Monday, December 31, 2007

Wearing Heels

There is an article in my local paper today, "Bunion tip: If the shoe won't fit, don't wear it" It reminded me of this picture that I had saved from the September 10, 2001 issue of AMA News. I could not find it by searching their archives, so I scanned it in. The picture is the work of Susan Kingsley.


The article is by Jodi Farrell and lists 5 things to know about bunions. I have supplemented it with information from the American College of Foot and Ankle Surgeons.


It's the shoes

  • Bunions are 9 times more common in women than men. The most common cause of bunions is the prolonged wearing of poorly fitting shoes. Usually the ones with a narrow, pointed toe box that squeezes the toes into an unnatural position.
What are bunions
  • Bunions are often described as a bump on the side of the big toe. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion's "bump." Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become increasingly prominent. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.
Prevention
  • The best advise is to switch to shoes that fit properly and don't compress the toes. Don't select shoes by size because sizes can vary by brands and styles. Judge the shoe by how it fits on your foot. Make sure the toe box is big enough not to pinch.
Dealing with bunions
  • Some shoes can be modified by stretching the areas that put pressure on your toes. Splints may be used to reposition the big toe. Orthotics may relieve the pain. If your bunion is caused by arthritis, anti-inflammatory medication may help.
Surgery
  • When non-surgical treatment fails, the foot pain is severe, there is swelling or stiffness, then surgery may be suggested. The recovery period will be 6-8 weeks. While the bunion surgery can reduce the pain and align the toes better, it will not allow you to go on wearing too-small sizes or too-narrow shoes. Surgical options are covered in this eMedicine article.
These are the shoes I wear in the operating room
(and often out of the operating room).

Sunday, December 30, 2007

SurgeXperiences 112 -- Call for Submissions

The Sterile Eye  will be  hosting the SurgeXperiences 112  on January 6th.  It will be the first edition of the 2008.   Please submit your articles here, by January 4th.

Don’t forget to check out the 111th edition, hosted at Buckeye Surgeon

The Sterile Eye is a blog by a Norwegian medical videographer.  He  shares his experiences and thoughts on this rather unusual line of work.  Check out this post of his on image of surgery.

Saturday, December 29, 2007

Lady Jane's Fans

This is a quilted wall hanging I made back in 1997. It was finished in October of that year. I made it for my friend Jane from her husband's old ties and shirts. I made four quilts and the Christmas tree skirt for the family. There are four children, all grown now with children of their own. This one is named Lady Jane's Fans because Dr. McConnell called his wife Lady Jane. He was a big fan of hers. The background of the fan blocks is a woven silk. The sashing and border a checked brown/black corduroy fabric. I hand embroidered each block to add to the Victorian feel.
If you start at the top left of the first row,
this picture is block 1 and 2.


This picture is block 4 and 7
(second row would contain blocks 4-6)
This picture contains block 5 and 8.

This picture contains block 3 and 6.

And this is block 9.

Friday, December 28, 2007

Lipodystrophy

Lipodystrophy is an umbrella term, covering three separate and possibly related changes in the way our bodies handle fat cells. Lipodystrophy includes both gains and losses in the body's stores of fat and changes in the amount of fat circulating in the blood. Scientists haven't yet agreed on the best way to measure or describe these dysfunctions and predicting who is at most risk for them is difficult.

The first two listed here are physical (or body). They are the ones I will spend time discussing as these are the patients I sometimes see. The third is in the blood. The three forms are:

  • Fat wasting, also known as lipoatrophy -- In this form fat is lost from particular areas of the body:
    • face (sunken cheeks, temples, and eyes)
    • arms and legs (veins may become more visible; this is called "roping")
    • buttocks

  • Fat accumulation, also known as lipohypertrophy -- In this form, fat builds up in particular parts of the body :
  1. back of the neck and upper shoulders (often described as "buffalo hump")
  2. abdomen (also called "protease paunch" or "Crixivan potbelly") This abdominal fat gained is underneath the muscle wall (visceral fat) and feels firm to the touch.
  3. breasts (in both men and women)
  4. lipomas (fatty growths in different parts of the body)
  • The third type is known as hyperlipidemia or dyslipidemia. It has been linked to higher rates of heart disease and diabetes-like symptoms. Before the availability and use of anti-HIV drugs, HIV disease progression was associated with decreases in cholesterol levels, particularly "good" cholesterol. An increase in this blood fat is uniquely associated with using certain anti-HIV drugs.

Lipodystrophy in combination with hyperlipidemia and insulin resistance is called lipodystrophy syndrome. For the metabolic discussions, may I suggest you read the 2nd, 3rd, and 4th articles in the reference section.

From the plastic surgeons viewpoint, these patients present wanting to regain a more "normal" face/body.

NONSURGICAL THERAPY

  • Diet and Exercise--Diet and exercise are essential to maintaining muscle mass and lean body mass, but will do nothing to address the substantial atrophy of the face or remove the "buffalo hump".
  • Anabolic Steroids hormones, the synthetic derivatives of testosterone, are thought to prevent catabolism and help preserve lean body mass. At this time, the only approved indications for these drugs are anemia, hereditary angioedema, and metastatic breast cancer, so their use in HIV-related wasting or lipodystrophy is considered “off-label.” Many products are currently available, including nandrolone and oxymetholone. Inherent in the use of anabolic steroids are the risks of hypertension, which may be treated with antihypertensive medications, and liver toxicity. Liver function tests should be monitored closely.
  • Growth Hormone is a naturally occurring product of the anterior pituitary. Growth hormone directly causes lipolysis of adipocytes and has indirect anabolic effects by the action of insulin-like growth factor I. Baseline growth hormone concentrations were found to be decreased in patients with lipodystrophy when compared with concentrations in unaffected HIV patients. There are reports by Torres et al. and Wanke et al. using recombinant growth hormone in HIV patients with truncal obesity and buffalo hump. Improvements in visceral adipose tissue and buffalo hump were noted in all patients. In addition, Torres et al. found that those patients who discontinued treatment experienced a recurrence of their dystrophic fat. Adverse effects of growth hormone included arthralgias, myalgias, carpal tunnel syndrome, and impaired glucose tolerance and hyperglycemia. Although growth hormone therapy is probably the safest and easiest way of increasing lean body mass, its utility is limited because it is prohibitively expensive for these patients, who are already taking a multidrug regimen presumably for the rest of their lives.
  • Metformin is an oral hypoglycemic used in the treatment of type II diabetes. Metformin decreases gluconeogenesis, improves insulin sensitivity, and decreases intestinal absorption of glucose. HIV patients treated with metformin have been shown to have significant decreases in weight and waist circumference, along with greater decreases in visceral adiposity. Although metformin may have minimal effects on HIV lipodystrophy–associated body composition, no study to date has mentioned the effects of metformin on buffalo hump, and it has no effect on the lipoatrophy aspects of the syndrome. Metformin is generally well tolerated in this population. However, lactic acidosis is a persistent and
    serious risk and there has been one fatal case reported in a man being treated with a nucleoside reverse transcriptase inhibitor and metformin.
  • Experimental Medications -- Several newer medications have been investigated in the treatment of HIV-associated lipodystrophy. Studies of the thiazolidinediones, a class of drugs that decrease insulin resistance and gluconeogenesis, have reported conflicting results. Ultimately, no drug therapy exists to fully ameliorate or correct the cosmetic changes of HIVassociated lipodystrophy. Studies of human growth hormone, however, have produced the most substantial results. If it is cost effective, human growth hormone may be the pharmacologic treatment of choice for certain patients with HIV lipodystrophy.

RECONSTRUCTIVE SURGERY

Three problems that can be treated with reconstructive surgery are the abnormal areas of fat deposition in the cervicodorsal fat pad (buffalo hump), gynecomastia, and facial wasting. The options include

  • suction-assisted lipectomy for anatomic areas that show abnormal fat deposition
  • injection of natural substances, such as collagen, as well as synthetic substances, such as New-Fill (Ashford Aesthetics, Inc., Belgium, Germany) and Sculptra (Aventis Pharmaceuticals, Bridgewater, N.J.), to treat facial wasting;
  • surgical injection of autogenous fat
  • a combination of lipoaspiration of the buffalo hump and use of the aspirate as a donor graft
  • fat/dermal grafting
  • alternative tissue grafting, using material from donor sites with concurrent deformities, such as gynecomastia tissue and cystic parotid gland.


Suction Lipectomy

Dense adipose tissue is routinely encountered in these patients, particularly in the cervicodorsal fat pads. Ultrasound-assisted suction lipectomy may make it easier (as compared to traditional liposuction) to do body contouring of fibrous areas. Timing of surgery and antibiotic prophylaxis is important, as the viral load in HIV-positive patients fluctuates during the course of their illness. It is recommended that surgery be postponed (1) during increased viral activity, (2) when preoperative laboratory results reveal an inversion of the normal 2:1 CD4-to-CD8 ratio, or (3) when patients report increased fatigue or weight loss.

Facial Fillers

New-Fill and, more recently, Sculptra, a hydrogel of microspheres of polylactic acid, have been used to correct facial fat atrophy in HIV lipodystrophy. In a large European study, 50 patients with HIV facial wasting were treated with New-Fill. At week 96, 43 percent of patients had increased their subcutaneous facial thickness more than 10 mm. Sculptra is a newer form of polylactic acid recently approved by the U.S. Food and Drug Administration for facial fill in HIV wasting. Treatment, however, is staged, time-limited, and expensive, ranging from $8000 to $10,000 per full course of treatment. Although no large studies have evaluated its efficacy in this population to date, it may serve an adjunctive role in the treatment of facial wasting. However, because severe wasting results from wasting of the buccal fat pad of Bichat, and the hollows of the malar region are also particularly deep, these superficially injected fillers may not adequately address the needs of the patient with severe facial wasting.

Autologous Free Fat

Serra-Renom et al. recently reported a series of HIV lipodystrophy patients with facial atrophy treated with autologous fat injection. Thirty-eight patients underwent augmentation with fat obtained from the infraumbilical region by liposuction. Symmetry and volume were evaluated at 6 months and 1 year, and in 12 cases, a new fat injection was performed to improve symmetry and resorption (often none of the fat will remain at 6 months and the loss may be uneven leaving a lumpy result). Some facilities may have the resources to store extra aspirate (frozen) which can then be injected 2 to 3 months later. This can be useful, as there is usually some resorption of the transplanted fat. Areas of dystrophic fat, such as the buffalo hump and gynecomastia tissue, are good sources for the fat used for augmentation. As the fat needs to be harvested and then injected and may need to be repeated this can be expensive.

Dermal-Fat Grafts

Strauch et al reported the use of dermafat transfers to the malar area for HIV facial wasting in five patients. The aesthetic results were dramatic and stable, lasting throughout the 1- to 2-year follow-up period. Dermafat grafts (dermis and fat in combination) have the ability to vascularize and persist indefinitely which may make them an attractive option in the reconstruction of HIV facial atrophy, either alone or in conjunction with other surgical techniques. The downside is the donor site which may result in an unsightly scar.

Malar Implants

Malar implants possess several substantial risks in the HIV population. The most serious of which are delayed infection and exposure, to which this immunocompromised group is already disposed. There is has been a few cases of the implants eroding through the thin wall of the anterior maxilla. This option may be less risky in non-HIV patients.

 

Algorithm (from the 6th reference below) lists Dr. Stevenson's preferences for surgical correction of HIV lipodystrophy. "Blue boxes indicate the presenting problems of HIV lipodystrophy: buffalo hump, gynecomastia, cystic parotid, and facial wasting, which we further classify as mild, moderate, or severe. Mild or moderate wasting may first be addressed with facial fillers and fat injection of buffalo hump (if available). Buffalo hump, if present, may initially be treated with suction-assisted liposuction (SAL); if it recurs or persists, it may need to be addressed with ultrasound-assisted liposuction (UAL). Gynecomastia may be treated with a subcutaneous mastectomy, and cystic parotid enlargement can be addressed with parotidectomy. Both of these autogenous tissues then may be used for treatment of severe cases of facial wasting, and they are more permanent than fat injection. These treatments may then be supplemented by additional fat injection."

REFERENCES

Lipodystrophy and Women--March 2005 Article at TheBody.com

Update on Lipodystrophy...Or Is It Just Lipoatrophy? by Donald P. Kotler, MD -- MedScape Article, 2002

Lipodystrophy, Generalized by Robert A Gabbay, MD & others --eMedicine Article, July 17, 2007

Lipodystrophy, HIV by Ali Hendi, MD & others -- eMedicine Article, January 18, 2006

Lipodystrophy -- DermNet NZ, updated 12-25-2007

Surgical Algorithm for Management of HIV Lipodystrophy; Plastic & Reconstructive Surgery, Vol 120(7):1843-1858, December 2007; Davison, Steven P. M.D., D.D.S.; Timpone, Joseph Jr M.D.; Hannan, Catherine M. M.D.

Cosmetic Interventions for HIV-Associated Lipoatrophy by Graeme J. Moyle, MD, MBBS -- MedScape Article

Thursday, December 27, 2007

Review of Medical Expenses--Update

This review was first posted on December 14, 2007.  I have added a couple of paragraphs at the end, as well as some (blue ink) changes in the chart.

My friend who incurred the self-inflicted gun shot wound to his right forearm has gotten his medical bills. I ask him to allow me to review them. I was interested in what was billed and what the insurance company actually allowed. Notice how long it has taken to get everything (well not everything--ambulance services still pending review) through insurance review (late August until today). Here is the breakdown.

Service Rendered   Billed Insurance Allowed Patient Responsibility
Ambulance--
ALS Emergency
Mileage ALS
Pulse Oximetry
IV Supplies
Disposable Supplies
 
$488.00
$146.25
$36.00
$42.00
$42.00

$463.00
$     9.00
$ 27.00
$ 39.00
$ 16.00
EMT service has no contract with insurance company, so no reduction--
$754.25
Hospital Charges
Radiology-
Emergency Room
Drugs
  $836.32
$213.93
$554.39
$ 68.00
$459.98
(insurance didn't break it down on their statement)
$459.98
ER Doctor Charges   $273.00 just received (12-22-07) & sent to insurance Paid $273 while waiting for insurance
X-Ray Reading   $28.00 $12.18 $12.18
Generic Pain Med   $4.06 $4.06 $4.06
         
Secondary
Wound Closure (done in office)
  $650 not actually billed (maybe $356 on hosp % reimburse) not actually charged (maybe $356 as based on ER reimbursement)
At home dressing
supplies
  not covered by insurance
$30.06
not covered
$30.06
$30.06 (Coban, guaze, etc)
         
Total Expenses   $2,575.69 $1,416.28* $1,889.53*

My friend has a Medical Savings Account so has a high deductible ($5700). The insurance coverage did decrease his actual out-of-pocket responsibility by "not allowing" $392.16 (more depending on the ambulance bill outcome). This is also money that the hospital and ambulance service did not receive. I know he is grateful for the savings. I, however, also see the other side. A reduction of nearly 50% seems absurd. Is the medical community really overcharging that much? Or are we charging fairly to cover the expenses of the hospital/office? Just as Wal-Mart has a built in "padding for loses" for each item sold (covers losses due to theft /shop lifting), the hospitals/offices need to be able to have the same "padding" to cover the services that aren't paid for by the patient (under-payment by Medicare/Medicaid, no insurance, simply doesn't pay, etc).

 

Update 12-27-2007

My friend received a bill from the ER doctor which is (apparently) separate from the hospital charge.  This bill arrived on December 22, 2007, nearly 4 months after the injury!  It had not even been sent to the insurance company first, even though I am sure the ER doctor had access to this information. 

Turns out the EMT (ambulance service) does not have a contract with his insurance so they balance bill for the entire amount. 

Wednesday, December 26, 2007

Postop Hematomas in Plastic Surgery

In the most recent issue of the Aesthetic Surgery Journal (ASJ), there is an interesting article on postoperative hematoma formation in plastic surgery patients. We have long been aware of the correlation of postoperative hematomas and blood pressure. (BP) Most of these studies have been done in face lift patients. In 1973, Straith showed that patients with elevated BP (greater than 150/100 mm Hg) on admission had a 2.6 times greater incidence of postop hematoma formation. Berner suggested that the patient should be medically protected against uncontrolled postop elevated BP's to reduce the incidence of postop hematomas. Postoperative "reactive hypertension" can be caused by coughing, retching or vomiting, postoperative pain, and anxiety. For facial and head/neck procedures, we ask patients to avoid bending over with their head down. We ask them to squat to pick up dropped items or ask someone else to pick them up. Baker used a strict antihypertensive and perioperative blood pressure control regimen of chlorpromazine, valium, and clonidine which reduced his incidence of postop hematomas from 8.7% to 3.97% in his face lift patients.

The ASJ article (see first reference below) was done in patients undergoing body contouring surgery (abdominoplasty, thigh lifts, etc). Many of these patients were placed on antithrombotic therapy, because most of them were massive weight loss patients, the surgery was of increased length, and the current (rightfully so) interest in preventing pulmonary embolus in surgery patients. The incidence of hematoma formation in abdominoplasty surgery ranges from 1%-10%. This study looked at blood pressure and antithrombotic therapy as risk factors in the formation of postop hematomas.

Plastic surgeons have long asked the anesthesiologist to keep the patient's blood pressure low (hypotensive anesthesia) for many of our procedures. This does result in lower pressures within the small vessels and capillaries, which helps keep the surgical field "dry". However, once the patient has returned to their normal blood pressure, these small vessels and capillaries may open (ones that weren't cauterized because they weren't bleeding and therefore missed), and bleeding may ensue. This may lead to a postop hematoma.

So it may be time to give up hypotensive anesthesia, as we begin to use more antithrombotic therapy. Of their 360 patients, 137 received enoxaparin (Lovenox). There were 11 (3.1%) hematomas among the 360 patients. Ten of the 11 (90.9%) occurred in patients receiving Lovenox. These patients were then evaluated for perioperative blood pressures and compared to similar patients without hematoma formation. Mean preoperative MAP's were similar (97.4 mm Hg in the hematoma patients, 95.8 mm Hg in the non-hematoma patients). The mean intraoperative blood pressures (within the last 2 hours of each case) differed significantly. In the hematoma patients, the MAP was 66.7 mm Hg and 82.4 mm Hg in the non-hematoma patients. Postoperative MAP's were 96.3 mm Hg in the hematoma patients and 88.5 mm Hg in the non-hematoma patients.

Though the risk of pulmonary embolus is small (0.1%-0.3%), they can be fatal. So currently, most surgeons feel that the increased risk of hematoma formation from use of antithrombotic prophylaxis is worth it. The things we can do to reduce the risk of hematoma formation are try to keep blood pressure more even between pre-, intra-, and postoperative periods. Then the small capillaries and veins that might get missed by hypotensive anesthesia can be seen and cauterized and the ones that might be missed would be less likely to bleed if the "hyper"tension postoperatively didn't occur.

  • Patients who are taking antihypertensive medication should be well maintained until the time of surgery and reinstated as soon as possible postoperatively.
  • Patients should be informed to stop all medications that can cause bleeding, such as aspirin, St. John’s wort, gingko, nonsteroidal anti-inflammatory drugs, and others. Aspirin and aspirin containing compounds are stopped for 2 weeks before surgery and 1 week postoperatively.
  • Patients should adhere to the restrictions given them postoperatively. It is good to get up and move, but do so in a way as to not raise your blood pressure. No heavy lifting means that. No speed walking or jogging means that. Squat rather than bending over.

REFERENCES

The Effect of Blood Pressure on Hematoma Formation with Perioperative Lovenox in Excisional Body Contouring Surgery; Aesthetic Surgery Journal, Vol 27, No 6, pp 589-593; Jordan P. Farkas, Jeffrey M. Kenkel, Daniel A. Hatef, Gabrielle Davis, Tuan Truong, Rod J. Rohrich, Spencer A. Brown

The Study of Hematomas in 500 Consecutive Face Lifts; Plastic & Reconstructive Surgery. 59(5):694-698, May 1977; Straith, Richard E. M.D.; Raju, D. Raghava M.D.; Hipps, Chauncey J. M.D.

Postoperative Hypertension as an Etiological Factor in Hematoma after Rhytidectomy; Plastic & Reconstructive Surgery, 57(3):314-319, March 1976; Berner, Robert E. M.D.; Morian, William D. M.D.; Noe, Joel M. M.

Reducing the Incidence of Hematoma requiring Surgical Evacuation following Male Rhytidectomy: a 30-year Review of 985 Cases; Plastic & Reconstructive Surgery. 116(7):1973-1985, December 2005; Baker, Daniel C. M.D.; Stefani, William A. M.D.; Chiu, Ernest S. M.D.

Aggressive pharmacologic protocols may be associated with TJR complications: To guide orthopedists in selecting prophylaxes, AAOS has issued new recommendations. By Susan M. Rapp ORTHOPEDICS TODAY 2007; 27:18

Tuesday, December 25, 2007

Monday, December 24, 2007

Christmas Tree Skirt

Here are some pictures (I finally found) of a Christmas tree skirt I made for a friend and his family. Vern McConnell, MD died in 1995. I told his wife, Jane, that I would be happy to make a quilt from his bow ties and shirts. Two years later she was ready and mailed me a large box of some of his clothing and ties. This is one of the items I made the family. The snowmen are from a terry cloth shirt (tennis shirt I think). Their scarfs are from the shirts and ties. The presents under the trees are from the labels on the ties and shirts. Some great labels! The buttons are from the clothing. The background fabric is a deep blue velvet that I had from making a dress.

The trees are just some green cotton fabric I had in my "stash".
The hats are both from his clothing and my fabric stash.
I made a several wagons using a label and buttons.

The "globe" was a label I turned into a ball.


Sunday, December 23, 2007

SurgeXperiences 111 is up

SurgeXperiences 111 is up over at Buckeye Surgeon. So take a break from your Christmas shopping, etc and grab some Christmas cheer. It is a great edition!

There is no host for the 112 edition yet, so please do not hesitate to contact Jeffrey if you are willing to host the 112 or a future edition.

UPDATE: The Sterile Eye will be hosting the 112th edition of the SurgeXperiences surgical blog carnival on January 6th. Please submit your articles here, by January 4th.

Saturday, December 22, 2007

Spiced Nuts Trail Mix

I love spiced nuts and usually make some every Christmas season. Spiced nuts make easy gifts for the delivery guys (Fed Ex, UPS, US Postal person) at the office, not to mention I have several family members who like them. This year I did them a little different. After spicing the nuts, I added some Chex Mix (chocolate peanut butter), and dried cranberries. It's really good and so easy! Here's the recipe:

Spiced Coated Nuts

3 egg whites
1 cup sugar
1.5 tsp ground cinnamon
1.5 tsp ground cumin
1.5 tsp black pepper
1.5 tsp ground red pepper (I left this out)
1 can (34 oz) Mixed Nuts

PREHEAT oven to 325°F. Beat egg whites in medium bowl with wire whisk until foamy. Add sugar and seasonings; beat until well blended. Add nuts; stir until evenly coated.

SPREAD into two lightly greased 15x10x1-inch baking pan (half on each).

BAKE 20 min., stirring occasionally. Cool completely. Store in airtight container at room temperature or use in the below recipe.

Now this is where I started added things:

Spiced Nuts Trail Mix

1 cooled pan of spiced nuts
1 cup dried cranberries
1 12 oz pkg of Choc- Peanut Butter Chex Mix
1 cup of Sam's Choice Nature Trail Mix

Store in airtight container at room temperature or in refrigerator. Enjoy and share!





"Roar" for Junkfood Science

Sandy Szwarc who writes Junkfood Science has been awarded a "Roar". I wanted to congratulate her. Her site does not allow comments, so this is my way of doing just that.

She was given the award by Harriet Brown, a journalist who writes passionately about issues important to women and children. The "Roar" award is a project launched at The Shameless Lions Writing Circle to celebrates the best and most powerful writing in the blogosphere.

Congratulations to Sandy at Junkfood Science. Keep up the great work. If you have never checked out her blog, please, do so.

Friday, December 21, 2007

Breast Swelling as a Medication Side-effect

A patient called last week upset that a drug, domperidone, she has been taking for her GI problems has enlarged her breasts. She had a breast reduction done several years ago (not one I did, I did some scar revision work for her), so this did not make her happy. She came in to talk about redoing her breast reduction. The enlargement is asymmetrical with one being much larger (about 1 bra cup bigger) than the other. This is not a complaint that plastic surgeons hear very often. I was not sure what to tell her regarding insurance. I told her that she will need a mammogram (her yearly is due anyway) to rule out something non-medication related. If the mammogram is normal, I think this will be a case where it would be good to do a pre-approval letter (or medical necessity letter) in advance unless she just wants to take her chances or pay out-of-pocket. It's tough enough getting insurance companies to pay for a breast reduction. Even though legit, I'm sure they will need convinced that a woman might need a second one.

Here are a few more commonly used drugs known to have this side-effect (swollen breasts, breast enlargement, or gynecomastia):

Carbemazepine (TEGRETOL®)

Cimetidine (Tagamet)

Chlorpromazine (Thorazine)

Clomipramine hydrochloride (Anafranil)

Doxazosin (Cardura, Cardura XL)

Dutasteride (Avodart)

Estrogens (including most birth control pills)

Ethosuximide (Zarontin)

Haloperidol decanoate

Methdilazine Hydrochloride (active ingredient in Dilosyn)

Methyldopa (Aldomet)

Metoclopramide (Reglan)

Nilutamide (Anandron®, Nilandron®)

Risperidone (Risperdal)

Sustiva (efavirenz, EFV)

Here is a list of drugs (according to the Physician Desk Reference) that can cause gynecomastia as a side effect. The risks are generally very low for male breast enlargement from these medications, but breasts in men can be a cause for embarrassment. [And often women don't mind a small (if symmetrical) enlargement.] Don't forget that some medications may be very important for your other medical problems.

Wednesday, December 19, 2007

Reduction Mammoplasty

Breast reduction (or reduction mammoplasty) is an operation designed to reduce and reshape large breasts. It is a surgical procedure designed to help reduce and in many cases eliminate, the pain and other symptoms associated with large breasts. Discomfort associated with large breasts can include chronic back, neck, and shoulder pain, as well as painful shoulder grooves from bra straps. It can also include chronic rashes under the breasts in the inframammary fold. These are the medical reasons to have a breast reduction. Most insurance companies will cover breast reduction surgery done for medical reasons. Be sure to check your policy.

Non-medical reasons may include difficulty finding a bra that will fit. also limit women’s abilities to perform routine daily activities and may cause significant emotional distress. By reducing breast size, breast reduction surgery can relieve many of these symptoms. It can also make it easier to perform routine daily activities and exercise more comfortably.

Some Historic Aspects of the Procedure

In 1922 Thorek introduced the free nipple grafting technique. A significant advance was the introduction of the pedicled nipple-areolar transposition, which improved nipple survival, provided a way to correct ptosis (sagging), and gave a possibility of breast feeding post-reduction (by leaving some of the gland tissue connected to the ducts). Schwarzmann introduced the concept of maintaining the dermal attachments to the nipple as a means of preserving or protecting its blood supply in 1937. This remains important in every procedure used today.

In 1956, Robert Wise published on his experience with a refined pattern that he had previously designed in the form of a key-hole. he emphasized the need for accurate preoperative marking and  provided a pattern for the "key-hole". This Wise pattern has been the workhorse for skin incision for breast reduction for several decades. It leaves an anchor-shaped (or inverted T) scar with a periareolar circle, a vertical scar in the midline of the inferior mammary hemisphere, and a curvilinear scar along the inframammary fold that follows the curved shape of the inferior pole of the breast. (photo credit)

In 1972, Paul McKissock modified Wise's technique by increasing the length of the vertical limbs of the design to try to compensate for the flat lower pole that was being achieved. It is now recognized that McKissock's technique tends to often result in the opposite effect, which is a "bottoming-out" and is not very well tolerated by patients and surgeons.

The vertical scar incision pattern was originally designed by Claude Lassus in 1964 and reported in 1970, with the problem of the inferior portion of the vertical scar ending up extending below the inframammary fold. Lassus corrected this by adding a small horizontal scar along the inframammary fold. Later on, he realized that the small horizontal scar ended up migrating up  toward the lower hemisphere of the breast. He subsequently redefined the pattern of skin excision until achieving one that left only a vertical scar above the inframammary fold. This is the skin incision that is used in the so-called Lejour technique (Madeleine Lejour, MD 1994).   (photo credit)

 

Each technique has advantages and disadvantages. The superior pedicle method (which involves the resection of the medial, lateral, and inferior portions of the breast tissue) was originally described by Daniel Weiner in 1973. It gained more popularity in Europe, initially, than in North and South America. It was thought to put at risk the sensation of the nipple-areola complex because of the belief that it transected the lateral branches of the fourth intercostal nerve. The sensory branches to the nipple-areola complex are now known to run deep at the level of the chest wall and perforate superficially through the breast tissue to reach to nipple areola complex. For this reason, it is good to keep some tissue on the pectoralis muscle/chest wall as it preserves the nerve supply to the nipple-areola complex and, thus, its sensation.

Today, the tendency is towards Vertical Scar Techniques rather than the ones that use the Wise pattern procedures. However, with truly large (greater than 1000 gm resections) breasts or Grade III ptosis with nipple to inframammary fold lengths greater than 20 cm that is not always possible or advisable. There are times when free nipple grafts are still the best option (safest).  (photos credit)

  

There is also interest in

liposuction reduction mammoplasty. Many insurance companies will not pay for this type of reduction mammoplasty. Liposuction reduction mammoplasty is contraindicated in breasts that are mostly glandular and in the presence of ptosis and/or poor skin elasticity. The only "lift" gained from this type of reduction depends on the skins elasticity.

 

Complications

In general, postoperative complications are seen more commonly in patients with large resections, obesity, history of tobacco use, and young age. Some evidence suggests that wound dehiscence, fat necrosis, and infection are less common in patients who undergo the Lejour technique than in those who undergo the Wise pattern and inferior pedicle techniques. However, some asymmetry, particularly along the bottom edge, tends to be more common in patients who undergo the Lejour technique; revision rates can be up to 10%. Liposuctioning of the breast has not been shown to increase the rate of local complications

Nipple necrosis

The incidence of complete nipple necrosis is 0.5%. Partial nipple necrosis occurs in a similar percentage of patients.

Infection

As with any surgery, infections can occur. They are not common (0.5-10%) in breast reduction surgery. Most surgeons give perioperative cephalosporins which has been shown to decrease the rate of infections.

Revisions

The revision rate will vary depending on the procedure done (from 1-10%). It may be done for puckers (vertical scar reduction) that may need to be excised. Puckers are often more of a problem of residual subcutaneous tissue (along the inframammary crease region) than of excessive skin. Or to correct an asymmetry problem. Or to correct hypertrophic scars.

Fat necrosis

Fat necrosis is usually minor and related to what is thought to be parasitic fat along the margins of the pedicle. Minor amounts of fat necrosis can be missed unless the breast is specifically examined for this complication. No treatment is needed except for explanation and reassurance. Patients do not usually require surgery to treat this complication.

Wound dehiscence

Delayed healing may occur and is most likely to be a problem at the inferior end of the vertical incision, where skin gathering is performed in the vertical scar reduction. It is common in the Wise-pattern reductions at the "corners" where the "T" forms. Care must be taken to close the vertical incision loosely and with superficial bites so that the skin is not constricted. This is more common with large reductions and in the obese patients.

Hematoma

Hematomas are usually minor when they occur and can be treated conservatively. It is very rare to have a major hematoma after a breast reduction. Some plastic surgeons routinely use drains. Many of us don't.

 

 

REFERENCES

Breast Reduction, Lejour by Antonio Espinosa-de-los-Monteros, MD -- eMedicine Article

Breast Reduction, Simplified Vertical by Elizabeth J Hall-Findlay, MD -- eMedicine Article

Breast Reduction, Inferior Pedicle by Susan E Downey, MD -- eMedicine Article

A preliminary report on a method of planning the mammoplasty; Wise RJ; Plast Reconstr Surg 1956 May; 17(5): 367-75

Breast reduction: evolution of a technique--a single vertical scar; Lassus C; Aesthetic Plast Surg 1987; 11(2): 107-12

Reduction mammaplasty with a vertical dermal flap; McKissock PK; Plast Reconstr Surg 1972 Mar; 49(3): 245-52

Vertical mammaplasty and liposuction of the breast; Lejour M; Plast Reconstr Surg 1994 Jul; 94(1): 100-14

Insurance Coverage: A Patient's Guide -- American Society of Plastic Surgeons Website

Breast Reduction, a Guide for the Patient –ASPS

 

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Medical Blog Awards


Thanks for nominating me for the Best NEW Medical Blog Award. I am honored that I have readers. Many thanks to all of you.



Here is the list of the other (very worthy) nominees:

Belaray Dermatology

Canadian Medicine

Corazén Hispano

Dr Shock MD PhD

EverythingHealth

The Happy Hospitalist

MedBlog.nl

NY Emergency Medicine

Update (12-21-2007)

These have been nominated since I first posted this:

Baby blue pyjamas
The Derm Blog
KOLAHUN
The Physician Executive
Unprotected Text

Update (12-26-2007)

More nominations for the Best New Medical Blog 2007 Award:

CareerMedicine
Dr. Val and The Voice of Reason
A fortunate man
Mousethinks
Prudence, M.D.
Respiratory Therapy 101: Just Keep Breathing
TomographyBlog

Tuesday, December 18, 2007

Marking

Marking is very important in both my quilting and my surgery work. I don't mean the kind of marking that gives you "yellow snow" (nod to Frank Zappa) or the kind that leaves you a trail of crumbs to find your way home (Hansel and Gretel).

In plastic surgery, a lot of time can be spent in the preop area marking your patient. So you want a marker that won't wash off so easily that it is gone with the scrub. For breast and body "work", I use (and the nurses tell me so do most of the others) a black Sharpie.


It is marketed as a permanent marker, but I still find that I have to remind the person prepping the patient to not "scrub too hard" or "that's enough". When you have marked the patient standing or bending in different ways to be sure you get the most skin removed, these positions and maneuvers can't be duplicated in the operating room. During the procedure, I use whatever marker the hospital has, usually the Accu-line products. Those are also what I use when I need a really fine line (ie eyelid) when marking.

 

The skin marker should be nontoxic and non-allergenic. If used during the procedure, then it must be sterilizable. The ink must have a visible color and must be non-reactant  with other chemicals used on the skin (e.g., povidone iodine). The ink must be resistant to mechanical cleaning but removable in time.

The photo to the right is from the first article referenced below. Note how the ink "disappears" with the scrub. Their skin marking ink (1) and frequently used skin markers (2, methylene blue dye; 3, Securline, a surgical skin marker; 4, red permanent marker; 5, black permanent marker; and 6, Viscot, a surgical skin marker). (Center) Skin prepared with povidone iodine solution and scrubbed five times. (Below) Skin prepared with Betadine and scrubbed five times. Their marking ink --The formula consists of basic fuchsin (1.3 g of dye material), 5.6 ml of acetone (resolvent), 11 ml of alcohol (dissolvent), and 100 ml of distilled water. This formula may be diluted by adding alcohol.

 


In quilting, you want a marker that will stay long enough to see the pattern you are quilting. You want to be able to either "brush" it off gently later (as with chalk pencils) or to wash it out. The different colors of fabrics used can sometimes make this more challenging. For the quilt I am preparing for hand quilting, I used the blue washable marker on the "mustard" (light fabric) and a silver chalk pen on the brown (dark fabric). Here are some links to tips by experts like Ami Simms (blue washable marker), and Sharon Darling (Quilter's Choice Marking Pencil, Miracle Chalk).



REFERENCES

Skin Marking in Plastic Surgery; Plastic & Reconstructive Surgery, 115(5):1450-1451, April 15, 2005; Ayhan, Meltem M.D.; Silistreli, Ozlem M.D.; Aytug, Zeynep M.D.; Gorgu, Metin M.D.; Yakut, Macide M.D.

Quilt Tips From Quilters Around The World--Marking Tips

Appalachian Mountain Quilters Marking Techniques by Kimberly Wulfert

Monday, December 17, 2007

Dan Fogelberg (Aug 13, 1951-Dec 16, 2007)

Dan Fogelberg died yesterday, Dec 16, 2007, at his home in Maine after battling prostate cancer. He was "big" in the 70's during my college years, so his music is associated with good memories for me. Please go to the Prostate Cancer Foundation for more information on the disease (diagnosis, treatment, etc).

From his official Web site

Sunday, December 16

Dear friends,
Dan left us this morning at 6:00am . He fought a brave battle with cancer and died peacefully at home in Maine with his wife Jean at his side. His strength, dignity, and grace in the face of the daunting challenges of this disease were an inspiration to all who knew him.

He had a long list of songs (lyrics can be found here), but at this time of year it's the Same Auld Lang Syne always brings tears to my eyes. Here it is:

Sunday, December 16, 2007

SurgeXperiences 111--call for submissions

The next edition of SurgeXperiences will be hosted by Buckeye Surgeon on December 23. Please feel free to submit a post (or two) regarding your experience with surgery here. The deadline for submission is December 21st.

The 10th edition of SurgeXperiences has been posted by Dr. Alice over at “Cut on the dotted line”. If you missed it, head on over and check it out.

And since it's the Christmas baking season, in honor of Buckeye, here's a recipe for Buckeye Candy. Enjoy!

Buckeye Candy
Yields - 72 candies (6 dozen total)
The perfect combination of peanut butter and chocolate -- a "chocolate lover's" dream come true....

Ingredients:

  • 2 cups creamy peanut butter, (not all-natural)
  • 1/4 cup (1/2 stick) butter or margarine, softened
  • 3 3/4 cups (16-oz. box) powdered sugar
  • 2 cups (12-oz. pkg.) Semi-Sweet Chocolate Morsels
  • 2 tablespoons vegetable shortening

Directions:
LINE baking sheets with wax paper.
BEAT peanut butter and butter in large mixer bowl until creamy. Beat in powdered sugar until mixture holds together and is moistened. Shape into 1-inch balls; place on prepared baking sheets. Freeze for 1 hour.
MELT morsels and shortening in medium, uncovered, microwave-safe bowl on HIGH (100%) power for 1 minute; STIR. Morsels may retain some of their shape. If necessary, microwave at additional 10- to 15-second intervals, stirring just until melted.
DIP peanut butter centers into melted chocolate using a toothpick, leaving a small portion of the center uncovered. Shake off excess chocolate and scrape bottom of candy on side of bowl. Return to baking sheets; refrigerate until chocolate is set. Store in covered container in refrigerator.

Saturday, December 15, 2007

Christmas Stockings

Here are three Christmas stockings. The front of the stocking is pieced and then quilted prior to being cut and sewn into a stocking. All are fully lined. The first one is a simple four-patch pattern using four fabrics for the "patches".


This one uses two fabrics sewn together into strips. The "cuff" at the top is large
I think it would be nice to have a name embroideried onto it.
This one is a "bow-tie" pattern using two fabrics.

Friday, December 14, 2007

Review of Medical Expenses

My friend who incurred the self-inflicted gun shot wound to his right forearm has gotten his medical bills. I ask him to allow me to review them. I was interested in what was billed and what the insurance company actually allowed. Notice how long it has taken to get everything (well not everything--ambulance services still pending review) through insurance review (late August until today). Here is the breakdown.

Service Rendered BilledInsurance AllowedPatient Responsibility
Ambulance--
ALS Emergency
Mileage ALS
Pulse Oximetry
IV Supplies
Disposable Supplies

$488.00
$146.25
$36.00
$42.00
$42.00
* Still waiting* Still Waiting
Hospital ER $836.32$459.98$459.98
X-Ray Reading $28.00$12.18$12.18
Generic Pain Med $4.06$4.06$4.06
Secondary
Wound Closure (done in office)
$650not actually billed (maybe $356 on hosp % reimburse)not actually charged (maybe $356 as based on ER reimbursement)
At home dressing
supplies
not covered by insurance
$30.06
not covered
$30.06
$30.06 (Coban, guaze, etc)
Total Expenses $2,302.69$862.28*$862.28*

My friend has a Medical Savings Account so has a high deductible ($5700). The insurance coverage did decrease his actual out-of-pocket responsibility by "not allowing" $392.16 (more depending on the ambulance bill outcome). This is also money that the hospital and ambulance service did not receive. I know he is grateful for the savings. I, however, also see the other side. A reduction of nearly 50% seems absurd. Is the medical community really overcharging that much? Or are we charging fairly to cover the expenses of the hospital/office? Just as Wal-Mart has a built in "padding for loses" for each item sold (covers losses due to theft /shop lifting), the hospitals/offices need to be able to have the same "padding" to cover the services that aren't paid for by the patient (under-payment by Medicare/Medicaid, no insurance, simply doesn't pay, etc).

Thursday, December 13, 2007

Panniculectomy vs Abdominoplasty

I posted this information back in July, but I thought it would be worth sharing again. As the number of gastric bypass and lap band procedures increase, the number of patients who need this information just continues to grow.
You’ve had your gastric bypass and have lost over 100 lbs. Now you have "all this loose, saggy skin that just hangs" and you have "rashes under the fold all the time". Will your insurance pay for a tummy tuck? Probably not what you are thinking of as a tummy tuck. They may pay for a panniculectomy, but not an abdominoplasty. So let me try to tell you the difference between the two. Photo from article (see below).

Panniculectomy is the removal of the loose (excess) skin and fat tissue below the belly button (umbilicus). Nothing is done to the (possible/probable) loose skin above the belly button. It is strictly to help remove the overhanging skin that is trapping moisture and creating a hygiene and chronic rash problem. It is not meant to improve your overall body shape.

An abdominoplasty is the removal of the loose (excess) skin and fat tissue from the abdomen (stomach area) with transposition of the skin around the umbilicus (the belly button doesn’t usually get moved, the skin around it does) and often tightening (plication) of the abdominal muscles. This creates a more pleasing shape as it addresses the entire abdomen. It is not just a functional surgery, but a cosmetic one.

Look at the above photos. The one on the left with minimal upper body excess skin might get both the functional and improved body shape (cosmetic result) with the panniculectomy. The one on the right would still have the "upper" skin roll as this is from skin above the umbilicus. So by definition, the panniculectomy would not do anything to improve this. The insurance company (see the California BC restrictions) would probably not be persuaded to make an exception for a full abdominoplasty which is what she would need. Chances are this person gets skin irritation below the upper roll also. Frustrating, isn’t it?

Prior to this year (2007) when a surgeon coded the surgical procedure for a panniculectomy or an abdominoplasty the same code was used. This made it difficult (without reading the operative note) to truly tell what had been done.
CPT 15831 Excision, excessive skin and subcutaneous tissue (including lipectomy);abdomen (abdominoplasty)

As of this year the coding has changed which makes it more clear to an insurance company what has been done for the patient. Perhaps it will also help clarify for the patient that a "cosmetic tummy tuck" is not what they will get (unless they are willing to pay the difference) when a panniculectomy is done. The new codes are:
CPT 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
CPT 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
Use 15847 in conjunction with 15830

To know whether your insurance policy will help you out with this issue, check your policy or call your insurance provider. Here is BC of California’s policy on the issue. Here is Cigna's. Many insurance companies have similar policies. Some consider it all cosmetic.


Photo--A Classification of Contour Deformities after Bariatric Weight Loss: The Pittsburgh Rating Scale; Plastic & Reconstructive Surgery. 116(5):1535-1544, October 2005; Song, Angela Y. M.D.; Jean, Raymond D. M.D.; Hurwitz, Dennis J. M.D.; Fernstrom, Madelyn H. Ph.D.; Scott, John A. M.S.; Rubin, J Peter M.D.
ASPRS Recommendations for Third-Party Payers--Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients

My First Award

Yesterday, I was given the ‘Be The Blog‘ award…

Be The Blog award

…created by Mark at Me and My Drum for bloggers who make their blog their own, stay with it, are interactive with their readers, and just plain have fun. I was given the award by ScanMan. I understand this is not a meme. I have I found the space in my sidebar and but Vijay has picked the friends who are inextricably linked to their blogs and to whom I would pass it along. I hope that don't mind being nominated twice.

Moof (All Blogged Up -- A Moof's Tale)
Lakshmi (I Think--too much)
Enrico (Mexico Med Student)
Rob (Dr Rob)
Bongi (other things amanzi)

To this list I would add a few quilting bloggers

Jude (Spirit Cloth)

Kate (Kate's Quilting Blog)

Penny (Penny Sanford)

Thank you Vijay.

Wednesday, December 12, 2007

Pay Telephones

In the local paper this weekend there was an article on the declining use of pay-phones. It seems that Bell System plans to get out of the pay-phone business after 129 years. It included a nice summary of the history of pay-phones. Here is the time line:

1878: The first pay phone has an attendant who takes the caller's money.

1889: The first public coin telephone is installed by inventor William Gray at a bank in Hartford, Connecticut. The phone is a "post-pay" machine where coins are deposited after the call is placed.

1898: The Western Electric No 5 Coin Collector goes into use in Chicago, Illinois. It is the first automatic "prepay" station. Coins are deposited before placing the call.

1902: There are 81,000 pay telephones in the United States.

1905: The first outdoor Bell System coin telephone is installed on a Cincinnati street.

1950s: Glass outdoor telephone booth begin replacing the wooden ones.

1957: Drive-up pay telephones are tested in Mobile, Alabama and Chicago, Illinois.

1960: The Bell System installs its millionth pay telephone.

1966: "Dial tone first" service is introduced in Hartford, Connecticut. Emergency calls could now be made without first depositing coins.

Feb 2, 2001: BellSouth announced that it is getting out of the pay-phone business.

Dec 3, 2007: AT &T Inc announces plans to leave the pay-phone business.

Today: There are about 1 million pay phones, down from 2.1 million in 1998. Local calls on pay phones have also dropped 30% since 1998.

I must admit that I can not recall the last time I used a pay phone. I think it was back in the early 90's prior to getting a cell phone. It seemed I could never find change when I needed to answer my pager, so I quickly got a cell phone. I miss the wooden phone booths you could find in restaurants. There was an elegance to them. The outdoor phone booths reminded my of Superman, so I miss them too.

I can't recall treating anyone from injuries that incurred from use of a phone booth, but I can imagine a few that probably happened. Whenever there is a door, there is a hinge and this means fingertip injuries. The phone booths out in the open are, of course, likely to be hit occasionally by motor vehicles. And as with any land-line phone, it was important not to use the phone during a lightning storm. If you have any to relate, I would love to hear about them.

Telephone injuries associated with lightning:

    • Injuries to persons using telephones or telephone headsets, such as those who take phone orders, are relatively common. The telephone becomes the conduit for the charge to enter or to escape from the structure (and the person). Although the telephone system may be grounded adequately for electrical surge protection, lightning is too fast and strong for typical grounding systems to be effective and reaches the person before the circuit breaker or other protection can be effective.
    • Electrical lightning damage occurs only with use of land-line phones. No lightning danger is inherent to cellular phones. Although many reports of lightning injuries involve people who are using cell phones, these reports represent the ubiquity of cell phone usage and of their users' inattentiveness to weather conditions and have nothing to do with the phones themselves.
    • Older portable phones, seldom used now in the United States, were a rare source of lightning injury to people standing close to the base station or charger. Those injuries were caused by the lightning jumping from the charger to anything close by and have little to do with the phone the person was carrying.

References

Pay Phones and Phone Booths -- Bell System Memorial

Lightning Injuries by Mary Ann Cooper, MD -- eMedicine Article

Tuesday, December 11, 2007

50-Minute Strength Workout

Yes, I am a member of AARP. My husband turned 50 last year and I did this year. The picture below is from the latest edition of the AARP Bulletin. The article, "The 50-Minute Strength Workout", suggests putting aside 50 minutes a week--two days of 25 minutes each. I would add, if that seems too hard, then try 5-10 minutes each day, rotating the exercises you do so that each muscle group gets used.

Remember that for most of our "life" activities, we need to keep those muscles strong. I know that for myself (I had an anterior cervical fusion, C6-7, done over 15 years ago), doing my pull ups (under-handed chin ups) and push-ups helps me perform surgery and carry groceries (as many bags as I can at one time) with fewer muscle aches in my neck and shoulders. I can tell the difference if I miss too many days. These are exercises I can do at home, as my husband put a chin-up bar in my closet doorway for me. They only take a few minutes.


We all know that these activities will help us:

  • build strength

  • maintain bone density (important for both women and men)

  • improve balance, coordination, and mobility

  • reduce your risk of falling

  • maintain independence in performing activities
    of daily life.

The old saying is true when it comes to muscle: “Use it or lose it.” The first reference listed below, Growing Stronger--Strength Training for Older Adults, is a very nice "book" that will walk you through all the exercises.

Some exercises need no equipment.

S Q UAT S
A great exercise for strengthening hips, thighs, and buttocks. Before long, you’ll find that walking, jogging, and climbing stairs are a snap!
1. Stand directly in front of a sturdy chair. Your feet should be slightly
more than shoulder width apart. Extend your arms so that they are parallel to the ground.
2. Place your weight more on your heels than on the balls of your feet. Bend your knees as you lower your buttocks towards the chair in a slow, controlled motion, while you count to 4.
3. Pause. Then, slowly rise back up to a standing position as you count to 2. Keep your knees over your ankles and your back straight.
Repeat the squat ten times. This equals 1 set. Rest for about 1 minute. Then complete a second set of 10 squats.

WA L L P U S H - U P S
This exercise is a modified version of the push-up you may have done years ago in physical education classes. It is easier than a push-up and you don’t need to get down on the floor—but it will help to strengthen your arms, shoulders, and chest.

1. Find a wall that is clear of any objects such as wall hangings and windows. Stand a little farther than arm’s length from the wall. Face the wall, lean your body forward and place your palms flat against the wall at about shoulder height and shoulder-width apart.
2. Bend your elbows as you lower your upper body toward the wall in a slow, controlled motion as you count to 4. Keep your feet planted.
3. Pause. Then, slowly push yourself back until your arms are straight as you count to 4. Make sure you don’t lock your elbows.
Repeat the wall push-up 10 times for 1 set. Rest for about 1 minute. Then do a second set of 10 wall push-ups.


Other exercises will need weights--these can be actual weight or a bottle of water (half-full or full).

BICEPS CURL


This one will help that gallon of milk feel a lot less heavy.
1. Stand or sit in a chair with a dumbbell in each hand. Your feet should be shoulder-width apart with your arms at your sides and your palms facing your thighs.



2. Rotate your forearms and slowly lift the weights as you count to 2. Your palms should be facing in towards your shoulders. Keep your upper arms and elbows close to your side—as if you had a newspaper tucked under your arm.
3. Pause. Then, slowly lower the dumbbells back towards your thighs as you count to four. Rotate your forearms so that your arms are again at your sides, palms facing your thighs. Repeat 10 times for 1 set. Rest for about 1 minute. Then complete a second set of 10 repetitions.



For more exercises check these references and live strong:


Growing Stronger--Strength Training for Older Adults (pdf file from the CDC) and More Exercises


Strength Training for Women


Balance, stretching and strength training -- Mayo Clinic

Monday, December 10, 2007

Spare Parts

I would like to direct you to a wonderful post on medical implants, Spare Parts. It is written by Lakshmi Gopal over at Nonoscience. She starts off:

"Soon after a deadline has passed, I end up treating myself to a movie, and this time, it was Hot Shots Part Deux. The only thing that made an impact on a brain fresh (or would that be exhausted?) with materials design was the various implants in the body of President Tug Benson. The president had ceramic eyes, asbestos skin, magnetic skull plate, aluminum siding facial bones, and stainless steel ear canals.



Artificial implants have been known for a long time [1]. My grandmother tells me that my ancestors had golden tooth implants, to showcase their wealth. I am told that after a certain age, they would pull out their perfectly normal teeth and replace them with gold and silver tooth (depending upon their financial position) and swore off manangombu and mysore paks for the rest of their lives. If I were given the choice between golden teeth and murukku , I would most definitely choose the latter. But I digress.

The first recorded case of implant was an accident. In 1952, Per Ingvar Branemark, a Swedish orthopedic surgeon was following the processes of bone healing by embedding microscope heads made of titanium metal in holes drilled into thighbone of anesthetized rabbits. .............."

She goes through a list that includes hip implants, artificial bones, dental implants, eye implants, biologic stents, materials used in cranioplasty, facial implant materials, etc. It is well worth reading.

SurgeXperience 110 is up!

The 10th edition of SurgeXperiences has been posted by Dr. Alice over at “Cut on the dotted line”. So head over and check it out.

The next edition of SurgExperiences will be hosted by Buckeye Surgeon on December 23. So feel free to submit a post (or two) regarding your experience with surgery here. The deadline for submission is December 21st.

And if you missed any of the earlier editions:

SurgeXperience 101:Pilot --Monash Med Student

SurgeXperience 102: Barbers --Monash Med Student

SurgeXperience 103-- Unbounded Medicine

SurgeXperience 104 -- other things amanzi

SurgeXperience 105 -- Suture for a Living

SurgeXperience 106 -- IntraopOrate

SurgeXperience 107 --Vitum Medicinus

SurgeXperience 108 -- Aggravated Doc Surg

SurgeXperience 109 -- Monash Med Student

Sunday, December 9, 2007

Skin Complications from Drug Abuse

Skin and soft tissue infections (SSTIs) are common among injection drug users (IDUs). Subcutaneous and intramuscular injection ("skin-popping") and the injection of "speedballs" (a mixture of heroin and cocaine) are risk factors for SSTIs in this patient population. Female IDUs appear to be at greater risk of SSTIs than male IDUs, most likely because of more difficult venous access. Most information regarding the microbiology of SSTIs in IDUs comes from data on skin and subcutaneous abscesses, where Staphylococcus aureus and organisms that originate from the oral flora predominate. These skin and subcutaneous abscesses (often hand/forearm) are the infections I saw as a resident. I haven't seen any in my practice. This doesn't delude me into thinking it has lessened.
Other uncommon outbreaks and infections including tetanus, wound botulism, and a sepsis/myonecrosis syndrome due to Clostridium species.
Skin infections in drug users are not only from injection. Methamphetamine use can cause formication. This is a sensation of something crawling on the body or under the skin. This can lead to skin-picking behavior, skin breakdown, and portals of infection. These may be anywhere (face, arm, torso, legs, etc) and do not "follow" vascular access routes.
Local complications occur at the site or in the area of injection. They can be broken down into two types:
Acute complications occurring within a few hours to 48-72 hr after injection.
  • Recent injection marks at the site of injection are present in all IDUs. These are also present in "therapeutic" injections done by nurses or other medical personnel. I always have an "injection mark" after giving blood for a couple of days afterwards. These are not only due to the "trauma" from the injection but can be made worse by the actual drug injected.
  • Cutaneous infections are common in IDUs. Abscesses (picture at right) and cellulitis occur in 22-65% of addicts. A combination of factors favor these infections. They include --contamination of the street drug used, absence of skin asepsis, unsterile equipment poor hygiene, and the act of indtradermal injection. The simple use of alcohol to clean the skin before injection may protect against cutaneous infections.
  • Necrotizing fasciitis (NF) is a rare but severe and life-threatening manifestation with a high rate of mortality and amputation NF occurs mainly after subcutaneous injection.
  • Necrotizing ulcers and cutaneous necrosis ulcers are most likely similar to the reaction of chemotherapy extravasation. They develop as a result of several combined factors -- mainly 'skin popping', toxicity and the irritant properties of the drug and adulterants, vascular thrombosis and infection. Quinine, for example, is used as an adulterant and has caustic effects. Cocaine has potent vasoconstrictive and thrombotic effects. Though most authors consider the mechanism to be related not to an infection but to a direct effect of the drug or adulterants, bacteria may be cultivated from necrotic ulcers and, in some cases infection may contribute to the formation of ulcerated lesions. Cutaneous necrosis also results from arterial thrombosis after direct intra-arterial injection such as scrotal skin necrosis after pudendal artery injection.
  • False aneurysm and mycotic aneurysms are rare but serious complications. False aneurysm is caused by vascular injuries after drug injection. Staph. aureus is the main pathogen in mycotic aneurysms. Most cases involve the femoral artery following groin injection but other locations such as the upper limbs have been described. The lesion manifests as a pulsatile mass located in the area of major arteries. In some case it may present as a non-pulsatile inflammatory mass and may be mistaken for a cutaneous abscess. If the local of the "abscess" is near or over an artery, aspirate prior to incision as an inappropriate incision can be disastrous. The treatment is difficult, and is based on ligation and surgical excision of the aneurysm.
  • Thrombophlebitis can occur from repeated trauma of venepuncture, local infections and the irritating qualities of the drugs and adulterants. These are causes for both superficial and deep venous thrombosis. Septic thrombosis is responsible for bacteraemia, with Staph. aureus as the most frequent pathogen. High-risk locations include iliofemoral and upper limb deep thrombosis.
  • Intra-arterial injections, whether inadvertent or deliberate, may cause severe tissue ischemia and necrosis. Immediately after injection, the patient will feel intense pain and burning. Within a few hours a marked edema will appear, followed by cyanosis in the territory of the artery. In the most severe cases necrosis occurs and can lead to amputation. Several mechanisms have been suggested to explain the vascular injury: 1) direct vasoconstriction may be caused by cocaine or amphetamines, 2) local chemical toxicity of drugs or adulterants may cause chemical endarteritis resulting in vasospasm and thrombosis, 3) and the mixture may contain microparticles that act as emboli. Microparticles is particularly the case when oral drug formulations such as crushed tablets are injected (as in the picture below). The result is a peripheral ischemia, edema and compartment syndrome, which will worsen the ischemia.

Delayed complications
  • Hyperpigmentation at the site of injection has been found to be the most common cutaneous finding, present in 54% of subjects. It is related to scars and tracks along the injected veins. Hyperpigmentation results from a postinflammatory process following the various skin injuries.

  • Scars and, in particular, needle tracks are the main stigmata of narcotic abuse . Most IDUs have scars along a vascular distribution, mainly the ante-cubital area and the dorsum of the hand. Repeated injections along a superficial vein can result in venous thrombosis and subsequent fibrosis to form linear cord-like hypopigmented or hyperpigmented scars ('railroad tracks') pathognomonic of intravenous drug addiction. 'Pop scars' (see above picture) form irreversible irregular round or oval hypopigmented or hyperpigmented, atrophic or hypertrophic scars, or keloids, 0.5-3 cm in diameter. The IDU may also have other scars resulting from various (indirect drug use ) skin injuries from trauma, infections, necrosis, burns, suicide scars, etc.
  • Chronic venous insufficiency and ulcers may be found in 88% of people with a history of injection drug abuse. Risk factors for the development of venous insufficiency include vein trauma, necrotic ulcers, superficial and deep vein thrombosis and blockage of the lymphatic system by repeated infections and the sclerosing effects of adulterants. Both lymphatic blockage and venous impairment contribute to chronic edema of the lower extremities and therefore to delayed leg ulcers.
Primary prevention strategies to reduce STIs among IDUs include
  • Preventing initiation of injection drug use
  • Increasing entry and retention of IDUs in substance abuse treatment (particularly methadone maintenance).
For IDUs who continue to inject drugs,
  • Increasing access to sterile injection equipment and alcohol swabs
  • Promoting hygiene (including hand washing, cleaning the injection site before injection, using a sterile syringe for every injection, and avoiding needle contamination) are important prevention goals.
Secondary prevention strategies include
  • promoting earlier medical and surgical treatment of STIs.
  • Microbiologic testing of street samples of black tar heroin also may help identify the causes of injection-related STI.
  • Ongoing research into the behavioral and biologic risk factors for STI may identify additional prevention interventions
References
Cutaneous Complications of Intravenous Drug Abuse --MedScape Article
Care of Injection Drug Users With Soft Tissue Infections in San Francisco, California; Hobart W. Harris, MD, MPH; David M. Young, MD; Arch Surg. 2002;137:1217-1222.
Skin Infections in IV Drug Users -- DermNet NZ
Methamphetamine Use and Methicillin-Resistant Staphylococcus aureus Skin Infections -- MedScape Article, Posted 11/19/2007
A Guide for Understanding Steroids and Related Substances, March 2004 -- US DEA Office of Diversion Control
Skin and Soft Tissue Infections in Injection Drug Users; Current Infectious Disease Reports, Volume 4, No 5, pp 415-419, September 2002; Patricia D. Brown and John R. Ebright
Classifying Skin Lesions of Injection Drug Users -- Center for Substance Abuse Treatment, 2002; Cagle, H.H; Fisher, D.G.; Senter, T.P.; Thurmond, R.D.; and Kastar, A.J. (has some nice photos for reference)
Soft Tissue Infections Among Injection Drug Users --- San Francisco, California, 1996--2000 -- MedScape Article