The jury found that Dr E had departed from the accepted standard of medical care
This month we look at the interesting question of whether a plaintiff in a malpractice lawsuit against a clinician may recover punitive damages when the clinician destroys or changes medical records in an attempt to avoid malpractice liability.
The case involved a 6-year old girl, Miss C, whose mother took her to a new pediatrician, Dr P, in mid-October. The pediatrician recommended that Miss C see a pediatric endocrinologist because the child’s blood sugar level was high. The girl’s mother asked Dr P for a referral and the pediatrician recommended Dr E.
Dr E, the endocrinologist, worked from a private office in the basement of her home. Her sister served as her office manager, and her two nephews helped with billing and appointment scheduling. The office was low-tech, and Dr E had a habit of using what she called “scribble notes” during exams and then typing the notes into the medical record at some later point in time.
Dr E saw the patient a total of 3 times – in late October, in mid-November, and in mid-December. Meanwhile, the patient’s pediatrician also saw her again in late November, and then early January.
The endocrinologist concluded that the child was obese and developing type 2 diabetes. At the conclusion of the mid-December office visit, the child’s mother was given an appointment card for an appointment two months later, in mid-February.
Tragically, the child never made that appointment. In late January, Miss C came home from school complaining of lethargy and that she wasn’t feeling well. She brought home a note from the school nurse describing her symptoms. That evening the child had a stomachache and vomited. The next day, the mother tried to have the child seen by the pediatrician, but she was not available, so the mother took Miss C to the hospital. The child remained in the hospital until her death, 3 days later.
The final autopsy report revealed the cause of death to be attributable to “bilateral cerebellar tonsillar herniation secondary to cerebral edema following diabetic ketoacidosis.”
On the subject of decreasing irritation to lower the chance of coronary heart illness and stroke, outcomes from the much-anticipated Cardiovascular Irritation Discount Trial (CIRT) point out that focusing on the appropriate inflammatory pathways in at-risk sufferers is essential. Final 12 months, the Canakinumab Anti-inflammatory Thrombosis Outcomes Research (CANTOS) confirmed that the interleukin-1? inhibitor canakinumab each focused a particular inflammatory pathway and consequently lowered charges of coronary heart assault and cardiovascular demise. Against this, the findings from CIRT confirmed that low-dose methotrexate neither inhibited that very same inflammatory pathway nor lowered main hostile cardiovascular occasion charges. These outcomes had been introduced by Paul Ridker, MD, director of the Middle for Cardiovascular Illness Prevention at Brigham and Ladies’s Hospital, throughout the American Coronary heart Affiliation Scientific Periods 2018, and revealed concurrently in The New England Journal of Medication.
“The contrasting outcomes between these two modern medical trials exhibit the significance of contemplating the mechanistic range of inflammatory pathways and of approaches to their inhibition,” mentioned Ridker. “Understanding these variations might be essential for future research focusing on irritation in atherosclerosis.”
Previous to CIRT, observational research had prompt that low-dose methotrexate, a cheap and efficient drug extensively used to deal with rheumatoid arthritis and different inflammatory illnesses, may cut back charges of cardiovascular occasions. The federally-funded CIRT was designed to carefully check whether or not low-dose methotrexate may successfully cut back threat of main hostile cardiovascular occasions – that’s, coronary heart assaults, stroke and cardiovascular demise. In parallel, Ridker and colleagues additionally designed and performed CANTOS, sponsored by Novartis, to check the identical outcomes for canakinumab, a drug that particularly targets interleukin-1β. Interleukin-1 is a pro-inflammatory cytokine that, if over-produced, ends in elevated irritation all through the physique in addition to elevated ranges of interleukin-6 and excessive sensitivity C-reactive protein (hsCRP), two essential biomarkers of irritation.
CIRT and CANTOS had been each randomized, double-blind, placebo-controlled trials, and each enrolled steady however high-risk atherosclerosis sufferers. CANTOS, nonetheless, was designed to incorporate solely sufferers with persistently elevated hsCRP ranges. CIRT didn’t make use of this criterion, and the typical hsCRP degree for the inhabitants was nicely throughout the regular vary. CIRT enrolled four,786 North American sufferers with prior coronary heart assault or multi-vessel coronary illness who moreover had both sort 2 diabetes or a metabolic syndrome. The trial stopped after a median follow-up of two.three years.
Associated Tales
In contrast to canakinumab as utilized in CANTOS, low-dose methotrexate as utilized in CIRT didn’t cut back the inflammatory pathway main from interleukin-1 to interleukin-6 and on to hsCRP. Concordantly, and in distinction to canakinumab, low-dose methotrexate didn’t decrease cardiovascular occasion charges in comparison with placebo. The crew experiences that 201 sufferers taking methotrexate suffered a significant cardiovascular occasion in comparison with 207 sufferers taking the placebo. But, methotrexate was related to elevations of liver enzymes, reductions in leucocytes and hematocrit, and the next incidence of non-basal cell pores and skin cancers.
“The outcomes from CIRT and CANTOS, when thought-about collectively, inform us one thing critically necessary: Not all irritation is identical, and never all medication that concentrate on irritation are the identical,” mentioned Ridker. “Whereas it’s disappointing that a cheap drug like methotrexate didn’t have the consequences we beforehand noticed in CANTOS, the outcomes from CIRT shed essential mild on the underlying biology that connects irritation with heart problems. The divergent trial outcomes present a transparent roadmap to information our efforts going ahead.”
Regardless of its vast medical use, the organic mechanisms underlying the anti-inflammatory results of methotrexate in rheumatoid arthritis and different inflammatory situations stays poorly understood. Medicine comparable to colchicine and oral NLRP3 inhibitors which will intersect with the interleukin 1 to interleukin-6 to CRP pathway are at present underneath investigation or in improvement.
“CANTOS and CIRT present the cardiovascular group proof-of-principle that particular focusing on of the interleukin-1 to interleukin-6 pathway of innate immunity is essential for stopping atherothrombotic occasions. The analysis purpose now and the medical want of our sufferers is to seek out cheap and extensively relevant brokers that may safely goal this pathway,” Ridker mentioned.
Supply:
https://www.brighamandwomens.org/about-bwh/newsroom/press-releases-detail?id=3191
November 12, 2018
Preschool-aged children (ages 3–5 years) should be physically active throughout the day
The US Department of Health and Human Services (HHS) has released the second edition of the Physical Activity Guidelines for Americans at the American Heart Association’s Scientific Sessions meeting. This document complements the Dietary Guidelines for Americans, which was released by the HHS and the US Department of Agriculture (USDA). The new edition was developed by the 2018 Physical Activity Guidelines Advisory Committee who conducted systematic reviews of available scientific literature.
This guidance, updated for the first time since 2008, provides evidence-based recommendations for children (ages 3-17) and adults. Specifically, it includes new guidelines for children aged 3–5 years and updated recommendations for children and adolescents aged 6–17 years, adults, older adults, women during pregnancy and the postpartum period, and adults with chronic health conditions or disabilities. The second edition outlines the types and amounts of activity recommended for these various populations. For example, while the previous guidelines had suggested that for adults, bouts of at least 10 minutes of physical activity were necessary, the new guidelines state that some physical activity is better than none, even if it is less than 10 minutes.
For preschool-aged children, the Committee recommends:
- Preschool-aged children (ages 3–5 years) should be physically active throughout the day to enhance growth and development
- Adult caregivers of preschool-aged children should encourage active play that includes a variety of activity types
“Probably the most important message from the 2018 guidelines is that the greatest health benefits accrue by moving from no, to even small amounts of, physical activity, especially if that activity is of moderate (eg, brisk walking) or vigorous (eg, jogging and running) intensity,” stated Paul D Thompson MD and Thijs MH Eijsvogels, PhD, in a recent JAMA Editorial. “The point for clinicians is that physical activity should be strongly considered as primary or adjunctive therapy for many common clinical conditions such as mild depression, anxiety, and sleep difficulties.”
The executive summary of the key guidelines can be found here.
For more information visit Health.gov.
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