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Doctors Are Refusing To Operate On Smokers. Here’s Why The Trend Will Grow
Created: Friday, 24 February 2017 04:28

An irate man contacted me recently to complain he’d been turned down for back surgery because he’s a smoker.

“It’s just not right,” said the Charlotte man, who suffers from chronic hip and leg pain. “I need this surgery. It’s to the point where I can’t walk around the block with my dogs.”

He acknowledged smoking is a “bad habit,” but after 35 years, he’s not sure he can quit. And he doesn’t think he should have to.

“It didn’t used to be this way,” he said. “Everybody’s got on their little righteous path.… My grandfathers on both sides smoked their entire lives. They didn’t die until one of them was 92, and one of them was 88.”

No doubt, genetics play a huge role in how healthy we are and how long we live. But personal behavior is also a big factor.

Most of us know that smoking is linked to heart disease and cancer. But in recent years, research has shown that smoking also inhibits wound healing because it decreases blood flow. As a result, smokers don’t do as well as non-smokers after having spinal fusion surgery and joint replacements.

One study found that smokers who got joint replacement surgery had an 80 percent higher chance than nonsmokers of needing repeat surgery because of complications from infection.

For this reason, surgeons who do those procedures have begun asking patients to quit smoking – or at least stop for four to six months before and after surgery.

“We want the best results possible,” said Dr. Bryan Edwards, head of orthopedic surgery for Novant Health. “We’re not denying you a surgery. We’re preventing you from having a complication.

“If you’re doing surgery, you’re trying to get the bones to unite, and if you don’t have good blood flow, the results aren’t as good,” Edwards said. “I tell patients, ‘Complications from surgery are far worse than whatever condition you have now. If you’ve got an infected back that doesn’t fuse, you don’t want that.’”

Unlike the man who said he was turned away by a surgeon, most patients are counseled about the risks and referred for help, such as smoking cessation classes. They’re not expected to quit cold turkey.

“I expect there may have been a miscommunication” in the case of the irate patient, said Dr. Leo Spector, a specialist in spine surgery at OrthoCarolina. “A lot of things obviously boil down to the physician and patient conversation.”

Smoking isn’t the only behavior patients may be asked to change as part of “surgical optimization” – the doctors’ term for getting patients in the best health possible before an operation to improve the outcome. Obesity and diabetes also decrease the chances of a successful surgery.

Spector said it’s part of a national trend for doctors to run down a checklist of behaviors in preparation for elective surgery. Before spinal fusion, Spector said he might tell a patient: “Listen, I want you to stop smoking, but if you can’t stop smoking, at least cut it in half. A two-pack-a-day smoker is going to have a higher risk (of complications) than a two-cigarette-a-day smoker.”

If patients are overweight or have diabetes, he might refer them for nutrition counseling and even bariatric surgery to help them lose weight and get their glucose levels under control. Spector said he’d ask patients with back pain to stop smoking and try physical therapy for three months to see if the pain would go away without surgery.

“Have I refused to operate because they wouldn’t stop smoking?” he asked. “Yes.”

Helping patients achieve better surgical outcomes will also help doctors as the health care payment system continues to evolve.

Today, most doctors continue to be paid in a fee-for-service system, which means they’re reimbursed for each appointment, test or procedure. Perversely, they make more money if a patient has complications and requires extra care.

In Charlotte, some surgeons who perform spine surgery and knee and hip replacements have begun using a “value-based” system that means accepting a single “bundled payment” for each patient encounter. This gives doctors an incentive to provide the best care for each patient.

If all goes well and care is delivered for less than the contract price, the doctor or hospital keeps the savings. If there are complications and the patient needs more care, the doctor or hospital absorbs the extra cost.

So, operating on smokers, with potentially expensive complications, could hurt the bottom line for physicians.

At OrthoCarolina, Spector said doctors agree that all patients who register for the bundled payment plan must go through “surgical optimization” so they’re as healthy as possible before surgery. At some point, insurance companies may even begin to refuse to pay for elective surgeries on smokers.

“A year from now, I’ll probably be at a point where I would require all my patients to stop smoking,” Spector said. “Currently, I evaluate it on a case-by-case basis. Over time, we’re going to feel comfortable being a little more stringent with our patients about these modifiable risks.”

Edwards said he finds many patients “don’t take it well at first” when he advises them to quit smoking or lose weight. But many of them thank him later.

“Everybody needs something in their life to motivate them,” he said. “Usually, if the patient makes the commitment to stop and gets through the procedure, I find the majority of them just stop smoking.”

Source:  sacbee.com

Trump Administration Plans Crackdown On Recreational Marijuana
Created: Friday, 24 February 2017 03:38

President Donald Trump’s administration said on Thursday for the first time that it will crack down on marijuana sales in states that have approved recreational pot use.

White House Press Secretary Sean Spicer said the Department of Justice will pursue enforcement of federal law against recreational use, but not medical use. The statement marked a major break with the Obama administration’s hands-off approach to the growing marijuana legalization movement.

“I do believe that you’ll see greater enforcement,” Spicer told reporters at his daily briefing. “Because again there’s a big difference between the medical use … that’s very different than the recreational use, which is something the Department of Justice will be further looking into.”

The decision is certain to provoke a fight with the states that have legalized recreational marijuana. Those states are Alaska, California, Colorado, Maine, Massachusetts, Nevada, Oregon and Washington and the District of Columbia.

Jay Inslee, Washington state’s Democratic governor, made it clear earlier this month that the state would fight hard if the Trump team tried to block its recreational pot sales. “I think it would be a really big mistake for them to pick this fight, and I hope it will not occur,” Inslee said.

California legalization could translate to $5 billion in annual retail sales if Trump doesn’t intervene, according to estimates from Marijuana Business Daily. A cannabis caucus formed in Congress last week and vowed to fight Trump, if necessary, and protect legalization. Among the co-founders is Rep. Dana Rohrabacher, a California Republican and Trump supporter whose name was floated for secretary of state before ExxonMobil CEO Rex Tillerson got the job.

Nevada Senate Majority Leader Aaron D. Ford called on the state’s attorney general to “vigorously defend” the state’s laws.

“Not only did voters overwhelmingly vote to approve the legalization of recreational marijuana, the governor’s proposed education budget depends on tax revenue from recreational marijuana sales,” Ford said. “Any action by the Trump administration would be an insult to Nevada voters and would pick the pockets of Nevada’s students.”

Seventy-one percent of voters say the government should not enforce federal marijuana laws in states that have legalized medical or recreational marijuana use, according to a Quinnipiac University Poll released Thursday. Fifty nine percent support legalizing recreational marijuana while 93 percent of Americans support medical marijuana use.

Washington and Colorado were the first states to legalize marijuana in 2012, while California followed suit last year. Twenty-eight states have legalized the drug for medical use.

Spicer compared the use of recreational marijuana to the opioid addiction crisis that has ravaged many communities across the nation. “The last thing we should be doing is encouraging people,” he said. He referred specific questions on enforcement to the Justice Department.

Source:  Sacbee.com

Widespread Flooding, Mudslides, Evacuations As Biggest Storm In Years Batters California
Created: Monday, 23 January 2017 04:50
The latest and most powerful in a series of three winter storms slammed into California on Sunday, flooding roads, forcing evacuations in communities near burn areas and adding more snow in mountains from the Sierra Nevada to the San Bernardinos. 

Numerous roads around Southern California were flooded by sustained bursts of intense rain. The 710 Freeway flooded, prompting the California Highway Patrol to close both directions of the thoroughfare at Pacific Coast Highway. The 110 Freeway experienced high water near Torrance, where the CHP shut down all lanes for several hours. Numerous surface streets were also blocked by standing water, fallen trees, and rockslides.

Source:  latimes.com

President Trump; "See You In Court" 9th Circuit Rules Against Reinstating Travel Ban
Created: Friday, 10 February 2017 01:19

President Donald Trump delivers remarks at the National Prayer Breakfast in Washington, February 2, 2017.


President Donald Trump's travel ban will remain blocked, a federal appeals court ruled Thursday.

The unanimous ruling from a three-judge panel means that citizens of seven majority-Muslim countries will continue to be able to travel to the US, despite Trump's executive order last month.
"On the one hand, the public has a powerful interest in national security and in the ability of an elected president to enact policies," the judges wrote. "And on the other, the public also has an interest in free flow of travel, in avoiding separation of families, and in freedom from discrimination. We need not characterize the public interest more definitely than this... The emergency motion for a stay pending appeal is denied."
It is a significant political setback to Trump's new administration and raises questions about how the courts will view his apparent vision for an expansive use of executive power from the Oval Office on which he is anchoring the early weeks of his presidency.
Trump immediately tweeted his reaction to the ruling: "SEE YOU IN COURT, THE SECURITY OF OUR NATION IS AT STAKE!"Source:  cnn.com
Remember "Read My Lps No New Taxes" Now Aide Says Trump Won't Release Tax Returns
Created: Sunday, 22 January 2017 21:15

WASHINGTON — President Donald Trump will refuse to release his tax returns, abandoning a campaign promise that he would do so after an audit of them is finished, an aide said Sunday.

"The White House response is that he's not going to release his tax returns. We litigated this all through the election. People didn't care. They voted for him," Kellyanne Conway, counselor to the president, said on ABC's "This Week."

Conway had been asked on the TV program about a White House petition posted Friday demanding release of the tax returns. There are well over the 100,000 signatures required to meet the threshold to get a White House answer.


Conway dismissed the observation about the signatures. She said people don't care about tax returns from Trump, the nation's first billionaire president, and are focused on what their own tax returns will look like while the Republican is in the White House.

"People want to know they will get tax relief," she said.

After Conway's remarks, the website WikiLeaks called on leakers to provide it with copies of Trump's tax returns.

WikiLeaks during the 2016 campaign published thousands of e-mails and internal documents hacked from the Democratic National Committee and top advisers to Clinton

Source:  sacbee.com


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