General Newsletter
May 3, 2010

Worth Quoting
"It doesn't hurt to be optimistic. You can always cry later. "

--Lucimar Santos de Lima


In This Issue
• Scalpels in Hand, Robots Take to the ER
• Interrupting a Nurse Makes Medication Errors More Likely
• After Teeth Are Pulled, Platelet-Rich Plasma May Speed Healing
• Brain Area That May Delay Need for Gratification Found
 

Scalpels in Hand, Robots Take to the ER


TUESDAY, April 27 (HealthDay News) -- People facing surgery often imagine themselves under the care of a trained surgeon wielding a scalpel with a steady hand and a cool disposition.

But that picture is changing.

The surgeon will still be there, but the steady hand might very well not be human.

Robotic surgery is becoming a popular alternative to traditional surgical practices. For example, the number of prostate surgeries performed using robotic instruments increased from 9 percent in 2003 to 43 percent by 2007, according to a study published in late 2009 in the Journal of the American Medical Association.

For the surgery, thin tubes containing cameras and robot-controlled surgical instruments are inserted into the body through tiny incisions, and the procedure is performed internally. Proponents of the method say the technology allows for less-invasive surgery, which leads to a faster recovery.

"You used to have to make a pretty big incision in the pelvis to do prostate surgery," said Dr. W. Randolph Chitwood Jr., director of the East Carolina Heart Institute and chairman of cardiovascular and thoracic surgery at East Carolina University, who is also a pioneer in the use of robotic surgery. "With this technology, we can now access the internal organs through tiny incisions."

The technology is not flawless. The Journal of the American Medical Association study found that people who underwent minimally invasive robotic prostate surgery had an increased risk of incontinence, erectile dysfunction and other genitourinary complications.

Surgeons had hoped that the use of robotic instruments would protect the nerves surrounding the prostate by removing some of the shakiness that exists in even the best-trained hands, said Dr. Otis Brawley, chief medical officer of the American Cancer Society.

"It is decreasing the shaking, but it didn't decrease the amount of trauma to the nerves," he said.

However, patients also sustained less blood loss, had fewer complications overall and were more likely to heal faster and spend less time in the hospital, the study found.

But how does the average person know whether robotic surgery would be the right option? And if you decide to pursue robotic surgery, how can you make sure you're in the best hands possible?

First, research the team that would perform the surgery, said Chitwood, who regularly trains surgical teams on the use of robotic instruments.

Successful use of the new technology, he said, depends on whether the surgeons already are skilled at the procedure in question.

"This will not teach you how to repair heart valves," he said. "But if you take someone who's already performed the operation and already knows what they're doing, this can make the surgery less invasive. What we preach to people [is that] if you haven't done much microvalve surgery, it's not the time to come learn from us."

The entire team that will be involved in the surgery should be trained in the use of robotics, Chitwood said. Surgeons need to know how to use the equipment, and assistants and nurses need to know how to troubleshoot the technology. "You train them on the nuances of the device, and then you do team training so the scrub nurse and the assistant and the surgeon can work in synchronicity," he said.

Someone considering robotic surgery also should ask how often a surgeon performs the surgery because repetition builds skill with the equipment, Chitwood and Brawley said. A surgeon who has performed the procedure hundreds of times simply has more experience than someone who's performed it a dozen times, they said.

Also ask about the outcomes of earlier patients, and how those outcomes compare with those of people who had traditional surgery at the medical center in question. "My experience is that the better doctors are willing to discuss that," Brawley said.

He suggests that people facing the choice of robotic versus traditional surgery interview three or four surgeons who perform one or both forms of surgery -- and also try to talk to some of their patients.

"Interview these doctors and then make a gut decision about what's right for you," Brawley said.

But even if you've found the right team, that doesn't mean robotic surgery is the right choice for you.

"The story has been written time and time again that the new technology or medicine is superior to the old standard," Brawley said. "Sometimes it is not."

A number of risk factors should be taken into account before choosing robotic surgery over traditional surgical methods, including the prospective patient's age and overall health, Chitwood said. And anyone who has a risk factor that increases the chances of complications should seriously consider standard surgery, he advised.

"No one wants a big cut, but they'll take a big cut for safety and to have the procedure done properly," he said.

More information

The U.S. National Library of Medicine has more on robotic surgery.


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Interrupting a Nurse Makes Medication Errors More Likely


MONDAY, April 26 (HealthDay News) -- Distracting an airline pilot during taxi, takeoff or landing could lead to a critical error. Apparently the same is true of nurses who prepare and administer medication to hospital patients.

A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error. As the number of distractions increases, so do the number of errors and the risk to patient safety.

"We found that the more interruptions a nurse received while administering a drug to a specific patient, the greater the risk of a serious error occurring," said the study's lead author, Johanna I. Westbrook, director of the Health Informatics Research and Evaluation Unit at the University of Sydney in Australia.

For instance, four interruptions in the course of a single drug administration doubled the likelihood that the patient would experience a major mishap, according to the study, reported in the April 26 issue of the Archives of Internal Medicine.

Experts say the study is the first to show a clear association between interruptions and medication errors.

It "lends important evidence to identifying the contributing factors and circumstances that can lead to a medication error," said Carol Keohane, program director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston.

"Patients and family members don't understand that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, associate professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own family members go out and interrupt the nurse when she's standing at a medication cart to ask for an extra towel or something [else] inappropriate."

Julie Kliger, who serves as program director of the Integrated Nurse Leadership Program at the University of California, San Francisco, said that administering medication has become so routine that everyone involved -- nurses, health-care workers, patients and families -- has become complacent.

"We need to reframe this in a new light, which is, it's an important, critical function," Kliger said. "We need to give it the respect that it is due because it is high volume, high risk and, if we don't do it right, there's patient harm and it costs money."

About one-third of harmful medication errors occur during medication administration, studies show. Prior to this study, though, there was little if any data on what role interruptions might play.

For the study, the researchers observed 98 nurses preparing and administering 4,271 medications to 720 patients at two Sydney teaching hospitals from September 2006 through March 2008. Using handheld computers, the observers recorded nursing procedures during medication administration, details of the medication administered and the number of interruptions experienced.

The computer software allowed data to be collected on multiple drugs and on multiple patients even as nurses moved between drug preparation and administration and among patients during a medication round.

Errors were classified as either "procedural failures," such as failing to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose.

Only one in five drug administrations (19.8 percent) was completely error-free, the study found.

Interruptions occurred during more than half (53.1 percent) of all administrations, and each interruption was associated with a 12.1 percent increase, on average, in procedural failures and a 12.7 percent increase in clinical errors.

Most errors (79.3 percent) were minor, having little or no impact on patients, according to the study. However, 115 errors (2.7 percent) were considered major errors, and all of them were clinical errors.

Failing to check a patient's identification against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the study reported.

In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages.

The idea, Kliger said, is based on the U.S. Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits non-essential activities and conversations with the flight crew during taxi, takeoff, landing and all flight operations below 10,000 feet, except when the safe operation of the aircraft is at stake.

Likewise, in nursing, not all interruptions are bad, Westbrook added.

"If you are being given a drug and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.

More information

The Institute for Safe Medication Practices has more on safe medication use.


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After Teeth Are Pulled, Platelet-Rich Plasma May Speed Healing


FRIDAY, April 23 (HealthDay News) -- Platelet-rich plasma accelerates healing and bone formation after tooth extraction, a new study shows.

Poor healing after tooth removal can result in excessive jaw bone loss that may delay the use of dental prosthetics or implants, require expensive reconstructive surgery, or be impossible to repair, according to the researchers.

The study included patients who had surgery to remove wisdom teeth. One extraction site was treated with platelet-rich plasma (PRP) while the site on the other side of the mouth was used as a control. During 24 weeks of follow-up, the patients were checked for jaw bone density, healing, bleeding, inflammation, pain and facial swelling.

"The PRP treatment has a positive effect on bone density immediately following tooth extraction," while the control sites showed a decrease in bone density in the first week after surgery, the researchers said.

"It took approximately six weeks for the control sites to reach the same bone density that the PRP-treated site had reached by week one," they wrote. "The immediate start of bone formation seen with PRP treatment is of clinical relevance because it is the initial two weeks following bone manipulation oral surgery that are important."

PRP had little effect on bleeding, inflammation, pain and facial swelling.

Using PRP to promote faster jaw bone formation may reduce the waiting time for dental prosthetics or implants to two to four months instead of the current four to six months, according to the researchers.

The study was recently published in the Journal of Oral Implantology.

More information

The American Association of Maxillofacial and Oral Surgeons has more about wisdom teeth.


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Brain Area That May Delay Need for Gratification Found


THURSDAY, April 15 (HealthDay News) -- A brain circuit that may govern the ability to resist instant gratification to achieve long-term benefit has been pinpointed by German researchers.

"Humans normally prefer larger over smaller rewards, but this situation can change when the larger rewards are associated with delays. Although there is no doubt that humans discount the value of rewards over time, in general, individuals exhibit a particularly significant ability to delay gratification," study author Dr. Jan Peters, of the University Medical Center Hamburg-Eppendorf, said in a news release.

The researchers used functional MRI to monitor the brain activity of volunteers who had to make a series of choices between smaller immediate rewards and larger delayed rewards. The results showed that the degree to which participants chose long-term rewards was predicted by signals in the anterior cingulate cortex (ACC), an area of the brain involved in reward-based decision making, and functional coupling of the ACC with the hippocampus, which is involved in imagining the future.

"Taken together, our results reveal that vividly imagining the future reduced impulsive choice. Our data suggests that the ACC, based on episodic predictions involving the hippocampus, supports the dynamic adjustment of preference functions that enable us to make choices that maximize future payoffs," Peters said.

The study is published in the April 15 issue of Neuron.

More information

The National Institutes of Health has more on the brain's reward systems.


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