Natural health products contain hidden ingredients: May pose serious risk to health

Three natural health products bearing the Natural Health Product Number NPN 80041194 and one unauthorized natural health product were tested by Health Canada and found to contain hidden ingredients (sildenafil analogs) that may pose serious risks to the health of Canadians. The products (called Innerget Instant Erection, Innerget Prolonged Performance, Innerget Everlasting Strength and Megaton 2080) were being sold by Lion King Health Enterprises Group Ltd., at 1328-8368 Capstan Way, Richmond, BC.

These products are promoted as male sexual stimulants and contain hidden prescription medications. Approved drugs that contain these ingredients can only be sold with a prescription and by a pharmacy. The use of these products can put your health at serious risk.

Consult your healthcare practitioner with any questions or concerns regarding use of these products.Report any adverse reaction potentially related to these products to Health Canada.Contact Health Canada’s toll-free line at 1-800-267-9675 with questions or complaints about these products.

Canadians who have purchased or used these products, particularly people with heart problems.

Sildenafil and its analogs are prescription medications that should only be used under the supervision of a health care practitioner. Products containing sildenafil or tadalafil should never be used by individuals taking any kind of nitrate drug (e.g. nitroglycerine) as they can cause potentially life-threatening low blood pressure.

Individuals with heart problems including high blood pressure, a history of heart attack, stroke, abnormal heart beat or chest pain are at higher risk of cardiovascular side-effects if they engage in sexual activity, including if they use sildenafil or tadalafil to help them achieve an erection. Other possible side-effects of using sildenafil or tadalafil include headache, facial flushing, indigestion, dizziness, abnormal vision and hearing loss.

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Synthetic Calcitonin (Salmon) Nasal Spray (NS) - Market Withdrawal of All Products, Effective October 1st, 2013 - For Health Professionals

Subject: Market Withdrawal of All Synthetic Calcitonin (Salmon) Nasal Spray (NS) Products, Effective October 1st, 2013

MIACALCIN® NS, DIN 02240775 (Novartis Pharmaceuticals Canada Inc.)SANDOZ CALCITONIN NS DIN 02261766 (Sandoz Canada Inc.)APO-CALCITONIN NS DIN 02247585 (Apotex Inc.)

The manufacturers of synthetic calcitonin (salmon) nasal spray (NS) products (listed above), in collaboration with Health Canada, would like to advise you of the market withdrawal of these Products, effective October 1st, 2013.

All three products are authorized in Canada for the treatment of postmenopausal osteoporosis in females greater than five years post menopause with low bone mass relative to healthy premenopausal females.

Following the review of safety and efficacy information for synthetic calcitonin (salmon) nasal spray products, Health Canada has concluded, in light of a newly identified risk of malignancies (cancer), that its benefit-risk profile for the treatment of postmenopausal osteoporosis is no longer considered favourable.As a result of these findings, calcitonin (salmon) nasal spray will be withdrawn from the market effective October 1st, 2013.Patients being treated for osteoporosis with synthetic calcitonin (salmon) should be switched to an alternative treatment.

Health Canada has evaluated information on the risk of malignancies from randomised controlled trials in patients with osteoporosis or osteoarthritis receiving calcitonin (salmon) nasal spray or an unlicensed oral calcitonin formulation. Patients treated with calcitonin in these trials had a low but observable increased rate of malignancies compared with patients taking placebo. The increased rates seen with calcitonin compared to placebo varied between 0.7% in studies with the oral formulation to 2.4% in the studies with the nasal formulation.Taking this new safety information and the available efficacy data into account, Health Canada concluded that the risks of calcitonin (salmon) nasal spray outweigh the benefits for the treatment of established post-menopausal osteoporosis.

As of July 3, 2013, the manufacturers cited above have ceased the sale of synthetic calcitonin (salmon) nasal spray (NS) products. Distribution of the products will be phased out and the DINs for the above-cited products will be cancelled on October 1st, 2013.

Healthcare professionals should no longer prescribe the above-mentioned products for the treatment of osteoporosis and are advised to seek alternative therapies for their patients. Pharmacists are advised that dispensing should cease by October 1st, 2013, since the DINs will become inactive on that date. To ensure full inventory depletion, we advise that the above-cited products be removed from your inventory by October 1st, 2013. Pharmacists wishing to return remaining unused product by that date may do so by returning to their wholesaler for a refund. Patients being treated for osteoporosis with any of the above mentioned products are advised to speak to their doctor for a recommendation of suitable alternative treatment.

Managing marketed health product-related adverse reactions depends on health care professionals and consumers reporting them. Reporting rates determined on the basis of spontaneously reported post-marketing adverse reactions are generally presumed to underestimate the risks associated with health product treatments. Any case of serious overdose symptoms or other serious or unexpected adverse reactions in patients receiving calcitonin NS should be reported to the respective product manufacturer or Health Canada at the following addresses:

MIACALCIN® NS:
Novartis Pharmaceuticals Canada Inc.
385 Bouchard blvd,
Dorval, Quebec, H9S 1A9
Phone: 1-800-363-8883 (Medical Information)
Fax:514-636-3175

SANDOZ CALCITONIN NS:
Sandoz Canada Inc.
145, Jules-Leger,
Boucherville, Quebec, J4B 7K8
Phone: 1-800-361-3062 (Drug Information)

APO-CALCITONIN NS:
Apotex Inc.,
150 Signet Drive,
Toronto, Ontario M9L 1T9
Phone: 1-800-667-4708 (Drug Safety)
Fax: 1-416-401-3819
Email: drugsafety@apotex.com

To change your mailing address or fax number, please contact Healthcare Advisor by fax at 1-866-825-7101 or by e-mail athealthcareadvisor@plexus360.com.

You can report any suspected adverse reactions associated with the use of health products to Health Canada by:

Calling toll-free at 1-866-234-2345; orVisiting MedEffect Canada's Web page on Adverse Reaction Reporting for information on how to report online, by mail or by fax

For other health product inquiries related to this communication, please contact Health Canada at:
Marketed Health Products Directorate (MHPD)
E-mail: mhpd_dpsc.public@hc-sc.gc.ca
Tel: 613-954-6522
Fax: 613-952-7738

Should you have any questions or require additional information regarding the use of calcitonin NS, please contact the respective manufacturer :

for MIACALCIN® NS - Novartis Pharmaceuticals Canada Inc., Medical Information Department at 1-800-363-8883,for SANDOZ CALCITONIN NS - Sandoz Canada Inc., Drug Information Department at 1-800-361-3062 andfor APO-CALCITONIN NS - Apotex Drug Information at 1-800-667-4708.
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Longer Looks: Mayo's Demands; Posting Hospital Prices

 

 
When the billionaire owner of the Minnesota Vikings football team decided last year he wanted a new, $1 billion stadium, he did what sports franchise owners often do: threaten to relocate to another state—at least implicitly—and thereby wrung nearly $500 million dollars from taxpayers. ... this year, a different kind of local juggernaut threatened to take its business elsewhere unless Minnesotans helped pay for a multibillion-dollar new development: The Rochester-based Mayo Clinic. ... the state legislature in May approved $585 million in city, county and state funds for infrastructure upgrades to accommodate Mayo's 20-year, $5.6 billion expansion. (Mayo itself is covering $3.5 billion of the cost, while healthcare-related businesses are expected to contribute $2.1 billion.) Worried that Obamacare will hurt its bottom line, Mayo is betting its future on its ability to lure an greater percentage of the wealthiest and sickest patients to its dazzling high-tech hospitals (Ilan Greenberg, 7/24).

The New Yorker: Tweeting Death
In the week before her death, Simon began live-tweeting his mother’s final days to his almost 1.3 million followers from her hospital room. The tweets were poignant and haunting, and have brought Simon—already a mini-celebrity—a new level of renown. Total strangers read what he wrote and responded deeply. ... The tweets, which felt almost aphoristic (a mere hundred and forty characters each), underscored one of the strangest things about being with someone at the end of her life: the surreality of time, the way that time bends and distorts, becomes material. ... It’s our equivalent of the ringing of church bells in the town square, for better or for worse (Meghan O'Rourke, 7/31).

The New York Times: Status And Stress
Although professionals may bemoan their long work hours and high-pressure careers, really, there’s stress, and then there’s Stress with a capital “S.” The former can be considered a manageable if unpleasant part of life; in the right amount, it may even strengthen one’s mettle. The latter kills. What’s the difference? Scientists have settled on an oddly subjective explanation: the more helpless one feels when facing a given stressor, they argue, the more toxic that stressor’s effects (Moises Velasquez-Manoff, 7/27).

The New York Times: Revealing A Health Care Secret: The Price
The Surgery Center of Oklahoma is an ambulatory surgical center in Oklahoma City owned by its roughly 40 surgeons and anesthesiologists. What makes it different from every other such facility in America is this: If you need an anterior cruciate ligament reconstruction, you will know beforehand — because it's on their Web site — that it costs $6,990 if you self-pay in advance. … What's remarkable is that this is remarkable. Why should a business become the subject of news stories simply because it tells people the cost of its services? Because it's health care (Tina Rosenberg, 7/31).

Los Angeles Times: 'Critically Ill' Author Frederick Southwick On What Ails Our Healthcare System
Mary Southwick was 34 when she developed pain on the bottom of one foot. After seeing a neurologist who said she had a nerve injury caused by dancing, she developed thrombophlebitis and was admitted to the hospital. An intern underdosed her heparin (blood thinner), and she suffered a large blood clot in a lung. This was soon followed by a heart attack, then respiratory failure, renal failure and shock. … Frederick Southwick, chief of infectious diseases at the University of Florida in Gainesville, says his wife's trauma motivated him to write the book "Critically Ill: A 5-Point Plan to Cure Healthcare Delivery." Here he offers some guidance to negotiate the healthcare system (Judy Mandell, 7/26).

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Viewpoints: Doctors' Sway Over Medicare Pay; Hospital Rankings Not All They Seem; Legal Immigrants' Health Needs Overlooked

 

Even before the latest Medicare trustees report came out at the end of May, the White House spin masters had already crafted a story to go with it. Medicare's finances have improved, we're being told. The trust fund will last longer. The unfunded liability is lower. One of the reasons is said to be ObamaCare. The core of the new health reform doesn't kick in until next year, but already it's improving things for seniors? Here's the real story (John C. Goodman and Laurence J. Kotlikoff, 7/24).

The Wall Street Journal: Those Hospital Rankings Could Use A Healthy Dose Of Skepticism
The U.S. News & World Report "Best Hospitals" rankings for 2012-13 were released last week, followed by the usual media hoopla and a few chest-thumping press releases from hospitals at the top of the list. Whether the rankings actually mean anything is an entirely different story. The highest-ranked hospitals are always quick to tout their rankings in hopes of attracting new patients who will pay top dollar (Ezekial J. Emanuel and Andrew Steinmetz, 7/24).

Los Angeles Times' Capital Journal: Big-Bucks Battle Shaping Up Over Bid To Raise Malpractice Award Limit
You don't need to be a Nobel economist to understand that dollars today aren't anything close to their worth four decades ago. Gasoline, real estate, medical care—they've all skyrocketed in cost. Everything's gone up, that is, except damage awards for pain and suffering caused by medical malpractice (George Skelton, 7/24). 

The New England Journal of Medicine: Observation Care — High-Value Care Or A Cost-Shifting Loophole?
Current CMS policy on observation care promotes cost shifting without rewarding higher value, since payment is time-based and does not reward the use of evidence-based clinical pathways or hospital units designed to provide efficient care for this group of patients. ... Not all observation care is the same; payment reforms should protect patients from excessive out-of-pocket expenses and reward the efficient care delivered in observation units, which prevents prolonged hospitalizations (Drs. Christopher W. Baugh and Jeremiah D. Schuur, 7/25).

The New England Journal of Medicine: Stuck Between Health And Immigration Reform — Care For Undocumented Immigrants
Although there are valid perspectives on multiple sides of the immigration debate, there are stark public health implications of continuing to permit the existence of a medical underclass comprising more than 10 million people. Neither the recent national health reform law nor the immigration bill currently being considered solves these vexing problems; indeed, these policies may increase the barriers for some undocumented immigrants. For the foreseeable future, undocumented immigrants will remain on the outskirts of our public programs and safety net, a controversial reminder of ongoing inequities in our health care system (Dr. Benjamin D. Sommers, 7/24).

The New England Journal of Medicine: Holes in the Safety Net — Legal Immigrants' Access to Health Insurance
While Congress debates whether publicly supported health care should be available to undocumented immigrants who may be placed on a path to citizenship under immigration reform, the health care needs of already legal immigrants continues to be overlooked. More than 12 million immigrants are lawfully present in the United States. ... Public policies that deny legal immigrants equal access to public insurance programs leave lawful residents and their health care providers unnecessarily vulnerable when injuries and illness strike. By encouraging immigrant-only programs, such policies also perpetuate needless complexity in the health care system (Wendy E. Parmet, 7/24).

The New England Journal of Medicine: Rationing Lung Transplants — Procedural Fairness In Allocation And Appeals
The well-publicized cases of two pediatric candidates for lung transplants have shaken the transplant community with emergency legal injunctions arguing that current lung-allocation policy is "arbitrary and capricious." Although the resulting transplantation seemingly provided an uplifting conclusion to an emotional public debate, this precedent may open the floodgates to litigation from patients seeking to improve their chances of obtaining organs. These cases questioned the potential disadvantaging of children and the procedural fairness in lung allocation. But legal appeals exacerbate inequities and undercut public trust in the organ-transplantation system (Keren Ladin and Dr. Douglas W. Hanto, 7/24).

The New England Journal of Medicine: Accountable Prescribing
As insurance coverage expands, we must ensure that greater access to prescription drugs confers better health, not harm. The need to advance performance measures as health care reform proceeds is well recognized. Ideally, we should assess outcomes valued by patients, but for reasons of feasibility, many measures focus instead on surrogate end points. To improve health, such end points must be based on strong evidence, and how you get there matters (Drs. Nancy E. Morden, Lisa M. Schwartz, Elliott S. Fisher and Steven Woloshin, 7/25). 

The New York Times: Justice For The Mentally Disabled
Gov. Andrew Cuomo closed out a shameful period in New York's history earlier this week when he agreed to give about 4,000 mentally ill people held in highly restrictive institutional settings the option of moving into supported housing, where they can live independently with the help of social service organizations. The agreement, outlined in a consent decree filed in federal court in New York City, ends a long legal battle and could bring a new day for people isolated in inadequate, for-profit residences that make their disabilities that much harder to bear (7/24).

The New York Times: Realities In Global Treatment Of H.I.V.
The World Health Organization recently issued aggressive new guidelines for treating people infected with H.I.V., the virus that causes AIDS. The guidelines are a welcome step forward but fall short of the treatment goals that could and should be set (7/24). 

JAMA: Why Obamacare Needs Millenials
One of the primary goals of the Affordable Care Act (ACA)—now known more commonly as Obamacare—is to make health insurance more accessible, particularly for people with preexisting conditions. … This focus on reaching young and healthy people is almost strangely ironic in that the new health insurance exchanges and Obamacare proponents appear to be engaging in the same "cherry picking" for which they have criticized insurers (Larry Levitt, 7/24).

National Journal: The Unprecedented – And Contemptible – Attempts To Sabotage Obamacare
When Mike Lee pledges to try to shut down the government unless President Obama knuckles under and defunds Obamacare entirely, it is not news—it is par for the course for the take-no-prisoners extremist senator from Utah. When the Senate Republicans' No. 2 and No. 3 leaders, John Cornyn and John Thune, sign on to the blackmail plan, it is news—of the most depressing variety (Norm Ornstein, 7/24).

Chicago Tribune: Looking Back To 2013
On Monday, Gov. Pat Quinn signed into law the state's massive Medicaid expansion. With that flick of his pen, 342,000 low-income Illinois citizens will be newly eligible for Medicaid starting in January. State officials also expect as many as 171,000 others who are now eligible but haven't signed up to do so as an Obamacare marketing campaign rolls out. If so, the number of Medicaid recipients would grow from today's 2.8 million to 3.3 million — more than 1 in 4 Illinoisans. ... We also hope that, a decade or two from now, Illinois citizens don't look back to 2013 and say: What were they thinking? How could the politicians be so willfully blind to the billions that the Medicaid expansion would cost taxpayers? (7/24).

Pittsburgh Post-Gazette: Much Is At Stake For Minorities In Medicaid Debate
As Pennsylvania decides whether to expand its Medicaid program, a new study says the decision will have a major impact on the state's racial and ethnic minorities. A Kaiser Family Foundation analysis found that 15 percent of African Americans in Pennsylvania are without health insurance and nearly two-thirds of them would qualify for coverage under federal poverty level criteria set out by the Affordable Care Act if Medicaid were expanded (Steve Twedt, 7/25).

Sacramento Bee: Use Health Law To Fight Tooth Decay In Kids
Tooth decay is the most common chronic health problem in children, according to the Centers for Disease Control and Prevention. More than a quarter of kids have decay in their baby teeth by the time they enter kindergarten. Nearly 68 percent of teenagers 16 to 19 have decay in their permanent teeth. The Affordable Care Act provides an opportunity to improve children's access to dental care starting in January 2014 – if the California state health exchange, called Covered California, does things right (7/25). 

The Huffington Post: Decline In Cost Of Health Care In America
Undeniably, over the past several years the singular focus of conversation among policy makers has shifted from simply more care and better quality of care to better value in health care, where value is defined as quality over cost. ... Yet if history is any indicator, as our economy strengthens costs of health care will rise once again. So, last month the Bipartisan Policy Center (BPC) made 50 bold recommendations on how to sustain the lower growth of health care costs (Dr. Manoj Jain and Dr. Bill Frist, 7/24).

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Weekend Reading: The Mystery Of Some Innovations That Are Slow To Be Accepted; Myths About The Obesity Crisis

 

Why do some innovations spread so swiftly and others so slowly? Consider the very different trajectories of surgical anesthesia and antiseptics. ... On October 16, 1846, at Massachusetts General Hospital, Morton administered his gas through an inhaler in the mouth of a young man undergoing the excision of a tumor in his jaw. ... By February, anesthesia had been used in almost all the capitals of Europe, and by June in most regions of the world. ... In the eighteen-sixties, the Edinburgh surgeon Joseph Lister ... perfected ways to use carbolic acid for cleansing hands and wounds and destroying any germs that might enter the operating field. The result was strikingly lower rates of sepsis and death. You would have thought that ... his antiseptic method would have spread as rapidly as anesthesia. Far from it. ... In our era of electronic communications, we've come to expect that important innovations will spread quickly. Plenty do ... But there's an equally long list of vital innovations that have failed to catch on. The puzzle is why (Dr. Atul Gawande, 7/29).

The New Republic: Weight Loss Is Not The Answer: What Michelle Obama Doesn’t Get About Obesity
The biggest mystery when it comes to obesity is not how to prevent it. It's how to treat it. Don’t get me wrong. We need to know what expands our girth so that millions more don’t suffer the type 2 diabetes and heart disease that follow. But millions are obese, right now, and the medical establishment doesn’t really know how to help them. I learned that to my dismay when I tried to find a program for a relative who seemed too young for stomach bands and gastric bypasses. The problem is simple and well known. It’s hard but not impossible to lose weight. But it’s nearly impossible to keep it off (Judith Shulevitz, 7/23).

The Atlantic: Answering To Patient Who Yell The Loudest
Few people would argue that scarce medical resources should simply go to patients and families who yell the loudest, but the recent case of a ten year-old Pennsylvania girl with cystic fibrosis shows how such a strategy can work. The parents of Sarah Murnaghan went to court to demand that their daughter be placed on the transplant list for new lungs.  The court agreed, and she has now received a second set of lungs after her immune system rejected the first set. There is a long—and storied—history of activist patients bucking the system to obtain treatments initially denied to them. ... But in an era of rising health care costs and passage of the Affordable Care Act (ACA), which seeks to reign and regulate spending, the privileges of activist patients need to be reexamined (Dr. Barron Lerner, 7/23).

New Scientist: Why Is The Rich U.S. In Such Poor Health?
Americans die younger and experience more injury and illness than people in other rich nations, despite spending almost twice as much per person on health care. That was the startling conclusion of a major report released earlier this year by the U.S. National Research Council and the Institute of Medicine. … As distressing as all this is, much less attention has been given to the obvious question: Why is the United States so unwell? The answer, it turns out, is simple and yet deceptively complex: It's almost everything. ... we can hope that the evidence of a health disadvantage in the United States is now so compelling that the terms of the conversation and even the political calculus will begin to change. Then, perhaps, we can start addressing that disadvantage and stop paying for it with our lives (Laudan Aron, 7/15).

Boston Globe: Hypothermia Making A Comeback In Medicine
The last Dr. Peter Franklin remembers, he was lying on a table in the cardiac catheterization lab in a Miami hospital when his chest started to hurt. Then he died. The medical team raced to restart Franklin's heart, then placed a stent in a blocked artery to allow blood to again flow freely. His doctors also worked to save his brain, using a technique that's as old as ancient Greece — hypothermia. With recent studies lending scientific credibility to the practice, doctors now know that lowering a patient's body temperature — using methods including cooling blankets or an infusion of cold fluid — can improve brain recovery in patients who are comatose after cardiac arrest (Dr. Daniela J. Lamas, 7/22).

The New England Journal of Medicine: The Residency Mismatch
For generations, the supply of practicing physicians in the United States has swung from too small to too large and back again. In 2006, alarmed about a growing physician shortage, the Association of American Medical Colleges (AAMC) recommended that medical school enrollments be increased by 30% over the next decade. ... But there's another barrier to creating enough practicing physicians: there are insufficient residency posts to accommodate all these medical graduates. ... The absence of health-workforce planning, a hallmark of the freewheeling U.S. market economy, may come back to haunt policymakers, particularly when physician shortages become more apparent as the ACA's coverage expansion takes hold

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Viewpoints: Indian Health Service Takes Big Cuts; Labor 'Mutiny' Over Health Law; Gov. Jindal Says Medicaid Expansion Would Have Moved Privately Insured To Medicaid

 
It's an old American story: malign policies hatched in Washington leading to pain and death in Indian country. It was true in the 19th century. It is true now, at a time when Congress, heedless of its solemn treaty obligations to Indian tribes, is allowing the across-the-board budget cuts known as the sequester to threaten the health, safety and education of Indians across the nation. ... One of the most important is the Indian Health Service, which serves about two million people on reservations and is grossly underfinanced even in good times. It routinely runs out of money halfway through the year. Though Medicare, Medicaid and veterans' health were exempted from sequestration cuts, the Indian Health Service was not (7/23).

The New York Times' Economix: The New Economics Of Part-Time Employment, Continued
A revised definition of part-time employment may have some popular appeal, but it will not repair the Affordable Care Act's disincentives for full-time employment or its extra costs for taxpayers (Casey Mulligan, 7/24). 

The Wall Street Journal: Obama's New York Model
President Obama has found a new example for the pending wonders of his health-care reform—New York. In his latest sales pitch last week, he declared that insurance rates in New York's ObamaCare exchange "will be at least 50% lower next year than they are today. Think about that: 50% lower." ... The real news is that New York ruined its individual insurance market two decades ago by imposing the same regulations that ObamaCare is about to impose on every other state (7/23).

The Wall Street Journal's Political Diary: Labor Vs. ObamaCare
The labor union mutiny against the Affordable Care Act expanded Thursday with a letter to President Obama from the head of the Laborers' International Union of North America, which represents more than 500,000 workers in construction and other industries. Echoing a similar appeal by three top union chiefs the previous week, union president Terry O'Sullivan wrote that ObamaCare will have "destructive consequences" for health plans that cover millions of workers and their families (Alexander Kazam, 7/23).

New Orleans Times-Picayune: Gov. Bobby Jindal: Why I Opposed Medicaid Expansion
First, as a general principle, we should not move people from private insurance onto government-run programs. It seems a matter of common sense that we should want to encourage self-sufficiency and target taxpayer spending only for those most in need. But Medicaid expansion would have moved up to 171,000 Louisianians off private insurance and stopped another 77,000 people from obtaining private insurance. To cover 214,000 low-income uninsured people in Louisiana, Obamacare would add more than twice that number -- more than 450,000 people -- to the Medicaid rolls. This makes no sense (Louisiana Gov. Bobby Jindal, 7/23).  

Health Policy Solutions (a Colo. news service): Not So Invincible – Young People Confused About Obamacare
Contrary to what many in the media may believe, young people do care about the implementation of Obamacare, the Affordable Care Act (ACA). But just like many other people in America, many of us may be confused about its provisions and which may apply to us and how. Though I am a senior at Boston University, and have studied health policy, I acknowledge that I do not understand everything I may need to know about the new law (Danielle Robbio, 7/24).

CNN: Will Obamacare Help Primary Care?
You're wiped out, eating too much, your chest feels funny when you climb stairs, sex isn't working well, you can't wait for a drink and your spouse is looking at you warily. But you just bought health insurance online from a health exchange. Now, before you head for an ER, if only you could find a doctor. ... Primary care doctors -- the pediatricians, family doctors and internists who constitute the foundation of our medical system -- are also in trouble (Dr. Tom Delbanco, 7/23).

Tampa Bay Times: Fed Must Save Children From State Apathy
The federal government took the only recourse available by finally asking the courts to end Florida's shameful practice of warehousing disabled children in nursing homes. For two years, Gov. Rick Scott's administration has made clear that it had no intention of changing course on a policy that punishes children with complex medical needs and keeps them from their homes, families and communities. If Florida won't comply with the antidiscrimination laws, then it falls to the federal government and the courts (7/23).

Bloomberg: How Republicans Can Help Us Grow Old Gracefully
If you thought the fight over Obamacare was bruising, brace yourself for the coming battle over long-term-care insurance. Demographic pressure and ill-fitting public programs make the current approach unsustainable, whether we like it or not. ... A better option is for the U.S. to follow the lead of almost every other developed country and create a social insurance plan for long-term care, in which the government collects premiums from the working-age population and uses the money to fund care for those who qualify (7/23).

The Seattle Times: Feds Make A Hash Of State's Mental-Health System
The U.S. Centers for Medicaid and Medicare Services informed the state of Washington that the state's outpatient mental-health system violated federal procurement laws, as articulated in OMB Circular A-87. Hope that didn't lose you. That accountant-speak is bone-dry. ... "Now wait a minute," longtime readers will say, "haven't you spent a lot of time arguing that health insurance doesn't necessarily make us any healthier? (7/22).

The Lund Report: Optimism Abounds In Cover Oregon Land – Is It Real?
Oregonians have been led to expect that they will receive large subsidies to help pay the cost of their personal health insurance now that health insurance is required. We also know they have been told that if they like their current insurance policy, they can keep it. Sounds good on the surface, but if we dig a little deeper we find that both statements don't hold much weight (John Gridley, 7/23).

Georgia Health News: Palliative And Hospice Care Help Make Life Livable
A hundred years ago, the average life expectancy in the United States was just under 50 years. Today it's nearly 80 years – a true testament to the benefits of modern medical advances. The development of highly effective treatments and technologies significantly extended Americans lives. However, these technological treatments can also affect quality of life, and not always for the better (Dr. Victor Alvarez, 7/23).

Minneapolis Star Tribune: Want Better Health Care? Be Pushy
I've been a physician for 35 years. During the most recent 25, I've devoted time to practice improvement and population health initiatives. In part, this involved helping individuals to be healthier. It also involved helping the care delivery system explore how to make care more effective, more efficient and more satisfying to patients (the combination labeled "the triple aim") (Dr. Charles J. Fazio, 7/23).

Bloomberg: What My Dog Taught Me About Health Insurance
Last February, on Valentine’s Day, the Official Blog Spouse and I took custody of an eight-week-old bullmastiff puppy named Fitzgerald. The first thing we did was to drive him home from Indiana and install him in the Stately McSuderman McMansion. The second thing we did was to buy him pet health insurance. "Now wait a minute," longtime readers will say, "haven’t you spent a lot of time arguing that health insurance doesn’t necessarily make us any healthier?" (Megan McArdle, 7/23).

JAMA: The Critical Role of Caregivers in Achieving Patient-Centered Care
Achieving high-quality, cost-effective medical care remains an elusive goal of the US health care system, but there is widespread agreement that patient-centered care will be a key ingredient.1 Yet for frail elders and patients with advanced illness, many of whom have multiple chronic diseases, patient-centered care is impossible without caregiver involvement. Although advocacy groups such as the National Alliance for Caregivers have long endorsed attention to family members and prominent research organizations such as the newly created Patient-Centered Outcomes Research Institute mention families in their research agendas, the critical role of caregivers deserves considerably more attention from clinicians (Dr. Muriel R. Gillick, 7/22).

JAMA: Who Owns Human Genes?
The [Supreme Court's] compromise ruling acknowledged difficult issues in a simmering controversy. Granting commercial rights over naturally occurring biological products seemed unethical because industry should not be able to control access to unaltered materials found in nature. However, failure to afford intellectual property protection could stifle innovation, robbing entrepreneurs of financial incentives for discovery. Myriad lost the exclusive right to isolate the BRCA1 and BRCA2 genes of individuals, but maintained the right to its unique method of synthetically creating BRCA cDNA to produce and market its tests (Lawrence O. Gostin, 7/22). 

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Viewpoints: Health Law Rollout Needs A Better Salesman; The Overhaul Is Shifting The Economy To Part-Timers

We need a serious and sustained presidential conversation with the country about the new health care reform laws—or progressives risk losing ownership of this once-in-generation liberal reform. If you listen to people in focus group discussions right now, they are clueless about the most basic policies in the reforms, even though parts of the law are already in place, the exchanges are to be launched in October, and the law’s requirements and benefits will become fully operative in January. ... And in the most recent national surveys, more people think their health insurance situation will be made worse by the impending changes (Stanley B. Greenberg, 7/30).

USA Today: Lift Health Care Reform's Deductible Cap
The Obama administration recently announced that it would delay until 2015 the Affordable Care Act's "employer mandate," which will require all companies with at least 50 full-time employees to offer health insurance or pay a fine. The delay represents a big help to large firms. Now it's time for the administration to throw a similar lifeline to small businesses -- by lifting the law's cap on annual deductibles (Janet Trautwein, 8/1). 

Fox News: Mr. President, ObamaCare Is Creating A Part Time Economy
The June unemployment rate remained unchanged from the previous month at 7.6 percent, but the June underemployment rate, which includes those who have stopped looking or settled for part-time work, rose sharply from 13.8 percent to 14.3 percent. This is partly due to the transition of employment from full-time to part-time, as the private and public sectors are forced into the perilous compliance standards of the president’s health care law (Rep. Sam Graves, R-Mo., 8/1). 

Chicago Tribune: The Part-Timing Of America
The Affordable Care Act will give companies -- and, surprisingly, their workers -- a big incentive to embrace more part-time employment. That isn't necessarily a problem, except when it comes to paying the health-insurance bills for all those part-timers. Looks like that job will fall to you, taxpayers. Some of the motives at play here will strike you as familiar; others are fresh insights on the part-timing of America (7/31).

New England Journal Of Medicine: The Unanticipated Consequences Of Postponing The Employer Mandate
The Obama administration's decision to postpone implementation of the employer mandate is the latest in a series of delays and alterations of the Affordable Care Act (ACA). But postponing the mandate — which requires larger employers to offer lower-income workers health insurance coverage similar to that available in the new insurance exchanges, on equal and affordable financial terms — may create large ripple effects. The good news is that as compared with instituting the mandate as planned, postponing it should barely increase the number of uninsured Americans after ACA implementation. But it affects other provisions, particularly the individual subsidies for purchasing insurance, and creates distorted incentives that may leave the government paying significantly more than planned (Mark Pauly and Adam Leive, 7/31).

Los Angeles Times: The Latest Misguided GOP Effort To Stop Obamacare
The House is expected to hold yet another symbolic vote this week on a bill to neuter the Patient Protection and Affordable Care Act, once again taking aim at the much-unloved "individual mandate" -- the requirement that virtually all adult Americans obtain coverage, starting in 2014. ... The problem with this approach -- beyond the fact that the bill would be dead on arrival in the Senate -- is that it would leave intact the requirement that insurers offer coverage to all applicants without regard to their medical histories. Insurers would also be barred from charging sicker or riskier customers higher premiums than healthy ones, and would be limited in the surcharges they could impose on older applicants and smokers (Jon Healey, 7/31).

WBUR: Cognoscenti: When Your Doctor Says 'Cancer': The Risks Of Fear Itself
Imagine your doctor saying, "You have cancer." How would you feel? The diagnosis would be more specific: "You have Ductal Carcinoma in Situ" (DCIS) rather than breast cancer, or "You have a Gleason score 4 prostate cancer" rather than prostate cancer. But you would no doubt hear only cancer. How would you react, even if the doctor went on to tell you that what you have is unlikely to ever grow into anything that could kill you, or even harm you, and that in the case of DCIS, it might even go away by itself? (David Ropeik, 8/1).

Sacramento Bee: A Cost Of Dismantling Mental Health Care
Kathy Gaither, the person in charge of daily operations at the California Department of State Hospitals, went on an unexplained administrative leave earlier this month, a week after the state Senate confirmed her appointment. ... Whatever the reason for Gaither's departure, the lack of permanent leadership raises questions of priorities. The California Department of State Hospitals has a $1.6 billion budget and more than 10,000 employees, and is responsible for the care of 6,560 severely mentally ill people in seven state hospitals. The department has been without stable leadership since the previous director retired in December 2010 (Dan Morain, 7/31).

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Study Finds Doctors Not Following Medical Guidelines On Back Pain

Researchers report that physicians are often overly aggressive by prescribing addictive narcotics to patients instead of other recommended drugs and are too often using surgery and unneeded imaging tools.

Los Angeles Times: Back Pain: Doctors Increasingly Ignore Clinical Guidelines
Doctors have increasingly ignored clinical guidelines for the treatment of routine back pain by prescribing powerful and addictive narcotics instead of other recommended painkillers and by recommending unwarranted diagnostic imagery, according to a new study. Researchers at Massachusetts' Beth Israel Deaconess Medical Center and Harvard Medical School based their conclusion on an examination of roughly 24,000 cases of spine problems in national databases from 1999 to 2010. Their findings appeared online Monday in JAMA Internal Medicine (Morin, 7/29).

Fox News: Doctors Don't Follow Back Pain Guidelines, Study Finds
A new study has found that many physicians are not following expert recommendations for the treatment of back pain. By not doing so, they are subjecting patients to unnecessary imaging tests, ineffective surgeries and unnecessary exposure to addictive narcotics, say the authors of the study published in JAMA Internal Medicine. Several guidelines for back pain stress a more hands off approach, largely because more aggressive treatments have not been shown to improve the pain and subject patients to risks (Tarkan, 7/30).

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State Highlights: Experts Cite 'Serious' Health Care Risks At Calif. Prison

 

Los Angeles Times: Court Experts Cite 'Serious' Health Care Risks At Corcoran Prison
Medical experts reporting to a federal court monitor say health care at the California state prison at Corcoran poses "an ongoing serious risk of harm to patients" that results in preventable deaths. The report, filed in federal court Monday, finds "serious patient care issues" within the general hospital at the prison, including life-threatening infections caused by unsanitary conditions, nurses who did not check vitals and doctors who repeatedly "cut and paste" the same patient notes (St. John, 7/30).

WBUR: With Higher Cigarette Taxes, Concerns About Smuggling
As of Wednesday, Massachusetts cigarette prices have increased $1 a pack, as part of the transportation finance bill passed by state lawmakers a week ago. Massachusetts now has the second-highest cigarette tax rate in the country -- a fact that's also raising concerns about a spike in cigarette smuggling. … But even if Massachusetts loses money, the tax still has its supporters. Casey Harvell, public policy director for the American Lung Association Massachusetts, says the price hike will encourage 25,000 smokers to quit, and prevent 27,000 children from taking up smoking in the first place (Lepiarz, 7/31).

North Carolina Health News: New Payment Plan Aims To Save N.C. Money For Psychiatric Care
Five years after North Carolina implemented a system in which the state and hospitals work together to provide beds for psychiatric patients, the General Assembly passed legislation this session intended to make that system more efficient. A provision in the state budget sets up a two-tiered system of paying hospitals for their inpatient psychiatric beds (Hoban, 7/31).

MPR News: State Grant Goes To Helping Low Income Latino Families Enroll In SNAP
Low income Latino families will get help signing up for food stamps thanks to a new state grant. The $20,000 grant to Neighborhood House will allow the St. Paul nonprofit to assist Spanish-speaking families who have trouble affording food. State officials say many low-income Latino families who are eligible for food stamps aren't enrolled in the food stamps program, officially called the Supplemental Nutrition Assistance Program, or SNAP. Often, people don't know how to sign up for the program, and are hampered by their inability to speak English, said Armando Camacho, president of Neighborhood House (Siple, 7/31).

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Viewpoints: Shutting Down The Government Over Health Law Is 'Nutty' Idea; GOP's Obamacare Playbook For Summer Recess

At its birth, the Affordable Care Act already seems gray, wheezing and gouty. For all its expressions of confidence, the Obama administration has been unable to implement key elements of the law. ... But there are a few bold, determined public officials who may rescue Obamacare. Among them are Sens. Ted Cruz (R-Tex.), Marco Rubio (R-Fla.) and Mike Lee (R-Utah). This is not, of course, their intention. They hate the law but have chosen to fight it in a particularly counterproductive way, which discredits responsible opposition and makes a Democratic takeover of the House more likely (Michael Gerson, 8/1). 

The Washington Post: The Party Of (Nutty) Ideas
It's not your imagination. The Republican Party really does seem to have taken leave of its senses. The House GOP majority has decided that its final act before the summer recess will be to take its 40th vote to repeal all or part of the Patient Protection and Affordable Care Act. ... Amazingly, this pointless exercise in the House makes more sense than what Republicans are doing in the Senate. There, Sen. Ted Cruz (R-Tex.) and his tea party-backed allies are threatening to shut down the whole government to strip Obamacare of all funding (Eugene Robinson, 8/1).

The New York Times: Saboteurs In The Potato Salad
[House Republicans] even have a master plan, a 31-page kit put together by the House Republican Conference, for every member to follow while back home [on summer recess] with the folks. ... Here's a sample suggestion, from Page 28, of how to stage a phony public meeting with business owners: "Confirm the theme(s) prior to the event and make sure the participants will be 100 percent on message. (Note: while they do not have to be Republicans, they need to be able to discuss the negative effects of Obamacare on their employees.)" And what if I have a child with cancer, and the insurance company plans to dump him if Republicans stop Obamacare in its tracks? Can I attend? Or what if I'm counting on buying into the new health care exchanges in my state, saving hundreds of dollars on my insurance bill? The kit has an answer: planting supporters, with prescreened softball questions, will ensure that such things never get asked (Timothy Egan, 8/1).

Los Angeles Times: 'Death Panels' Done Right
Among the most egregious distortions to cloud the health care debate in 2009 was the false notion that the Patient Protection and Affordable Care Act called for "death panels," through which the government would determine whether seniors and the disabled should receive care. So dishonest was this characterization, popularized by Alaska's then-Gov. Sarah Palin, that PolitiFact named it the "Lie of the Year." In truth, one of the provisions of the act that gave rise to Palin's critique would have done just the opposite: help patients make their own decisions about their treatment at the end of life (8/1).

The New Republic: Six Reasons Hipsters Will Bite On Obamacare
You're a 26-year-old single dude, holding down a pair of part-time jobs tending bar and painting houses, and making about $24,000 a year. Thanks to Obamacare, you can finally get decent health insurance, just like people with full-time jobs at large companies do. But when you go online to check out your options, you see that even the cheapest "bronze" plan, which has high deductibles and co-payments, will cost you about $100 a month. Obamacare's penalty for carrying no insurance next year is less than one-tenth of that. Do you buy the insurance anyway? ... But there [are] good reasons to think the critics are wrong, that young people will sign up for health insurance, and that Obamacare will work as its designers intended. Here are six of those reasons (Jonathan Cohn, 8/1).  

The New York Times Economix blog: The Sleeper In Health Care Payment Reform
In the arsenal now being assembled on the payment side of health care to address rising costs, reference pricing may well turn out to be the sleeper, because it is a potentially powerful method of "putting the patient's skin in the game," the delicate phrase we use for "cost-sharing by patients." As it is able to shift significant market power from the supply side to the payment side of the health sector, reference pricing is much feared by the providers -- physicians, hospitals, pharmaceutical companies and others (Uwe E. Reinhardt, 8/2). 

The Lund Report: Don't Let A Federal Board Override The Doctor-Patient Relationship
Imagine being told by your family doctor that the treatment she recommends is available, but not to you, because the federal government had decided its medical judgment is better than your doctor's. As Oregon and other states begin to implement the Affordable Care Act (ACA), known by many as Obamacare, much of the focus has been on the changes to insurance plans (Dr. Frank Palmrose, 8/1).

Boston Globe: You've Got Mail: Someone's Else's Medical Test Results
The first e-mail came at the end of June. It was from a doctor's office in another state -- a large cardiology group. The note listed the name of a test. It listed the full name of the patient. It listed the full name of the doctor who treated that patient. It said the test was normal and provided a number that I could call for more information. Presumably, this was supposed to be good news. But it was someone else's test result. ... Recently, though, I've noticed a new kind of misrouted e-mails that seem less trivial than some of the other unwelcome missives that show up in my inbox. These are notes or test results from other people's doctor's offices. The security of health information in the digital age is a big concern (Carolyn Johnson, 8/1). 

Des Moines Register: Iowa View: Webcam Abortions Have Nothing To Do With Health
According to the Food and Drug Administration, 2,207 women have been injured by this human abortion cocktail, known as mifepristone (or RU-486), and 14 have died from it. Here in Iowa, the RU-486 human abortion pills are being remotely dispensed by the thousands via a "telemed abortion" scheme approved by the Iowa Board of Medicine three years ago. The current board has revisited this approach to human abortion, which allows these toxic pills to be dispensed without a doctor present. They are calling for an end to telemed abortions, also called webcam abortions. The board deserves our support (Tom Quiner, 8/2).

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Failed Back Surgery Syndrome (FBSS)

Failed back surgery syndrome (FBSS) is a syndrome characterised by continuing back and/or leg pain despite undergoing lower spinal surgery. FBSS is diagnosed when the outcome of such surgery does not meet the expectations of the patient or the surgeon that were outlined before the surgery.

FBSS occurs as a complication in 5–40% of patients undergoing lower spinal surgery.

It is thought that patients undergoing spinal surgery may be more likely to develop FBSS if they have:

Epidural fibrosis (development of hard connective tissue around one of the layers surrounding the spinal cord and part of the nerves coming from it)Recurrent disc herniationInstability of a segment of spineIncorrect initial diagnosis of the back problemIncomplete decompression (reduction in pressure on the nerve root)Decompression at the wrong levelPoor patient selection for surgeryArachnoiditis (inflammation of one of the layers surrounding the spinal cord and part of the nerves coming from it) Permanent nerve root damageFacet joint disease

The progression of FBSS varies between individuals. It is probably influenced by factors such as the underlying problem with the back before surgery, what kind of surgery was performed, why and when FBSS develops, and how it is managed.

Individuals with FBSS usually experience significant long term back or leg pain following surgery. This may occur in the early stages after surgery, or some time later. Often medication and physiotherapy do not fully relieve this pain, which may result in a reduced level of function.

FBSS is commonly associated with conditions such as depression, anxiety disorder and substance abuse. These conditions need to be identified and managed in order to best treat the pain associated with FBSS.

All chronic pain conditions are significantly impacted by, and have a large impact on, the state of mind of the person experiencing the pain. How the person feels about the pain and how they approach it psychologically plays a significant role in how they function.

The doctor will examine the patient's back, as they would for all patients presenting with back pain. This includes feeling for painful structures, testing range of movement, testing reflexes (by tapping places such as the knees and ankles), checking sensation (touch, hot/cold, pain), and checking leg strength.

There are many tests that may be carried out to determine the underlying cause of FBSS, though the diagnosis can usually be made on the basis of what the patient is feeling (their symptoms).

Possible tests that may be suggested include x-rays, MRI, CT scan, and injection of structures in the back (e.g. the discs and joints).

Unfortunately, FBSS is very difficult to treat effectively, and there is no one treatment known to effectively cure the pain that accompanies FBSS. The likelihood of reducing the pain depends on the underlying cause, and the methods used to treat that cause. 

No one treatment is effective for all people with FBSS. Treatment will vary according to the individual, and the underlying cause of FBSS.

Conservative management

Pharmacotherapy

Medication may be used in pain management. Opioid medication should be used with caution, as it can be habit-forming, and the long term outcome of its effectiveness in FBSS is not clear. GPs or specialists (surgeons, pain specialists, etc) will prescribe medication if it is appropriate.

Exercise/physiotherapy

Gentle exercise programs assist with return to function and psychological wellbeing. It is best if this exercise is tailored to the individual by a physiotherapist or exercise physiologist;

Counselling

Counselling may help with pain management and control strategies. The GP or specialist may arrange a referral to a clinical psychologist to provide this counselling.

Pain clinic

Each of the options outlined above may be combined and provided in the setting of a specialist pain clinic. A GP or specialist may arrange a referral to a pain clinic, which is usually based at a tertiary hospital.  

Spinal cord stimulation

Spinal cord stimulation (SCS) involves electrodes being implanted next to the spine, and an electric current applied. This current modifies the pain signals that are sent by damaged structures. This is an effective option for some individuals with FBSS, as it has been shown to improve health related quality of life in this group.

Injections

Injecting anaesthetic or steroids into the structures around the spine may provide short term relief. Injecting saline or other substances to physically break up scar tissue, a process called lumber percutaneous adhesiolysis, may be effective in some cases.

Further surgery

Some causes of FBSS may be treated with further surgery. For example, if a disc bulge has re-occurred following surgery, it may need to be repaired again. Cutting certain nerves from the spine (medial branch neurotomy) may occasionally be suggested.

For more information about spinal cord stimulation devices, click here.

Anderson VC, Israel Z. Failed back surgery syndrome. Curr Rev Pain. 2000; 4(2): 105-11.Van Goethem JW, Parizel PM, van den Hauwe L, De Schepper AM. Imaging findings in patients with failed back surgery syndrome. J Belge Radiol. 1997; 80(2): 81-4.Schofferman J, Reynolds J, Herzog R, Covington E, Dreyfuss P, O'Neill C. Failed back surgery: Etiology and diagnostic evaluation. Spine J. 2003; 3(5): 400-3.Fiume D, Sherkat S, Callovini G, Parziale G, Gazzeri G. Treatment of the failed back surgery syndrome due to lumbo-sacral epidural fibrosis. Acta Neurochir Suppl (Wien). 1995; 64: 116-8.Heithoff KB, Burton CV. CT evaluation of the failed back surgery syndrome. Orthop Clin North Am. 1985; 16(3): 417-44.North RB, Kidd DH, Campbell JN, Long DM. Dorsal root ganglionectomy for failed back surgery syndrome: A five-year follow-up study. J Neurosurg. 1993; 39: 301-311.Wilkinson H. The failed back syndrome: Etiology and therapy [2nd edition]. Philadelphia: Harper & Row; 1991.Long DM, Filtzer DL, BenDebba M, Hendler NH. Clinical features of the failed-back syndrome. J Neurosurg. 1988; 69(1): 61-71.North RB, Ewend MG, Lawton MT, Kidd DH, Piantadosi S. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery. 1991; 28(5): 692-9.Fan YF, Chong VF. MRI findings in failed back surgery syndrome. Med J Malaysia. 1995; 50(1): 76-81.Talbot L. Failed back surgery syndrome. BMJ. 2003; 327: 985-6.Mavrocordatos P, Cahana A. Minimally invasive procedures for the treatment of failed back surgery syndrome. Adv Tech Stand Neurosurg. 2006; 31: 221-52. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: A randomized, controlled trial. Neurosurgery. 2005; 56(1): 98-106.Skaf G, Bouclaous C, Alaraj A, Chamoun R. Clinical outcome of surgical treatment of failed back surgery syndrome. Surg Neurol. 2005; 64(6): 483-9.Polatin PB, Kinney RK, Gatchel RJ, Lillo E, Mayer TG. Psychiatric illness and chronic low-back pain. The mind and the spine-which goes first? Spine. 1993; 18(1): 66-71.Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine. 1994; 19(10): 1132-7.Schwarzer AC, Wang SC, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophyseal joint pain: A study in an Australian population with chronic low pack pain. Ann Rheum Dis. 1995; 54(2): 100-6.van Akkerveeken PF. The diagnostic value of nerve root sheath infiltration. Acta Orthop Scand. 1993; 64(Suppl 251): 61-3.Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, et al. Etiologies of failed back surgery syndrome. Pain Med. 2002; 3(3): 200-14.Derby R, Kine G, Saal JA, Reynolds J, Goldthwaite N, White AH, et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine. 1992; 6(Suppl): S176-83.Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995; 20(1): 31-7.Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: A multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007; 132(1-2): 179-88. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005; (3): CD000335.Bala MM, Riemsma RP, Nixon J, Kleijnen J. Systematic review of the (cost)effectiveness of spinal cord stimulation for people with failed back surgery syndrome. Clin J Pain. 2008; 24(9): 741-56. Manca A, Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, et al. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). Eur J Pain. 2008; 12(8): 1047-58.


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Chronic Pain Syndrome

Chronic pain syndrome encompasses any pain that persists longer than the reasonable expected healing time for the involved tissues. The duration of pain is often arbitrarily set at 3 months duration. In contrast to acute pain, which is a vital protective mechanism, chronic pain serves no physiological role.

It is not a symptom, but rather a disease state. Some conditions that lead to chronic pain syndrome include:

Low back pain (e.g. lumbar radiculopathy, spinal stenosis, facet syndrome, myofascial pain); Neck/shoulder pain (e.g. whiplash, cervical radiculopathy, fibromyalgia); Headache (e.g migraine, cluster, tension type, cervicogenic); Musculoskeletal pain (e.g. soft tissue injury, myofascial pain syndrome, fibromyalgia, arthritis);Neuropathic pain (e.g. post-herpetic neuralgia, chronic regional pain syndrome I and II, phantom limb pain, diabetic neuropathy); Chronic postoperative pain (e.g. post-thoracotomy pain, neuroma formation, neuropraxia).

Chronic pain syndrome has been reported to effect up to 54% of the population at some stage.

Chronic pain syndromes are more common in womens health than men health. People with depression or anxiety are also more likely to develop chronic pain syndromes. Some people who have chronic pain syndrome later develop anxiety or depression as a result of their illness.

Chronic pain syndromes often develop after an acute pain, such as an injury, but they may develop with no recognised preceding injury. Chronic pain is defined as pain that lasts for longer than the expected time for recovery of injured tissues, nominally 3 months.

The history of the pain varies greatly according to the type of pain, but can include

Headaches;Pain;Back pain;Muscle pain;Neuropathic pain;Chronic postoperative pain.

Your doctor will ask you questions about how long the pain has been a problem, how it started, what treatments you have tried and which treatments were effective, what makes the pain better and what makes it worse as well as a general history on other body systems.

Results of the clinical (physical) examination is variable according to the cause of the pain.

Your doctor may order some investigations when determining the cause of your pain, however investigations are not useful once a chronic pain syndrome has been diagnosed.

The prognosis for chronic pain syndromes is extremely variable.

Treatment for chronic pain syndrome can involve several different approaches. It is not always possible to get rid of chronic pain completely. When thinking about managing your pain, the goal may not be to be entirely pain free, but rather to be able to complete more of your daily activities than before (for example, be able to play golf or tennis again).

 

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Domestic Violence

Domestic violence is when an individual is in some way hurt by a person that he or she knows. Domestic violence is not limited to physical harm: a person also can be sexually abused or psychologically abused. Often a victim is hurt in more than one of these ways. Domestic violence usually continues over a long period of time and gets more frequent and more severe over time.

In 2000, the National Violence Against Women Survey (US) reported, in a study of 8000 women and 8000 men, that nearly 25% of women and 7.9% of men indicated that a current or former spouse, cohabitating partner, or date victimized them at some time in their life. Rape was reported by 7.7% of women and 0.3% of men. Physical assault affected 22.1% of women and 7.4% of men. Within the previous 12 months, 0.2% of women reported having been raped, which would equate nationally to 201,394 women. Physical assault was reported by 1.3% of women and 0.9% of men, resulting in national estimates of 1,309,061 women and 834,732 men so victimized. Victimization often occurs repeatedly.

Data from the survey revealed that women averaged 6.9 physical assaults by the same partner, with men averaging 4.4 assaults. Given the data on multiple attacks per victim, it is estimated that every year approximately 4.8 million intimate partner rapes and physical assaults are perpetrated against women, and approximately 2.9 million are committed against men. Almost 5% of women and 0.6% of men in the survey indicated that an intimate had stalked them, with an annual rate of 0.5% of surveyed women and 0.2% of surveyed men. Extrapolation from these data indicates that 503,485 women and 185,496 men were stalked by an intimate partner within the previous 12 months. High-profile news may affect willingness to report domestic violence. Following the Simpson and Goldman murders, the Los Angeles County Sheriff's Department noted a significant increase in domestic violence dispatches. Estimates indicate that at least 2 million women are assaulted by their partners each year. The true incidence may be twice that. Exact figures for males are hard to come by.

Certain groups of women may be at higher risk for abuse. These include women who: Are single, separated or divorced (or planning separation or divorce). Are between the ages of 17 and 28. Abuse alcohol or other drugs or whose partners do. Are pregnant. Have partners who are excessively jealous or possessive.

Characteristic injuries: Bilateral injuries, especially to the extremities. Injuries at multiple sites. Fingernail scratches, cigarette burns, rope burns. Abrasions, minor lacerations, welts. Subconjunctival hemorrhage suggests a vigorous struggle between victim and assailant. Fingernail markings

Three types of fingernail markings may occur, either singly or in combination as follows:

Impression marks: These result from fingernails cutting into the skin. They may be shaped like commas or semicircles. Scratch marks: These are superficial and long and may be narrow or as wide as the fingernail. Scratches caused by the longer fingernails of women are frequently more severe than those from a male assailant. Claw marks: These occur when the skin is undermined, thus they appear to be more dramatic and vicious. While claw marks may be grouped parallel markings down the front of the neck, they often are randomly scattered.

Domestic violence typically recurs and progressively escalates both in frequency and severity. Of persons first injured by domestic violence, 75% continue to experience abuse. Half of battered women who attempt suicide try again. Brookoff reported a study of 62 episodes of domestic assault, in which 68% involved the use or display of weapons (5 handguns, 1 shotgun, 17 knives, and 19 blunt instruments such as hammers or baseball bats), and 15% resulted in serious injury. Eighty-nine percent of victims reported previous assaults by their current assailants, with 35% experiencing violence on a daily basis. The ultimate result of domestic violence may be death from suicide or homicide.

It may seem obvious that a victim of domestic violence should leave the abuser, but it's not always that simple. Some victims of abuse were raised in violent households as children and are caught in a cycle of abuse. Sometimes years of psychological abuse cause victims to believe they deserve to be treated this way. They may feel defeated from repeated abuse and unable to see a way out, or they may desperately hope that the situation will change. They may fear what the abuser will do if they try to leave. Other reasons women do not leave their abusers include having no place to go, no money or no place that will accept her children; fear of losing custody of children; concerns about immigration status (being reported); and religious or cultural beliefs that make abuse seem acceptable.

Abbott J: Injuries and illnesses of domestic violence. Ann Emerg Med 1997; 29: 781-785. Bachman R, Saltzman LE: Violence against women: Estimates from the redesigned survey August 1995. NCJ-154348 Special Report. US Department of Justice. Heilig S, Rodriguez M, Martin S, Louie D, eds: Domestic violence: A practical approach for clinicians. San Francisco Medical Society: 1995.


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Female Sexual Dysfunction (FSD)

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The World Health Organisation defines female sexual dysfunction (FSD) as “the various ways in which an individual is unable to participate in a sexual relationship…she would wish.” FSD is classified into a range of disorders depending on the specific nature of the sexual difficulties a woman encounters. They are:

Women suffering from FSD become anxious or distressed about being unable to engage in or experience sexual activity as they wish. However, other women may experience sexual difficulties (e.g. inability to orgasm) which do not cause them distress. These women do not have FSD.  Amongst women with FSD, hypoactive sexual desire and orgasmic disorders are the most commonly reported.

There are many physical causes of FSD and these are mainly related to hormone levels and changes. However, FSD is most commonly the result of psychological factors (e.g. relationship satisfaction, depression).  Even when FSD is the result of physical factors, psychological factors often contribute to the problem (e.g. women who have difficulty achieving adequate vaginal lubrication or find sex painful may become anxious about approaching sexual encounters, and find it even more difficult to lubricate).

Research suggests that the majority of women experience sexual dysfunction at some point in their lives, and for many it is an ongoing or recurring issue. A large survey of Australian women reported that 70% had experienced sexual difficulties (including inability to orgasm and not feeling like sex) in the year before the survey. Women over 50 were most likely to experience sexual difficulties, although they were common in all age groups (over 60% of women aged over 50 reported lack of interest in sex, and more than half of women aged 16-49 also reported this difficulty).

Survivors of sexual assault often experience difficulties in future sexual relationships, which may bring back difficult memories of incidents of assault. Women who are pregnant, have recently given birth or are breastfeeding are more likely to experience sexual dysfunction than those who are not. Hormonal imbalances and psychological factors both play a role for these women. 

Women also often experience sexual dysfunction following menopause, which is mainly a result of hormonal imbalances.

Sexual dysfunction associated with cancer

Between 10 and 88% of patients diagnosed with cancer experience sexual problems following diagnosis and treatment. The prevalence varies according to the location and type of cancer, and the treatment modalities used. Sexuality may be affected by chemotherapy, alterations in body image due to weight change, hair loss or surgical disfigurement, hormonal changes, and cancer treatments that directly affect the pelvic region.

Sexual problems are reported in many patients with breast and gynaecological (e.g. cervical or vulval) cancer. They are also reported in patients with cancer that does not directly effect sexual organs, including lung cancer (48% of patients), Hodgkin's disease (50%), and laryngeal (60%) and head and neck cancers (39-74%). 

For more information, see Sexual Difficulties Associated with Cancer in Women.

While sexual dysfunction is wide spread in Australia, it is more common in particular groups of women.  Factors associated with sexual dysfunction in women include:

It is uncertain how they influence sexual function, but you may also have an increased risk if FSD if you have:

Hormonal changes, which are the most common physical cause of FSD, tend to occur during and after childbirth and following menopause. Certain medications (e.g. antidepressants, hypertension medication) can also alter hormone levels. FSD is more common in women who take these medications.

Unlike in men, sexual dysfunction in women is most commonly the result of psychological factors which can arise throughout life. There is an immense amount of pressure on women in their roles as employees, wives and mothers. This can lead to stress, anxiety and fatigue, which are all more common in women who suffer from FSD than in those who do not. Women who are not satisfied with their relationships more commonly report FSD, as do those who are depressed.

FSD impacts on women’s sexual functioning and on their overall sense of wellbeing. It is associated with depression and relationship satisfaction. Although it is not clear whether FSD causes depression and relationship satisfaction or vice versa, it is likely that, at least in some cases, FSD leads to depression and dissatisfaction with relationships. If you suffer from FSD it is also likely to affect your sexual partner, so you may both want to talk to about professional.

The effects on the partner can have important implications. For example while studies are limited, it has been shown that female sexual function can be negatively impacted on by male sexual dysfunction. A study comparing the sexual function of women with partners with erectile dysfunction to those without showed that sexual arousal, lubrication, orgasm, satisfaction, pain and total score were significantly lower in those who had partners with erectile dysfunction. Later in that study, a large proportion of the men with erectile dysfunction underwent treatment. Following treatment, sexual arousal, lubrication, orgasm, satisfaction and pain were all significantly increased. It was concluded that female sexual function is impacted by male erection status, which may improve following treatment of male sexual dysfunction.

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Lewy Body Dementia (LBD)

Dementia with Lewy bodies (DLB) is a neurodegenerative disorder associated with abnormal structures (Lewy bodies) found in certain areas of the brain. In addition to dementia, patients with dementia with Lewy bodies experience hallucinations, motor impairment, and fluctuating alertness.

Dementia with Lewy bodies is the third most frequent cause of dementia in older adults, and accounts for 15–35% of all dementias. Dementia with Lewy bodies is also the most common dementia syndrome associated with Parkinsonism. It is primarily a disease affecting the elderly population. Men may be at higher risk of developing Lewy body dementia than women.

The cause of dementia with Lewy bodies is still unknown. A very few cases of familial (inherited) dementia with Lewy bodies have been reported, but this is rare.

As with other forms of dementia, the patient will experience a steady decline in their cognitive ability. This may include loss of recent memory, poor awareness of location and the development of inappropriate behaviours. This occurs in a similar fashion to Alzheimer's disease.

In some cases of Lewy Body dementia, patients may also develop increased muscle activity resulting in muscle stiffness and the development of a tremor. The severity of the physical and psychological symptoms may fluctuate greatly, making some days more difficult than others. Patients with this disease may also be unusually sensitive to certain medications such as anti-psychotics and sedatives, which must be used carefully to avoid an increase in the severity of symptoms.

People with dementia with Lewy bodies may present with classical symptoms of any dementia: the subtle development of defects in thinking, reasoning, remembering, imagining, or learning words.

In particular, people with dementia with Lewy bodies will have the following:

Motor symptoms such as rigidity and tremor (similar to the symptoms of Parkinson's disease).Fluctuations in alertness and consciousness.Frequent visual hallucinations.Increased sensitivity to some drugs which act on the brain.

As with other forms of dementia, the aim of investigation is to exclude other causes of the altered mental state. A large number of blood tests and imaging procedures will be carried out to exclude infection, electrolyte imbalance, anaemia, thyroid and liver disease. A CT and MRI scan of the patient's head may be required to improve the accuracy of diagnosis and exclude certain brain conditions that may result in an altered mental state.

The prognosis of dementia with Lewy bodies is generally poor, as there is no specific treatment to reverse the progression of disease. Many patients with this form of dementia respond well to medications that may improve psychological and physical symptoms over a limited period of time. This condition, however, will inevitably progress over time.

Any secondary causes of DLB should be treated if found - these are infrequent (10%), but must be excluded as some causes are potentially reversible. There is currently no treatment to cure Lewy body dementia, or to slow its progression. As such, medical treatment aims to control the symptoms of the dementia, such as the muscle stiffness, tremor and psychiatric disturbances.

Medications can be divided into the following groups:

Acetylchlinesterase inhibitors (e.g. galantamine or donepezil): these may be used to treat agitation and hallucinations, or to reduce confusion and symptom fluctuation. They do not worsen motor symptoms of disease.Anti-Parkinson's medications (e.g. levodopa/carbidopa, dopamine agonists): these are used to treat the motor symptoms (muscle stiffness and tremor) of Parkinson's disease, which are similar to the motor symptoms of Lewy body dementia. However, patients with DLB are often very sensitive to these medications, with little change to motor symptoms but worsening hallucinations and confusion. Because of this, anti-Parkinson's medications are used very carefully in DLB, and only in patients with severe motor symptoms.Antidepressants: these may be used to treat symptoms of depression, common in patients with DLB.
For more information on dementia, including Alzheimer's disease and other types of dementia, information for carers of dementia patients and supportive care, as well as some useful tools and videos, see Dementia.
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