ovarian, uterine, cervical and vulvar biopsies. This 1998 review led to doctors cancelling six operations and five chemotherapy treatments. In a study of brain and spinal cord cases at the University of Texas M.D. Anderson Cancer Center, 8.8 percent of patients who asked for second opinions found major errors in their reports. Some types of cancer are more difficult to diagnose and are more prone to error. These include ovarian, cervical, and skin or lymphatic cancers. Biopsy reports also rate how fast-growing and advanced a cancer is, which can affect how aggressively a patient is treated. This is a little scary, but it reveals how important it is to have a second opinion. Ižve seen people who were told they have a malignant disease prepare themselves for the worst and then a second biopsy shows nothing is wrong. The same holds true for radiology and other types of lab reports. How do you get a second opinion? You ask for it. Donžt be shy when your life is at stake. #5 Doctors Admit Falsifying Insurance Information To Help Patients April 11, 2000 - Chicago (AP) More than a third of doctors surveyed nationwide admit deceiving insurance companies to help patients get the care they need. Their tactics include: exaggerating the severity of an illness to help patients avoid being sent home early from the hospital; listing an inaccurate diagnosis on bills; and reporting nonexistent symptoms to secure insurance coverage. In a random mailed survey of 720 doctors nationwide in 1998, 39 percent said they had used at least one of those tactics "sometimes" or more often within the preceding year. The results were published in Wednesday's Journal of the American Medical Association. Thirty-seven percent said their patients "sometimes" or more often asked them to deceive insurers. More than a quarter -- 28.5 percent -- said it is necessary to "game" the system to provide high-quality care. Of the doctors who reported using deceitful practices, 54 percent said they did so more often than in the past. "As pressures to control health care costs increase, it is likely that manipulating reimbursement systems will increase," wrote the researchers, led by Dr. Matthew K. Wynia of the AMA's Institute for Ethics in Chicago. "Health plans in which the use of these tactics is common should carefully review their rules and procedures and work with physicians to reduce the perceived need for covert advocacy." Dr. Charles M. Cutler, chief medical officer for the American Association of Health Plans, which represents more than 1,000 HMOs and other insurance plans, said doctors who deceive insurers are "essentially allowing people to get benefits for which they haven't paid." "The people who pay for that are everybody else who's paying for the premiums," Cutler said. He said the practice will ultimately backfire and cause costs to rise. A smaller survey published in the AMA's Archives of Internal Medicine last year found that more than half of doctors approved the use of deceitful practices with insurance companies. The authors of the latest survey said theirs is the first to report what doctors are actually doing. Although doctors were not asked why they engaged in deception, the researchers suggested such reasons as managed-care restrictions and patients' demands. An accompanying editorial said Wynia's study provides the most reliable information to date on the extent of such deception and calls the findings "stunning." The practice may result in part from the public's contradictory expectations of medicine and insurance -- wanting costs contained but demanding access to the finest health care and expecting "their physicians to be faithful, uncompromising agents," wrote Dr. M. Gregg Bloche of the Georgetown-Johns Hopkins University Program in Law and Public Health. #6 Don't Ignore That Snoring Problem - It Could Mean Hypertension Journal of the American Medical Association, April 12, 2000 Therežs growing evidence that habitual snoring is something to be taken seriously. In the largest study of its kind to date, researchers have linked sleep-disordered breathing and the related clinical syndrome, sleep apnea, to high blood pressure in middle-aged and older people. The researchers looked at 6,132 participants in the Sleep Heart Health Study and found that hypertension increases significantly in proportion to the severity of sleep-disordered breathing, according to a report in the Journal of the American Medical Association (JAMA). The hypertension occurs even when adjusting for demographics and other variables, such as sex, body-mass index, race and alcohol and tobacco use. Some experts still donžt know if apnea actually triggers hypertension, but there is a strong indication that untreated sleep disorders induce sustained hypertension, according to an accompanying editorial in JAMA. The connection between apnea and hypertension certainly bears further investigation. In the face of this study, we shouldnžt think itžs funny if someone has a snoring problem. #7 Smoking Slows Physiologic Recovery From Occupational Raynaud's Phenomenon Occup Environ Med 2000;57:341-347 In individuals with occupational Raynaud's phenomenon, also called vibration white finger, smoking appears to slow physiologic improvement after exposure to the cause of this condition has ended, according to a report in the May issue of Occupational and Environmental Medicine. Researchers headed by Dr. Martin Cherniack of the University of Connecticut Health Center in Farmington made this discovery when they evaluated vascular function in 601 metalworkers who used pneumatic tools. The subjects had been referred for evaluation of a vasospastic disorder that developed during the use of pneumatic tools. The results of plethysmography were expressed as "a proportion (test finger/control finger) finger systolic blood pressure percentage," with the most affected finger cooled to 10 degrees C. They found that symptoms and finger systolic blood pressure percentage response to cold were more severe in the 317 smokers than in the 284 nonsmokers. Follow-up testing was performed 12 to 13 months later in 199 severely affected subjects who had not worked with pneumatic tools for 2 years. Dr. Cherniack's group found that the "smokers were almost twice as likely to have more severe vasospasm...than were non-smokers." The 53 subjects who had quit smoking during the interim exhibited greater improvement in finger systolic blood pressure percentage than continuous nonsmokers. Provoked vasospasm changed much less markedly in continuing smokers. They also note that "vascular responses in smokers who had recently stopped smoking resembled nonsmokers." Overall, the authors conclude that "continued smoking after the end of exposure to vibration aggravates and prolongs pathological arterial hyperresponsiveness." However, "the clinical pattern of cold hyperresponsiveness in both smokers and nonsmokers that seems to persist for many years after exposure has ended may not be amenable to [cold challenge plethysmography]," they add. "Severity and resistance to recovery may also be consequences of altered physiology rather than indices of prolonged exposure, only." #8 March 17, 2000 - New York (Reuters Health) A new drug for treating children and adolescents suffering from juvenile rheumatoid arthritis has been found to be remarkably effective, according to a report published in The New England Journal of Medicine. Children who were given the drug etanercept had significant improvement in their symptoms, and there were no signs of serious side effects, note Dr. Daniel J. Lovell of Children's Hospital Medical Center in Cincinnati, Ohio, and colleagues. Rheumatoid arthritis causes the immune system to attack the body's own tissues, causing joint swelling and pain. Between 30,000 to 50,000 children in the United States have juvenile rheumatoid arthritis, according to statistics published in 1998 in the journal Arthritis and Rheumatism. About one third of all children suffering from the condition are treated successfully with anti-inflammatory drugs and physical therapy, Lovell and colleagues explain. But most patients need more aggressive therapy. Many of them are treated with the drug methotrexate, which is effective and well tolerated by children, though the frequency and severity of side effects increase with higher doses of the drug. "Although methotrexate can benefit patients with juvenile rheumatoid arthritis, many do not have an adequate response to this drug, and there is concern about long-term side effects," writes Dr. David S. Pisetsky of Duke University Medical Center in Durham, North Carolina, in an accompanying commentary. "The other options for disease-modifying therapy for children have not been thoroughly tested. The availability of another safe and effective medication for children with arthritis is therefore an important advance." Etanercept is a genetically engineered drug that blocks a protein called tumor necrosis factor, which plays a complex role in initiating inflammation with rheumatoid arthritis. In the study of patients aged 4 to 17 years, 81% of patients who received (an inactive) placebo had a flare-up of the disease. In contrast, only 28% of patients taking etanercept had flare-ups during the same time period. "The significant clinical response supports the use of etanercept in children with juvenile rheumatoid arthritis," Lovell and colleagues conclude.