Malignant hyperthermia claimed the life of a Florida teen after a routine cosmetic surgery late last month in a case that demonstrates how unpredictable, sudden and potentially fatal the rare complication is.

Stephanie Kuleba, 18, underwent corrective breast augmentation surgery on March 21 to reshape asymmetrical breasts and an inverted areola. The outpatient procedure was conducted at the office-based ASC of Steven Schuster, MD, a board-certified plastic surgeon based in Boca Raton.

About two hours into the procedure and without warning, Ms. Kuleba's heart rate and metabolism increased, her core temperature spiked to over 110 degrees F, her body became rigid and she was diagnosed with MH.

According to news reports, a staff member called the Malignant Hyperthermia Association of the United States' MH hotline. A Mayo Clinic expert guided Dr. Schuster, his anesthesia provider and the surgical team through emergency procedures. Ms. Kuleba was transported by ambulance to the Delray Medical Center three miles away, but she died the following day.

Surgical authorities quoted in news coverage of the incident attest to the genetic condition's rarity and severity.

In a similar surgical emergency, says Jeff Jacobs, MD, staff anesthesiologist at the Cleveland Clinic's Weston, Fla., campus, "there would be three to five things I'd do before I think of malignant hyperthermia. As you go through your checklist, you're soon left with some scary things. One of those is malignant hyperthermia."

David A. Lubarsky, MD, MBA, chair of the anesthesiology department at the University of Miami's medical school, describes the speed and precision necessary in responding to MH. "No matter how hard this surgeon worked, a full-blown, fulminant case of malignant hyperthermia would take more than one pair of experienced hands," he says.

David Bernard

A proposed amendment to New Jersey's Healthcare Practitioner Self-referral Law, also known as the Codey Law, passed the state Senate on March 17. If the bill becomes law, physicians will be legally able to refer patients to surgical facilities in which they have financial interests. It would also set a two-year moratorium on new licenses for surgery centers.

The amendment, introduced by Senate President (and the Codey law's original sponsor) Richard Codey, would clear up the controversy over the self-referral law that originated last November from insurance litigation in which state Superior Court Judge Robert P. Contillo unexpectedly ruled that physician-owned ASCs violated the law.

The ruling caused concern among physicians and prompted the New Jersey Board of Medical Examiners to propose emergency amendments to its regulations in order to allow physician-owned ASCs to temporarily operate without fear of breaking the law.

"This bill recognizes that these physicians [operated] in good faith and in the open. In fact, they did so in broad daylight," said Richard J. Scott, MD, president of the Medical Society of New Jersey, to the Senate Health and Human Services Committee before the bill's adoption.

Kent Steinriede

A study published in the March 5 issue of the Journal of the American Medical Association challenges the common belief that polyps are the primary cause of colon cancer.

Researchers from the Veterans Affairs Palo Alto Health Care System in California reviewed data from 1,819 patients who underwent elective colonoscopies over a one-year period. They found that 170 of the patients had nonpolypoid colorectal neoplasms, which were almost ten times more likely to contain carcinomas than polypoid lesions of any size.

Viewed in terms of size and shape, nonpolypoid neoplasms with carcinomas tended to be smaller in diameter by a mean difference of about three millimeters than polypids containing carcinomas. The researchers also reported that depressed nonpolyp neoplasms carried the highest risk of containing invasive carcinomas.

The study's authors suggest that stronger efforts to detect these neoplasms in addition to polyps could make colonoscopies more effective at preventing cancer. But they also noted that lesions that turn cancerous look the same regardless of their origins.

Nathan Hall