Ten Interesting Medical Stories from 2008

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The end of the year seems to be a time for making list.  Best of the year.  Worst of the year.  Predictions for the coming year.  Resolutions for the coming year.  So I thought I would share some (not necessarily the best or worst or even in order of importance) of the medical news of 2008 I found interesting.  Feel free to share your suggestions in the comments section.

1.  The changes in Health Policy that 2009 may bring

Thousands of forums have been taking place throughout the nation since Dec. 15, and reports are being uploaded to www.Change.gov. According to the Web site, the Health Policy Transition Team will prepare a report for the President-elect using information collected from all across the country.

2.  In February, Dr Hootan Roozrokh was accused of hastening a patient's death to harvest the organs.

It’s the stuff of horror movies: an evil, deranged surgeon purposely kills people to harvest their organs. In the 1978 movie "Coma," patients were kept in comas and shipped off to a mysterious location where their organs were removed.

In December, he was found innocent of the charge.

Dr. Hootan Roozrokh was found not guilty after two months of trial and two days of deliberation jury. If the court verdict had been against the doctor, he would have faced up to four years in prison.

3.  Dr Michael DeBakey, pioneer of heart procedures, died this year at age 99 years.

4.  November 2008, a Colombian woman, Claudia Castillo, received a trachea transplant using her own stem cells.    Doctors in a Barcelona, Spain hospital used her stem cells into a trachea taken from a cadaver.  Because the new windpipe is "almost indistinguishable" from the her normal bronchi, her body should not reject the transplant.

5.  In March, a little girl was born with facial duplication.   The condition usually results in stillbirth, but not always as seen in this recent news report of this little girl born March 11, 2008.

They are not ashamed of the extraordinary looking little girl, the villagers who live near her, the young parents, the overprotective local doctor. That's because while she may only be 2½ weeks old, she is far more famous than any resident of this part of the country has ever been. She is famous because she was born with a condition known as facial duplication. She has one body and two faces.

6.  Healthcare conscience rule and how they may change patient care / access to care.

Women's groups, state governments, and a host of others have reacted harshly to the new conscience rights regulation put forth by the Department of Health and Human Services last week. The National Family and Reproductive Health Association stated that the "new regulations will limit access to contraception to low-income and uninsured women and men and will create new hurdles for family-planning service providers," Deborah Kotz reports. The National Partnership for Women and Families noted, "These regulations leave the term 'abortion' undefined, so individuals and institutions are free to classify birth control as abortion." And the ACLU also expressed its "grave concern."

7.  Dr Alan Bittner’s office was served with a warrant on Friday, November 14, 2008. 

Dr. Bittner currently has three lawsuits filed against him by three women who had plastic surgery work done at his facility……..Besser confirmed to Canyon News that Dr. Bittner fled the country. It is not known exactly when he fled, and it has been alleged that he is collecting his assets in off-shore accounts. Besser also stated that “Dr. Bittner's home and vehicle were served with a search warrant on the same day that the Beverly Hills Liposculpture facility was served with a search warrant.”

And if that wasn’t enough, it seems he was using the fat removed from liposuction patients to fuel his vehicle.

8.  Cleveland Clinic did the first near total face transplant done in the United States. 

In a 22-hour procedure performed within the past two weeks, surgeons transplanted 80 percent of a woman's face who suffered severe facial trauma -- essentially replacing her entire face, except for her upper eyelids, forehead, lower lip and chin. For the privacy and protection of those involved, no information will be released on the patient, the donor or their families. (A written statement from the patient's sibling is available at http://www.clevelandclinic.org/face.)

9.  A 70-year old woman gave birth to a baby girl.

Rajo Devi delivered her baby by caesarean section Nov. 28, said Dr. Anurag Bishnoi of the National Fertility Centre in northern Haryana state. Dr. Bishnoi told journalists that Devi and her baby, who weighed just over 3lbs, are in good health.

10.  Never Events – so well covered in this post by Buckeye Surgeon

Just when I was starting to calm down about the controversy surrounding "never events", the New York Times unloads a masterpiece of naivete and contempt. Reading this, my eyeballs almost popped out of my skull. One would think that the editorial staff of such a renowned, prestigous newspaper would exhibit a little more intellectual rigor when composing such a denunciatory op-ed piece. I almost thought Diane Suchetka had infiltrated the NY Times hierarchy.

And now, from the other side of the political spectrum, comes a piece from the National Review (arch conservative publication)that uses the concept of never events in such a way to elucidate the danger of government managed health care delivery. (Thanks to Alice at Cut on the Dotted Line)………….

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Moneduloides is this week's host of Grand Rounds. It’s the “Darwin” edition!  You can read it here (photo credit).

 

Welcome to Grand Rounds 5.13: At the interface of evolution and medicine, a celebration of blogging on the myriad ways evolutionary biology influences medicine. Why evolution and medicine, you may ask? Why now? Well, in anticipation of the new year, of course; 2009 marks the bicentenary of Darwin’s birth, and the 150th anniversary of the publication of On The Origin of Species, and the one thing that just doesn’t get as much recognition as it should is the role of evolutionary biology in both research and clinical medicine.

The Christmas edition of Change of Shift (Vol 3, No 13) is now up over at Nurse Ratched's Place !  It’s a grand edition and I hope you will check it out (photo credit).  You can find the schedule and the COS archives at Emergiblog. 

Welcome to the Christmas Edition of Change of Shift. Curious George and the man in the yellow hat are hosting this year’s holiday edition. I want to thank Kim from Emeriblog for allowing George to share his Christmas story with the readers of Change of Shift. George recently had a big adventure at a children’s hospital. Take a look.

MedGadget is asking for nominations for the best of medical blogs. Last year I was honored to be nominated in the “best new medical blog” category and this year I somehow have been nominated for the “best medical blog”.  Thank you.

You can make your nominations here by leaving a comment with your choice.

The categories for this year's awards are:
-- Best Medical Weblog
-- Best New Medical Weblog (established in 2008)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

Medicine for the Outdoors has a nice post on motion sickness and the side effects of transdermal scopolamine (photo credit). 

The patch should be positioned at least 3 hours before rough seas are encountered. If you touch the medicated (sticky) side of the patch with a finger and then let that finger come in contact with your eye, your pupil will almost certainly dilate and stay that way for up to 8 hours. So, as the distributor strongly recommends, be sure to wash your hands thoroughly with soap and water immediately after handling the patch, so that any drug that might get on your hands will not come in contact with your eyes. Also, local absorption of the drug through the skin can dilate the pupil of the eye on the same side of the patch, causing difficulty with focusing of vision. The picture here shows someone with a dilated pupil associated with a patch.

Geek2RN has written a lovely post on “Voice Lessons” at her blog Toasty Frog.  It’s about a patient who taught her and I hope you will read the entire post.

…... Once in a while, one comes along who teaches me more than I have to offer in return.

Jerry* was one of those. He had a mental illness that included psychotic symptoms, and was back in the hospital for a medication tune-up. He was very interested in the new medications the doctor wanted to try, and what their effects would be, so we were going over his medications together. One of them, naturally, was an antipsychotic. When I explained that it would help to diminish the voices, Jerry looked alarmed. “Oh, I don’t want the voices to go,” he told me. “It’s too lonely without them!”

I heard this segment on NPR this weekend “Cocktails: A Liquid Year In Review”.  Host Liane Hansen is talking with the curator of the Museum of the American Cocktail, Ted Haigh, about drinking, changes in the world of cocktails, and changes in Americans’ drinking habits over the past year.  I admit to being mostly a teetotaler, but love the various glasses, the names of drinks, and how lovely many of the drinks look.  One of the drinks discussed is “corpse reviver” (recipe and photo credit).

There will be no Dr Anonymous show this week. You can check out the archives of his Blog Talk Radio show.   He’ll be back in the new year after the holidays.  Here is the upcoming schedule:

1/8: Podcamp Ohio
1/15: ProMed Network
1/22: Guest co-host Kim
1/29: Guest co-host Dr. Gwenn

Shoulder Morbidity following Latissimus Dorsi Breast Reconstruction – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Not only can the shoulder function be impacted from the axillary dissection when treating breast cancer, it can also be impacted by the reconstruction of the breast.  This is of concern when using the latissimus dorsi muscle in breast reconstruction.  The action of the latissimus dorsi muscle is adduction, extension, and internal rotation of the humerus and plays a crucial role in the stability of the glenohumeral joint.

The authors of this article (see full reference below) wanted to look at this issue from a prospective view as current literature has only looked at it from a retrospective view. 

The literature already supports the absence of long-term effects from this procedure. However, all studies and subsequent reviews are based on retrospective studies, thus making it impossible to assess recovery time scales compared with preoperative values. In this prospective study, the authors set out to define the impact on shoulder function and, importantly, to assess recovery time scales compared with preoperative values.

Their methods included measuring shoulder range of motion, strength, function, and pain.  These assessments were done  preoperatively and then at 6 weeks, 6 months, and 1 year postoperatively.  The biggest weakness of the study (as they themselves point out) is the small number of subjects.  There were only 22 subjects in the study.  The ages ranged from 37 to 69 yrs with an average of 50 yr.

Of these 22 subjects, 17 underwent delayed reconstruction and five underwent immediate reconstruction, with five subjects requiring axillary node sampling. Fourteen subjects required a latissimus dorsi flap with implant breast reconstruction and eight required an extended latissimus dorsi flap breast reconstruction.

Their conclusions (remember too small a group to do statistical analysis).

Range of Motion

A loss of shoulder joint range of motion could be anticipated in the early period after surgery. However, the eventual increase in motion at 1 year after surgery was unexpected. When examining this increase in motion, it was noted that for each plane of movement the increase was less than 10 degrees. This minimal change could be attributed to measurement error, and it is also questionable whether such a small change would be clinically significant to the subject's function. ……. A number of subjects who previously underwent mastectomy reported a feeling of loosening of the shoulder joint following their breast reconstruction. This could have been attributable to release of residual scar tissue during the reconstructive surgery. Further investigation, with larger numbers of subjects, into morbidity following immediate and delayed reconstruction may establish whether this is a factor.

Strength

Although there was a slight decrease in shoulder strength at 1 year compared with preoperative values, this was minimal (<1 kg) and could therefore be attributed to measurement error. This loss of strength would also be unlikely to be clinically significant to the subject's function. The lack of significant deterioration in shoulder strength following removal of the latissimus dorsi muscle may be attributable to the synergistic action of the teres major, as has been suggested in other studies.  However, of the loss of power seen, it remained in the first 6 months, returning to or near preoperative values in the second 6-month period after surgery.

Function

Absence of any significant alteration in upper limb function when compared with preoperative values supports the theory that the minimal increase in motion and decrease in strength have no impact on the subject's activities of daily living. However, this study would suggest that it takes a full 12 months for preoperative values to be achieved. This would fit with the period of significant scar maturation. However, when comparing the extended and traditional reconstruction groups, it is noted that the extended latissimus dorsi group reported a 7 percent higher disability. Further research with greater numbers of subjects would be necessary to explore this finding. This is particularly of note, as the extended latissimus dorsi flap is becoming even more popular. It is not surprising that those subjects whose breast reconstruction was on the same side as their dominant hand took longer to recover their activities of daily living.

Pain

The initial increase in pain following surgery was anticipated. However, the majority of subjects reported a decrease in pain at 1 year compared with preoperative measurements. Further examination would be necessary to establish the cause of the reported preoperative pain. The presence of adhesions following previous mastectomy could account for the pre-reconstruction pain.

Overall, a nice start.  It would be nice to see the study extended to include a statistically significant number of participants.  Until then, the take home message is that it takes a year to get the function and strength back in the shoulder.


REFERENCE
A Prospective Assessment of Shoulder Morbidity and Recovery Time Scales following Latissimus Dorsi Breast Reconstruction; Plastic and Reconstructive Surgery:Volume 122(5)November 2008pp 1334-1340; Glassey, Nicole M.Sc., Grad.Dip.Phys.; Perks, Graeme B. F.R.C.S., F.R.C.S.(Plast.); McCulley, Stephen J. F.C.S.(S.A.)Plast., F.R.C.S.(Plast.)

SurgeXperiences 214 – Call for Submissions

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The next edition (214) of SurgeXperiences will be hosted will be hosted by Dr Bruce Campbell, Reflections in a Head Mirror, on January 4th. He is an ENT surgeon and wonderful writer.  In fact, he writes a second blog, Behind the Head Mirror, which is also worth checking out. 

If you aren’t familiar with his blog, Reflections in a Head Mirror, check it out.  Here is an excerpt from a recent post called “Surgery as a Form of Dance”

Years ago, I realized that Surgery sometimes resembles Dance. Just like beginning students of the tango or the waltz, young physicians tend to focus on the “steps” needed to get from Start to Finish. But learning the “steps” is only the beginning of learning how to operate.  

You see, Surgery, at its most glorious, is a form of choreography — a whole team that seems instinctively aware of each other’s movements and focus. When the “Dance” goes well, surgeon, assistant, and technician all drive the procedure forward.  

The deadline for submissions is midnight on Friday, January 2nd.  Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Disappearing Nine Patch Baby Quilt

I have a neighbor who is pregnant and due in March 2009.  I have seen this quilt pattern, Disappearing Nine Patch, in many places / blogs this year.  I wanted to make a baby quilt that would work for either girl or boy  and decided I would use it.  The quilt is machine pieced and quilted.  It is 34.5 in X 46 in.  It goes together quickly.

Here is a close photo to show some of the fabrics.

Merry Christmas to you!

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

You know I love my dog Rusty.   I used to make Columbo, Girlfriend, and Ladybug home-made dog biscuits for Christmas.  I didn’t make any last year when it was just Rusty.  I decided I needed to make him some this year. 

I found this recipe years ago at a site that doesn’t seem to be active anymore.  It can be found here though.  My dog  loves them, as do the neighbors’ dogs.  I’m sharing the recipe with you.   If your toddler wants to sample them, it’ll be okay.  My husband likes them too.

 

Fido’s Fabulous People Biscuits

1/4 cup hot water                                  1 1/2 cups tomato juice
8 cubes chicken bouillon cube         2 cups  all purpose flour
1 pkg  dry yeast                                       2 cups  wheat germ
1 tsp  sugar                                                1 1/2 cups whole wheat flour

Preheat oven to 300° F. 

Pour the water into a large bowl and add the sugar and yeast.  Let stand for about 5 minutes.

Add chicken bouillon cubes.  Crush them with a fork as you stir them in.  Add tomato juice, 1 cup of flour and 1 cup of wheat germ.  Stir with a large spoon to form a smooth batter.

Then stir in the remaining flour (both kinds).  This will make the dough very dry and stiff.  You’ll probably have to use your hands to finish mixing. 

Divide the dough into two balls.  Sprinkle flour on the counter surface and roll out the dough to 1/4 inch thickness.  You can use a table knife to cut the dough into “people” shapes or do as I did and use cookie cutters in the shapes of bones and fire hydrants.

Place the biscuits onto a cookie sheet.  Bake at 300° F for 1 hour.  Afterwards, let them dry in the turned off oven for quite a while (4 hrs or more).

Merry Christmas!

Do Overs

Earlier this year I saw a breast reduction patient whose surgery I did early in my career and with her permission I am sharing this.

I did her breast reduction using an inferior pedicle technique for the safety of the blood supply to the nipple-areolar complex. She came back to see me because her nipple “sits too high”. Actually, the nipple doesn’t set too high. The distance from the sternal notch to the nipple (SN-N) is the correct length for her height. She has what we call “bottoming out”.

Notice how the breast tissue seems to have slipped down the chest and no longer sits behind the nipple/areolar complex.

When I saw her again, I couldn’t help but think about how I would do her surgery differently today. I am at a different point on the learning curve than I was then, so I have tried not to be too harsh on myself. Still, I would have used a superior-medial pedicle. That simple change would have (most likely) kept her from this visit. Superior-medial pedicles rarely if ever “bottom out”.

Another thing I would have done differently is the incision/scar. I used the Wise–pattern and she has an anchor-shaped (or inverted T) scar with a periareolar circle. She has a long (looong) inframammary scar. Today, even when I do need to use the Wise pattern incision, I can often half the length of that inframammary scar. Today, I do many more using just the vertical scar and periareolar circle so there is no inframammary scar. That technique has really only become popular and accepted as safe in the last 10 years.

I can’t go back and “do over” her surgery from the very beginning with my knowledge and skills of today. Fortunately (and I do feel blessed that she understands that), she doesn't blame or fault me. It is me doing the soul searching and wishing I could go back.

The best I can do for her is correcting the “bottoming out” which I find easy to do. I just wish there were no need for it.

To correct the bottoming out, I mark (as can be seen in the photos above) the true inframammary crease. I measure 6-7 cm from the nipple and plan a wide elliptical excision of the inframammary scar. In this woman’s case, the old scar fell near the center of the ellipse. I then excise skin only, do a minimal undermining superiorly, reshape the breast tissue with some heavy vicryl sutures, and then close the incision. Here are some post-procedure photos.

Shout Outs

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Walter Jessen, Highlight Health, is this week's host of Grand Rounds. It’s the “dreaming of Grand Rounds” edition! You can read it here (photo credit).

Seasons Greetings! Welcome to the Holiday Edition of Grand Rounds, featuring some of the best articles of the biomedical and healthcare blogosphere. At this time last year, I announced the Highlight HEALTH Network, a single source that aggregates content from all the Highlight HEALTH websites. This year, I have a similar gift for biomedical and healthcare blogosphere readers:

MedGadget is asking for nominations for the best of medical blogs. Last year I was honored to be nominated in the “best new medical blog” category. You can make your nominations here by leaving a comment with your choice.

The categories for this year's awards are:
-- Best Medical Weblog
-- Best New Medical Weblog (established in 2008)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

Medicine for the Outdoors us a great post, Frostbite Update (photo credit). It is a guest post from Luanne Freer MD who founded and directs the Everest Base Camp Medical Clinic, which operates each spring climbing season in Nepal.

From a historical perspective, frostbite has been known since ancient times, with indications of frostbite being present in a 5000-year-old pre-Columbian mummy discovered in the Chilean mountains. Napoleon’s surgeon general, Baron Dominique Larrey, described mechanisms of frostbite in 1812, during his army’s retreat from Moscow. He noted the harmful effects of the freeze-thaw-freeze cycle when soldiers warmed frozen hand and feet over the campfire at night, only to have them refreeze when they were removed from the warmth of the fire.

Check out Addicted to Medblogs – Days of Christmas Series
On the first day – A Partridge for Nurse Ratched
On the second day –MakeMineTrauma gets Two Turtle Doves
On the third day – Three French Hens for Medic 61
On the fourth day – Code Blog gets Four Calling Birds
On the fifth day – Monkey Girl gets Five Golden Rings
On the sixth day – Six Geese for Tundra PA
On the seventh day – Disappearing John’s Seven Swans
On the eight day -- Eight Maids a Milking for Emergiblog
On the ninth day --Nine Pipers Pipin for Vitum Medicinus
On the tenth day --Ten Dancin Ladies for ER Nursey
On the eleventh day –Eleven Lords Leapin Over Platypus
On the twelfth day – Drummers for GuitarGirl, RN
Check out these two posts on the Good Samaritan Ruling recently by GruntDoc and Symtym.

Now if you have been following the dialog across medblogs with GruntDoc, you’ll notice the major theme of whether California’s EMS Act confers certain tort immunity generally or specifically. Generally, in terms of applying to the general population. Specifically, in terms of applying to a specific population (i.e., the EMS practitioners defined in the EMS Act). Granted, what we think and believe in 2008 has merit, but it does not necessarily speak to legislative intent. It has been suggested that “no person who in good faith,” from a textual read, can only mean everyone, generally, in the state. What did the Legislature really say? (emphasis added)

There will be no Dr Anonymous show for the next two weeks. You can check out the archives of his Blog Talk Radio show. He’ll be back in the new year after the holidays.

Plastic Surgery Posthumous

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The recent article referenced below (HT to Kevin MD who HT’d Dr Tony Youn) reminded me of a conversation I had with a patient early in my career. She was a young widow. She was back in my office for a follow up visit after surgery. We got off on her grieving, her husband's illness, and other topics. He had died from a tumor in his lower face /upper neck that was inoperable due to the way it was connected and invading the structures nearby (think carotid and inferior jugular). It had left him very disfigured. She told me she regretted not being able to have an open casket funeral for him.

“I hope you don’t find this strange, but I wish the tumor could have been removed after he died. Then we could have had an open casket funeral.”

I blurted out "I would have removed for you."

"Really, you would?" she said.

"Yes, I would have."

"Thank you, Dr Bates. That would have meant the world to me."


Thinking back, I'm not sure why I blurted it out other than the connection we had at the moment. I don't regret saying it. I meant what I said to her. Inoperable tumors become operable after death because you don't have to worry about the blood supply to the brain anymore. You no longer have to worry about whether they might stroke out if you disrupt that supply. So debulking a tumor so the deceased looks "more normal" would be feasible. It would also be good practice for a young surgeon doing the dissection without worry of harming the person.

I don't think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say "goodbye" more easily.

REFERENCE
Final Touch: A Cosmetic Lift for Your Funeral? by Diane Mapes; MSNBC, Dec 9, 2008
Hat Tip to Kevin MD: Do you want to look better dead than alive? who Hat Tipped Dr Tony Youn: Plastic Surgery by Morticians? Not Really....

SurgeXperiences 213 is Up!

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This edition (213) of SurgeXperiences is hosted by Make Mine Trauma, IntraopOrate.  She is a surgical assistant who is enthusiastic about trauma and surgery in general.   She was featured by Addicted to MedBlogs in the 12 Days of Christmas series.   You can read the current SurgeXperiences edition here.

The next edition (214) will be hosted by Dr Bruce Campbell, Reflections in a Head Mirror, on January 4th. The deadline for submissions is midnight on Friday, January 2th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Another Pink Quilt

This quilt was made using two blocks left over from making Vijay’s daughter her pink quilt . I liked the individual blocks, but didn’t like them with the other pinks in her quilt. I played around with them and decided to just make the two blocks the “center” of a quilt. I added simple strips of more pinks and one black strip in the same manner as the blocks themselves. The quilt is machine pieced and quilted. It is 50 in X 61 in. I have given it to my friend Theresa and her DSO.

Here is a close photo to try to show some of the quilting stitches.

And another close photo.

Face Transplantation – First in the US Done

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Yesterday, Cleveland Clinic shared information on the first face transplantation done here in the United States. It involved replacing over 80% of the woman’s face. You can read more here and see the interview here. If you go here, you can see a visual “explanation” of the surgery.

I wrote a post on face transplant in March when Pascal Coler had his FULL face transplant done. He had spent much of his life horribly disfigured by Von Recklinghausen's disease. It is a rare genetic disorder suffered over 100 years ago by Elephant Man Joseph Merrick (played by John Hurt in the movie).

As I said then, I am watching this procedure with much fascination at the possibility for improving someone life. Pascal’s case is a great example. Yes, there is the great risk with this procedure, but in this man's case and in his words

"My chance had finally come. Even with the risk of dying, there was no question of me hesitating."

Isabelle Dinoire would agree with Pascal Coler. She is now three years out from her surgery and has gained some function (ie smile, blinking) of her facial muscles. Here are photos and a quote from Isabelle Dinoire (the first person to receive a face transplant) are from a CNN article yesterday

In 2005, French doctors performed the world's first partial face transplant on a 38-year-old woman who was disfigured when she was attacked by a dog.

"I hope the successful operation will help other people like me to live again," said Isabelle Dinoire, the French woman who received a nose, lips and chin.

This comments made in this article [Surgery Transplanted Most of Patient's Face; CNN article, Dec 17, 2008; by Madison Park] show the divide between those for and against this procedure:

Candidates for a face transplant are survivors of trauma, such as burn or accident victims, who have exhausted all other reconstructive possibilities. The recipient in France, Isabelle Dinoire, had been mauled by a dog, and the Chinese man, Li Guoxing, was attacked by a bear. Both suffered major facial disfigurements.

Facial transplants are not a question of vanity, Siemionow said in the 2006 interview. Some patients have undergone 30 to 40 reconstructive procedures hoping to have some normalcy in their appearances.

"Those people are not coming in with such a commitment because they want to be beautiful," she said then. "They want to be normal."

But critics, such as Peter A. Clark, director of the Institute of Catholic Bioethics at St. Joseph's University, in Philadelphia, Pennsylvania, said a facial transplant introduces unnecessary risks for a procedure that is not a matter of life and death.

"With something like a liver or kidney transplant, it's a life or death transplant," Clark said. "Even with a kidney or liver [transplant], you have to be put on immunosuppressants with serious side effects."

Clark suggested the viable option is reconstructive surgery, which would not require immununosuppressants. But doctors say that reconstructive surgery has its limits.

"If you look at the outcomes, they're far superior doing a face transplant than any reconstructive surgery," said Dr. David Young, a professor of plastic surgery at the University of California, San Francisco.

Young said plastic surgeons who do large facial reconstructions often find that patients "never really look that great." "Anyone telling you that doing reconstructive surgery is as good is deluding themselves," he said.

Treatment of Pressure Ulcers – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

In the United States,  pressure ulcers are now classified as “never events”.    So if we ever reach that goal, then perhaps all this information will be moot.  Until then, we need to continue to look for the best treatments possible to treat the ones that do occur. 

The first article in the reference below attempted to do just that – see if there is a best treatment.  The authors of the article noted that even though many treatments for pressure ulcers are used and  promoted, the relative efficacy of these treatments remain unclear.  They stated their objective as:

To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers.

Using a database search of  MEDLINE, EMBASE, and CINAHL, all relevant randomized controlled trails (RCT’s) in English language, published from inception through August 23, 2008 were reviewed by three of the investigators.

A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings.

Then these were categorized into 3 groups to mirror the way wound specialist approach pressure ulcer management:

• RCT investigated the management of underlying contributing factors (first:  reduce or eliminate underlying contributing factors – support surfaces and nutritional supplementation)
• RCT investigated the effects of local wound care (second: provide local wound care – wound dressings and biological agents)
• RCT investigated adjunctive therapies (third: consider adjunctive therapies – ie vacuum therapy, surgery)

Here are their conclusions:

Relatively few RCTs evaluating pressure ulcer treatments follow standard criteria for reporting non-pharmacological interventions.

High-quality studies are needed to establish the efficacy and safety of many commonly used treatments.

There is little evidence from RCTs to justify the use of 1 support surface or dressing over alternatives.

Similarly, there is little evidence to justify the routine use of nutritional supplements, biological agents, and adjunctive therapies compared with standard care.

Clinicians should make decisions regarding pressure ulcer therapy based on fundamental wound care principles, cost, ease of use, and patient preference.

Even though there does not seem to be evidence to justify the one support surface or dressings over the others, here are some other references you may find helpful in understanding the care of pressure ulcers should one occur.

REFERENCE

Treatment of Pressure Ulcers: A Systematic Review; JAMA. 2008;300(22):2647-2662; Madhuri Reddy; Sudeep S. Gill; Sunila R. Kalkar; Wei Wu; Peter J. Anderson; Paula A. Rochon

Guidelines for the treatment of pressure ulcers; Wound Repair Regen. 2006;14(6):663-679; Whitney J, Phillips L, Aslam R; et al. (PubMed)

European Pressure Ulcer Advisory Panel; European guidelines for pressure ulcer treatment; Published in 1998.

Pressure Ulcers, Surgical Treatment and Principles; eMedicine Article, Aug 5, 2008; Brandon J Wilhelmi MD and Michael Neumeister MD

Pressure Ulcers and Wound Care; eMedicine Article, Aug 10, 2006; Richard Salcido MD and Adrian Popescu MD

Pressure Ulcers, Nonsurgical Treatment and Principles; eMedicine Article, Jul 8, 2008; Christian N Kirman MD and Joseph A Molnar MD

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The winning bidder of the Hawaiian Lobster Quilt is  Dr Bruce Campbell!  The winning bid was $450.  Between the winning bid and the multiple donations, $950  was raised for the  Childhood Brain Tumor Foundation – MD since December 1st.    Donations can still be made  to the charity here.   Many thanks to you all!

Laurie,  A Chronic Dose, is this week's host of Grand Rounds.   It’s the “Best of” edition!  You can read it here.

It’s the time of year when the “Best of ” lists start popping up everywhere. As a writer, I pay the most attention to the holiday book lists and that is where I got the inspiration for this edition’s theme. Quality writing is a gift to everyone who reads it, so I challenged the medical blogosphere to send me the best writing of the year--the funniest, most poignant, most controversial, etc. What follows are the Best Posts of 2008, as selected by each of the 49 bloggers who submitted to this week’s Rounds.

(*= Editor’s Choice. Think of these posts as the best of the "Best Of...")

The latest edition of Change of Shift (Vol 3, No 12) is now up over at Marijke: Nurse Turned Writer !  You can find the schedule and the COS archives at Emergiblog.  It comes complete with a video introduction (a first for COS).    The issue is on “The changing face of nursing”.  Go check it out.

MedGadget is asking for nominations for the best of  medical blogs.  Last year I was honored to be nominated in the “best new medical blog” category.  You can make your nominations here by leaving a comment with your choice. 

The categories for this year's awards are:
-- Best Medical Weblog
-- Best New Medical Weblog (established in 2008)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

A little humor from a new medical blogger, Your ER Doc, but also some caution (photo credit) on the ill effects that the holidays can place on us. 

I see patients with anxiety just about every single shift, and the winter holiday season definitely ramps things up a lot. The holidays are just plain stressful. However, I suspect that a lot of the medical problems I see are indirectly caused from holiday stress as well.

From the Quilt Gallery Newsletter (Issue 7), some links that are very nice if you are interested in women, quilts, and history:

Judy Anne Breneman has published a series of Old Testament Bible Quilt Block Patterns (pictured)
Women On Quilts
The Alliance for American Quilts
Womenfolk: The Art of Quilting
Quilters Spirit
Patterns from History (Free quilt patterns)
Patches from the Past (History of Quilts)

This week  Dr Anonymous will be his Christmas Show on his  Blog Talk Radio show.  I hope you will check it out.  So come join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room. That's where all the fun is.

Studies Probe Oral Health–Diabetes Link, an article review

 Updated 3/2017-- photo and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I know this isn’t the usual topic for a plastic surgeon, but I have two Type II Diabetics in my immediate family.  My mother and one of my brothers.  My brother leapt to my thoughts when I first saw this article in the Dec 3 issue of JAMA (full reference below).  He has poor dentition due to many things:  diabetes, use of oral tobacco products, and avoidance of dentists.  I have tried to get him to see the dentist more regularly, but he has a fear of them like many of us.  I don’t think this article will change things with him, but I wish his doctor could use it to get him to see the dentist.  Perhaps his diabetes would be easier to manage and his overall health would be better.  (photo credit)

Physicians and dentists have long known that the health of an individual's mouth can have significant effects on the health of the rest of the body. The link between periodontal disease and heart disease is one of the most commonly known associations, but researchers are finding many more medical reasons to maintain good oral hygiene.

Diabetes, the focus of much attention lately due to its rising incidence, appears to have a particularly close relationship with conditions within the oral cavity. This relationship seems to go both ways—diabetes can lead to unwanted changes in the gums and periodontal tissues, and periodontal diseases—including gingivitis and severe periodontitis—can make it more difficult to control diabetes……….

Oral Health Problems Linked to Diabetes

Patients with inadequate blood glucose control appear to develop periodontal disease more often and more severely, and they lose more teeth than individuals who have good control of their diabetes. According to the American Dental Association, the most common oral health problems associated with diabetes are the following:

• tooth decay
• periodontal disease
• salivary gland dysfunction
• fungal infections
• lichen planus and lichenoid reactions (inflammatory skin disease)
• infection and delayed healing
• taste impairment

Physicians can play a role in encouraging patients' oral health by recommending good maintenance of blood glucose levels, a well-balanced diet, good oral care at home, and regular dental checkups. When glycemia has been difficult to control, a physician might consider asking patients when they last saw their dentist and whether periodontitis has been diagnosed.

REFERENCE
Studies Probe Oral Health – Diabetes Link; JAMA Vol 300, No 21, pp 2471-2473; Tracy Hampton PhD (Medical News & Perspectives section)

SurgeXperiences 213 – Call for Submissions

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The next edition (213) of SurgeXperiences will be hosted will be hosted by Make Mine Trauma, IntraopOrate, on December 21st.  She is a surgical assistant who is enthusiastic about trauma and surgery in general.  You can read her own  call for submissions here.  This is how she describes herself:

I am a surgical first assistant, also known to my friends as surgery junkie, ambulance chaser,trauma whore, or trauma slut (depends on whether or not I am getting paid for that case).

The deadline for submissions is midnight on Friday, December 19th.  Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Quilt Auction Ending Soon

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The auction for this quilt started on Monday, December 1. It will end on Monday, Dec 15, at noon. Currently, the bid is at $400 (LQ006). If you are interested in bidding, don’t let the time get away from you.

I’m reposting the particulars regarding the auction and how to bid (see below) to try to keep the interest up. Remember it is for a good cause and if the bid is too high for your budget, perhaps you can make a small donation here at First Giving instead. Several of you have done just that (made donations rather than bids). Zippy, Dr Rob, and I thank you all.

…………………………………………….

That charity is Childhood Brain Tumor Foundation - MD. If you would like to simply donate to the charity rather than make a bid you can do so here.

For the entire story (and more photos), see the previous posts here and here and here.

The item being auctioned is this wall hanging quilt. It is a Lobster Hawaiian Appliqué. It is 41 in X 41 in. It is machine appliqued and machine quilted. There is hand embroidery around the appliqued edges.

Here are the rules for this silent on-line auction:

• I have set up an e-mail account for the sole purpose of this auction. It is lobsterquilt(AT)gmail(DOT)com
• If you wish to make a bid, email me at the above address with “auction” in the subject line. Include your name, the amount of the bid, and a working email address. I will e-mail you back that the bid was received and give you an identifier number. This will be how I “track” each bidder and their subsequent bids.
• The bidding will start at $200. The minimal increment will be $10 for subsequent bids, though I would love to see the increments increase by $25 or more.
• Several times a day, during my awake hours and as work permits, I will tweet and post the current bid and time it was received. The bidder’s name will not be posted, but the bidder’s identifier number will be.
• So you can check my tweets or check back here to see how the bid is going. Take note: I will mainly use twitter for the updates!
• If you have sent a bid to me that was higher than the one posted, please, be aware of the time received (it will be CST) and either recheck later or e-mail me again. We all know that sometimes e-mails are lost.
• The auction will last two weeks. Bidding starts Monday December 1st at 6 am (CST) and closes on Monday December 15th at noon (CST). I will notify the winner by e-mail shortly thereafter.
• The winning bidder will be required to make a donation here at First Giving in the amount of the bid (or higher) and asked to leave a comment “I won the lobster quilt!” They will then need to forward a copy of their receipt so that I can match the name/e-mail address to the winning bid. This will need to be done within 48 hrs (or by December 17, 5 pm)
• Once the donation is confirmed, then arrangements will be made with the winning bidder on shipping. Shipping costs and any insurance will be the winner bidders responsibility. Options will be US Postal, Fed Ex, or UPS.
  

A Gift from India

I didn’t make Vijay’s daughter the pink quilt expecting anything in return.  Vijay (Scanman) and his wife, however, wanted to give me a gift from their country.  This is what they chose.  It is a Tanjore metal plate, and I think it is lovely.  I am trying to decide the best place to hang it in my home.

 

Here is some information on the history of the craft:

The creation of the Tanjore metal plate is credited to Raja Serfoji II (1797-1832), the Maratha ruler of Thanjavur (or Tanjore), who asked his royal artisans to create an object that would reflect the glory of his kingdom. Silver, brass, and copper are encrusted on to each other to create this stunning piece of art. The effect of silver in high relief on the reddish copper ground is unusual and striking. Artisans of the Vishwakarma community follow this hereditary profession in Thanjavur (Tamil Nadu).

This metal plate has as its base a plate of brass prepared by a heavy-metal worker; the relief on copper is worked upon by a jeweler while the encrusting is done by a stone-setter with silver. All the three processes could even be carried out by a single craftsman also. The tools involved include hammers, pincers, moulds, punches, chisels, grinding stones and a forge.

The first stage involves cutting the base to the size of plate planned and polishing its front side. It is then fixed firmly to an asphalt bed with a wooden base which is then heated with a blow pipe and leveled so that the basic design die is prepared. The silver and copper sheets are then cut to the size, heated slightly before being cast into an impression on to the die. The impression thus achieved is finished by etching and refining the embossing with the aid of chisels and punches.

The next stage involves encrusting and superimposing the metal sheet(s). This is done by filling with wax made of brick powder, gingili oil, and frankincense the hollow depressions at the back of the relief sheet. The relief sheet is then placed on the base plate and riveted on by punching along the grooves. This is then followed by the final polishing.

Designs on the central circular metallic disc may include a representation of deities like Nataraja, Saraswati, Ashta Lakshmi and Ganapaty while the designs around the central motif can be from the pantheon of Hindu deities or floral designs. Besides plates, other products such as bowls, boxes, key chains and paper weights are made using the same technique.ns, and paper weights --- are made using the same technique. Logos and emblems of corporate houses and organizations have also been embossed.

Crazy Quilt in Diamonds

Here is the second quilt for Sterile Eye.  It goes to his youngest daughter.  It is crazy quilt pieces cut into diamonds and then sewn together with sashes and smaller diamonds.  It is machine pieced and quilted.  It is 38.5 in X 52 in.

Here are a couple of detail photos to show some of the fabric interest.  I hope the little girl will enjoy finding things in her quilt.  In this photo you can find a car, skiers, carolers, birds, and more.

In this one you can find a lion, butterfly, Tinker Bell, a tulip, and many different colors.

Her is a photo (which doesn’t do it justice) of the back which is a coral pink fabric.   I hope you can see some of the quilting detail.  Each large diamond was quilted in a cross-hatch manner that broke it (the diamond) into sixteen smaller diamonds.  The two border strips were quilted using a simple cable.

Wrong Doctor

This past weekend I received a page from a woman whom I’ll call Flora.  I didn’t recognize the name or phone number that I was given.  I called anyway and when she answered, it went like this.

Me:  “I’m Dr Ramona Bates.  You had me paged.” 

Flora:  “You removed some lesions from my face on Monday, and I’m having some pain.”

Me:  “Ma’am, I don’t know you.  Are you sure you have the right doctor?”  I know confusion is audible in my voice as I’m going back over my schedule for the week in my mind.  I recall the procedures I did and there were no facial patients at all for the week.

Flora:  “I’m looking for Dr Bates.”

Me:  “Which Dr Bates?”

Flora:  “Dr Ramona Bates.”

Me:  “Well, that’s me, but I didn’t remove any facial lesions for anyone this week.  Are you sure a Dr Bates did your surgery?”

Flora:  “I’ll get my paperwork out and call you back.”

 

I never got re-paged, so hopefully Flora got the name of her doctor off her paperwork and called the right one.

Mama said there’d be days like this

Updated 3/2017--photo/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

(cartoon photo credit)

The above is a cartoon that was in the paper on December 2, 2008. In reviewing my twitters that morning (prior to reading the paper), I saw this one from Vijay to which I responded.

scanman wondering if @Bongi1, @rlbates & @DrCris have such days http://is.gd/a0dH :P

rlbates @scanman Regarding: have such days http://is.gd/a0dH Fortunately not in the OR, but with quilting and life. Worry about it sometimes.

This has been on my mind a lot lately. I have been trying to find a way to put it into words. Another female surgeon who sews, the Stitching Surgeon, recently had a day like this with her sewing.

stitchinsurgeon spent the last 3 hours with my embroidery machine...every project ruined! going to the YMCA to work out some of this frustration! 1:32 PM Dec 1st

Then the next day she posted some lovely work she had done and said this:

I set up my embroidery machine and while it is working I am hard at work on my Bernina.
I'm just "sew" efficient.

When I am sewing and I find that things aren’t going right, I’m ripping out every other or every seam and having to redo them or making cutting errors and “wasting” fabric, then I just put the project aside for the day. I go do something else just like Stitching Surgeon did. If I had a day like that in the operating room, I would not be able to do that. I would have to finish what I had started. It would have to be done right. I do think that there are days for me, both in the OR and in sewing, where things just seem easy, almost magical. There are other days when I seem to struggle more than I would like, but I haven’t had any days (thankfully) where I have felt like I would (and by extension, the patient would) be better off if I could do the surgery another day. Still the thought lingers with me.

So let me leave you with the song (video) the title was taken from

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

Dr. Elkhonon Goldberg and Alvaro Fernandez, Sharp Brains, are this week's host of Grand Rounds.   You can read it here.

"If Dr. Rob can interview Santa, why can't I interview a select group of health & medical bloggers? They will have some good ideas to share".

So did President-elect Obama came to realize a few days ago. After his people kindly contacted our people, we felt compelled to grant him open access to our collective wisdom. Without further ado, below you have Grand Rounds 5:12 - a Q&A session led by the incoming President on how to reform (for the better, we hope) healthcare.

A Repository for Bottled Monsters is the blog associated with National Museum of Health and Medicine (nee the Army Medical Museum) in Washington, DC.  Recently they posted on a new exhibit they are putting together on facial reconstruction.  I wish I could go see it, but will have to be content with the blog post.

The exhibit is contained in one wall-mounted cabinet and is called Facial Reconstruction. We have really cool and interesting plaster models and they're what make up the bulk of the cabinet. Here are four on them on a cart, waiting to go into the cabinet. They're various stages of one person's reconstruction.

Jordan, In My Humble Opinion, pens a lovely post.  I hope you will read it in its entirety.

There is a moment in some peoples lives were god given talent and passion mesh to create something beautiful and unique. Those who are lucky enough to experience this rare gift have a special power. The power to change the world.

I was born thinking medicine was my passion……..

Being a physician no longer ignited me...no longer set my heart on fire. But something did. Strangely and unexpectedly it was writing……….

………..I knew that I caught something that everyone else had missed. So I made a few changes and added a key medication and within 24 hours she was better. It might take some time but I know she will recover.
On my way home yesterday it hit me like a ton of bricks………

Gift and passion. Passion and gift. Somehow they've missed each other so far in my life. But what if....what if for just a moment I could realign them again.
Oh the the things I could accomplish!

An offering in the “spirit of the season” – well, a recipe from Kerry, SixUntoMe, for some chocolate cookies she made for her husband.  I plan to make some of these as gifts for my neighbors.  You can get the recipe for the awesome chocolate cookies here (photo credit).
 

This week  Dr Anonymous will be discussing Podcamp Ohio on his  Blog Talk Radio show.  I hope you will check it out.

Skin Cancer -- Melanoma

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

Continuing with the reprise of this series on skin cancer.  This was originally posted on July 20, 2008.  I have changed it so that I hope it is easier to read and added more pictures.  You may also want to check out my post from February 2008 on melanoma.

Melanoma is a malignancy of pigment-producing cells (melanocytes) located predominantly in the skin, but also found in the eyes, ears, GI tract, leptomeninges, and oral and genital mucous membranes. Melanoma accounts for only 4% of all skin cancers; however, is responsible for more than 77% of skin cancer deaths worldwide. Early detection of thin cutaneous melanoma is the best means of reducing mortality. In the United States, one person each hour dies from metastatic melanoma. (photo credit)

The development of melanoma appears to be related to multiple risk factors, including fair complexion, excessive childhood sun exposure and blistering childhood sunburns, an increased number of common and dysplastic moles, a family history of melanoma, the presence of a changing mole or evolving lesion on the skin, and, importantly, older age. Melanoma occurs most commonly on the trunk in white males and the lower legs and back in white females. In African American, Hispanic, and Asian person, the most common site is the plantar foot (sole), followed by subungual, palmar, or mucosal sites.

A new or changing mole or blemish is the most common warning sign for melanoma. ABCDE criteria (Friedman, 1985, Abassi 2004) for a changing mole is very useful. They have the greatest diagnostic accuracy when used in combination. More recent use of the "ugly duckling" warning sign, wherein skin examination is focused on recognition of a pigmented or clinically amelanotic lesion that simply looks different from the rest, may assist with detection of lesions that lack the classic ABCDE criteria (Grob, 1998; Gachon, 2005).

Asymmetry: Half the lesion does not match the other half.

Border irregularity: The edges are ragged, notched, or blurred.

Color variegation: Pigmentation is not uniform and may display shades of tan, brown, or black. White, reddish, or blue discoloration is of particular concern.

Diameter: A diameter greater than 6 mm (the size of a pencil eraser) is characteristic, although some may have smaller diameters. Any growth in a nevus warrants an evaluation.

Evolving: Changes in the lesion over time are characteristic. This factor is critical for nodular or amelanotic (no color or pigment) melanoma, which may not exhibit the classic criteria above. (photo credit)

Four major subtypes of primary cutaneous melanoma have been identified:
Superficial spreading

• melanoma is most common on the trunk in men and women, and on the legs in women. It is most commonly seen in individuals aged 30-50 years. It manifests as a flat or slightly elevated brown lesion with variegate pigmentation (ie black, blud, pink, or white discoloration). It is generally greater than 6 mm in diameter, irregular, and with asymmetric borders.

Nodular melanoma

• occurs in 15-30% of patients. It is most commonly seen on the legs and trunk. Rapid growth may occur over weeks to months. This subtype is responsible for the most thick melanomas. It manifests as a dark brown-to-black papule or dome-shaped nodule, which may ulcerate and bleed with minor trauma. It may also be amelanotic. It tends to lack the typical ABCDE melanoma warning signs and may elude early detection.

Lentigo maligna melanoma

• is typically located on the head, neck, and arms (chronically sun-damaged skin) of fair-skinned older individuals (average age 65 yrs). It grows slowly over 5-20 years. The in-situ precursor lesion is usually large (1-3 cm or more in diameter), present for a minimum of 10-15 years, and demonstrates macular pigmentation ranging from dark brown to black, although hypopigmented (white) areas are common within lentigo maligna. Dermal invasion (progression to lentigo maligna melanoma) is characterized by the development of raised blue-black nodules within the in-situ lesion.

Acral lentiginous melanoma

• is the least common subtype (2-8% of melanoma cases in white persons). It accounts for 29-72% of melanoma cases in dark-skinned individuals (African American, Asian, and Hispanic persons) and because of delays in diagnosis, may be associated with a worse prognosis. Acral lentiginous melanoma occurs on the palms, on the soles, and beneath the nail plate (subungual variant). Subungual melanoma may manifest as diffuse nail discoloration or a longitudinal pigmented band within the nail plate. It must be differentiated from a benign junctional melanocytic nevus of the nail bed which has a similar appearance. Pigment spread to the proximal or lateral nail folds is termed the Hutchinson sign and is a hallmark for acral lentiginous melanoma.

Rare melanoma variants (less than 5%) include desmoplastic/neurotropic melanoma, mucosal (lentiginous) melanoma, malignant blue nevus, melanoma arising in a giant congenital nevus, and melanoma of soft parts (clear cell sarcoma).
Amelanotic melanoma (less than 5% of melanomas) is non-pigmented. It appears, clinically, pink or flesh-colored, often mimicking basal cell or squamous cell carcinoma or a ruptured hair follicle. It occurs most commonly in the setting of the nodular melanoma subtype or melanoma metastasis to the skin.


Primary risk factor for or clinical warning signs of melanoma include:
Changing mole (most important clinical warning sign)
Clinical atypical/dysplastic nevi (particulary more than 5-10)
Large number of common nevi (more than 100)
Large (giant) congenital nevi (more than 20 cm in diameter in an adult)
Personal history of melanoma or First-degree relative with melanoma
Sun sensitivity/history of excessive sun exposure
Prior nonmelanoma skin cancer (BCC or SCC)
Male
Age older than 50 years

Presence of xeroderma pigmentosum or familial atypical mole melanoma syndrome (Both of these genodermatoses confer a 500-1000 fold greater relative risk of developing melanoma)

A fair-skin phenotype (blue/green eyes, blond or red hair, light complexion, sun sensitivity) and the occurrence of blistering sunburn(s) in childhood and adolescence are universal risk factors for melanoma.

Surgery is the primary mode of therapy for localized cutaneous melanoma.

The narrowest efficacious margins for cutaneous melanoma have yet to be determined. Surgical margins of 5 mm are currently recommended for melanoma-in-situ, and margins of 1 cm are recommended for melanomas up to 1 mm in depth (low-risk primaries). In some settings, tissue sparing may be critical and Mohs margin-controlled excision may be appropriate. Prophylactic lymph node dissection for primary cutaneous melanoma of intermediate thickness initially was believed to confer a survival advantage on patients with tumors of 1-4 mm in depth. Lymphatic mapping and sentinel node biopsy have effectively solved the dilemma of whether to perform regional lymphadenectomy (in the absence of clinically palpable nodes) in patients with thicker melanomas (>1 mm in depth).

Surgical oncologist will usually do the surgical excision, lymph node excision, etc. Medical oncologist are needed to discuss adjuvant therapy with IFN alfa, experimental melanoma vaccines, or other clinical trials. They may also discuss (and initiate) treatment of metastatic melanoma (stage IV) with chemotherapy, high-dose IL-2, biochemotherapy, or clinical trials, as indicated. Radiation oncologist may be needed for adjuvant treatment of resected regional nodal metastasis with extracapsular extension or for palliative treatment fo distant metastatic disease (particularly bone metastasis or brain involvement).

Further Reading
Malignant Melanoma; eMedicine Article, Jan 23, 2008; Susan M Swetter, MD
Current Treatments and Guidelines for Metastatic Melanoma; Medscape Article, 2007; Jedd D Wolchok, MD

SurgeXperiences 212 is up!

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

The 212 edition of SurgeXperiences is hosted by by QuietusLeo at the Sandman. He is an Israel-based anesthesiologist. He recently celebrated his 1st year blog anniversary. Read the edition here.

Welcome to the the 12 edition of SurgeXperiences Blog Carnival season 2! This is my second time hosting. Enjoy!

Since there is no theme, for better or for worse I've sort of catagorized the posts. This time I'll be starting with posts from patients (after all, we do all we do for them, right?)

The next edition (213) will be hosted by Make Mine Trauma, IntraopOrate, on December 21st. The deadline for submissions is midnight on Friday, December 19th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Quilt Auction for Zippy’s Charity

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

The auction for this quilt started on Monday, December 1.  Currently, the bid is at $300 (LQ004).  I’m reposting the  particulars regarding the auction and how to bid (see below) to try to keep the interest up.  Remember it is for a good cause and if the bid is too high for your budget, perhaps you can make a small donation instead.   Several of you have done just that (made donations rather than bids) and I and Zippy thank you all.

…………………………………………….

That charity is  Childhood Brain Tumor Foundation - MD.  If you would like to simply donate to the charity rather than make a bid you can do so here. 

For the entire story (and more photos), see the previous posts here and here and here. 

The item being auctioned is this wall hanging quilt. It is a Lobster Hawaiian Appliqué.  It is 41 in X 41 in.  It is machine appliqued and machine quilted.  There is hand embroidery around the appliqued edges. 

 

Here are the rules for this silent on-line auction:

• I have set up an e-mail account for the sole purpose of this auction.  It is lobsterquilt(AT)gmail(DOT)com
  
• If you wish to make a bid, email me at the above address with “auction” in the subject line.  Include your name, the amount of the bid, and a working email address.  I will e-mail you back that the bid was received and give you an identifier number.  This will be how I “track” each bidder and their subsequent bids.
  
• The bidding will start at $200.  The minimal increment will be $10 for subsequent bids, though I would love to see the increments increase by $25 or more.
  
• Several times a day, during my awake hours and as work permits, I will tweet and post the current bid and time it was received.  The bidder’s name will not be posted, but the bidder’s identifier number will be.
  
• So you can check my tweets or check back here to see how the bid is going.  Take note:  I will mainly use twitter for the updates!
  
• If you have sent a bid to me that was higher than the one posted, please, be aware of the time received (it will be CST) and either recheck later or e-mail me again.  We all know that sometimes e-mails are lost.
  
• The auction will last two weeks.  Bidding starts Monday December 1st at 6 am (CST) and closes on  Monday December 15th at noon (CST).   I will notify the winner by e-mail shortly thereafter. 
  
• The winning bidder will be required to make a donation here at First Giving in the amount of the bid (or higher) and asked to leave a comment “I won the lobster quilt!”  They will then need to forward a copy of their receipt so that I can match the name/e-mail address to the winning bid.  This will need to be done within 48 hrs (or by December 17, 5 pm)
  
• Once the donation is confirmed, then arrangements will be made with the winning bidder on shipping.  Shipping costs and any insurance will be the winner bidders responsibility.  Options will be US Postal, Fed Ex, or UPS.
  

So let the bidding begin!

Trip Around the World Quilt

If you were in the chat room the night of Sterile Eye’s interview on Dr A’s BTR show, then you know I offered to make his two girls quilts. Here is the first one. It is for the 4 yr old. The pattern is called Trip Around the World (or sunshine and shadow). It’s a fun pattern to play with colors. This one has most of the colors of the rainbow or color spectrum (ROY G BIV) though I began with the blue in the center and then progressed out with the pink to red to orange to yellow to green. The quilt is 42 in X 50 in. It is machine pieced and quilted.

Here is a closer view so you can see some of the fabrics. They include a girl in a sailor suit, some small animals, some clowns, stars, etc.

Here is a picture of the back of the quilt. The fabric is from the Robert Hoffman collection called Kaleidoscope. It continues the color spectrum and adds the purple not on the front.

I just noticed an “error” while writing this post. Too late to fix it as the quilting is done and has been mailed. I’ll tell you what the error is later in the comments, but first I’ll see if any of you notice it.

Skin Cancer – Squamous Cell Carcinoma

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Continuing with the reprise of this series.  This post was originally posted July 19, 2007.  I redid the layout slightly, so that I hope it is easier to read.

Squamous cell carcinoma (SCC) is the second most common form of skin cancer, with over 250,000 new cases per year estimated in the United States. Most (96-97%) are localized and if identified early and treated promptly will not be serious. The other 3-4% can be very invasive in nature, can spread to distant organs (metastasize) and become life-threatening. SCC on the lip or ear appear to be the sites most likely to metastasize. These should be taken seriously. Photo credit.

SCC is a malignant tumor that arises in the squamous cells of the upper layer of skin (of epidermal keratinocytes). Most arise from sun-induced precancerous lesions known as actinic keratoses (AKs) and patients with multiple AKs are at increased risk for developing SCC. SCC is capable of locally infiltrative growth, spread to regional lymph nodes, and distant metastasis, most often to the lungs. Once lung metastasis occurs, the disease is incurable.

General risk factors include :

• Age 50 yrs or older, Male, Fair Skin (burns easily, very or rarely tans)
• Geography–lives closer to the equator (Florida, Australia)
• History of prior non-melanoma skin cancer
• Exposure to UV light--natural or tanning bed or treatment (psoralen plus UVA (PUVA) for psoriasis
• Exposure to chemical carcinogens (arsenic, tar)
• Radiation exposure–treatment for other cancers (lymphomas, etc)
• Chronic immunosuppression–a history of solid-organ transplantation, hematologic malignancy (CLL), HIV infection or long-term use of immunosuppressive medications for an autoimmune condition
• Chronic scarring condition–Marjolin ulcer refers to an SCC that arises from chronically scarred or inflamed skin. Patients may report a change in the skin (induration, ulceration, weeping) at the site of a preexisting scar or ulcer. The latency period is often 20-30 years. Major burn scars. Chronic venous ulcers. Not scars from simple lacerations.
• Genodermatoses -- Human Papilloma Virus (HPV) infections–Virally induced SCC most commonly manifests as a new or enlarging warty growth on the penis, vulva, perianal area, or periungual region. Patients often present with a history of "warts" that have been refractory to various treatment modalities in the past.

Warning signs: (credit -- photo examples)

• A wart-like growth that crusts and occasionally bleeds.

• A persistent, scaly red patch with irregular borders that sometimes crusts or bleeds

• An open sore that bleeds and crusts and persists for weeks.

• An elevated growth with a central depression that occasionally  bleeds. A growth of this type may rapidly increase in size.

Treatment Modalities are similar to those of BCC (see yesterday's post).

Prognosis:
Most SCCs are readily treated with an expectation of cure. The 3-year disease-specific survival rate has recently been estimated to be 85%; this rate approaches 100% for lesions with no high-risk factors (see below), but it decreases to 70% for patients with at least 1 risk factor.

Local recurrence following definitive treatment is not uncommon, and metastasis and death may ensue. Most series in the literature quote an across-the-board prevalence rate of metastasis for primary cutaneous SCC of 2-6%.

When SCC does metastasize, it is usually occurs within several years from the time of diagnosis and involves the primary draining lymph nodes. In general, metastasis from SCC of the forehead, the temples, the eyelids, the cheeks, and the ears is to the parotid nodes; metastasis from SCC of the lips and the perioral region is primarily to the submental and submaxillary (upper cervical) nodes. Once nodal metastasis of cutaneous SCC has occurred, the overall 5-year survival rate has historically been in the range of 25-35%. Prognosis is extremely poor for patients who have 1) a compromised immune system, 2) metastasis to multiple lymph nodes, or 3) cervical lymph nodes greater than 3 cm in diameter. Metastasis to distant organs remains incurable.

Thus, close surveillance and early detection of nodal metastasis can be life saving and is extremely important.

There is a subset of SCC that is considered high risk because of its aggressive behavior. These SCC have a tendency for rapid local growth, higher rates of recurrence and regional metastasis, and a poor prognosis. SCC can be characterized as high-risk by virtue of tumor-related factors (intrinsic factors), patient-related factors (extrinsic factors), or a combination of both.

Risk factors associated with higher rates of recurrence and metastasis

Tumor-related factors in high-risk SCC:

• Tumor location (ie, lips,ears, scar)--The historical rates of metastases for SCC of the external ear and the lip are approximately 11% and 10-14%, respectively. Marjolin ulcer subtype of SCC behaves aggressively, with a metastatic rate of approximately 18-38%.
• Tumor size greater than 2 cm –These may have a metastatic rate of up to 30.3%.
• Invasion to subcutaneous fat (or deeper) --SCC with a depth of less than 2 mm rarely metastasizes. SCC with a depth of invasion less than 4 mm has a historical recurrence rate of 5.3% and a metastasis rate of 6.7%; these rates increase to 17.2% and 45.7%, respectively, for tumors invading greater than 4 mm.
• Poorly differentiated tumor – are generally accepted to behave more aggressively.
• Recurrent tumor-- has a site-dependent rate of metastasis of 25-45%.
• Perineural involvement --has been estimated to occur in 2.4-14% of persons with cutaneous SCC, most commonly in elderly men with tumors of the head and neck. The prognosis in such cases is extremely poor, with historical rates of local recurrence and metastasis reported to be as high as 47%.

Patient-related factors in high-risk SCC

• Organ transplant recipient --SCC in OTRs occurs more frequently, appears at an earlier age, is often multicentric, and may be clinically aggressive. The rate of local recurrence has been reported to be as high as 13.4%, while metastasis occurs in 5-8% of patients. Metastatic SCC in OTRs has a dismal prognosis, with a 3-year disease-specific survival of only 56%.
• Hematologic malignancy (eg, CLL) --in patients with CLL, the recurrence rate of SCC treated with MMS was 7-fold higher at 5 years compared with patients without CLL. In addition, a small case-control study found the 5-year cumulative incidence of SCC metastasis to be 17.7% for patients with CLL.
• Chronic immunosuppressive therapy or disease state: HIV infection or AIDS--In one small case series, 5 of 10 patients with HIV and aggressive SCC died of metastasis within 7 years of the initial diagnosis.

Patients should be counseled to avoid excessive UV radiation by limiting outdoor activity to early morning and late afternoon, using protective clothing, and wearing a broad-brimmed hat to shade the head and the neck area. Counseling patients regarding treatment of areas of chronic skin inflammation or trauma is important in preventing the future development of SCC at those sites.