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5 Readers Responses published for 5 different topic sources.

Articles			Letters
	Clinical Crossroads: A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error Gallagher (12 August 2009) [Abstract] [Full text] [PDF]		Expectations and Responses in Medical Error Disclosure John C. Moskop   (8 August 2009) Read every Readers Response to this article
	Clinical Crossroads: A 66-Year-Old Man With an Abdominal Aortic Aneurysm: Review of Screening and Treatment Schermerhorn (11 November 2009) [Abstract] [Full text] [PDF]		A View Through the Smoke Javier Ena   (30 October 2009) Read every Readers Response to this article
	Clinical Crossroads: A 52-Year-Old Woman With Disabling Peripheral Neuropathy: Review of Diabetic Polyneuropathy Rutkove (7 October 2009) [Abstract] [Full text] [PDF]		A 58-Year-Old Woman With Disabling Peripheral Neuropathy Zhu Shen   (7 October 2009) Read every Readers Response to this article
	Clinical Crossroads: A 52-Year-Old Woman With Obesity: Review of Bariatric Surgery Wee (9 September 2009) [Abstract] [Full text] [PDF]		A 52-Year-Old Woman With Obesity Juan Carlos Rodriguez Garcia   (15 September 2009) Read every Readers Response to this article
	Clinical Crossroads: A 64-Year-Old Man With Low-Risk Prostate Cancer: Review of Prostate Cancer Treatment Sanda and Kaplan (27 May 2009) [Abstract] [Full text] [PDF]		Informed decision making for prostate cancer treatment Richard M. Hoffman   (22 May 2009) Read every Readers Response to this article

Clinical Crossroads: A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error Gallagher (12 August 2009) [Abstract] [Full text] [PDF] A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review... Expectations and Responses in Medical Error Disclosure 8 August 2009 John C. Moskop, Ph.D. Wake Forest University School of Medicine Send response to journal: Re: Expectations and Responses in Medical Error Disclosure jmoskop{at}wfubmc.edu John C. Moskop This case offers an instructive example of patient expectations and provider responses following a medical error. Ms. W expresses multiple common expectations, including prompt acknowledgement of the error, a clear apology, an opportunity to share her own account of what happened and how the error could have been prevented, information about how procedures have been changed to prevent similar errors in the future, and an offer of compensation for her suffering and lost income.(1-7) The timely and clear responses by the attending physician and by hospital representatives were effective in assuaging Ms. W’s distress about the error and repairing damage to the therapeutic relationship. Because her desires for clear and honest communication, acceptance of responsibility, expression of concern, and compensation were addressed, Ms. W is unlikely to pursue litigation as a way to express her anger about the error, to learn more about how the error occurred, or to obtain compensation.(3-7) The fact that the error in this case was immediately obvious to the patient may make prompt acknowledgment and apology easier. If an error is not obvious, providers may be tempted not to disclose it, hoping that the patient will never discover that an error occurred and so have no reason to seek legal redress for injuries suffered as a result of the error. The ability of this approach to limit liability is uncertain, but it does clearly compromise an open and honest relationship with the patient.(8) Ms. W expresses regret that she was not given an opportunity to speak with the surgical fellow who mismarked the surgical site. Since the fellow’s action played a significant role in the error, it is reasonable that Ms. W would want to discuss this with him or her. The explanation given, namely, that the fellow “was not around any longer,” seems highly implausible in light of the fact that the error was promptly acknowledged and the patient later underwent a second surgical procedure. Perhaps a more likely explanation is that the fellow felt ashamed, guilty, fearful, or uncertain about what to say to Ms. W, and the attending physician agreed to “cover” for him or her.(9-10) If that is the correct explanation, it has several major drawbacks. First, it was clearly unsatisfying to Ms. W, since it did not allow her to discuss the error with a provider who bore some measure of responsibility for it. Second, it squandered an opportunity to help the fellow come to terms with understandable negative emotions and to engage in sensitive communication with the patient about the error. Physician-educators have a responsibility to help trainees develop proficiency in acknowledging and disclosing medical errors.(8) If the fellow had been present when the attending physician discussed the error with Ms. W, he or she would have had the benefit of participating in a disclosure and apology process that reassured the patient and would have been able to discuss his or her role in the error with the assistance and support of the attending. The author has no relevant financial interests to report. References 1. Mazor KM, Simon SR, Yood RA et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409-418. 2. Hobgood C, Peck CR, Gilbert B et al. Medical errors-what and when: what do patients want to know? Acad Emerg Med. 2002;9:1156-1161. 3. Gallagher TH, Waterman AD, Ebers AG et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007. 4. Cohen JR. Advising clients to apologize. S Cal Law Rev. 1999;72:1009-1069. 5. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963-967. 6. Beckman HB, Markakis KM, Suchman AL et al. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370. 7. Hickson GB, Clayton EW, Githens PB et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA. 1992;267:1359-1363. 8. Moskop JC, Geiderman JM, Hobgood CD et al. Emergency physicians and disclosure of medical errors. Ann Emerg Med. 2006;48:523-531. 9. Wu AW. Medical error: the second victim. the doctor who makes the mistake needs help too. BMJ. 2000;320:726-727. 10. Hobgood C, Hevia A, Tamayo-Sarver JH et al. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758-764.

Clinical Crossroads: A 66-Year-Old Man With an Abdominal Aortic Aneurysm: Review of Screening and Treatment Schermerhorn (11 November 2009) [Abstract] [Full text] [PDF] A 66-Year-Old Man With an Abdominal Aortic Aneurysm: Review of Screening and Treatment A View Through the Smoke 30 October 2009 Javier Ena, MD, MPH Hospital Marina Baixa. Alicante. Spain Send response to journal: Re: A View Through the Smoke ena_jav{at}gva.es Javier Ena A major risk factor for the development of abdominal aortic aneurysm is smoking, and more than 90% of patients with such aneurysms have been smokers. After the cessation of smoking, the risk of developing an aneurysm declines each year, to approximately one thirtieth of the original risk [1]. The risk of rupture is low for aneurysms 5.5 cm or less in diameter, but above this threshold the risk increases markedly. After an aneurysm ruptures, only approximately 25% of patients reach the hospital alive, and only 10% reach the operating room alive [2]. Although blood pressure and lipids are currently well controlled, smoking is a significant risk factor for anerysm growth. I would send him to a smoking clinic and meanwhile check every 6 mo. the aneurysm size. If and when aneurysm size increases, an evaluation from a vascular surgeon will determine the feasibility of performing endovascular repair rather than open repair. An evaluation of pulmonary-function testing for chronic lung disease is also required [3]. Javier Ena, MD, MPH Dept. of Internal Medicine Hosp. Marina Baixa Alicante, Spain No conflicts of interest reported. 1. Wilmink TBM, Quick CRG, Day NE. The association between cigarette smoking and abdominal aortic aneurysms. J Vasc Surg 1999;30:1099-1105. 2. Brown LC, Powell JT, UK Small Aneurysm Trial Participants. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. Ann Surg 1999;230:289-297. 3. Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg 2007;94:709-716.

Clinical Crossroads: A 52-Year-Old Woman With Disabling Peripheral Neuropathy: Review of Diabetic Polyneuropathy Rutkove (7 October 2009) [Abstract] [Full text] [PDF] A 52-Year-Old Woman With Disabling Peripheral Neuropathy: Review of Diabetic Polyneuropathy A 58-Year-Old Woman With Disabling Peripheral Neuropathy 7 October 2009 Zhu Shen, MD, PhD Southwest Hospital, Third Military Medical University Send response to journal: Re: A 58-Year-Old Woman With Disabling Peripheral Neuropathy zhushencq{at}gmail.com Zhu Shen Epidemiology Neuropathy is a common complication of diabetes. It increases with both age and duration of diabetes. The overall prevalence of neuropathy was estimated 28.5%, from 5% in the 20-29 year age group to 44.2% in the 70-79 group (1). The prevalence of neuropathy is estimated to be about 8% in newly diagnosed patients and greater than 50% in patients with long- standing disease (2). Who should be tested and how? There is increasing evidence that even pre-diabetic conditions are also associated with some forms of neuropathy (3). Thus people with diabetes, regardless of the presence of symptoms and/or signs of peripheral nerve dysfunction, should be tested periodically. The evaluation requires a careful history and clinical examination of the feet, including patient questionnaire. Nerve conduction studies can quantify the degree of nerve injury and neuropathy progression over a long period of time, particularly if the patient is asymptomatic. Because there are no distinguishing features unique to diabetic neuropathy, other possible causes of neuropathic disorders must be ruled out by careful history, physical examination and imaging examinations (2). Treatment options Recent progress has been made toward understanding the biochemical mechanisms of diabetic neuropathy, and as a result, new treatment modalities are being explored. Treatment options include pharmacological and nonpharmacological treatments. The former include glycemic control, symptomatic therapies (such as antidepressants, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, mexilitine, opiates, and so on), causal therapies (such as ranirestat, zenarestat, benfotiamine, alpha-lipoic acid, and so on) (2). Despite these choices, diabetic neuropathy continues to pose considerable challenge to clinicians. Many therapies are available to alleviate the symptoms of diabetic neuropathy, but few options are available to eliminate the root causes. Based on efficacy and safety data benfotiamine and alpha-lipoic acid should be considered as first choices among pathogenically-oriented treatments. Most likely, combination therapy will be applied in the future for neuropathy treatment. The optimal choice could be to combine pathogenically-oriented and symptomatic treatment (4, 5). Lack of promising responses and unwanted adverse effects of conventional drug treatments force many patients to try alternative therapies such as acupuncture and near-infrared phototherapy (6). Nonpharmacological treatment also includes stem cell transplantation. Recent evidence suggested that diabetic neuropathy is causally related to impaired angiogenesis and deficient growth factors. Evidence showed that bone marrow-derived endothelial progenitor cells could reverse various manifestations of diabetic neuropathy in rats. These therapeutic effects were mediated by direct augmentation of neovascularization in peripheral nerves (7, 8). These findings suggest that EPC transplantation could represent an innovative therapeutic option. Treatment of diabetic foot by autologous transplantation of bone-marrow cells was demonstrated in a randomized trial in 2002 (9). Recommendations Two recommendations: Firstly, general consensus holds that good glucose control should be the first step in the treatment of any form of diabetic neuropathy. Secondly, combination therapy should be applied and the optimal choice should be to combine symptomatic and pathogenetically oriented treatment, including the promising stem cell transplantation. No relevant financial interests. REFERENCES 1. Young MJ, Boulton AJ, MacLeod AF, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia. 1993; 36: 150-154. 2. Edwards JL, Vincent AM, Cheng HT, et al. Diabetic neuropathy: mechanisms to management. Pharmacol Ther. 2008; 120: 1-34. 3. Singleton JR, Smith AG, Russell JW, et al. Microvascular complications of impaired glucose tolerance. Diabetes. 2003; 52: 2867-2873. 4. Várkonyi T, Kempler P. Diabetic neuropathy: new strategies for treatment. Diabetes Obes Metab. 2008; 10: 99-108. 5. Bureković A, Terzić M, Alajbegović S, et al. The role of alpha-lipoic acid in diabetic polyneuropathy treatment. Bosn J Basic Med Sci. 2008; 8: 341-345. 6. Tesfaye S. Advances in the management of diabetic peripheral neuropathy. Curr Opin Support Palliat Care. 2009; 3: 136-143. 7. Jeong JO, Kim MO, Kim H, et al. Dual angiogenic and neurotrophic effects of bone marrow-derived endothelial progenitor cells on diabetic neuropathy. Circulation. 2009; 119: 699-708. 8. Shibata T, Naruse K, Kamiya H, et al. Transplantation of bone marrow- derived mesenchymal stem cells improves diabetic polyneuropathy in rats. Diabetes. 2008; 57: 3099-3107. 9. Tateishi-Yuyama E, Matsubara H, Murohara T, et al. Therapeutic angiogenesis for patients with limb ischaemia by autologous transplantation of bone-marrow cells: a pilot study and a randomised controlled trial. Lancet. 2002; 360: 427-435.

Clinical Crossroads: A 52-Year-Old Woman With Obesity: Review of Bariatric Surgery Wee (9 September 2009) [Abstract] [Full text] [PDF] A 52-Year-Old Woman With Obesity: Review of Bariatric Surgery A 52-Year-Old Woman With Obesity 15 September 2009 Juan Carlos Rodriguez Garcia, MD. Internal Medicine and infectious diseases consultant Complejo Hospitalario. Pontevedra. Spain Send response to journal: Re: A 52-Year-Old Woman With Obesity juan.carlos.rodriguez.garcia{at}sergas.es Juan Carlos Rodriguez Garcia 1) When is it appropriate to consider weight loss surgery? Be well-informed and motivated. Have a BMI >40. Have acceptable risk for surgery. Have failed previous non-surgical weight loss. Adults with a BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates. (1) 2) How effective is surgery and how much can one expect to lose from surgery? The mean overall percentage of excess weight lost was 61% (95% CI 58-64%), varying according to the specific bariatric procedure performed. (2, 3, 4) 3) What are the risks associated with surgery and what is its effect on mortality? Procedure-related mortality depends upon the type of procedure, surgical experience, and patient characteristics. A meta-analysis estimated that, overall, 30-day operative mortality was 0.1% for purely restrictive procedures, 0.5 percent for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch. (5, 9, 10) The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioral therapy. 4) What is the effect of surgery on psychological function and overall quality of life? Several studies have demonstrated that bariatric surgery is effective in reducing obesity-related comorbidities, while having additional benefits such as reducing monthly medication costs and the number of sick days and improving quality of life. A benefit on overall and cause-specific mortality has also been demonstrated. (7, 8) The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioural therapy. The Swedish Obese Subjects Trial (SOS) is the largest trial comparing surgical versus medical treatment of morbid obesity and confirm clearly this observations. (6) Surgically treated patients were significantly less likely to require medications for cardiovascular disease or diabetes at two and six years. Among those not already requiring such medications, surgery reduced the proportion who required initiation of treatment. Costs of medications were reduced significantly in the surgically treated group. Surgically treated patients had dramatic improvement in scores on validated measures of quality of life compared with only minor and sporadic improvement in medically treated patients at two years. The magnitude of benefit was related mostly to the degree of weight loss, which was greater in the surgical group. Similar benefits were observed on validated batteries of psychiatric dysfunction. At 10 years of follow-up overall outcome was still significantly better in the surgical than the medically treated group. (7, 9) 5) What do you recommend for Ms J? I recommend she undergo bariatric surgery with laparoscopic adjustable gastric banding because of its simplicity and lower complication rates. As an alternative treatment I would choose laparoscopic Roux-en-Y gastric bypass. Bariatric surgery needs to be performed in conjunction with a comprehensive follow-up plan consisting of nutritional, behavioral, and medical programs. All persons and of course all patients needs quality of life. Everything has a price, but in my point of view, I say: “do it, Ms J”. REFERENCES 1. Guidelines for Bariatric Centers of Excellence. ASBS Newsletter 2003. 2. Buchwald, H, Avidor, Y, Braunwald, E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA.2004; 292: 1724. 3. Maggard, MA, Shugarman, LR, Suttop, M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005; 142: 547. 4. Santry, HP, Gillen, DL, Lauderdale, DS. Trensds in bariatric surgical procedures. JAMA 2005; 294: 1909. 5. Lancaster, RT, Hutter, MM; Bands and bypasses: 30-day morbidity and mortality of baratric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS- NSQIP data. Surg Endosv 2008; 22: 2554 6. Sjostrom, L, Narbro, K, Sjostrom, CD, et al: Effects of bariatric surgery on mortality in Swedish obese subjects. N. Engl J Med 2007; 357: 741. 7. Sjostrom, L, Lindroos, AK, Peltonen, M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N. Engl J Med 2004; 351: 2683. 8. Ryden, A, Sullivan, M, Torgerson, JS, et al. A comparative controlled study of personality in severe obesity: a 2–y follow after intervention. Int J Obes Relat Metab Disord 2004 ; 28: 1485. 9. Mun, EC, Pi-Sunyer, FX, Martin, KA, et al. Surgical management of severe obesity. Up To Date. Ver 17.2. 2009. 10. Mun, EC, Friedman, LS, Pories, SE, et al. Complications of bariatric surgery. Up To Date. Ver 17.2. 2009. Dr Rodriguez reports no relevant financial interests.

Clinical Crossroads: A 64-Year-Old Man With Low-Risk Prostate Cancer: Review of Prostate Cancer Treatment Sanda and Kaplan (27 May 2009) [Abstract] [Full text] [PDF] A 64-Year-Old Man With Low-Risk Prostate Cancer: Review of Prostate Cancer Treatment Informed decision making for prostate cancer treatment 22 May 2009 Richard M. Hoffman, MD, MPH University of New Mexico School of Medicine Send response to journal: Re: Informed decision making for prostate cancer treatment rhoffman{at}unm.edu Richard M. Hoffman The first step in managing Mr. D’s case is to clarify his treatment options and their potential risks and benefits. He uses the phrase “watchful waiting” which actually connotes a palliative approach to prostate cancer, where the intention is to offer symptomatic relief if and when cancer progresses. Given the often indolent course of prostate cancer, this approach makes most sense for men with limited life expectancies due to advanced age or comorbidities. However, Mr. D is young and fairly healthy, so watchful waiting is not necessarily an appropriate option. Even though his cancer is moderately differentiated, population-based survival data suggest that, without treatment, he has over a 20% chance of dying from prostate cancer in 20 years (1). At the same time, he might be one of the estimated 23% to 42% of men with PSA-detected cancers who never have clinical problems with prostate cancer (2)—other than those associated with diagnosis and treatment. Many men with an early-stage cancer who share Mr. D’s concerns about treatment complications--but are uncomfortable with foregoing treatment-- have opted for androgen deprivation therapy (ADT)(3). However, ADT is not really an acceptable compromise for these men because it also has many potential complications, does not cure cancer, and is expensive. So, are there any other options for Mr. D? He could consider active surveillance (AS). This strategy, which is recommended for men with less than a 10- to 15-year life expectancy, PSA ≤ 10 ng/mL, low tumor burden, and no worse than a moderately differentiated cancer, involves serial PSA testing, digital rectal examinations, and prostate biopsies (4). Engaging in AS means that a future decision for curative treatment would be based on evidence that cancer is progressing—rising PSA, changing DRE, or worsening Gleason score. This may strike a reasonable balance for men who want to avoid complications from unnecessary treatment but do not want to ignore their cancer. Recent observational data from a small multi-institutional cohort study found that 75% of subjects remained on active surveillance after a median follow-up of 29 months--and only one developed skeletal metastases (5). So while a cancer could progress under active surveillance and become incurable, the chance of this seems small. Admittedly, Mr. D may not quite fit the guideline indications for AS; the foci of atypia and high-grade intraepithelial neoplasia suggest that his tumor volume could have been underestimated and he has a long life expectancy. Whether or not he opts for active surveillance, Mr. D should be fully educated about the natural history of prostate cancer and the potential risks and benefits associated with various treatment options. He should also understand that radiotherapies (external beam and brachytherapy), unlike radical prostatectomy, have never been evaluated in controlled trials of men with early-stage cancer. Thus, there is no evidence-based consensus on the optimal treatment. Given this uncertainty about treatment selection and the risks for overdiagnosis, the most important recommendation for Mr. D is that he be involved in an informed/shared decision-making process regarding his treatment. References 1. Albertsen PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localized prostate cancer. Jama. May 4 2005;293(17):2095-2101. 2. Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context. J Natl Cancer Inst. Mar 18 2009;101(6):374-383. 3. Cooperberg MR, Moul JW, Carroll PR. The changing face of prostate cancer. J Clin Oncol. Nov 10 2005;23(32):8146-8151. 4. Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. Jun 2007;177(6):2106-2131. 5. Eggener SE, Mueller A, Berglund RK, et al. A multi-institutional evaluation of active surveillance for low risk prostate cancer. J Urol. Apr 2009;181(4):1635-1641; discussion 1641.