If you think about it, the comparison of doctors to mechanics is pretty apt. Given the specialized nature of their work and the general helplessness of most patients, doctors, like mechanics, are rarely held accountable for their actions. Sure, for the most part, doctors have your best interest at heart, but like in any profession, there are both good and bad apples. According to the National Patient Safety Foundation, 42 percent of people believed they had personally experienced a medical mistake. Additionally, numerous statistics have shown that a staggering amount of people die each year due to medical error. The following doctors made such blatant mistakes and/or lapses in judgment that they, at the very least, have a reputation that garnered them recognition on this list.
1.Dr. Earl Bradley, Monster: Nothing is worse than violating the trust of a child, which is why Bradley, a former pediatrician from Lewes, Delaware, is such a monster. In February of 2010, he was indicted on 471 charges of child sex abuse involving 103 children. Initial allegations against Bradley surfaced during the mid-’90s, but the hospital for which he worked was unable to verify the claims. They were enough, however, to prompt him to move to Delaware, where more allegations surfaced a decade later, including that he had abused his own son. Bradley was initially arrested in December of 2009 after a year-long investigation, which prompted the indictments two months later.
2.Dr. Robert Ricketson, Screw Up: Ricketson is no longer practicing medicine and the world is better for it. During a spine operation he performed on 73-year-old Arturo Iturralde in 2003, Ricketson intentionally inserted a piece of a screwdriver into the patient’s spine instead of a titanium rod. The rod he had intended to use went missing prior to the surgery, so he took it upon himself to improvise. As a result, Iturralde endured three additional surgeries to insert the proper rod and correct complications. After one of the operations, pieces of the screwdriver were recovered by nurses and the family was alerted. Iturralde became a paraplegic and died two years later, and his family was awarded $5.6 million in a malpractice lawsuit in 2006. During the aftermath, it was discovered that Ricketson’s medical license had been suspended in Oklahoma and Texas and he was denied consideration for a medical license in Kansas in 2002, a year after the botched surgery. He had previously been sued for malpractice several times and had history of narcotics abuse. Not a very impressive resume to say the least.
3.Dr. Jan Adams, Plastic Surgeon Imposter: Adams is most famous for performing the breast augmentation surgery on Donda West, Kanye West’s mom, that resulted in her death in 2007. But that’s not the only blemish on his record. In a malpractice suit against Adams, a previous patient claimed that she didn’t receive proper preoperative or postoperative care, leading to an infection that needed two more surgeries. What’s more, one patient claimed he got her drunk after a surgery and impregnated her, and another claimed a surgical sponge was left inside of her after a breast augmentation. Adams, who attended Harvard University, never received his diploma despite apparently completing his academic requirements. He’s also not a board certified plastic surgeon despite claiming to be one. How was this guy getting work?
4.Julie Ponder and Connell Watkins, Child Killers: Alternative medicine can be a risky proposition given the unproven nature of many of its methods. Attachment therapy in particular can yield tragic results when taken to an extreme. The treatment is used to remedy attachment disorders primarily suffered by adopted and fostered children who persistently misbehave or display little affection toward their new caregivers. In 2000, 10-year-old Candace Newmaker was killed during such treatment when she was suffocated during an intensive rebirthing session. Wrapped in a flannel sheet by psychotherapists Julie Ponder and Connell Watkins, she told to free herself from it while Ponder and Watkins held her down. She pleaded for her life, but was told by Ponder "You want to die? OK, then die. Go ahead, die right now." Newmaker was declared brain dead the next day due to asphyxia. The entire session was videotaped and presented as evidence against Ponder and Watkins, who were each given 16-year prison sentences — Watkins was paroled in 2008 after serving seven years.
5.Dr. James Burt, Ghastly Gyno: The notorious Dr. Burt was exposed for his harmful and downright bizarre practices in the late 1980s when numerous former patients came forward and initiated lawsuits. Beginning in the late 1960s, Burt took it upon himself to perform "love surgeries" in which he altered his patients’ vulvas without their consent. He justified his work in a book he authored in 1975, explaining that "Women are structurally inadequate for intercourse. This is a pathological condition amenable by surgery." He stated the procedure turns them into "horny little mice," though in reality, many of them suffered sexual dysfunction, infection and required corrective surgeries as a result. A $21 million suit was filed against Burt that couldn’t have come close to covering the physical and emotional damages endured by the at least 40 women he hurt.
6.Dr. Cecil Jacobson, Seed Spreader: As a fertility doctor, it was Dr. Jacobson’s duty to assist women in conceiving, and in the 1980s, it appeared he was doing a pretty good job. His patients reported high success rates due to his use of hCG, a hormone released during pregnancy that causes the typical bodily changes. During the supposed pregnancies initiated by hCG, he would identify the fetuses during an ultrasound, but they would usually "die" after about three months. Patients who suspected something was amiss informed a local television station, which investigated and exposed Jacobson. In the process, they discovered he used his semen to artificially inseminate patients who were told they were matched with an anonymous donor. Genetic testing later showed that he was the biological father of at least seven of his patients’ children. Jacobson, who won the Ig Nobel Prize for Biology in 1992 and claimed to have successfully oversaw the impregnation of a male baboon in the 1960s, was stripped of medical license and sentenced to five years in prison.
7.Dr. Rolando R. Sanchez, Accidental Amputator: To be fair to Dr. Sanchez, he has done a fine job of rehabilitating his reputation after the costly mistake he oversaw in 1995 — in fact, he’s still practicing. Even still, it’s the kind of inexcusable error you’d never wish on your worst enemy. In the process of amputating Willie King’s leg, Sanchez was informed by a nurse that he had cut into the wrong one. It was too late, however, and he had to finish what he started — King would later have the original leg amputated by another doctor. Consequently, Sanchez was suspended on the grounds that he presented an "immediate and serious danger to the health, safety and welfare of the public," and King later settled with the hospital.
8.Dr. Red Alinsod, Organ Tattoo Artist: Ingrid Paulicivic certainly won’t be recommending Dr. Alinsod given what occurred during her June 2009 hysterectomy. According to Paulicivic’s lawsuit, while putting the finishing touches on the surgery, Dr. Alinsod decided to brand his work by using an "electrocautery device to carve and burn" her name into her removed uterus. Alinsod claimed the move was necessary to ensure he wouldn’t confuse the uterus with others. Paulicivic became aware of the branding during a follow-up visit in which she complained of the resulting burns on her legs.
9.Dr. Elias Hanna, Carvey Carver: Dr. Hanna nearly caused the premature death of yet another Saturday Night Live legend. In 1998, he botched Dana Carvey’s heart bypass surgery by connecting a healthy portion of his artery to a healthy diagonal vessel instead of the damaged arterial section. It wasn’t until two months after the operation that Hanna discovered the mistake, resulting in an emergency angioplasty for Carvey — his fourth in less than a year. Before it was corrected, he was susceptible to suffering a fatal heart attack. Carvey filed a medical malpractice lawsuit and eventually settled for $7.5 million.
10.Alan Hutchinson, Dirty Dentist: Hutchinson, a dentist from Batley, West Yorkshire, UK, made headlines in 2007 when he was accused of using sterilized instruments to clean his ears and fingernails, working on teeth without washing his hands or using gloves, and urinating in a surgical sink. Complaints from a patient and his nurse, Claire Pygott, eventually led to a guilty verdict from the General Dental Council in London. Pygott said that she was "shocked, disgusted and appalled" by the dentist’s actions, which she had witnessed on more than one occasion.
Source : http://www.mastersinhealthcare.com/blog/
special thanks to Celina Jacobson
Showing posts with label Orthopedics. Show all posts
Showing posts with label Orthopedics. Show all posts
Sunday, January 30, 2011
Tuesday, December 14, 2010
Case Study : Teenager with Knee Pain
First of all the question is how we can localize the salient abnormality ?
T2W versions of essentailly the same images:
Here are coronal STIR images of same knee:
Saturday, July 31, 2010
Ewing Sarcoma
Ewing sarcoma (ES) and primitive peripheral neuroectodermal tumor (PNET) were originally described in the early 1900s as distinct clinicopathologic entities. It become evident that these entities are actually part of a spectrum of neoplastic diseases known as the Ewing sarcoma family of tumors (EFT), which also includes extraosseous ES (EES), adult neuroblastoma, malignant small-cell tumor of the thoracopulmonary region (Askin's tumor), paravertebral small-cell tumor, and atypical ES.
Because of their similar histologic and immunohistochemical characteristics and shared nonrandom chromosomal translocations, these tumors are considered to be derived from a common cell of origin. Although the histogenetic origin has been debated over the years, evidence from immunohistochemical, cytogenetic, and molecular genetic studies supports a neuroectodermal origin for all EFT
The EFT can develop in almost any bone or soft tissue, but is most common in the flat and long flat bones; patients typically present with localized pain and swelling. Although overt metastatic disease is found in fewer than 25 percent at the time of diagnosis, subclinical metastatic disease is assumed to be present in nearly all patients because of the 80 to 90 percent relapse rate in patients undergoing local therapy alone. As a result, systemic chemotherapy has evolved as an important component of treatment
Advances in multidisciplinary management of EFT over the past 30 years have resulted in a marked improvement in survival and a greater likelihood of limb-sparing surgery rather than amputation
In data derived from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute, five year survival rates for patients with ES rose from 36 to 56 percent during the periods 1975 to 1984 and 1985 to 1994 .
With modern multidisciplinary treatment, long-term survival can be achieved in 70 to 80 percent of patients presenting with nonmetastatic disease
Clinical Presentation:
Primary sites — ES most often arises in the long bones of the extremities (predominantly the femur, but also the tibia, fibula and humerus), and the bones of the pelvis. The spine, hands, and feet are affected considerably less often .
Within the axial skeleton, tumors arose from the pelvis, chest wall, spine/paravertebral region, or head and neck in 45, 34, 12, and 9 percent of cases, respectively. Compared to undifferentiated ES of bone, PNET and EES more often arise within the axial rather than the appendicular skeleton
Approximately 25 percent of patients have a soft tissue primary.
Signs and Symptoms :
Patients with EFT typically present with localized pain or swelling of a few weeks or months duration
Trauma, often minor, may be the initiating event that calls attention to the lesion. The pain may be mild at first, but intensifies fairly rapidly; it may be aggravated by exercise, and is often worse at night. A distinct soft tissue mass can sometimes be appreciated. When present, it is usually firmly attached to the bone and moderately to markedly tender to palpation . Swelling of the affected limb with erythema over the mass is not uncommon.
Patients with juxta-articular lesions may present with loss of joint motion, while lesions involving the ribs can be associated with direct pleural extension and large extraosseous masses .
When the spine or sacrum are involved, nerve root irritation or compression can result in back pain, radiculopathy, or symptoms of spinal cord compression (eg, weakness or loss of bowel and/or bladder control).
Constitutional symptoms or signs, such as fever, fatigue, weight loss, or anemia, are present in about 10 to 20 percent of patients at presentation . Fever is related to cytokines produced by the tumor cells, and along with other systemic symptoms, is associated with advanced disease.
Approximately 80 percent of patients present with clinically localized disease, although as noted previously, subclinical metastatic disease is presumed to be present in nearly all. Overt metastases may become evident within weeks to months in the absence of effective therapy. The significance of this lies in the frequent delay between the onset of symptoms and diagnosis, which in one report averaged over nine months .
Patients with primary pelvic tumors are significantly more likely to present with metastatic disease compared to other sites .Other factors associated with clinically evident metastatic disease at presentation include high level of lactic dehydrogenase (LDH), the presence of fever, an interval between onset of symptoms and diagnosis less than three months, and age older than 12 years
Sites of metastatic disease at diagnosis are similar to those seen with recurrent disease; lung and bone metastases predominate, in roughly equal proportions. The spine is the most frequently involved bone.
Lung metastases represent the first site of distant spread in 70 to 80 percent of cases, and are the leading cause of death for patients with EFT.
Lymph node, liver, and brain involvement are distinctly uncommon.
Radiographic Studies :
The diagnostic work-up is usually initiated with a plain radiograph of the affected area. ES involving bone typically presents as a poorly marginated destructive lesion, most often associated with a soft tissue mass. The tumors tend to be large, and in long bones are metaphyseal or diaphyseal in location.
The radiographic appearance has been described as "permeative" or "moth-eaten", indicative of a series of finely destructive lesions that become confluent over time. The cortex at the site of the lesion is often expanded, and the periosteum displaced by the underlying tumor, resulting in the clinical sign of Codman's triangle. The characteristic periosteal reaction produces layers of reactive bone, deposited in an "onion peel" appearance.
The soft tissue component of the tumor rarely shows any calcification or ossification. Sclerosis, if present, represents a secondary bone reaction rather than the primary bone formation that characterizes osteosarcoma. A pathologic fracture is present at diagnosis in 10 to 15 percent of cases.
Compared to plain radiographs, a CT scan of the primary site better delineates the extent of cortical destruction and soft tissue disease
However, definition of tumor size, local intraosseous and extraosseous extent, and the relationship of the tumor to fascial planes, vessels, nerves, and organs is best achieved by magnetic resonance imaging (MRI)
Imaging of the entire involved bone is necessary to exclude the presence of skip lesions (ie, medullary disease within the same bone, but not in direct contiguity with the primary lesion)
Prognostic Factors :
--Disease Extent: Presence or absence of metastases,patients with bones and lungs metastases fared worse than patients with bone metastases alone
--Tumor site and size : For patients presenting with localized disease, those with axial primary tumors (ie, pelvis, rib, spine, scapula, skull, clavicle, sternum) have a worse treatment outcome than those with extremity lesions
--Response to therapy: Patients with apparently localized disease have only a 10 to 20 percent likelihood of cure if treated with surgery or radiotherapy alone; this is improved dramatically when chemotherapy is added to treatment.Both the completeness of surgical resection and the response to induction therapy are important prognostic factors. Patients who are left with significant amounts of viable tumor in the resected specimen following neoadjuvant chemotherapy do worse than those with minimal or no residual tumor.
--Histology:In most but not all studies, neither the presence of neural differentiation (eg, as in PNETs) nor extraosseous origin has a significant adverse influence on outcome
--Age: contraversy about age as prognostic factor, the five-year relapse-free survival was significantly better for children younger than 10 compared to older children
--Molecular findings:deletion of the short arm of chromosome 1p, homozygous deletions of CDKN2A and p16/p14ARF, and p53 mutations have all been associated with poor response to chemotherapy and a worse prognosis
Treatment:
Systemic chemotherapy is the mainstay of therapy ,often being used before surgery .Doxorubicin ,cyclophosphamide or ifosfamide,etoposide ,vincristine and dactinomycin are active drugs .Local treatment for the primary tumor includes surgical resection ,usually with limb salvage or radiation therapy .Patients with lesions below the elbow and below the mid-calf have a 5-year survivl rate of 80% with effective treatment .Ewing sarcoma is a curable tumor even in the presesnce of obvious metastatic disease,especially in children<11 years old.
uptodate
Harrison's Internal Medicine 2008
Because of their similar histologic and immunohistochemical characteristics and shared nonrandom chromosomal translocations, these tumors are considered to be derived from a common cell of origin. Although the histogenetic origin has been debated over the years, evidence from immunohistochemical, cytogenetic, and molecular genetic studies supports a neuroectodermal origin for all EFT
The EFT can develop in almost any bone or soft tissue, but is most common in the flat and long flat bones; patients typically present with localized pain and swelling. Although overt metastatic disease is found in fewer than 25 percent at the time of diagnosis, subclinical metastatic disease is assumed to be present in nearly all patients because of the 80 to 90 percent relapse rate in patients undergoing local therapy alone. As a result, systemic chemotherapy has evolved as an important component of treatment
Advances in multidisciplinary management of EFT over the past 30 years have resulted in a marked improvement in survival and a greater likelihood of limb-sparing surgery rather than amputation
In data derived from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute, five year survival rates for patients with ES rose from 36 to 56 percent during the periods 1975 to 1984 and 1985 to 1994 .
With modern multidisciplinary treatment, long-term survival can be achieved in 70 to 80 percent of patients presenting with nonmetastatic disease
Clinical Presentation:
Primary sites — ES most often arises in the long bones of the extremities (predominantly the femur, but also the tibia, fibula and humerus), and the bones of the pelvis. The spine, hands, and feet are affected considerably less often .
Within the axial skeleton, tumors arose from the pelvis, chest wall, spine/paravertebral region, or head and neck in 45, 34, 12, and 9 percent of cases, respectively. Compared to undifferentiated ES of bone, PNET and EES more often arise within the axial rather than the appendicular skeleton
Approximately 25 percent of patients have a soft tissue primary.
Signs and Symptoms :
Patients with EFT typically present with localized pain or swelling of a few weeks or months duration
Trauma, often minor, may be the initiating event that calls attention to the lesion. The pain may be mild at first, but intensifies fairly rapidly; it may be aggravated by exercise, and is often worse at night. A distinct soft tissue mass can sometimes be appreciated. When present, it is usually firmly attached to the bone and moderately to markedly tender to palpation . Swelling of the affected limb with erythema over the mass is not uncommon.
Patients with juxta-articular lesions may present with loss of joint motion, while lesions involving the ribs can be associated with direct pleural extension and large extraosseous masses .
When the spine or sacrum are involved, nerve root irritation or compression can result in back pain, radiculopathy, or symptoms of spinal cord compression (eg, weakness or loss of bowel and/or bladder control).
Constitutional symptoms or signs, such as fever, fatigue, weight loss, or anemia, are present in about 10 to 20 percent of patients at presentation . Fever is related to cytokines produced by the tumor cells, and along with other systemic symptoms, is associated with advanced disease.
Approximately 80 percent of patients present with clinically localized disease, although as noted previously, subclinical metastatic disease is presumed to be present in nearly all. Overt metastases may become evident within weeks to months in the absence of effective therapy. The significance of this lies in the frequent delay between the onset of symptoms and diagnosis, which in one report averaged over nine months .
Patients with primary pelvic tumors are significantly more likely to present with metastatic disease compared to other sites .Other factors associated with clinically evident metastatic disease at presentation include high level of lactic dehydrogenase (LDH), the presence of fever, an interval between onset of symptoms and diagnosis less than three months, and age older than 12 years
Sites of metastatic disease at diagnosis are similar to those seen with recurrent disease; lung and bone metastases predominate, in roughly equal proportions. The spine is the most frequently involved bone.
Lung metastases represent the first site of distant spread in 70 to 80 percent of cases, and are the leading cause of death for patients with EFT.
Lymph node, liver, and brain involvement are distinctly uncommon.
Radiographic Studies :
The diagnostic work-up is usually initiated with a plain radiograph of the affected area. ES involving bone typically presents as a poorly marginated destructive lesion, most often associated with a soft tissue mass. The tumors tend to be large, and in long bones are metaphyseal or diaphyseal in location.
The radiographic appearance has been described as "permeative" or "moth-eaten", indicative of a series of finely destructive lesions that become confluent over time. The cortex at the site of the lesion is often expanded, and the periosteum displaced by the underlying tumor, resulting in the clinical sign of Codman's triangle. The characteristic periosteal reaction produces layers of reactive bone, deposited in an "onion peel" appearance.
The soft tissue component of the tumor rarely shows any calcification or ossification. Sclerosis, if present, represents a secondary bone reaction rather than the primary bone formation that characterizes osteosarcoma. A pathologic fracture is present at diagnosis in 10 to 15 percent of cases.
Compared to plain radiographs, a CT scan of the primary site better delineates the extent of cortical destruction and soft tissue disease
However, definition of tumor size, local intraosseous and extraosseous extent, and the relationship of the tumor to fascial planes, vessels, nerves, and organs is best achieved by magnetic resonance imaging (MRI)
Imaging of the entire involved bone is necessary to exclude the presence of skip lesions (ie, medullary disease within the same bone, but not in direct contiguity with the primary lesion)
Prognostic Factors :
--Disease Extent: Presence or absence of metastases,patients with bones and lungs metastases fared worse than patients with bone metastases alone
--Tumor site and size : For patients presenting with localized disease, those with axial primary tumors (ie, pelvis, rib, spine, scapula, skull, clavicle, sternum) have a worse treatment outcome than those with extremity lesions
--Response to therapy: Patients with apparently localized disease have only a 10 to 20 percent likelihood of cure if treated with surgery or radiotherapy alone; this is improved dramatically when chemotherapy is added to treatment.Both the completeness of surgical resection and the response to induction therapy are important prognostic factors. Patients who are left with significant amounts of viable tumor in the resected specimen following neoadjuvant chemotherapy do worse than those with minimal or no residual tumor.
--Histology:In most but not all studies, neither the presence of neural differentiation (eg, as in PNETs) nor extraosseous origin has a significant adverse influence on outcome
--Age: contraversy about age as prognostic factor, the five-year relapse-free survival was significantly better for children younger than 10 compared to older children
--Molecular findings:deletion of the short arm of chromosome 1p, homozygous deletions of CDKN2A and p16/p14ARF, and p53 mutations have all been associated with poor response to chemotherapy and a worse prognosis
Treatment:
Systemic chemotherapy is the mainstay of therapy ,often being used before surgery .Doxorubicin ,cyclophosphamide or ifosfamide,etoposide ,vincristine and dactinomycin are active drugs .Local treatment for the primary tumor includes surgical resection ,usually with limb salvage or radiation therapy .Patients with lesions below the elbow and below the mid-calf have a 5-year survivl rate of 80% with effective treatment .Ewing sarcoma is a curable tumor even in the presesnce of obvious metastatic disease,especially in children<11 years old.
uptodate
Harrison's Internal Medicine 2008
Subscribe to:
Posts (Atom)