sábado, 5 de marzo de 2011

Innovations in Health Care


Innovations in Health Care

  • JIM CHAMPY

    Radically Rethinking Health Care Delivery

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. When I first suggested to a team of health care clinicians that their work needed to be radically redesigned, I was told that the word "radical" was reserved for only the most serious of medical procedures and I had no license to use the word — after all, I... More »
  • CLAYTON M. CHRISTENSEN

    A Disruptive Solution for Health Care

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. The challenge that we face — making health care affordable and conveniently accessible to most people — is not unique to health care. Almost every industry began with services and products that were so complicated and expensive to provide that only people with a lot of skill and a... More »
  • DAVID M. CUTLER

    Searching for Health Care's Entrepreneurial Spirit

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. At first blush, it would appear that entrepreneurship is alive and well in health care. And that's true in many areas: New devices, pharmaceuticals, and surgical techniques regularly get developed and incorporated into practice. Virtually every day, there is information about a clinical study with a new way to... More »
  • SCOTT C. RATZAN, MD, MPA

    Vaccine Literacy, a Crucial Healthcare Innovation

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. As we face the challenges of advancing "Healthcare and Innovation" at the Harvard Advanced Leadership Initiative, advocating for further diffusion of cost-effective and proven heath benefits of vaccination improves quality and access, and is a key to preventing disease. While vaccines (initially discovered in 1792) now enter their fourth... More »
  • ASHISH JHA

    21st Century Medicine, 19th Century Practices

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. By the time I saw Mr. Johnson (not his real name), he had received three CT scans in less than 24 hours — and we had done nothing to make him feel better or cure his clinical problem. The day prior, he had seen his primary care physician in... More »
  • BARRY R. BLOOM

    The Case for Innovation in Health Care

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. Health is defined by the World Health Organization as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity...The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race,... More »
  • DAVID GERGEN

    Leadership That Longfellow Would Appreciate

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. In a famous scene in 1875, Henry Wadsworth Longfellow returned to Bowdoin College with his classmates to celebrate their 50th reunion. Many had died, but through verse, Longfellow challenged those remaining to think how much they could still do: "For age is opportunity no less Than youth itself, though... More »
  • ROSABETH MOSS KANTER

    The Traits of Advanced Leaders

    Editor's note: This post is part of a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. Welcome to the dawning era of social innovation, in which more people aspire to tackle old problems in new ways with new tools. Lacking confidence in established organizations and governments to do the trick, innovators think that it's time to reinvent institutions to make progress on social issues such... More »
  • ROSABETH MOSS KANTER

    Why Innovation Is So Hard in Health Care - and How to Do It Anyway

    Editor's note: This post is the first in a three-week series examining innovation in health care, published in partnership with the Advanced Leadership Initiative at Harvard University. Supposedly, everyone working in health care wants the same thing: to help people get and stay healthy. "Everyone" includes primary care doctors, medical specialists, nurses, hospital administrators, health insurance providers, nutritionists, pharmaceutical companies, medical technology manufacturers, fitness gurus, paraprofessionals, public health commissioners, and charities dedicated to a disease... More »

Twisting and the Herniated Disc


Twisting and the Herniated Disc

This is Part 4 in the series: "What Causes Herniated Discs?"
golf-swing-250w
In the previous installment, we discussed the various stress factors that contribute to disc failure and then examined one of those risk factors. This time I'd like to take a look at another one of those factors, but before we do that here's a little something to refresh your memory:
"In physics, stress is classified according to type such as tensile strength (stretching the object), torsional strength (twisting the object), shear strength (lateral tearing of the object), and compressive strength (load bearing ability).
Of course, the normal intervertebral disc is designed to withstand all of these stress factors, but the two that appear to have the most impact on herniation are twisting and compressive loading."
In that last article, we specifically looked at the effect of compressive loading and the role it plays in producing herniated discs. This time we're going to examine torsional stress -- sometimes referred to as axial torque -- or what we laymen would simply call twisting.
And, for the sake of simplicity, we're going to confine ourselves to answering the following three questions:
  1. What does twisting do to the walls of the disc?
  2. Can axial torque result in a herniated disc?
  3. What activities present the greatest risk for disc failure?
Let's start with number one...

What Does Twisting Do to the Walls of the Disc?

You will recall that the outer portion of the disc is called the annulus and is a series of concentric rings of fibrous connective tissue that surrounds the nucleus much like a ring of forts built one inside the other.
Also, you may remember that the basic hypothesis is that as the disc dries out (either because of age, inactivity or both) the tough fibrous rings of the annulus start to break down and cracks begin to form. This process of deterioration is often referred to as degenerative disc disease.
So the question that is of most interest to us is what happens to this crumbling fortress when a twisting force is applied? McGill gives us a clue based on his observations...
"While we have not performed a lot of research on the effect of twisting on the discs, it appears that repeated twisting causes the annulus to slowly delaminate. This is evidenced by the tracking of the nucleus into the annulus in all directions. While we do not yet know the relationship between number of cycles and loads, we do know that added torsion reduces the compressive strength of the joint (Aultman et al., 2004)." [1]
That seems reasonable. If you take a sheet of rotten plywood and start flexing it, it would not be unexpected for the various layers to begin to separate (or delaminate as McGill puts it). So what about our next question:

Can Axial Torque Produce a Herniated Disc?

I believe that technically a disc can be considered herniated the moment the nucleus begins its initial break through the walls of the annulus even though it may not be to the point of causing a bulge and may be years away from actually extruding into the spinal canal.
So perhaps a better question might be, could a sudden twisting force cause a disc on the verge of rupturing to finally fail?
McGill gives us an interesting example that he and his colleagues observed during one of their research efforts:
"Our most recent work on disc herniation uncovered the dependency of the location of the herniating bulge on the axis of motion (Aultman et al., 2005). For example, in 20 motion segments, we flexed them repeatedly about an axis that was 30 degrees rotated from the pure flexion axis (mostly flexion with some lateral bend). One specimen simply failed abruptly and was removed..." [1]
When flexing disc segments about an axis of rotation, that is, ones that were twisted, one of them failed (herniated) immediately. The rest just took a little longer.
Again, this result comes as no surprise. It's what you would expect to happen if you started applying torque to a weak disc. Perhaps a good analogy would be wringing the water out of a dishrag. Twisting the rag (disc) causes the liquid (nucleus) to seek a way out.
What is important to note is that this has been observed under laboratory conditions. It is not just the result of speculation.
So, since we know for a fact that twisting is a potentially harmful movement…

What activities present the greatest risk for disc failure?

baseballpitch1
The type of activity, which would apply a twisting force to the spine similar to what McGill is describing, would include such things as a golf swing, bowling, swinging a tennis racket, pitching a baseball, certain high velocity thrust-type spinal manipulations or any other forceful rotational movement.
None of the above activities are inherently dangerous or harmful to a healthy spine, but their cumulative effect needs to be recognized as a possible contributing factor to disc degeneration.
Discs that are not in perfect condition are no doubt going to be delaminating and accumulating additional cracks and tears each time one of these movements is performed.
And this says nothing about the impact of these activities on discs that are already in a weakened state and may be on the verge of catastrophic failure. Just teeing off on the ninth hole or bowling that last set may be all it takes.

Table of Contents for this series:

  1. What Causes Herniated Discs?
  2. The First Step in Repairing Herniated Discs
  3. Compression Loading and Herniated Discs
  4. Twisting and the Herniated Disc
  5. My Philosophy of Disc Rehabilitation

About the Author

Dean Moyer is the author of the books, Rebuild Your BackRebuild Your Neck and The Pain Relief Manual. Copies of his books are available for a donation to support this website. (See the Donations page for details.)

References:

1. McGill, S. Low Back Disorders, Evidence-Based Prevention and Rehabilitation, 2nd Edition. (p. 44-47) Human Kinetics (2007)
2. Tampier C, Drake JD, Callaghan JP, McGill SM. Progressive disc herniation:an investigation of the mechanism using radiologic, histochemical, and microscopic dissection techniques on a porcine model. Spine. 2007 Dec 1;32(25):2869-74.
3. Drake JD, Aultman CD, McGill SM, Callaghan JP. The influence of static axial torque in combined loading on intervertebral joint failure mechanics using a porcine model. Clin Biomech (Bristol, Avon). 2005 Dec;20(10):1038-45.
4. Aultman CD, Drake JD, Callaghan JP, McGill SM. The effect of static torsion on the compressive strength of the spine: an in vitro analysis using a porcine spine model. Spine. 2004 Aug 1;29(15):E304-9.

Last Updated: Feb 12, 2009

SHOULDER MRI


Symposier uploaded this video.

SHOULDER MRI CASE 1

Date: 07 Jun 2010
Uploader: Symposier
Lenght: 1m 3s
Specialty: Orthopedic - Surgery   Radiology   
Uploaded and Shared in Youtube by: RadPod — Shoulder MRI Case

Bunions Can Affect Quality of Life


 

WebMD.com—February 24, 2011   
Bunions -- deformities at the base of the big toe that can cause pain and disability -- are common and can really slow a person down, a new study shows.
The study, which is published in Arthritis Care & Research, found that more than one in three older adults has at least one bunion, a hard bony bump that forms at the base of the big toe.
So what can be done to prevent a bunion or keep it from getting worse?
“There are all kinds of splints and padding that you can put between your toes and things like that to try to prevent the toe from drifting over,” says Andrew J. Elliott, M.D., a foot and ankle orthopaedic surgeon at Hospital for Special Surgery in New York City.
However, he notes that previous studies have shown that up to 90% of people who get bunions report a family history, which may mean that some feet are just more susceptible to them than others.
“If it’s going to drift over, it’s going to do that, and it’s mostly because of an imbalance in the muscles as well as maybe some laxity in some ligaments that allow the bones to sort of drift in the direction that they’re going to, which is where it is going to rub up against the shoe,” Elliott says.
He says patients should consider surgery if they’re in steady pain, or if they’ve noticed their bunion getting rapidly worse in the last year. As a bunion gets worse, it may also cause hammertoes or crossover toes, or pain in the ball of the foot, called metatarsalgia.
“As the deformity gets bigger, it gets harder to get a good outcome with correction,” he says.
Correction typically involves surgery to cut the bone and move it over, but it doesn’t always fix things completely.
Up to 15% of people will still experience some discomfort in their feet after surgery, and up to one-third say they still can’t always wear the shoes they’d like to after the procedure, Elliott says.
And to add insult to injury, bunions can come back, even after surgery.
In the meantime, Elliott recommends reconsidering what’s on the shoe rack.
“You can make it a lot less painful by wearing appropriate footwear,” he says.
Read the full story at WebMD.com.

La desconfianza en la relación médico/paciente


La desconfianza en la relación médico/paciente


Había empezado a hablaros sobre la Oncología Radioterápica y, aunque seguiré haciéndolo, para mí el blog siempre ha sido un medio de desahogo y hoy lo necesito con ese fin.  Perdonadme porque sé que estos desahogos/reflexiones no son tan útiles, pero no puedo dejarlos.

Hoy me he visto como si me hubieran tirado un cubo de agua fría de realidad encima... Admito que a veces soy demasiado "ilusa", me gusta tener ilusiones y pensar que las cosas pueden ser así. Sé que la realidad está bastante lejos de ellas pero si no las tuviera no estaría donde estoy, ni sería lo que soy. Es mi "coraza",esa que me permite sacar una sonrisa todos los días a mis pacientes intentando hacer todo más llevadero para ellos, intentando crear un lazo de confianza entre nosotros para que todo sea un poco más fácil. Algo que me parece fundamental cuando hablamos de la salud.

Si yo me hice médico fue para curar a la gente, o, si no es posible, al menos ayudarles en ese proceso tan duro como es la enfermedad. Cuando se habla de la salud, hasta la gastroenteritis, el catarro o el dolor de cabeza "más tonto" te hace pasar malos ratos y si una cosa tengo clara es que al médico uno no va por gusto ni mucho menos (salvo raras excepciones, que es cierto que existen). Si ya paso a hablar de lo que veo en mi especialidad con el cáncer, el estado en que llega el paciente a la consulta es de "miedo" "respeto"por la enfermedad, por lo que le podamos llegar a decir sobre ella, su tratamiento y su pronóstico... y pienso que es importante ser lo más cercano posible e intentar hacer más llevadera esa consulta. Considero que la empatía y el saber ofrecer una sonrisa a tu paciente es algo fundamental, y por eso me esfuerzo por hacerlo todos los días, lleve lo que lleve por dentro. Si tengo un mal día, me pongo mi coraza y ¡a por ello!, que el paciente no tiene la culpa de lo que me ha pasado y se merece lo mejor. Hago todo ésto por eso, porque tengo ilusión por crear esa relación de confianza entre el médico y el paciente que considero tan necesaria. ¿Qué pasa? Que hay días como hoy en los que me encuentro con la desconfianza que tienen muchos pacientes con sus médicos y se me quitan las ganas de todo, me planteo si estoy donde tengo que estar o si soy,  perdonadme por la expresión,  una imbécil que se ha hecho médico pensando en que eso se puede conseguir. Si no hay confianza entre el médico y el paciente, mal vamos... no?! Demasiados malos ratos nos llevamos los médicos cuando las cosas van mal, cuando no conseguimos curar al paciente y, no sólo eso, sino que la mejoría es mínima; cuando le causamos toxicidades que le hacen pasar malos ratos; cuando pedimos pruebas, a veces invasivas, que luego no nos dan ningún tipo de información... El paciente es el que más sufre, cierto, pero nosotros también sufrimos cuando pasan estas cosas. Más de una noche y más de dos las pasamos pensando en qué podemos hacer para tratar a tal paciente, qué solución podemos darle a su problema... En fin, a diferencia de otras profesiones, en la sanitarias, y hablando concretamente de la mía como médico, nosotros tratamos con la salud de las personas con todos los pros y contras que eso conlleva. Los pros son muchos y compensan con creces a los contras, aunque sean menos. Al menos eso me pasa a mí, o me pasaba, hasta ahora. Digo me pasaba porque, visto lo visto, cuando una se encuentra con que un paciente duda de lo que le ha dicho su médico y, en vez de hablar con él sobre sus dudas, recurre a otro "a sus espaldas" o, peor aún, se fía más de lo que le dice una página de internet... mal vamos. Me parece muy bien que se pida una segunda opinión, claro que sí, a veces es necesaria, sana... Somos humanos, no lo sabemos todo y ya se sabe eso de "4 ojos ven más que 2" pero siempre diciéndoselo a tu médico. Si no se lo dices, cuando le llegues con la opinión de un 2º y le digas cosas como "El Dr Tal de la Clínica Cual me dijo que estaba de acuerdo con el tratamiento que me propuso, así que, adelante" Tú médico te tratará pero te aseguro que la relación no será la misma, es inevitable que se marque una distancia y una cierta inseguridad por lo que uno dice/hace o deja decir/hacer. Ese tipo de cosas conducen a otras como la medicina defensiva. Ahora todo está protocolizado y ojo no te saltes el protocolo que como algo vaya mal (por cualquier cosa! Aunque no tenga nada que ver con lo que has hecho o dejado de hacer) prepárate que puedes tener una reclamación , una demanda, a la vuelta de la esquina... ¿Qué hemos conseguido? Que ahora se pidan muchas más pruebas, muchas veces innecesarias y, no sólo eso, sino que se ponen tratamientos para"porsi"... que ufff!!! miedo me da! Por ej, en el tema de los antibióticos estamos consiguiendo que se creen cepas resistentes  de tal manera que cuando llega la hora de la verdad y realmente hay una bacteria que tratar, cada vez nos cuesta más erradicarla. Y no sólo utilizamos mal, a la defensiva los antibióticos. También pasa ésto con otras muchas cosas.

Así que me encuentro un día como hoy desilusionada, decepcionada, planteándome si no estaría mejor haciendo otra cosa lejos de la salud. Me quedan dos meses para acabar la residencia y no sé qué será de mi vida laboral después de ésto, dónde iré... Se acaba una etapa para dar paso a otra y sí, se supone que debería pensar en que los cambios son buenos, que seguro que me llegan muchas cosas buenas, cambios positivos pero, ¡¿y si no es así?! No llevo nada bien la incertidumbre y ahora que me encuentro con esa desconfianza me planteo si no debería hacer otra cosa que no fuera la medicina. Algo sin tanta responsabilidad que a veces te trae tantos disgustos y ningún tipo de compensación... En el fondo sé que si no soy médico no valgo para nada, vamos, quiero decir, que he nacido para ser médico, me gusta mucho la medicina, y en concreto me gusta mucho la Oncología Radioterápica, mis pacientes y el trato con ellos pero... uffff!!!! A veces te planteas dejarlo todo porque total, ¡¿relamente merece la pena llevarte estos disgustos?!

He hablado como médico, de la desconfianza de algunos pacientes hacia nosotros, pero admito que también pasa a la inversa, muchos médicos desconfían de sus pacientes y estamos en las mismas. Si no hay confianza en esta relación las cosas no pueden ir bien... algo va mal.

Pie en la diabetes


Pie en la diabetes

Os dejo una presentación de la enfermera con la que compartí cuatro años de trabajo sobre prevención del pie diabético. Ella, excelente persona y profesional, prefiere permanecer en el ‘anonimato’, pero desea compartir su presentación a través de mi blog. Ningún mérito me pertenece a mí.
Dedicado a todos los enfermeros/as, cuya labor es imprescindible y a veces (demasiadas) minusvalorada y poco oída por las instituciones y la sociedad en general.