Saturday, June 30, 2007

Type 2 Diabetes

I often talk to my patients about maintaining an active life (or gaining one) and not just watching their children play sports or dance classes or band practices. I talk to them about trying to eat healthy (aim for 80-90 per cent of the time, allow for special celebrations, etc). I am not a nutritionist, so I will refer them or suggest books. I gave my mother Type 2 Diabetes for Beginners by Phyllis Barrier, MS, RD, CDE when she was first diagnosised.
Yes, I have a family history of Type 2 Diabetes. My grandmother (maternal), my mother, and a brother. I am very aware that I have to watch my weight and exercise to try to prevent myself my manifesting this disease. I am also aware that I have a weakness for sweets, especially chocolate. Here are my answers to the diabetes risk test found at the American Diabetes Association web site. You may wish to take it yourself and see what your risk is.
Diabetes Risk Test
1. Please select your age category: 18-44 45-64 65 or older
2. Please enter your height: 5 feet 3.5 inches
3. Please enter your weight: 124 pounds
4. I am under 65 years of age AND I get little or no exercise. True False
5. I have a sister or brother with diabetes. True False
6. I have a parent with diabetes. True False
7. I am a woman who has had a baby weighing more than nine pounds at birth. True False


Diabetes Risk Test Results:
You have scored 7 points . This means I am at low to medium risk for having type 2 diabetes now, BUT may be at higher risk in the future. By simply changing my answer to question #4 to true (I get very little or no exercise) my score would go to 12 and put me in the high risk catagory. [0-2 is very low risk; 3-9 is low to medium risk; 10 or more is high risk].
I can keep my risk low by:
1. Keeping my weight in control
2. Staying active most days of the week (walk, dance, run, just move
3. Eating low fat meals high in fruits, vegetables and whole grain foods

For more information, call 1-800-DIABETES (1-800-342-2383) Monday through Friday, 9 am – 8 pm (EST).

I'm going to get up and go take my dogs for a walk.

Friday, June 29, 2007

Virginia L Johnson

I'd like to write a memorial to a friend of mine. Her name is Virginia Johnson (Jan 21, 1928--June 27, 2007). She was married to Jim Johnson. This December would have been their 60th wedding anniversary. She was the first woman to run for governor in Arkansas (in 1966 and no woman has ever won, yet). She and her husband have three sons (and daughter-in-laws) and six grandchildren She was a remarkable woman, intelligent, caring, a great cook. She will be missed. Photo credit.

She had only one flaw that I am aware of--she smoked. And it got her in the end. She died of lung cancer. Smoking is responsible for nearly 1 in 5 deaths in the United States.


There are many reasons to quit smoking and I would love to convince just one person to quit or not start:
In addition, there are non-medical reasons not to smoke. A pack-a-day habit cost around $1000 a year. You may lower your car insurance costs. Please, do yourself (and your loved ones a favor) and if you smoke quit. If you don't, good for you. I hope you never take it up.

Wednesday, June 27, 2007

Progress Note

S(subjective):

O(objective):

  • Pieceing of quilt top done, 50 in X 70 in

A(accessment):

  • Time to procede to quilting

P(plan):


Tuesday, June 26, 2007

Mending a Hole

Mending holes in clothing or in earlobes can be done. Some  methods work better than others. Often with both, simple preventive measures are very useful. When mending clothes, resewing a button before it is lost is best. Using an iron-on interfacing to re-inforce an area in a garment where the fabric is getting thin can prevent the hole from occuring or at least delay it, giving longer life to the garment.
 


For earlobes, not wearing heavy ear rings can help prevent the stretching of the hole. Being careful when put on or removing clothing so as not to "catch" the earring can help prevent the lobe from being torn. Being careful around babies/toddlers who want to play with shiny/dangling objects can help prevent the lobe from being torn. Another way is to use the "earlobe support" which is a stick-on disc that help support the earlobe when heavy earrings are worn. Used early, this can prevent the stretching or slow tearing of the lobe due to the weight of the earring. Photo credit.

Once the stretching occurs or the tear is completed, then the only way to fix it is to repair it. There are variations on "how" this is done, but they all require excising (freshing) the edges so they can be sewn back together. The variations are mainly in how the excision is structured–straight, z-plastied, or L-shaped. I do not think the straight excision is the best way to do the repair. If the scar "shortens" at all (as straight scars are prone to do), then the lobe is "gathered" up and ends up "W" shaped at the bottom. The other reason is that unless you (the patient) are very good at repositioning the new hole to the side (either) of the scar (which is weaker by at least 20% of the surrounding skin), the tear is very likely to re-occur as the earrings pull-through the scar over time.

The Z-plasy or L-shaped scar avoid the "W" by changing the scar into a non-straight scar. Which one is best will depend on the tear and shape of the earlobe being repaired. Also, it may depend on whether there is an intention to re-pierce the earlobe. Not all do. Another alternative to pierced ears is found here. As I have not figured out how to put sketches in my text, I have linked here to Dr. Michael Bermant, MD site. This is usually an office procedure done using a local block. Most insurances will not cover this procedure as they consider it cosmetic in nature.

A really good article with nice, clear instructions on the Z-plasty technique is REPAIR OF THE SPLIT EARLOBE USING A HALF Z-PLASTY; Journal of Plastic & Reconstructive Surgery, Vol 101(3):855,856, March 1998; Gajiwala, Kalpesh M.S., M.Ch.

Monday, June 25, 2007

Tailoring

There is a “tailor” in every plastic surgeon, especially when it comes to the surgeries needed for massive weight loss patients (MWL). The brachioplasty procedure is used to reduce the excess arm skin (sleeve, if you will) so that it fits the underlying subcutaneous tissue/muscle/bone frame. When adjusting a pattern for a large upper arm, slashes are made in two directions to add fabric for the sleeve. When doing the brachioplasty, think about reversing the adjustments made for the sleeve. Now transfer these adjustments to the underside of the arm so that the resulting scar will be least visible. The bi-directional adjustments are made (1) along the length of the upper inside of the arm and (2) by Z-plasty into the axilla. With fabric/patterns you must remember to keep the adjusts parallel to the grainline. In surgery, we have to remember the anatomical structures that we don't want to injure (nerves, blood vessels, lymphatics), scar placement, and not to resect too much skin and thereby forming a constriction band. (Photo credit)


The ideal candidate for a brachioplasty (arm lift) has what we call highly deflated arms. In other words, lots of loose skin and not much underlying fat tissue. Those with significant residual fat around the arms may benefit from liposuction of the arms done at an earlier stage than the skin excision. If much liposuction needs to be done at the time of skin excision, this can greatly increase the post-surgery edema (swelling) that will occur. Swelling can be a significant problem postsurgery. It is important to limit elbow flexion (static, okay when arm is being used) and to keep the arms elevated when not being used for the first 2-3 weeks. When resting, it is helpful to gently open and closed the hands/fists--squeeze on an anti-stress ball.

Scar placement is important for more reasons than just to be “not as visible”. It is important that the Z-plasty part of the scar is well placed in the axilla so that no axillary contracture is formed. This can limit shoulder/arm motion. Good scar (incision) placement decreases the risk of injury to the cutaneous skin nerves, so there will be less chance of postoperative skin numbness.

Scar placement is usually either in the bicipital groove or more posterior at the most inferior point of the upper arm while it is raised and abducted (positioned away from the body). The second choice is less visible in everyday activity. Either way, the scar is there. The scar can be quite apparent, so this procedure should never be undertaken if the patient is not willing to make this trade-off (less skin, but a significant scar). Pre and Post-operative photos here.

References:

  1. The L Brachioplasty: An Innovative Approach to Correct Excess Tissue of the Upper Arm, Axilla, and Lateral Chest; Hurwitz, Dennis J. MD, Holland, Sarah W. MD; Journal of Plastic & Reconstructive Surgery;Vol 117(2):403-411, February 2006.

  2. A Technique of Brachioplasty; Strauch, Berish MD, Greenspun, David MD, Levine, Joshua MD, Baum, Thomas PAC; Journal of Plastic & Reconstructive Surgery;Vol 113(3):1044-1048, March 2004.

  3. Textbook: Body Contouring After Massive Weight Loss by Al S Aly, MD

  4. Shaping Futures Web Site (you must register for access to the procedures)

Sunday, June 24, 2007

Planning 25th Medical School Reunion

This is the 25th year since my UAMS class graduated. The reunion is in September. Somehow I got designated the "host" of our class to help the Alumni Office get folks to come. This feels like an odd fit to me as I was never the social butterfly, but I have taken the "job" seriously. I have learned how to set up a Google calendar just for the group, adding in local team schedules (University of Arkansas Football, Arkansas Travelers baseball) and looking up Art Center information, etc. I have set up a Facebook Group page to try to encourage input on activities the class would like, sharing of information, and sharing of pictures. So far very few takers. Still I keep trying. I have googled nearly everyone looking for pictures (several hospital photos) which I added to the Facebook page (so far 43 pictures). Two of our local classmates (married to each other) have offered their home for a pig roast. We will probably take them up on the offer. Our class had yearly actual pig roast while in school. We dug our own pits, cooked the pig, and the "pot-lucked" the sides and desserts. It was great fun! This one will be catered, but it will still be fun.

The sad (bitter-sweet) part of all this searching/planning is remembering the ones who are no longer with us. I think we have lost six (have asked the Alumni Office if they know for sure). The first one we lost, Morris Hughes, was in 1988 to a plane crash. The class set up a scholarship fund in his name. Another was a death to a motor vehicle accident. One to a heart attack. The saddest was a suicide. I always find suicides sad, but especially physician suicides. I always wonder if it was the professional part of their life that "pushed" them over or their personal side or both. I always regret that they were not able to ask for help when they would so willing give it.

I sure hope I can convince most (well even 20-50%) to show up. We only had seven show up at the 20th, but had many more for our 15th. I would love to see them. [photo credit]

Friday, June 22, 2007

Latex Allergy

Once or twice a year I have a patient who is Latex allergic. I use it as a reminder to review the information. There is a wonderful article, Latex Allergy by Sumana Reddy, MD published by the American Academy of Family Physicians. I don’t think I can do a better review, so lets just hit some highlights.
The natural latex allergen is from the rubber tree Hevea brasiliensis. Those persons most susceptible to sensitivity are persons with significant cumulative latex exposure, such as those in the health care and rubber industries, as well as those undergoing repeated surgeries, especially if those surgeries are early in life (e.g. spina bifida patients).

Avoiding exposure to NRL (natural rubber latex) allergens is the only effective means for prevention of sensitization. Avoidance of powdered NRL gloves results in a decrease in sensitization and subsequent problems. It has been shown that continued avoidance can result in complete loss of sensitization. Avoidance can be hard to do, as a large number of medical and nonmedical products have NRL in them: elastic bandages, tourniquets, Foley urinary catheter, Penrose drains, tape, rubber innersoles of shoes, ballons, latex mattresses, household rubber gloves, and inflatable mattresses. There is also a cross reaction to other plants and foods: Poinsettia, banana, avocado, passion fruit, chestnut, kiwi fruit, melon, tomato, celery.

Important questions to ask patients if you suspect a latex sensitivity:
Allergy history:
  • Do you have a history of hay fever, asthma, eczema, allergies or rashes?

  • Are you allergic to any foods (remember those above)?

  • Do you experience rash, oral itching, swelling or wheezing when exposed to these foods?

Occupation history:

  • Are you exposed to any products that contain latex, including gloves, at work?

  • If you have had a rash on your hands after wearing latex gloves, how long after putting on the gloves did the rash develop?

  • What did the rash look like?

Hidden reactions to Latex:

  • Do you ever have swelling, itching, hives, shortness of breath, cough or other allergic symptoms during or after blowing up a balloon, undergoing a dental procedure, using condoms or diaphragms, or following a vaginal or rectal exam?

  • Have you ever had an allergic reaction of unknown cause, especially during a medical or dental procedure?

Surgical History:

  • Have you ever had surgery? What kind?

  • Do you have spina bifida or any urinary tract problem requiring surgery or catheterizations?

Surgical patients who are Latex-sensitive should be scheduled as the first case of the day, when aerosolized latex particles are at a low. If blood pressure cuffs and tubing are made of latex, the patient's extremities should be wrapped to prevent contact. While it has been recommended that medications not be drawn up through rubber-stoppered vials or allowed to sit in preloaded syringes that contain latex rubber, and that latex ports should not be used for intravenous injections, these precautions appear to be impractical for all but the most exquisitely latex-sensitive patient and are likely not necessary. Non-latex gloves should be worn by surgeons and staff. Premedication with antihistamines, steroids and histamine H2-blockers is sometimes carried out, but anaphylactic reactions have occurred despite such pretreatment.

If you are a latex-sensitive patient, please, wear a Medic-Alert identification. Consider carrying an epinephrine auto-injection kit. Maybe carry extra pairs of nonlatex gloves for emergency medical or dental care.

Thursday, June 21, 2007

Size Matters

You know size does matter. In quilting and in bust size. When making a quilt, it helps to decide what you want its function to be. For the QOV group, the suggested size is --Your top should be at least 50"x 60". Please don't go larger than a twin sized (63" x 87"). I try to make mine 50" X 70". If I am making a baby quilt for a friend or relative, then it will vary, 36" X 48" or maybe 45" X 60". A table for standard bed size quilts can be found here.

When I am talking to a woman about breast size, the question is often what size should I be? We (she and I) may be deciding how much larger (an augmentation) or how much smaller (a reduction) to make her breasts. The deciding factors in my mind are her body type (height, weight, bone structure), her personality (or as good a handle as I can get on it during our time together--I ask them to be honest with themselves about "entering a room bust first"), how they want their clothing to fit. Off the rack clothing is usually sized for a B/C bra cup for the corresponding chest measurement. Anyone fuller busted often has to buy a size larger and then the shoulders may be too large, or safety pin the "gaping buttons" or have clothing custom made. So the augmentations, I try to caution not to go too large (C cup for shorter and up to D for taller women). For reduction patients, I try to caution them not to go too small (some think they want to be A or B cups due to the extreme discomfort they have endured). Most of us women have hips that need C cups to truly balance them, and these women will get the relief they seek in part from the intrinsic lift that comes with a breast reduction. The final say in size is theirs (the patient), but when they ask my opinion I tell them. I am conservative when it comes to breast size. For my taste, bigger is not always better (most of us can not carry off the Dolly Parton look and yet she makes "hers" look good).

Wednesday, June 20, 2007

Sunshine and Shadow

For me part of the lore of quilts is the names. This pattern is called both "Sunshine and Shadow" thought to refer to the different times in our lives, the good and the bad, the difficult and the easy times, the rainy and sunny days. The other name is "Trip Around the World". It makes me think of the old movie--Around the World in 80 Days-- or trips I'd like to take or trips friends have taken (and I through them). This quilt is in the planning stages (as TBTAM's Italy trip is) and may end up with different colors, but right now I like this contrast.

Tuesday, June 19, 2007

Deep Venous Thrombosis Prevention

For me the prevention of DVT (deep venous thromboembolism) is more important than the diagnosis. As I read several sources of medical literature, it seems the family physicians are more concerned with the diagnosis, and that is probably as it should be. For them often the presentation of DVT may be a symptom of some under-lying illness (ie cancer). For surgeons, we want to prevent being the cause of DVT’s in our patients, because for us DVT is a complication not just a disease process. I (we) don’t like complications. Just different perspectives, as we all work towards the goal of the patient’s good health.

From the prevention side, here are a few things to remember. Patients are ranked into risk categories. These are:
  1. Low: Minor procedure, Patient less than 40 yrs old, No other risk factors
  2. Moderate: Minor procedure, Age between 40-60 yrs, No other risks factors
  3. High : Non-minor (major) procedure, More than 60 yrs, No other risks factors
    Or Age between 40-60 yrs with other risks factors
  4. Highest: Major procedure, Multiple risk factors, Hip/knee arthroplasty, Hip fracture surgery, Major trauma, Spinal cord injury

    Other risks factors include: recent pregnancy (less than one month ago) [This is why, along with the recent blood loss of delivery, and often anemia of pregnancy that women should never have a tummy tuck at the time of their C-section. The risks are too high for complications.], varicose veins, overweight, personal or family history of blood clots, personal history of cancer, use of birth control or hormone replacement, recent travel (long flights or car rides without movement), etc. Recall the journalist who died after sitting in a tank for long hours with little to no movement.

Preventive Therapy consists of:
All surgical patients should have intermittent pneumatic compression devices used (unless the procedure will be less than 1 hour).

  • Low Risk (less than 2 %)
    Ambulate three times daily for 5 minutes minimum each time
    Flex and extend ankles often

  • Moderate Risk (10-20%)
    1. Ambulate as above
    2. Flex and extend ankles often
    3. TED stockings

  • High Risk (20-40%)
    1. Same as moderate (1-3)
    2. Lovenox (enoxaparin sodium) SQ for 7-14 days

  • Highest Risk (40-80%)
    1. Same as high risk
    2. Lovenox, Fondaparinux SQ, Heparin or Warfarin (will depend on the procedure being done and on patient history)

REFERENCES

Prevent DVT.org

Prevention of Venous Thromboembolism in the Plastic Surgery Patient; Plastic and Reconstructive Surgery, Vol 114 (3) September 1, 2004, pp 43e-51e.

Deep Venous Thrombosis Prophylaxis Practice and Treatment Strategies among Plastic Surgeons: Survey Results, Plastic and Reconstructive Surgery; Vol 119 (1) January 2007, pp 157-174.

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

Sunday, June 17, 2007

Tattoos--Graffiti or Art?

I must confess up front that I don't get tattoos. To me they are like graffiti on public buildings, not art or murals. To me the tattoo on a woman's shoulder ruins the lovely evening gown or sundress she wears. But that's me. I'm not alone--"Years ago, I naively failed to anticipate that laser tattoo removal would inevitably lead to—more tattooing. This is sad, because I have never met a tattoo more beautiful than the skin onto which it was placed. With equal naivete perhaps, I suggest that we should continue to work on making tattoos safer and more removable than ever. Otherwise, what looks like sunlight at the end of this tunnel is surely the headlight of an oncoming train filled with unhappy, tattooed passengers." R. Rox Anderson, MD, Department of Dermatology, Massachusetts General Hospital.
Humans have marked their bodies with tattoos for thousands of years. "These permanent designs—sometimes plain, sometimes elaborate, always personal—have served as amulets, status symbols, declarations of love, signs of religious beliefs, adornments and even forms of punishment. Joann Fletcher, research fellow in the department of archaeology at the University of York in Britain, describes the history of tattoos and their cultural significance to people around the world, from the famous "Iceman" a 5,200-year-old frozen mummy, to today’s Maori." (Smithsonian Magazine).

There was a nice article recently in the New York Times that covers the regret that often comes months to years later after getting the tattoo--"Erasing Tattoos, Out of Regret or for a New Canvas". Today's lasers have made it easier to have them removed, but the cost of removal is still many times the cost of getting one.

There is also safety issues to be considered (not just the regret factor) when getting a tattoo. Today's inks are not all specifically created for tattoos and may result in allergic reactions, infection, and severe cellular inflammation or excessive tissue growth around the wound site known as granulomas or keloid scars. These inks have known toxic and carcinogenic properties and are not easily removed even with the improved lasers.
These risks and complications led to the development of a new ink, Freedom-2, by leading dermatologists and academic institutions. This ink combines products known to be safe for human usage, making it safer and more easily removed. The innovation of safe, quality inks for the purpose of tattoos, permanent cosmetics and the creation body art is at the heart of Freedom-2. Freedom-2 inks are specifically designed to be easier to remove in the future.
It is to go on sale this fall.

Tattoo removal can be done by laser, dermabrasion, or direct excision. None of these are necessarily simple, so if you see tattoos as art, please, just be sure you truely want it before proceding. Then enjoy your "art".

Friday, June 15, 2007

Iron Deficient Anemia

I went to the local Red Cross today to give blood, but they wouldn't take any. My Hct was too low. Your Hb must be 12.5 or above, the Hct must be 38% or above. [Eligibility guidelines.] So now I must work on getting it up. Mine is simply iron deficient anemia (giving blood and not enough iron in my diet). This can sometimes be a problem postoperatively too. We don't give blood to surgery patients as readily as when I was a medical student. Now we won't treat with transfusion post-surgery unless the patient is still bleeding, the Hct is less than 29%, or the patient is symptomatic (short of breath, weak, etc).
Now that I have become deficient in iron to the point that I have developed anemia, increased intake of iron-rich foods is beneficial, but usually isn't enough to correct the problem. I will need iron supplementation to build back my iron reserves and still meet my body's daily iron requirements. For mild iron deficiency anemia, a daily multivitamin containing iron will often be enough. But typically, doctors recommend iron tablets — such as prescription ferrous sulfate tablets or an over-the-counter supplement. These oral iron supplements are usually best absorbed in an empty stomach. However, because iron can irritate your stomach, you may need to take the supplements with food. Iron absorption is increased when taken with vitamen C (orange juice).

Iron deficiency anemia can be prevented by eating foods rich in iron, as part of a balanced diet. Eating plenty of iron-containing foods is particularly important for people who have higher iron requirements, such as children and menstruating or pregnant women or regular blood donators. Foods rich in iron include red meat, seafood, poultry and eggs. Meat sources of iron are easily absorbed by your body. Plant-based foods also are good sources of iron, although they're less easily absorbed. Among the best are iron-fortified cereals, breads and pastas. Beans and peas, dark green leafy vegetables — such as spinach — and raisins, nuts, and seeds also contain iron. You can enhance your body's absorption of iron by drinking citrus juice when you eat an iron-containing food. Vitamin C in citrus juices, like orange juice, helps your body better absorb dietary iron from animals and plants.
  • Maybe I'll have a nice spinach salad with blueberries & almonds, along with my iron suppliment. Then I'll try to give blood again in a few months (give my body some time to build back up).

Thursday, June 14, 2007

Aspirin

After a surgical patient of mine told me that she was taking Excedrin (2 days after her surgery) I wanted to review which "common" products that contain aspirin (listed here). [I may need to list them all rather than just saying "no aspirin".] Excedrin, for me, is an easy one. I have to remind myself that Pepto Bismol contains aspirin. I also thought I would share a brief review of aspirin. Folks my age (I’ll hit 50 yr later this year) grew up with aspirin. It’s what we used for fever and headaches. My nieces and nephews have never had aspirin.

Aspirin will be 100 years old this October! Aspirin was developed in Germany by a chemical process described by research chemist Felix Hoffman on October 10, 1897. The active ingredient in aspirin, acetyl salicylic acid, is a synthetic derivative of a compound, salicin, which occurs naturally in plants, notably the willow tree. Extracts of willow were traditionally used in folk medicine and as early as 400 BC the Greek physician Hippocrates recommended a brew made from willow leaves to treat labour pains. Later in 1763 an English clergyman, Reverend Edward Stone carried out the first proper scientific study of the herbal medicine when he described the benefits he observed after giving ground up willow bark to 50 parishioners suffering from rheumatic fever.

How aspirin works was a mystery until relatively recently. During the 1970s the British scientist Professor John Vane discovered that it blocked an enzyme needed for the production of natural hormones called prostaglandins involved in many body processes including pain and tissue injury. In 1982 Professor Vane, now Sir John Vane, won the Nobel Prize for Medicine for this work.

The liver appears to be the principal site for salicylate metabolism, although other tissues may also be involved.. The half-life of aspirin in the circulation is from 13 to 19 minutes so that the blood level drops quickly after absorption is complete. However, the half-life of the salicylate ranges between 3.5 and 4.5 hours, which means that 50% of the ingested dose leaves the circulation within that time. [The affect on platelets can be "felt" up to 10 days, which is why patients are asked not to take aspirin for 2 weeks prior to surgery.] Excretion of salicylates occurs principally via the kidneys. Salicylate can be detected in the urine shortly after its ingestion but the full dose requires up to 48 hours for complete elimination.


ASA is one of the most frequent causes of accidental poisonings in toddlers and infants. The adult aspirin is 5 grains (325 mg), the "baby" aspirin is 1.25 grains (81 mg). A toxic dose of aspirin is equivalent to 1 gr per pound of body weight (150 mg / kg). A minimal lethal dose is equal to 3-4 grains / lb (450 mg / kg). Symptoms of an overdose: In mild overdosage these may include rapid and deep breathing, nausea, vomiting, vertigo, tinnitus, flushing, sweating, thirst and tachycardia. In more severe cases, acid-base disturbances including respiratory alkalosis and metabolic acidosis can occur. Severe cases may show fever, hemorrhage, excitement, confusion, convulsions or coma and respiratory failure.

Treatment of an overdose: Activated charcoal can be given as soon as possible and, if bowel sounds are present, may be repeated q 4 h until charcoal appears in the stool. Treatment then consists of prevention and management of acid-base and fluid and electrolyte disturbances. More in depth treatment information can be found at Merck Medicus

Wednesday, June 13, 2007

Sudoku Puzzle Quilt

I like puzzles. I am fairly good at Sudoku. I can never finish the New York Times crossword.
I like quilts. So a while back I did a quilt based on sudoku. It was for the QOV Foundation. So I wanted the quilt to be close to 50" X 70" in size. Since the sudoku puzzle is a grid of 9 rows by 9 columns. I planned the quilt to be 3 of those 9 X 9 grids across and 4 down for a total of 12 grids. I used 9 different fabrics as if they were the numbers. This is how it turned out. The quilt is 54" X 72", each square is 2".

Tuesday, June 12, 2007

Herbal Suppliments and Plastic Surgery

Many people take herbal supplements these days for many reasons. Chondroitin and glucosamine (My husband swears by them. My 14 yr old labrador, Girlfriend takes them.) are supplements that are taken together. Both are components of the normal cartilaginous matrix and are used to treat osteoarthritis. Echinacea is often used for prevention and treatment of viral and bacterial infections. It has been shown that echinacea, both in vitro and in vivo, possessing immunostimulation properties because of enhancing phagocytosis and nonspecific T-cell stimulation. Ginkgo biloba has become widely used for its efficacy in treating peripheral and cerebral circulatory disturbances, including claudication and memory impairment (e.g., Alzheimer’s Disease). Garlic is taken to aid in the reduction of atherosclerosis and hypercholesterolemia. It is also taken as an antioxidant, an antibiotic, a diuretic, an antitussive, to remove “evil” spirits, strengthen the stomach and spleen, and relieve diarrhea. Ephedra is used to promote weight loss, increase energy, and treat respiratory tract conditions, such as asthma and bronchitis. It is contained in many over-the-counter “slimming preparations.”

Many people take these suppliments with no thought of "side effects" or interactions with their prescriptions. Chondrotin and heparin are similar in chemical composition and researchers speculate that bleeding complications may arise from chondroitin use, particularly when used in combination with other blood-thinning medications. Because echinacea does have immunostimulation properties, it is contraindicated in systemic and autoimmune diorders. The immunostimulatory effects can offset the immunosuppressive actions of corticosteroids and cyclosporin. Side effects of echinacea also include GI upset, headache, dizziness, and potential allergic reactions. Prolonged use of ecchinacea (8 weeks) has been documented to cause tachyphylaxis through an unknown mechanism. Echinacea is also an inhibitor of cytochrome P450, 3A4, and sulfotransferase and can potentiate the toxicity of drugs that are metabolized by these pathways (benzodiazepines, barbiturates). Gingko biloba has the ability to inhibit platelet-activation factor and possesses an anti-inflammatory effect. Gingko biloba has induced spontaneous hyphema (bleeding from the iris in the anterior chamber of the eye), subarachnoid hemorrage, and spontaneous bilateral subdural hematomas. It should not be used with other anticoagulants. Other side effects of gingko include headache, GI symptoms, and allergic skin reactions. The active ingredient in garlic is allicin, which has been reported to inhibit platelet aggregation. It should not be taken with other coagulation inhibitors (e.g. warfarin, heparin, nonsteroidal anti-inflammatory inhibitors, and aspirin). Other side effects of garlic include halitosis, nausea, hypotension, headache, bloating, and possible allergic reaction. Ephedrine, a chemical contained in ephedra, has medical uses, mostly in operating rooms and intensive care units. It is sympathomimetic agent and causes positive inotropic and chronotropic responses to raise blood pressure and heart rate, respectively; dilates bronchioles; and increases metabolic rate. Side effects such as psychiatric disturbances, heart attack, cardiac dysrhythmias associated with volatile general anesthetic agents (e.g., halothane) and cardiac glycosides (e.g., digitalis), stroke, and even death. Of note, patients taking ephedra under general anesthesia can have severe hypotension that can be controlled with phenylephrine instead of ephedrine.

It has become important to ask patients about suppliments. It is important to caution them to stop them prior to surgery. Gingko biloba should be discontinued at least 36 hours before surgery. Garlic should be discontinued at least 1 week prior to surgery. The exact time for chondrotin is unknown, so recommendations are based on guidelines from the American Society of Anesthesiologists, which advises that all herbal medicines without formal study be discontinued at 2 to 3 weeks before an elective surgical procedure. Echinacea should be discontinued 2-3 weeks prior to surgery. Ephedra should be discontinued at least 24 hours prior to surgery.

Herbal suppliments are being studied as medications, but still too much is unknown. If you are the patient, tell your doctor which ones you are taking. If you are scheduled for an elective surgery, stop taking the suppliments for 2-3 weeks prior to surgery.

Some references:
1. Kleiner, S. M. The true nature of herbs. Phys. Sports Med. 23: 13, 1995.

2. Eisenberg, D. M., and Kessler, R. C. Unconventional medicine in the United States: revalence, costs and patterns of use. N. Engl. J. Med. 328: 246, 1993.

3. Kaye, A. D., Kucera, I., and Sabar, R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol. Clin. North Am. 22: 125, 2004

4. Ang-Lee, M. K., Moss, J., and Yuan, C. Herbal medicines and perioperative care. J.A.M.A. 286: 208, 2001

5. Heller, Justin B.S.; Gabbay, Joubin S. M.D.; Ghadjar, Kiu; Jourabchi, Mickel; O'Hara, Catherine B.A.; Heller, Misha B.S.; Bradley, James P. M.D. Top-10 List of Herbal and Supplemental Medicines Used by Cosmetic Patients: What the Plastic Surgeon Needs to Know. Plastic & Reconstructive Surgery. 117(2):436-445, February 2006.

6. Broughton, George II M.D., Ph.D., Col., M.C., U.S.A.; Crosby, Melissa A. M.D.; Coleman, Jayne M.D.; Rohrich, Rod J. M.D. Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review. Plastic & Reconstructive Surgery. 119(3):48e-66e, March 2007.

Monday, June 11, 2007

Prevention of Dog Bites

I saw a young girl recently with a dog bite to her face. Her mother brought her in for me to check the scar (and remove the stitches placed in their local ER). The third full week of May is National Dog Bite Prevention Week, but it never hurts to review this information as more than 4.7 million people a year receive bites from man/woman’s best friend (and I dearly love my dogs).

Each year, nearly 1 million Americans seek medical attention for dog bites; half of these are children. Most dog bite-related injuries occur in children 5-9 years of age. Almost two thirds of injuries among children 4 yrs or younger are to the head or neck region. Dog bites are a largely preventable public health problem, and adults and children can learn to reduce their chances of being bitten.
Basic safety around dogs:
• Do not approach an unfamiliar dog.
• Do not run from a dog and scream.
• Remain motionless (“be still like a tree”) when approached by an unfamiliar dog.
• If knocked over by a dog, roll into a ball and lie still (“be still like a log”).
• A child should not play with a dog unless supervised by an adult.
• A child should immediately report stray dogs or dogs displaying unusual behavior to an adult.
• Avoid direct eye contact with a dog.
• Do not disturb a dog who is sleeping, eating, or caring for puppies.
• Do not a pet a dog without asking permission from its owner first.
• Do not pet a dog without allowing it to see and sniff you first.

Things to consider before adding a dog to your household:
• Learn about suitable breeds of dogs for your household.
• Dogs with histories of aggression are inappropriate in households with children.
• If your child is fearful or apprehensive around dogs, then don’t get one. it will not make the child less fearful.
• Spend time with a dog before buying or adopting it. Use caution when bringing a dog into the home of an infant or toddler.
• Spay/neuter virtually all dogs (this frequently reduces aggressive tendencies).
• Never leave infants or young children alone with any dog.
• Do not play aggressive games with your dog (e.g. wrestling).
• Properly socialize and train any dog entering the household. Teach the dog submissive behaviors (e.g. rolling over to expose abdomen and relinquishing food without growling.
• Immediately seek professional advice (e.g. from veterinarians or animal trainers) if the dog develops aggressive or undesirable behaviors.

Sunday, June 10, 2007

Tactile Quilts

The Quilt of Valor Foundation has asked for tactile quilts to give to blind or sight-impaired soldiers. The tactile sense training seems to help them train the brain to "see" in other ways. The reason is not fully understood, but is known as sensory substitution. This refers to the capacity of the brain to replace the functions of a lost sense by another sensory modality. The most commonly used form of sensory substitution is Braille reading which allows the blind to read by touch (somatosensory system).

So instead of just using the usual quilting cottons, the tactile quilts are made of fabrics with interesting feel: corduroy, jeans, flannel, wool (washable), linen, pleated fabric, ruched fabric. The one constant is the fabric needs to be washable. I know that one of the things I love about fabric (and yarn) shops is "touching" the fabrics. I won't buy a fabric (or yarn) if I don't like the way it "feels" to my touch.

So I tried to find more information as to how this "touch" (somatosensory system) was so important in training the vision impaired. I found a few sources, like this study done by Nicholas A. Giudice at the Minnesota Lab for Low-Vision, Center for Cognitive Sciences,University of Minnesota, it was shown that "blind participants demonstrated activation in primary visual, extrastriate and higher level visual cortices in response to tactile stimulation, whereas sighted subjects showed no such consistent "visual" activation to the same tactile stimuli. An important new finding is the observation of functionally relevant reorganization in all three blind participants. That is, while meaningful stimuli, like the Braille, embossed roman letters and tactile shapes showed the greatest and most defuse occipital activation in the blind subjects, the presentation of tactile noise alone showed little activation in these regions. In concert with this progression of salience and functional relevance is a fairly consistent pattern of areas associated with higher visual processing being activated by the more meaningful tactile stimuli across the blind participants."

Brain plasticity: from pathophysiological mechanisms to therapeutic applications. by Duffau H in J Clin Neurosci. 2006 Nov; 13 (9):885-97


The Occipital Cortex in the Blind, Lessons About Plasticity and Vision by Amir Amedi, Lotfi B. Merabet, Felix Bermpohl and Alvaro Pascual-Leone; 1Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center

Saturday, June 9, 2007

Scar Prevention


So the stitches are out, What can be done to minimize the scar? Scars may fade, but will not disappear.
  • First--remember that the wound/cut/incision is not "technically" healed at this point. The wound is just now entering that third phase, the maturation phase, of healing. The stitches need to come out early so that there will not be "stitch marks" or "rail road marks" from the stitches themselves. The area needs to still be protected from tension. Steristrips can do this, but so can a piece of paper tape applied along (or across) the "healed" scar. Both of these allow the strip or tape to have the tension placed on them rather than actual scar. The tensions are the scar will vary depending on its location. The shoulder gets a lot of tension as use of the arm is allowed (If we didn't allow use of the shoulder, it could "freeze" up--that's worse than a wide scar.) The breast/chest skin gets some tension with arm use, but can be decreased by not allowing backward motions of the arm (ie vacuuming) or full stretching, as in reaching for the top shelf.

  • Second--protect the scar from the sun. Apply sunscreen daily to the scar, if exposed (face, neck, hand), for 6 months or more. This will allow the red color (as the increased capillaries are absorbed) to fade.

  • Third--scar massage helps in the "realignment" of the collagen during the maturation phase (up to two years). It is easier to do scar massage if you use something like cocoa butter, vitamin E, Mederma, Aquafor, or just a favorite lotion. The key here is to do it. Gently massage along the scar. Gently "pinch" the scar up if the scar feels like it is trying to "stick" or adhere to the underlying tissues.

  • Fourth--If the scar allows (won't work on areas with great movement), silicone sheeting products can be used. It is hard to use both this and some of the scar massage suggestions at the same time. The Mederma or vitamin E, etc must be cleasned off the skin really well befor applying the silicone sheeting.
Scar revisions are not done for a minimal of 6 months, as we know that scars change, flatten, and fade. Exceptions to this rule are when the scar is obviously creating a tether across a joint (can not straighten the elbow) or deforming (pulling the lower eyelid away from the eye). If the scar appears to be getting "puffier" or thicker, it can often be helpful to inject the scar with Kenalog. This must be done carefully, as the injection can thin the scar/skin (atrophy) and decrease pigmentation in the skin. These risks must be weighed against the benefits expected to be gained.
Other things that can help with healing include: not smoking, good nutrition, and keeping other disease processes under control (ie diabetes and hypothroidism).

Friday, June 8, 2007

Basic Suture Techniques

Direct approximation of the wound margins is required for healing by primary intention. This is prefered when possible. However, if infection or excessive tension is present, then healing by secondary intention (spontaneous contraction and epithelialization) or tertiary intention (delayed surgical closure) will most likely be necessary. The following surgical axioms are important to remember in the goal of obtaining a fine-line scar that compromises neither function nor appearance:

Adequate debridement and hemostasis. All devitalized tissue and foreign bodies must be removed. Complete hemostasis should be acheived.
Atraumatic technique. Gentle handling of tissues is very important.
Alignment with relaxed skin tension line. Place elective incisions parallel to the lines of facial expression. Scars can be hidden in wrinkles.
Angle of incision. Incisions are placed perpendicular to the dermis except in the scalp and eyebrows where the incision should be parallel to the hair follicles.
Area of body. Areas of greater vascularity (head and neck, hands) usually yield better scars than areas of lesser vascularity (lower extremities).
Age of patient. Scarring is minimized in older patients due to decreases in skin tension and inflammatory response.

Critical elements include the obliteration of dead space, layered tissue closure, and eversion of skin margins. Deep dermal sutures align the skin edges and help decrease tension on the skin closure. Everting skin sutures are placed by encompassing a larger amount of deep dermis than epidermis in the closure. The suture is tied under the minimal tension necessary to appose the skin margins. Because nonabsorbable synthetic monfilament sutures (nylon, Prolene) are minimally reactive, they are preferred for skin closure when cosmesis is essential. Absorbable synthetic braided sutures (Vicryl, Dexon) are ideal for deep dermal closure, acting as transient but necessary skin splints. Absorbable natural sutures (catgut, chromic catgut) induce inflammation as they are degraded by phagocytosis. Still they are useful where suture removal is difficult and cosmesis is not critical (in the mouth, inside the nose, and non-facial wounds in children).

The simple interrupted suture is the most common skin closure method. Horizontal mattress sutures facilitate tissue eversion with the use of 50% fewer sutures. Vertical mattress sutures are useful in wounds under significant tension. Running sutures speed the closure of uncomplicated linear wounds. Subcuticular running sutures yield cosmetically pleasing results in wounds under mild tension.Optimal wound healing and epithelial migration occur in a moist environment free of coagulum or scab interposed between the healing surfaces. Epithelialization takes 2-3 days with air exposure, but only 18-24 hours with occlusion. So a light coat of antibiotic ointment and an occlusive dressing for 24-48 hours is beneficial. Most incisions may be safely cleansed with soap and water after this time. Sutures are removed after 3-5 days in the face and neck, 7-10 days in most other sites, and 10-14 days in the hands and feet. Suture marks are reduced by minimal tension on the skin closure and timely suture removal. In wounds under moderate tension, adhesive tape (Steristrips or paper tape) may be applied for 1-2 weeks to help minimize widening of the scar.

Thursday, June 7, 2007

Suture

It's not "Silver Threads and Golden Needles" used to repair a laceration. Nor is it these lovely threads from my sewing room at home. When I was in medical school (having used a needle and thread since age 5 yr) I often slipped and called suture thread. I thought it was an honest miss-speak as we "threaded" those Keith needles. My superiors (residents and staff) did not, and always corrected me. Suture, not thread, is used to repair lacerations.

Suture varies in characteristic---tensile strength, ease of handling, inflammatory response elicited, contribution to infection, knot security, and re sorption (only in absorbables). Suture may be absorbable or nonabsorbable. It may be monofilament or multistrand (twisted or braided together).

Absorbable--biologically derived:
Plain Catgut is derived from sheep or cattle bowel intima. It's has a tensile strength for only 4-5 days, and wound security is almost gone by 2 weeks. It has a moderate-to-high tissue reactivity. It glides poorly through tissue and requires multiple square knots to prevent the knot from unraveling. It is primarily used when tissue healing is rapid and there is minimal tension on the wound or when suture removal will be difficult (children).
Chromic Catgut has good tensile strength for up to 3 weeks. It is more reactive than catgut, so is most often sued for suturing mucosal surfaces (inside the mouth). There its added strength outweighs the increased tissue inflammation, and the scars are not visible.

Absorbable--Synthetic--Monofilament
Monocryl has excellent pliability for easy handling and tying. It is virtually inert in tissue (minimal to none tissue reactivity). It has predictable adsorption. At 1 week, 50% of the initial strength remains; at 2 weeks, 30% remains; and all the original suture strength is lost by 3 weeks. Absorption is essentially complete in approximately 3 months.
PDS (polydioxanone surgical) keeps its tensile strength longer. At 2 weeks, 75% of the initial strength remains; at 4 weeks, 60% remains; and at 6 weeks, 40% remains. Complete absorption occurs in 6 months. As a monofilament, PDS has less tendency to harbor bacteria. It has some intrinsic stiffness and a prolonged memory which some find difficult to handle during surgery.

Absorbable--Synthetic--Multistrand
Vicryl comes in dyes (purple) and un-dyed (white). It is braided. It has a lubricant coating which gives it excellent handling and smooth tie-down qualities. Its tensile strength retention at 2 weeks is 75% and less than 25% at 4 weeks. Complete absorption is between 2 - 3 months. It has low elasticity which predisposes it to cutting through soft pliable tissue if care is not taken ("approximate, don't strangulate"). It is most appropriate for buried intradermal or deep suturing. If placed too close to the surface of a cutaneous wound, Vicryl may be extruded (or spit) before dissolving completely.
Dexon is know for its excellent tensile and knot strengths. Also for delayed absorption and tissue reactivity when compared to catgut. Its tensile strength at 2 weeks is 20% and at 4 weeks on 5%. Complete adsorption occurs after 3-4 months.
Maxon has the excellent tensile strength retention. At 2 weeks its tensile strength is 80%, at 4 weeks 60%, and at 6 weeks 30%. Complete absorption takes place in 6-7 months.

Nonabsorbable--Natural
Silk is made of natural protein filaments spun by the silkworm, usually black (though can be white), and is braided. Possibly the easiest suture to handle (Isn't that true with silk thread too. And silk thread blends in so beautifully when appliquing!). It has the lowest tensile strength of all the sutures mentioned here. Even though it is classified as nonabsorbable, it losses most of its tensile strength in about 1 year and cannot be detected in tissue after 2 years. It results in more tissue reaction than any other suture material except catgut. Because of its increased tendency toward fluid absorption and capillarity, its use is undesirable in areas prone to infection.

Nonabsorbable--Synthetic
Nylon has a high tensile and minimal tissue reactivity. Its prominent memory is its main disadvantage, making it important to throw 3 plus square knots to hold the stitch in place. Although classified as a nonabsorbable, it partially degraded in vivo (in the body). It has only 90% of its tensile strength at 1 year, and only 70% at 2 years.
Prolene/Surgilene (polypropylene) is extremely inert. It expands when stretched (as with wound swelling postoperatively or injury) and helps prevent strangulation of tissue. It is extremely smooth and knot security requires extra throws (square knots) to compensate.
Ethibond/Mersilene (braided polyester) has greater tensile strength than most synthetic nonabsorbale sutures and has improved handling and knot-security qualities.
Wire sutures are stainless steel (so still no silver thread). They are available in monofilament or multistrand, and are seldom used except in sternal (breast bone) closure or tendon repair.

Skin--Healing a Simple Wound/Laceration


All wounds heal through the same orderly process. Consider the simple laceration which is a well-studied wound. There are three phases of wound healing: the inflammatory, fibroblastic, and maturation stages.


The Inflammatory phase begins with the injury/laceration which is the stimulus needed to initiate the cellular and vascular response that serve to clean the wound of devitalized tissue and foreign material. The initial changes are vascular--a transient 5-10 minute period of vasoconstriction (aids hemostasis) followed by active vasodilation. Inflammation begins after injury and peaks at three to five days. The wound site swells as the biochemical ingredients needed for healing gather: leukocytes and monocytes for bacterial phagocytosis (wound cleaning) and lysis, fibrinogen for adherence of wound edges, histamine, prostaglandins, and vasoactive substances for hemostasis. All this must occur to prepare the wound for the succeeding phases of healing. Therefore, drugs which limit inflammation, such as non-steroidal anti-inflammatories or steroids, can slow the healing of a wound.


The Fibroblastic Phase begins on day 2 or 3 with fibroblasts moving into the wound along a framework of fibrin fibers. These fibroblasts begin to proliferate and position themselves for their principal task, collagen synthesis. As collagen content increases, the number of synthesizing fibroblasts begin to decrease until the rates of collagen degradation and synthesis are equivalent (collagen homeostasis). This is the time when the wound site strengthens. Sutures may be removed in three to fourteen days, depending on their location. However, the wound's tensile strength and collagen content increase over the next several weeks; collagen turnover within the wound continues indefinitely.


The Maturation Phase (or remodeling phase) begins approximately 3 weeks after injury and lasts the longest. This phase may continue for several years, with concomitant improvements in wound appearance. During this interval collagen synthesis and degradation are accelerated (no net increase in collagen content), large numbers of new capillaries growing into the wound regress and disappear, and collagen fibers initally deposited in a haphazard fashion gradually become more organized and arranged into a pattern determined by local mechanical forces. The formerly indurated, raised, and pruritic scar becomes a softer, less conspicuous scar, while the wound continues to gain tensile strength. As new collagen is deposited during this phase, more stable and permanent cross-links are established.


The tensile strength of a wound is a measurement of its load capacity per unit area. All wounds gain strength at approximately the same rate during the first 14-21 days, but thereafter the curves may diverge significantly according to the tissue involve. In skin, the peak tensile strength is achieved at approximately 60 days after injury. Even given optimal healing conditions, the tensile strength of a wound never reaches that of the original, leveling off at about 80%.


If more information is desired on wound healing, a very good review is the article "Wound Healing: An Overview"written by George Broughton II, M.D., Jeffrey E. Janis, M.D. and Christopher E. Attinger, M.D., published in the Plastic & Reconstructive Surgery Journal Volume 117, Number 7S, June Supplement 2006.

Wednesday, June 6, 2007

Skin


A recent study by scientists at the National Jewish Medical & Research Center and the University of Colorado Health Sciences Center have discovered that skin cells ward off infection with a protein called human β-defensin-3. This study helps explain why infection of healthy skin cells rarely occurs, even though they are constantly exposed to bacteria. One more reason to be amazed by this amazing organ--skin.


The skin/integument system is the largest organ in the body. It is a tough, resilient barrier that covers the body. It is composed of an outer epidermis, an underlying dermis layer, and the subcutaneous fat layer. The structure of the skin varies considerably from one area of the body to another. The scalp is much thicker than the eyelid skin. The scalp has much more hair (for most of us) than our forearms. Our palms and soles have no hair. The axillary skin has many more sweat glands than the abdominal skin. The skin is commonly affected in systemic diseases. It is also the location of many diseases limited to the skin. It is often damaged by external stimuli such as fire, sunlight, chemicals, allergens, and infectious agents. The skin serves critical functions:

Protection• Thermoregulation• Immunologic Response• Barrier to water loss• Secretion of Wastes• Sensory

Tuesday, June 5, 2007

Robert Leroy "Lee" Archer, MD

Today my medical school classmate was honored with a "chair"--The Investiture of Robert Leroy "Lee" Archer, MD, the inaugural recipient of the Major and Ruth Nodini Chair in Neurology. Lee (Dr. Archer) is an associate professor in neurology at University of Arkansas for Medical Sciences (UAMS). He was honored with the endowed chair funded by friends, family and patients who want to remain anonymous. He chose the name (the Major and Ruth Nodini Endowed Chair in Multiple Sclerosis and Related Autoimmune Diseases) to honor the longtime, highly respected El Dorado residents and relatives
of his wife, Nancy.

Here is a brief summary of his bio printed in the program:
  • Lee was born in El Dorado, AR in 1956. He attended El Dorado Public Schools. He went to the University of Arkansas at Fayetteville on a track scholarship, graduating in 1978 with a BS degree in Natural Sciences. He married Nancy (Huskey) in 1977. He graduated from the UAMS College of Medicine in 1982 (class president), followed by an internship and Neurology Residency at UAMS. He immediately joined the faculty and next year will celebrate 30 years of being on the UAMS campus. He achieved the rank of Associate Professor in 1992. He has received numerous teaching awards from students and humanitarian awards from both students and colleagues. He currently serves as chairman of the University Hospital Ethics Committee.
  • He serves the community by organizing international medical mission trips to Honduras through his church, Trinity Presbyterian. He currently serves on the Boards of ARORA, the Pulaski County Medical Exchange, the Pulaski County Medical Society, and the Arkansas Division of the National Multiple Sclerosis Association. He is the immediate past president of the Pulaski County Medical Society and has served on the Board of Directors of the Arkansas Medical Society.
  • He developed an interest in multiple sclerosis early in his career after a visit from local representatives of the National M.S. Society. It has continued to be the primary focus of his clinical practice. He approached family and friends, who wish to remain anonymous, with the desire to fund an endowed chair for multiple sclerosis, to further the level of care and research at UAMS. He asked permission to name the chair after Major and Ruth Nodini, who had provided lifelong support and advice to Nancy and to him for over 30 years. Today we (family, friends, teachers, coaches, mentors, nurse, and M.S. advocates) honored him.

It's Happened Again

A patient calls–My right implant has ruptured. I woke up this morning and now my right breast is smaller than the other. I gently correct her–Your implant has deflated. Saline implants deflate, they don’t rupture.

Patient–Is it going to harm me?/I have a trip planned for this coming week. Me--Your body will simply absorb the IV saline that was used to fill the implant. It isn’t a medical emergency though it can be embarrassing. We can take our time and fit it into your life/work schedule (If patient is pregnant, it can safely wait until the delivery of her baby.) Put a shoulder pad or some other padding in your bra to even it out for now. When would you like to be seen?

Patient–Well what do we have to do? I didn’t realize they would do this. Me–Yes, I reviewed this with you before surgery. All implants fail at some point. Just like anything else man-made.

Patient–So what do we do now. Me--I will need to see you and then call the implant company to arrange the free implant replacement(s). Do you know if you have the "extended warranty"?

Patient–No, I don’t think so. I think my surgery was yyyy. Me–Okay, the extended warranty program didn’t exist prior to October 1, 2000, so you won’t get any other financial help. Just the free implants.

Patient–So what will this cost me? Me–The surgery center will charge you $800, anesthesia’s charge is $500, and my fee is $***(depends on time passed since surgery and whether I was the initial surgeon). This time we will make sure you get the extended warranty (I began paying for it for each patient out of my fee back in 2002 when I realized too many of them were failing to spend the extra $100.)

Patient–I will have to talk to my husband and see if we can afford that. Me–Okay, just let me know when you want to go forward. I will need a minimum of 2-3 days between the office visit and the surgery date (shipping time for the implants and the paper work to facilitate payment, if warranty is in effect). Would you like to schedule an appointment or call back after talking to your husband?


I truly appreciate the patient who remembers the preoperative discussion and who read the information brochure (pdf file). I try very hard to make sure the woman knows that the saline implant is not permanent. Approximately 1% deflate within 1 year, 3% within 3 years, and 10% within 5 years. Because of the warranty set at 10 years, I caution all of them that the mean deflation is 10-12 years (or half at that point). I tell them that it is rare to have a deflation at 1 year, but it can happen. And yes, the implant may last for 20 years, but don’t count on it. I tell them to begin saving money, if they get to 8-9 years without a deflation because they will likely end up out of the extended warranty period.

And all this is said on top of reminding them that this is surgery, the risks of surgery are infection, bleeding, anesthesia/drug reactions, scar, loss of/or decrease nipple sensation. The risks due to the implant include capsular contracture, asymmetry, visible wrinkling of the implant, deflation, repeat surgery to correct any of the before mentioned problems. You will need to be more careful with your mammograms. Four views will need to be done rather than just two. Make sure you go to a facility that is comfortable with implants and do mammograms often on women who have implants.

FDA Breast Implant Safety Report

Mentor Enhanced Advantage Warranty

INAMED (McGhan) ConfidencePlus™ & ConfidencePlus™ Platinum Breast Implant Limited Warranties

Monday, June 4, 2007

Flying Geese--a finished project

This is a picture of the finished quilt top from the previous post (Paper Work). It is 51" X 70" and will now be sent to a quilter (part of the QOV group). When finished it will be sent to a wounded (& hopefully recovering) soldier. The pattern is Flying Geese.

Now I will get to start planning another. I will get to go through my quilt books, get my sketch pad out (graph paper), and colored pencils. Then I will get to go through the fabrics I have on hand prior to going off to the fabric store. I had to make myself start doing this last step a few years ago as my "stash" got out of control. Now it is part of the challenge to use what I have and to only add as I need. [Don't always leave the fabric store with just what I went in for.]

Sunday, June 3, 2007

Good posture for Sewing (or Blogging)

For comfort and to decrease the risk of strain injury, it is important to pick a good chair and to set the sewing machine at a good height for your own body. Susan Delaney Mech, M.D answered this question as follows:
  1. The first step is to set the height of your sewing chair. The seat should be at a height that allows your feet to rest flat on the floor and your knees to make a perfect 90-degree angle. A secretarial chair makes a good, adjustable sewing chair.

  2. The next step is to lower your sewing machine table until, with your elbows bent at a perfect 90-degree angle, your fingertips can rest on the feed dog of your machine. I am 5 feet 6 inches tall, and my sewing machine table is 22 inches off of the floor.

  3. Proper chair and sewing machine height, combined with good posture of your back and neck, and hourly breaks, will go a long way toward preventing (or healing from) Repetitive Strain Injury.

Avoid slouching. Keep your neck and shoulders relaxed. Try to keep your elbow, hips, and knees at right angles (ninety degrees). Avoid pressure to the back of the knees. If your feet can't comfortably be flat on the floor, then consider a foot rest. You should also consider taking breaks every 30-60 minutes and do some stretching exercises for your wrists and hands and body. Sometimes, as in the OR, breaks can't be taken that often. Do the best you can with table/chair (computer moniter/OR table/etc) height and stretch when you are able. It will help keep the aches at bay and the joints a little more supple. That will allow you to enjoy your hobby (sewing, knitting, bloggin) and maybe your work for many more years.

You may want to check out this OSHA sewing station design page. Another interesting source for prevention of injury while sewing/quilting is a powerpoint presentation at Sport & Spine Physical Therapy website is "How to Quilt Forever"

Saturday, June 2, 2007

Snake in the Yard

I found this under my patio table in the backyard yesterday. Yikes! I really don't like snakes, but can deal with them when necessary. Fortunately, my husband was home. So he dealt with the snake (It's a good snake, says he.) while I took the dogs for a walk. It turns out he was right. The snake is a Eastern Hognose Snake (Heterodon platirhinos). In Arkansas, our poisionous snakes include Copperhead / Pigmy Rattlesnake, Cottonmouth, Timber Rattlesnake / Coral Snake, Western Diamondback Rattlesnake. Comparative risks tables place the annual death from drownings at more than 6,000 and the annual deaths from snake bites at 5.5.


There is a very nice review article of snake bites (Bites and Stings: Snake Bites) at Medscape. First Aid in the field (or home) consists of:
  1. Preventing systemic absorption of the toxin which may be done with compressive dressings and immobilization of the bitten extremity.

  2. If signs of envenomation begin to occur, a constriction band to impede lymphatic flow should be placed on the extremity, proximal to the bite. Transport to a hospital should take place immediately.

  3. The site should be wiped off and cleaned. The use of field first-aid methods such as incision and suction, tourniquets, and cryotherapy has been associated with a threefold increase in the likelihood of the need for surgical intervention.

  4. Although popular belief has it that snakebites kill within minutes, in fact, the toxicity from snake venom usually does not even begin to affect the body for several hours. In one review, 64% of deaths from snakebite occurred between 6 and 48 hours after the patient was bitten.

I have never in my years of practice had to deal with a snake bite, but have a healthy fear of cotton mouths and copper heads. I know that snakes may be an important part of our environment, but I still don't like snakes.

Have a safe summer enjoying the outdoors!