Eight Too Many

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

I want to begin this post by basing it on “facts” reported in the news (ABCNews, Reuters, LA Times, Times Online):

• single 33 yo mother, self described “professional student”

Nadya Suleman, who describes herself as a “professional student” who lives off education grants and parental money, broke up with her boyfriend before the birth of her first child seven years ago.

• six children, ages 7 yo, 6 yo, 5 yo, 4 yo, 3 yo, and 2 yo twins
• residing with her parents in a three bedroom home 
• single mother’s own mother reports that her daughter used infertility treatments
• recently gave birth to EIGHT babies, 

  The babies were born by Caesarean section nine weeks premature and ranged from 1 pound, 8 ounces to 3 pounds, 4 ounces. The woman was carrying 24 pounds of baby.

• plans to breast feed (or more correctly use breast milk donated by other women to supplement her own)
• source of income  (see above) – education grants and parental money though recently reported

THE single mother of octuplets born in California last week is seeking $2m (£1.37m) from media interviews and commercial sponsorship to help pay the cost of raising the children.

• no mention of her insurance coverage, if there is any

I want to try to avoid the issue of fetal reduction and concentrate on some the other issues I find troubling.  
She seems (evidence is the six children she already has) to have had no need for infertility treatments.  So why did any fertility clinic take her own as a patient?  Were they more greed driven than patient driven?  That is my (outsider) view.
Human females were not made to have litters, and that is what eight babies to me is.  Sorry if I offend someone, but the risk of health issues related to such a pregnancy are multiple and serious: 

• miscarriage, pregnancy-induced hypertension/stroke, preeclampsia, gestational diabetes, acute polyhydramnios, vaginal/uterine hemorrhaging, and preterm labor & delivery.

The preterm labor and delivery is a “given”.    The length of pregnancy is usually 39 weeks for singletons, 35 weeks for twins, 33 weeks for triplets, and 29 weeks for quadruplets.  Generally, once the pregnancy reaches about 32 weeks, the complications associated with premature delivery are significantly reduced. 
Risks of complications to mother from premature delivery (incomplete list)

• Surgical and medical issues related to C-section
• Emotional issues
• Fatigue even if she has enough support

Risks of complication to each baby from premature delivery (incomplete list)

• Inability to breathe or breathe regularly on their own because of underdeveloped lungs
• Feeding and growth problems because of an immature digestive system
• Intracranial hemorrhage (bleeding into the brain)
• Hearing or vision problems related to immature nerves or treatment side effects
• Developmental delay and learning disabilities from brain damage related to immaturity
• Special problems for low birth weigh babies (less than 3.5 lbs)

Who pays for all of this and should we care?
Each one of these babies weighed less than 3.5 lbs.   Lets assume they all live (and I hope they do and that they beat the odds and don’t have any major long-term health issues). 
Median cost for NICU care (29 wk, 58 day stay in 1999) $61, 724 for each baby

The state of California is bankrupt.  The cost of each of these babies just for the first year of life is going to cost the California taxpayer more than I can imagine. 

I agree that the woman has the right to have more children, but I only agree to that IF she has the ability and resources to take care of them at the time she has them (I’m allowing for future unforeseen calamity).  I do not think she or anyone has the right to take money from my pocket that I could use to help my children (if I had any) or my nieces or nephews get their medical care or allow them to go to college.  Nor should I support her children instead of helping out my elderly parent.

Though it appears now from the Times Online that she is attempting to turn the birth of her eight babies into a source of income.  I hope she will remember to pay the hospital and doctors.  I hope she will put money into the continued health expenses these eight preemies will have. 

Although still confined to an LA hospital bed, she intends to talk to two influential television hosts this week - media mogul Oprah Winfrey, and Diane Sawyer, who presents Good Morning America.

Other Blog Posts on This Topic
Fat Doctor – Six and Eight
Medical Quack -- Obsessed with Having Babies?  Update on the Octuplets Story
Survive the Journey --Nadya Suleman's Octuplets -- How Many is too Many?
Dr Rob -- Don’t Forget the Kid(s)
NeoNurseChic – The Ethics of Octuplets
Moof -- Ooooopsie
Dr Cris – Making Babies or Saving Lives


REFERENCES
Multiple Pregnancies, Maternal Risks – Womens Health Channel
Multiple Birth Pregnancy – University of Pennslyvania
Premature Babies – Medline Plus
Premature Births – March of Dimes

Wild Rose Quilt Block

The summer block of my Four Seasons quilt is the wild rose block. I found it in the “Award Winning Quilts” by Effie Chalmers Pforr (published in 1974). It was submitted by Mrs Rex Watson of Valparaiso, Indiana. She is quoted

“I chose the Wild Rose pattern because it makes such a beautiful quilt, and it brings back memories of girlhood days on the farm, where we had the delicate wild rose blooming along the fence row.”

It could have been my own words. I love wild roses.

I replaced the “satin-like” fabric center with a slightly smaller yellow cotton center. I like it much better. I did the machine stitching on the leaves, buds, and flowers BEFORE doing the quilting. I have outlined quilted the roses/leaves and then cross-hatched the background.

Refinements in Nasal Reconstruction – an Article Review

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 article “Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap” and the “discussion” both recently published in the Journal of Plastic and Reconstructive Surgery (see full references below) give a truly nice review of the procedure.

Nasal reconstruction is often challenging. The forehead flap is a workhorse flap in nasal reconstruction. It provides similar skin color, texture, structure, and reliability. A disadvantage of the forehead flap includes a difficult arc of rotation. This can displace the medial eyebrow hair. The vertical design can encroach on the scalp which can risk incorporating unwanted hair into the nasal reconstruction.

Historically, the median forehead flap was based on a wide pedicle whose base sit in the center of the forehead. Both supratrochlear vessels were included. This pedicle did not extend below the eyebrows. This wide pedicle had the potential to increase the torsion on vessels which could then lead to compromising the blood flow to the flap.

The paramedian flap design is centered directly over the supratrochlear artery (note: only one vessel, not both) above the medial side of the eyebrow. The proximal flap does not extend below the eyebrow, resulting in shorter flap length.

The midline forehead flap combines features of both the median and the paramedian forehead flaps. The skin paddle is centered in the midline based on a unilateral supratrochlear vessel. The pedicle can be dissected at its emergence from the superior medial orbit.

The article describes the authors' modification of the established oblique paramedian forehead flap.

Stage 1

The cross-paramedian forehead flap is based on the supratrochlear vessel contralateral to the nasal defect. The flap is designed to extend across the midline of the forehead to the contralateral side. The flap is an axial pedicle flap until it crosses the midline. The distal third of the flap crosses the midline to become a random flap.

The flap is elevated in the subgaleal plane from distal to proximal to the supraorbital region. The dissection plane becomes subperiosteal at the level of the upper eyebrow. Inferior dissection is carried into the orbit in the subperiosteal plane to facilitate a safe arc of rotation without tension.

The periosteum is incorporated at the most inferior extent of the pedicle and carefully freed toward the supratrochlear vessels to facilitate flap rotation. The pedicle is designed with a narrow skin bridge 8 mm in width with a sufficiently wide subcutaneous and galeal pedicle to safely include the supratrochlear vessels. The narrow skin pedicle is carried below the medial eyebrow toward the medial canthus.

The forehead flap is mobilized and rotated downward into the nasal defect. If the flap appears robust, the frontalis muscle can be thinned from the distal half. The flap is folded on itself distally to replace the nasal lining if necessary. This design provides a longer hairless flap, which is advantageous when reconstructing lining. The donor site is closed primarily. We prefer to base the pedicle on the contralateral side of the defect because it provides a smooth arc of rotation and a longer non-hair-bearing flap.

Stage 2

The flap is divided and inset at 2.5 to 3 weeks. The skin width is narrow proximally and is excised in or parallel to the glabellar frown line. This results in a linear scar in the glabella region.

Secondary refinements of the forehead flap may be necessary to defat the flap and refine the aesthetic contour.

Both article and discussion are worth your time to read and study.
REFERENCES

Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009, pp 87-93; Angobaldo, Jeff M.D.; Marks, Malcolm M.D.

Discussion of Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 94-97; Menick, Frederick J. M.D.

Prophylactic Mastectomy

 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 article recently published online in the journal Cancer (due in print in their March issue) looks at the risks factors that increase the likelihood of a woman being diagnosed with breast cancer in her “other” breast after being diagnosed with breast cancer.

The article was done at MD Anderson Cancer Center in Houston.  It looked at 542 women with breast cancer diagnosed in one breast (unilateral breast).  All of the women decided to have this and the other breast (contralateral prophylactic mastectomy).

The researchers identified are three factors that increases the chance of cancer in the other breast.  These three factors are:

• having more than one tumor in the same breast at the time of initial diagnosis of breast cancer
• having invasive lobular breast cancer, which begins in the milk-producing glands called lobules rather than in the milk ducts, and then invades surrounding tissues
• having a high score in the so-called Gail model that calculates breast cancer risk and considers things such as age at first menstrual period, age when first child was born and whether close relatives like mother or sister had the disease.

Factors that did not help determine the risk of developing a future cancer in the other breasts included:  race and hormone receptor status of the cancer.

The study did not focus on whether mutations in the genes called BRCA1 and BRCA2 that raise the risk of breast cancer also raised the risk of having cancer later develop in the initially unaffected breast.  Often women with these mutations or a strong family history of breast cancer get preventive mastectomies even before any tumor has developed in either breast.

Having a breast surgically removed when you have breast cancer in the other breast has long been an option, but there appears to be a renewed interest among women (and their doctors). 

When I was a plastic surgery resident and early in my practice, prophylactic mastectomies were an accepted way to deal with the “high risk” of breast cancer.   We often did bilateral prophylactic mastectomies.   I found my copy of the American Society of Plastic and Reconstructive Surgeons Position Paper on Prophylactic Mastectomy (recommended criteria for third-party payer coverage) from 1994.  Here are the indications listed:

Prophylactic mastectomy is recommended for either the treatment of breast symptoms or to prevent cancer from developing in the breast.  Accepted indications for mastectomy include the presence of biopsy-proven tissue of uncertain behavior, the presence of microscopic foci of lobular carcinoma or ductal carcinoma in-situ, and both personal and family histories of breast cancer.  In these high-risk patients, statistics support prophylactic mastectomy.  Fibrocystic mastopathy may generate enough fibrosis to render mammography useless for cancer detection.

Other indications for mastectomy and reconstruction include injected silicone mastopathy, a history of multiple breast biopsies, cancerphobia, progressive fibrocystic mastopathy preventing adequate examination, and refractory mastodynia.

Definite indications for prophylactic mastectomy include lobular or ductal carcinoma in-situ; proliferative atypical dysplasi; severe dysplasia; personal history of breast cancer; personal history of breast cancer in opposite breast; one first-order relative with bilateral, premenopausal breast cancer; two first-order relatives with premenopausal breast cancer; desmoid tumor of the breast or giant fibroadenoma; cystosarcoma phylloides; significant virginal hypertrophy, and post-injection silicone mastopathy.

Two or more of the following conditions also represent indications for prophylactic mastectomy:  one first-order relative with premenopausal breast cancer, one first-order relative with postmenopausal breast cancer, obscured mammograms due to fibrosis, history of multiple breast biopsies, and refractory fibrocystic mastodynia.

It is nice to have this new study as it reinforces many of the reasons I was taught, but it also “refines” the reasons.  However, this is not a new treatment.  It is a “resurgence” of an old treatment.  It fell out of favor because it became difficult to get insurance to pay for it.

REFERENCE

Predictors of Contralateral Breast Cancer in Patients with Unilateral Breast Cancer undergoing Contralateral Prophylactic Mastectomy; CANCER Print Issue Date: March 1, 2009; Published Online: January 26, 2009; DOI: 10.002/cncr.24129 (abstract); Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, Banu K. Arun, Isabelle Bedrosian, Gildy V. Babiera, Rosa F. Hwang, Henry M. Kuerer, Wei Yang, and Kelly K. Hunt.

Shout Outs

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

Jenni Prokopy, Chronic Babe, is this week's host of Grand Rounds. It is the “totally Babelicious!” edition and can be read here.

Call us biased, but we think chicks rule. There's a ton of health information on the 'net, but often, medical research and reporting focus more on men—so we thought it was high time the ladies got a little attention in Grand Rounds, a showcase for the best health and medical writing on the web.

We had a stand-out winner this week:

Normally when we host Grand Rounds, we don't play favorites...but this time we made an exception. Doc Gurley takes the video approach in teaching Babes anything and everything they need to know about (drum-roll, please) The Lost Tampon! It's a serious women's health topic, with a very un-serious approach. Watch, giggle, and learn.

The second edition of Change of Shift (Vol 3, No 15) for 2009 is hosted by Kim, Emergiblog! Kim, as always, did a great job. I hope you will check it out. You can find the schedule and the COS archives at Emergiblog.

Welcome back to Emergiblog, for the post-inaugural edition of Change of Shift!
If you didn’t get a chance to check out this week’s Grand Rounds, hosted by Dr. Val of Getting Better With Dr. Val and presented at MedPage Today, be sure to do so!
As is the custom on Emergiblog, since the “theme” is nursing, I’ll present the submissions themselves as the theme of the edition.

MedGadget has announced the winners of the 2008 Medical Weblog Awards. Wow, what a great list of blogs!

Best Medical Weblog

• Kevin, M.D.

Best New Medical Weblog (established in 2008)

• Life in the Fast Lane

Best Literary Medical Weblog

• Running for My Life: Fighting cancer one step at a time

Best Clinical Sciences Weblog

• Clinical Correlations

Best Health Policies/Ethics Weblog

• Respectful Insolence

Best Medical Technologies/Informatics Weblog

• Life as a Healthcare CIO

Best Patient's Blog

• Six Until Me

Let’s support Shadowfax again this year as he gets ready to shave his head for pediatric cancer research.

I will be participating in the St Baldrick's program to raise funds for pediatric cancer research. I will be shaving my head at Fado's Pub in Chicago on March 13, sacrificing my beautiful locks to the cause of finding cures for these terrible diseases. Last year, we did the same, and Nathan's Network raised just about $40,000. You, my readers, were instrumental in helping us achieve that goal.

So, again, I ask you to consider donating whatever sum you can -- simply click on the image below and it will take you to the secure online donation site. The top donor will get first swipe with the razor, should he or she care to come to Chicago! All donors will receive an image of my glistening bald scalp and an extra helping of good karma.

Hat tip to Uveal Blues: How Our Eyes See vs. How Our Cameras See by Allen Weitz

The human eye, with support from the brain (the fastest CPU on the planet), visually reconstructs our surroundings in real-time as we go about our days and nights. Describing the human eye and how it interprets the world around us in terms of camera optics is a tricky process to explain, and that's before we even get to the 'how does it compare to my camera' part of the story.

Hat tip to WhiteCoat. It is a very moving story which many of us will be able to relate to.

An extremely powerful story about an intern on her first day in the emergency department in Medscape Emergency Medicine
Some of my most vivid memories of emergency medicine involve situations such as hers.

Maxillofacial Injuries and Violence Against Women – 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.

The referenced article below has recently been published in Archives of Facial Plastic Surgery.  It takes a look at the ugly side of facial fractures.  They stated their objective as

To determine if patterns of facial injuries differed between those of female assault victims with maxillofacial injuries and those of female patients with maxillofacial injuries from other causes.

To accomplish their objective, they reviewed the records for adult (over 18 yrs) women who received treatment for facial trauma between January 1998 and December 2004 at the University of Kentucky Medical Center and the Kentucky Medical Services Foundation.  There were 481 (234 + 247) such women identified.  Of these 481 patients, 140 (67 + 73) had to be excluded due to missing or incomplete medical records.  There were 14 (3 + 11) others excluded due to duplication of records, etc.  This left them with 326 (164  + 162) cases to review. 

The records were then combed for information that included

… demographic data (patient age and ethnicity), date of injury, date of earliest presentation for medical attention, diagnosis codes, and treatments.

Patients were grouped as to whether their injuries were caused by IPV (ie, assault perpetrated by a current or former spouse, partner, or dating relationship), family violence (ie, assault perpetrated by a parent, sibling, or other blood relative), fall, work-related injury, assault by a known assailant not domiciled with the victim (ie, assault perpetrated by a friend, neighbor, or acquaintance), assault by an unknown assailant, motor vehicle crash, self-inflicted gunshot wound, sporting accident, other accident, or unknown/undocumented cause.

Most recorded injuries were grouped as bruising, lacerations, nasal fractures, mandible fractures, zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries.

For the target population, additional information extracted included whether assault victims did or were able to identify their assailant(s) and whether there was documentation of notification to the police or a social worker when the patient presented for care. The method of injury (ie, gunshot, stabbing, punching, kicking, hitting, biting, burning, bludgeoning, pushing, throwing) was also recorded when available.

They found that the most common cause of facial trauma in the adult female patients was motor vehicle crashes (42.9%), followed by falls (21.5%), assault (13.8%), undisclosed or undocumented mechanisms of injury (10.7%), sporting injuries (including all-terrain vehicle accidents,7.7%), other accidental causes (2.4%), self-inflicted gunshot wounds (0.6%), and work-related accidents (0.6%).  

Of the 45 assault victims, 19 (42.2%) were documented victims of IPV or family violence.  Of these 19, most were IPV cases (18 [94.7%]).  Of the other 26 assault victims, most (92.3%) could not or did not identify their assailant.

Several causes of injury were found to correlate with pattern of injury. 

• Assault was associated with mandible fractures, zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries.
• Specifically, higher than expected numbers of zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries were found in IPV victims.
• Victims assaulted by unknown or unidentified assailants were more likely to have mandible fractures than were other assault victims.
• In contrast, higher than expected counts of mandible fractures, alveolar ridge fractures, intracranial injuries, and facial lacerations were found in motor vehicle crash victims.
• Nasal fractures, which were the most common injuries, correlated with family violence, falls, work-related injuries, assault by a known assailant (not IPV), sporting accidents, other accidents, and unknown/undocumented cause of injury.
• Patients with falls as the cause of injury were more likely than expected to have nasal fractures, alveolar ridge fractures, and facial lacerations.
• Alveolar ridge fractures also correlated with unknown/unspecified cause of injury.

Sadly,  25-33% of American adult women are affected by intimate partner violence abuse by a spouse or significant other.   Of these victims, 88% to 94% will seek medical help for head and neck injuries.  More than half (56%) of these women will have facial fractures.

Because of these numbers, facial plastic surgeons and other health care providers who treat maxillofacial injuries need to be able to identify these victims.  These women should then be referred to local domestic violence service programs where they can get help with safety planning, information and referrals, support services and advocacy.

National Domestic Violence Hotline:  1-800-799-SAFE (7233) or TTY 1-800-787-3224.

Source Article
Maxillofacial Injuries and Violence Against Women; Arch Facial Plast Surg. 2009;11[1]:48-52; Oneida A. Arosarena, MD; Travis A. Fritsch, MS; Yichung Hsueh, MD; Behrad Aynehchi, MD; Richard Haug, DDS

SurgeXperiences 216 – Call for Submission

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

The next edition (216) of SurgeXperiences will be hosted at “Frankie’s Hideout“ by Dr Frank Drackman on February 1st.   The welcome to his blog reads:

The recollections of one Frank Drackman, complete with flashbacks and derogative colliloquy. Hideout Rules of Engagement are written for your safety and for that of your team, They are not flexible, nor am I, either obey them or you are history, is that clear?

The deadline for submissions is midnight on Friday, January 30th.  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.

Hands Across America Flag Quilt

Taking a break from my four seasons quilt, let me show you this flag quilt that I made in 1999.  I was inspired by the stars and bars flag of the American Civil War, by the eagle motif I found in an old book, and a sign I saw around the same time with the @ overlying a hand.  The name of my quilt is “hands across America”.  I designed three hands with the letters “U”, “S”, and “A” (using @ for my A).  I appliqued this shapes using small flags for the fabric.  The quilt is 23 in X 39 in, both machine and hand sewn/quilted.

Here is a close photo of the eagle.  I used the machine trapunto method for the “relief” effect.  That’s correct, the eagle is machine quilted.  The “rays” are hand quilted.

Here is the back to show the quilting of the eagle.

Here is a close view of the letter “A”/hand.

It is my hope that as America moves forward with her new President that we will all work together for her good.

Splinting after CTR – 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.

I admit, I splint after carpal tunnel release (CTR), though after reading this article I will change my ways. My use of splints after CTR has been because “I was taught that in training”. Not always a bad thing, but not always a good thing either. I was reminded of this by the opening of the article (first reference below):

Dogma is pervasive in all of medicine, and hand surgery is no exception. As the movement toward evidence-based medicine continues, clinical researchers have striven to dispel dogmatic practices for which no scientific support exists. One such target is the practice of splinting after carpal tunnel release. There have been five prospective, randomized trials, all since 1995, showing that postoperative splinting after this procedure is of no benefit, with one of them demonstrating that it is actually detrimental.

I have not read the five articles (2 – 6 references below) they mention in the opening above.

The authors sent a questionnaire to all members of the American Society for Surgery of the Hand (2257 total). They excluded residents, fellows, and supporting members. Recipients were asked whether they splint their patients in the immediate postoperative period after CTR, and if so, for how long they maintain the splint. They were also asked to indicate their training (i.e., orthopedic, plastic, or general surgery).

Of the 2257 questionnaires mailed, 1091 were returned (48% response). Sixty-nine percent of respondents were trained in orthopedic surgery, 16 percent were trained in plastic surgery, and 3 percent were trained in general surgery. An additional 2 percent were trained in both orthopedic surgery and plastic surgery. These percentages are congruent with the overall American Society for Surgery of the Hand membership profile. Ten percent of respondents did not specify their specialty.

The results were similar regardless of the specialty:

Fifty-three percent of respondents use full-time splinting postoperatively.

Five percent of these respondents also prescribe the use of night splints after a variable period of full-time splinting.

Night splinting is used as the only postoperative immobilization by 1 percent of respondents (night splinting was not offered as an option on the questionnaire so may be underrepresented as it required a write-in response)

In addition, 1 percent of respondents wrote that they apply a bulky dressing. This practice was not counted as splinting.

Within the subset of surgeons who apply splints after carpal tunnel release, there is tremendous variation in splinting duration, with a range of 1 day to 6 weeks.

The duration reported most frequently (i.e., the mode response) within this subset is 7 days.

It is noteworthy, however, that when considering the entire survey population, the most frequently reported duration is, decisively, 0 days (i.e., no splinting).

In their discussion section, the authors reviewed the five articles (2-6 references below) that show no advantage and some disadvantage to postop splinting. Here is what they say in summarizing the article by Cook et al

In the first of these trials, Cook et al randomized 50 patients undergoing open carpal tunnel release to be splinted for 2 weeks postoperatively or to begin unrestricted active motion on the first postoperative day.
The drawbacks of immobilization were striking. At 1-month follow-up, the splinted group fared significantly worse with respect to the incidence of scar tenderness and pillar pain, patients' subjective pain rating, grip and key pinch strength, and patients' assessment of outcome.
Even more conspicuous was the splinted group's slower return to activities of daily living (12 days versus 6 days; p = 0.0004) and light-duty work (27 days versus 17 days; p = 0.005).
There were no wound complications, hematomas, bowstringing or adherence of flexor tendons, or neuromas in either group.
The authors concluded that splinting is largely detrimental but acknowledged that certain rare complications, such as bowstringing, might occur in a larger series. They recommended early mobilization but advised against simultaneous finger and wrist flexion, which might be more likely to result in bowstringing

The prevention of flexor tendon bowstringing is frequently cited as the reason for splinting after carpal tunnel release. The authors of this survey article notes that

To our knowledge, this complication has been reported only once, in a 1978 article by McDonald et al. In their series of 186 carpal tunnel releases, bowstringing was observed in two patients. Interestingly, these patients were splinted postoperatively, and in both cases the bowstringing occurred after reoperative carpal tunnel release.

In their words, Bowstringing of the flexor tendons is a rare complication, possibly occurring as a result of removing a segment of the transverse carpal ligament or from inadequate immobilization following a carpal tunnel release.

Splinting seems like such a small thing to worry over, but it is important to question the reason we do things. To be sure we do them for the correct reasons. To be able to base them on current scientific standards. To continue to learn.

REFERENCE

1. Splinting after Carpal Tunnel Release: Current Practice, Scientific Evidence, and Trends; Plastic & Reconstructive Surgery:Vol 122(4), Oct 2008, pp 1095-1099; Henry, Steven L. M.D.; Hubbard, Bradley A. M.D.; Concannon, Matthew J. M.D.

2. Cook, A. C., Szabo, R. M., Birkholz, S. W., and King, E. F. Early mobilization following carpal tunnel release: A prospective randomized study. J. Hand Surg. (Br.) 20: 228, 1995

3. Bury, T. F., Akelman, E., and Weiss, A. P. C. Prospective, randomized trial of splinting after carpal tunnel release. Ann. Plast. Surg. 35: 19, 1995

4. Finsen, V., Andersen, K., and Russwurm, H. No advantage from splinting the wrist after open carpal tunnel release: A randomized study of 82 wrists. Acta Orthop. Scand. 70: 288, 1999

5. Bhatia, R., Field, J., Grote, J., et al. Does splinting help pain after carpal tunnel release? J. Hand Surg. (Br.) 25: 150, 2000

6. Martins, R. S., Siqueira, M. G., and Simplicio, H. Wrist immobilization after carpal tunnel release: A prospective study. Arq. Neuropsiquiatr. 64: 596, 2006

7. McDonald, R. I., Lichtman, D. M., Hanlon, J. J., et al. Complications of surgical release for carpal tunnel syndrome. J. Hand Surg. (Am.) 3: 70, 1978.

Scars and Their Therapy – 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. 

As I continue to catch up on my journal reading, I thought I would review and share this (full reference below) article with you on scars and current therapies.

The article begins by touching on the three stages of wound healing:   inflammation, proliferation, and matrix remodeling/scar formation.  Then goes on to discuss first the emerging scar-reducing therapies and then the currently available therapies.

The list and discuss the following as emerging scar-reducing therapies:

TGF-β Superfamily--

TGF-β has been studied as a potential scar-reducing agent since the 1980s.  TGF-β1, TGF-β2, and TGF-β3, have been demonstrated to have major roles in scar production.   Investigations of TGF-β as a scar-reducing agent have sought to simulate the fetal wound-healing environment by increasing the relative ratio of TGF-β3 to TGF-β1 and TGF-β2 to minimize scarring.  There are several ongoing Phase II clinical trials evaluating Juvista, human recombinant TGF-β3, with the next trials due to report in mid 2008. Although demonstrating positive preliminary efficacy with high safety, it remains to be seen with great anticipation what the long-term efficacy in larger trials will be compared with current therapy and what practical role if any TGF-β-modulating agents will play in future therapeutic protocols.

COX-2 Inhibitors and Nonsteroidal Antiinflammatory Drugs:

There has been growing interest in the role of the COX-2 pathway in scar reduction.  Topical application of a selective COX-2 inhibitor immediately after wounding resulted in a statistically significant reduction in local neutrophils, prostaglandin E₂ levels, TGF-β1, collagen deposition, and scar formation in a mouse study.  Of note, it has been demonstrated that topical application of COX-2 inhibitors does not have a negative effect on wound reepithelialization.  There is conflicting evidence on the effect of constitutive inhibition of COX-1 and COX-2 on wound healing. One study has suggested that inhibition of COX-1 may cause delayed wound healing, whereas another study demonstrates no delay in wound healing.

Collagen Synthesis Inhibitors

Modulation of collagen metabolism is another potential target for preventing excessive scar formation. ……………. has shown modest benefit of scar reduction to date, and these remain agents of interest for further investigation.

Angiotensin-Converting Enzyme Inhibitors

It is well accepted in the cardiovascular literature that up-regulation of angiotensin-converting enzyme participates in adverse fibrous cardiac remodeling.   Recent studies have shown that a locally functioning tissue renin-angiotensin system operates in human skin.  It has been demonstrated that exogenous angiotensin II may accelerate wound healing in animal models.  ……… Further investigation of their role in scar reduction is warranted.

Minocycline

A recent study found that systemically administered minocycline significantly reduced the severity of hypertrophic scarring in a rabbit ear scar model.  The mechanism by which minocycline reduces scar formation in this model remains unanswered. …… Additional studies are needed to elucidate the mechanism of this intriguing agent.

Gene Therapy

There have been few published studies, limited to animal models, using gene therapy to investigate scar reduction. To date, fibroblasts have been used as the primary targets for a gene therapy approach to scar reduction. A major obstacle is that scarring is a very complicated process involving many different factors, and much of the outcome of scar formation is likely programmed by the early inflammatory response to wounding. Most studies to date have demonstrated modest or inconclusive results on scar formation.

They list and discuss the following as currently available scar-reducing therapies:

Topical and Intralesional Corticosteroid Injections

Triamcinolone is currently the most commonly used corticosteroid for the treatment of scars. When used as a monotherapeutic agent, studies show 50 to 100 percent efficacy of intralesional injection of triamcinolone.  However, many of these studies lack well-designed controls and standardized objective measures of scar outcome and thus are of limited value………

5-Fluorouracil

Use of intralesional 5-fluorouracil for treatment of hypertrophic scars has been shown to be effective in multiple studies.  However, most of these studies lack adequate controls and are of limited value. Combinations of 5-fluorouracil with intralesional corticosteroids and pulsed dye laser have been used to achieve better results than 5-fluorouracil as a monotherapy.  Notably, the combination of 5-fluorouracil with corticosteroids has been shown to decrease the side effects related to prolonged therapy with corticosteroids alone. …….

Bleomycin

Bleomycin is an antibiotic with well-known antitumor, antibacterial, and antiviral activity.  Studies have shown that intradermal injection or the multipuncture method of bleomycin injection results in significant improvement in keloids and hypertrophic scars.  However, all of these studies involved a small sample size and lack well-designed controls and thus are of limited value.  ……

Adverse sequelae of bleomycin include hyperpigmentation (75 percent) and dermal atrophy in the skin surrounding treated scars (10 to 30 percent).  Further large controlled trials are needed to evaluate the efficacy of bleomycin.

Laser Therapy

Pulsed dye laser therapy has been shown to have positive efficacy in numerous studies, but many of these studies lack well-designed controls and are of limited value. The primary indication for pulsed dye laser is to reduce erythema. Pulsed dye laser therapy is based on the principle that hypervascularity plays a key role in scar appearance. ……

Common side effects of pulsed dye laser treatment include posttreatment purpura, which usually subsides after 7 to 10 days, and hyperpigmentation in 1 to 24 percent of patients.  ……… if further controlled trials support its efficacy.

Silicone Gel Sheets

Numerous studies have demonstrated the utility of silicone gel sheeting in treating hypertrophic scars but overall yield inconclusive evidence for its mechanism of action and efficacy in reducing existing scars.   Silicone gel sheeting has also been investigated for its potential utility in scar prophylaxis when applied in the postoperative period. Controlled studies investigating silicone gel sheeting applied to wounds immediately and 2 weeks postoperatively significantly decreased scar volume over controls in mirror-image incisional wounds. However, the largest controlled study demonstrated no improvement in scar prophylaxis.   A recent Cochrane review cites 13 trials involving 559 patients and concludes there is weak evidence of a benefit of silicone gel sheeting as a prevention for abnormal scarring in high-risk individuals, but most studies are of poor quality and highly susceptible to bias…….

Pressure Therapy

Pressure therapy has been a conservative management of scars since the 1970s,  despite a paucity of well-designed controlled clinical studies demonstrating its efficacy. ……..The largest randomized controlled trial showed no significant differences in scar reduction with pressure therapy compared with controls.

Current evidence does not support the efficacy of pressure treatment as a monotherapy for scar reduction. The appropriate role of pressure therapy in scar reduction protocols may be as an adjunctive treatment as part of a polytherapeutic strategy of scar management, but this must first be evaluated in clinical studies.

Cryotherapy

There have been many reports of cryotherapy used as a combination therapy with surgical excision for hypertrophic scar and keloid reduction.   Most of these studies are difficult to evaluate because of small sample sizes and lack of adequate controls. …… The main adverse effects reported were atrophic depressed scars and residual hypopigmentation (75 percent of cases).   ….. there is limited evidence for the long-term efficacy of cryotherapy for scar reduction.

Radiation

Radiation therapy has been used in scar management primarily in the treatment of keloids, frequently being used as an effective adjunct to surgical excision.  Radiation likely mediates its effects on keloids through inhibition of proliferating fibroblasts and neovascular bud formation, resulting in decreased collagen production. 

Surgical excision in combination with radiotherapy is considered the most effective treatment available for severe keloids. There is limited and inconclusive evidence regarding optimal dosage, fractionation, indications for treatment, or timing of radiotherapy with respect to surgical procedures. However, a single dose given within 24 hours of excision appears to yield the highest cure rate in recurrent keloids. …….

Surgical Treatment

There are many different surgical strategies for scar revision, including excision with linear closure, excision with split- or full-thickness skin grafting, Z-plasty, W-plasty, and if all other options fail, excision followed by flap coverage. Tissue expansion and serial scar excision may be used to provide more tissue for advancement or local flap coverage of revised scars……

The article is well written and is a nice review of scar therapies.  I would have to agree with their conclusion that

There is a great need to use large controlled trials to examine currently available and emerging strategies of scar reduction to standardize scar treatment protocols and evaluate emerging agents that could potentially benefit patients with scars refractory to currently available treatments.   Two major shortcomings of current clinical studies include (1) a lack of well-designed controls and (2) a lack of standardized and comprehensive evaluative measurements of scar outcome.

REFERENCE
Scars: A Review of Emerging and Currently Available Therapies; Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008; Reish, Richard G. M.D.; Eriksson, Elof M.D., Ph.D.

Other related posts:
Skin – Healing a Simple Wound/Laceration
Scar Prevention

Shout Outs

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one. 

Dr Val, Better Health, is this week's host of Grand Rounds. It is the inaugural Grand Rounds and can be read here at MedPageToday.  

On this historic inauguration day, I thought it fitting to dedicate Grand Rounds to the subject of healthcare reform. The medical blogosphere is uniquely positioned to provide commentary "from the trenches" and I sincerely hope that policy-makers in Washington (like Tom Daschle) will bend an ear to us on a regular basis.

Wouldn’t it be great if we could accurately diagnosing Skin Cancer without a biopsy?  Well, it may soon be possible.  Check out this video clip from Vanderbilt!  Exciting news.

Daniel Kozan is a medical student in Canada.  He is putting together a website, Plastic Student, to help with teaching plastic surgery concepts to medical students. 

PlasticStudent.com is a website designed to teach core concepts in plastic surgery to medical students around the world. Plastic surgery education in medical school is often limited, and this site intends to fill the gap by providing clinically oriented cases and reference material for students to learn from. We hope this site will help students prepare for exams, electives, and their future careers.

If you happen to be in Washington DC on February 4, 2009, you might want to attend  a lecture at the National Museum of Health and Medicine:  "Health, Illness and the Presidency"

Join NMHM as we celebrate the centennial year at Walter Reed Army Medical Center. Lawrence C. Mohr, Jr., MD will discuss his experiences as White House Physician to three presidents – Reagan, Bush and Clinton – and his career at Walter Reed.

A wonderful source for information on cold water immersion hypothermia (hat tip to Dr Paul Auerbach):  Cold Water Boot Camp

Most of the water in Canada is cold year round. It’s cold water that is a major contributor to recreational drowning deaths year after year. Nine Boot Camp volunteers offered to ‘jump in with both feet’ and experience first hand what happens in 6 degree Celsius water. On this site you can:

View - video clips of boot campers’ immersions that will take you into the water with them.

Join - Dr Gordon Giesbrecht, (Professor Popsicle) in the classroom to learn about his 1-10-1 formula for survival in cold water.

Discover - information on Lifejackets...your first line of defense against cold water immersion.

Learn - about the medical and physical data related to cold water accumulated by researchers, agencies and the Coast Guard from across the country

Trauma Junkie, Surviving RT School, is a starting a new blog carnival.  I love the logo (photo removed 3/2017)! The first edition is planned for Friday, February 13th.  If you have any posts related to lung/respiratory care than I would encourage you to submit them.  You can find the instructions here.

I'm planning a blog carnival for Respiratory Bloggers: therapists, students, patients, and anyone who has anything pertaining to respiratory care, lung disease, breaking news for respiratory therapists and modern advances in equipment. Basically, anything that has do with respiratory therapy will be included in the carnival, regardless of who submits it

Body Image and Facial Burns – 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. 

I came across this article, Body Image and Facial Burns, in the journal Advances in Skin & Wound Care.  It is a short, but interesting article.  I came away feeling they had fallen short on my expectations from the title and what the authors state as the purpose of the article:

This article reviews the literature (PubMed, Medline, and Ovid databases) on the effect of facial burns on body image and discusses the theory and research behind normal and altered body image. Facial burns illustrate the clinical application to provide efficacious treatment strategies for people with disfigurement.

There are 58 articles listed in their reference, but in the body of the article they don’t state the total number of  articles they did find with their search.  Nor do they define the criteria for the articles they did review, only that

Although body image models have been proposed, only a small body of literature relating to facial disfigurement exists. These models, although theoretical, provide a framework for managing altered body image.

I did enjoy the section on the theory of body image. 

Schilder defined body image as "the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves."
Schilder noted body image was fluctuant, varying with age, mood, or clothing.
Price proposed the body image model, comprising body reality, body presentation, and body ideal.
Body reality is an individual's phenotype and depends on genotype and environmental factors.
Body presentation refers to an individual's dress, adornment, and behavior.
Body ideal is how an individual desires to appear. It comprises various facets including physical dimensions and body function.
Body reality and presentation are compared with the body ideal, consciously and subconsciously. Body ideal, in accordance with Schilder, alters with time and environment and may be emotionally influenced. These factors are suggested to be in a state of balance; altering one may cause compensatory change in the others.

The article goes on to discuss primary and secondary socialization and several different models (ie fear-avoidance model of psychosocial difficulties following disfigurement).  The article goes on to discuss the importance of faces:

Faces facilitate understanding of our identity and ancestry and provide clues to age and mood.  A person's face is the main point of focus during social interaction-providing conscious and unconscious expressions.   Approximately two-thirds of communication is nonverbal, mediated principally by facial expression.

Facial disfigurement describes the visual effect of scars, skin grafts, asymmetry, or altered pigmentation. It may cause disruption to body image and, especially if there is loss of self-recognition, constitute a major life crisis.

Then tries to condense the findings from the reviewed articles, but it left me with little to “hand my hat on”.

Some researchers have found more psychological problems in adolescents and persons in their early 20s. 

However, Robinson et al  found no correlation of patient age or duration of disfigurement with levels of anxiety and depression, although only 13 participants younger than 27 years were included in their study.

Yet, this supports other work suggesting that the development of effective coping mechanisms determines psychosocial outcomes.

If  Sir McIndoe is correct (as quoted in the article), then have we gone backwards by getting rid of wards and having only private rooms?  Is the need for infection control harming the treatment of psychological aspects of facial trauma?

Sir Archibald McIndoe made groundbreaking advances reconstructing allied air-force pilots who were burned in World War II. He noticed that the burns of the men on the ward healed better than the officers who had been kept in cubicles: "Camaraderie was the obvious answer. The officers on their own tended to fret, lose their appetite, and think too much about their disfigurement.’

The conclusion section is better in my opinion.

Body image models, although they have limitations, provide a framework for the analysis and treatment of disfigured individuals. For some, a blemish may cause huge anxiety; others with far more disfiguring burns may cope well.

Experiences and levels of perceived social support sculpt an individual's self-esteem and interpretation of specific situations. This seems to alter emotional and behavioral responses more than demographic or physical characteristics. Those who do well tend to confront their anxieties, whereas those who avoid them develop negative coping strategies and fare worse.

Various modalities can be used in the management of facial disfigurement, including surgery and psychosocial therapies. Efficacious psychological interventions must target specific cognitive and behavioral elements that predispose individuals to experience distress as a consequence of their disfigurement.

Future research using qualitative and longitudinal techniques needs to be conducted to rigorously evaluate these psychosocial interventions and enable the demolition of this last bastion of discrimination.

Actually, I got more out of the article going back through it a second and third time to write this review.  Still I wanted more of a black and white conclusion and there can’t be at this time (and maybe never will be).

…………………………………………………………….

A comment from the second article listed below:

Patients undergoing cosmetic surgery, like most of the general population, have emotional and social concerns specific to aspects of facial appearance, albeit to a greater degree.  Perhaps this greater level of concern is a cause for action to undertake cosmetic surgery. For the most part, these concerns do not represent pathologic states, and, in fact, the incidence of body image psychosocial disorders is quite low in this population.

This study validates the fact that a positive change in a feature of concern is accompanied by a resultant lessening of concern related to that feature. This "cause and effect" phenomenon stands in stark contrast to a true body image disorder wherein no amount of surgical alteration will yield the preferred decrease in associated distress.

REFERENCES

Body Image and Facial Burns; Advances in Skin and Wound Care,  Vol 22, No 1, pp 39-44, January 2009;  David CG Sainsbury, BMedSci (Hons), MBBS, MRCS (Eng)

Impact of Cosmetic Facial Surgery on Satisfaction With Appearance and Quality of Life; Arch Facial Plast Surg. 2008;10(2):79-83; Jason A. Litner, MD, FRCSC; Brian W. Rotenberg, MD, FRCSC; Maureen Dennis, BA, RN; Peter A. Adamson, MD, FRCSC

SurgeXperiences 215 is Up!

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one. 

This edition (215) of SurgeXperiences is hosted by the founder Jeffrey Leow, formerly "Monash Medical Student", now Vagus Surgicalis.   You can also follow him on twitter.  He calls this the Gupta edition and you can read this edition here.

Welcome to the 15th edition of SurgeXperiences Season 2. Today we will unveil 2 things. First, as you might already have noticed, is the change of my blog name from “monash medical student” to “Vagus Surgicalis“. Second? I’ll keep you in suspense!
Let me first introduce to you my co-host for today, Dr. Sanjay Gupta!

The host of the next edition (216), February 1st, will be Frank Drackman, “Frankie’s Hideout“. The deadline for submissions is midnight on Friday, January 30th. 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.

Windblown Tulips Quilt Block

The spring block of my Four Seasons Quilt is the Windblown Tulips quilt block. It is a Marie Webster design, and was first published by Mountain Mist in 1930. I got the pattern from one of their wrappers when I bought some batting in the early 1990’s. You can find the pattern in Mountain Mist Quilt Favorites (published 1998).

Like the winter block, Dresden Plate, I cross-hatched the background of this block after outlining the flowers and leaves. The tulips were also quilted with red thread to add some detail. The large blade-leaves were quilted with a dark brown thread to add a center vein detail.

The rayon fabric of the leaves addes some of it's own detail to them.

Latisse for Longer, Darker Lashes

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

Have you ever wished you had longer, darker lashes?  Well, now there is an FDA approved drug that can help you with your wish.  Friday, December 26, 2008, Allergan Inc. made the announcement.

The drug, Latisse, can be obtained by prescription only, so will be available through a doctor’s office.  

The primary ingredient in Latisse, bimatoprost, is a prostaglandin analog that is present in hair.  It is thought to help in the development and regrowth of hair follicles.

Latisse is applied once-daily to the base of the upper eyelashes with a sterile, single-use-per-eye disposable applicator.  Users may begin to see results as early as six to eight weeks.  However, it takes 16 weeks to see the full results. 

• Latisse should not be applied to the lower lid. 
• Lashes on each eye lid may not grow in the exact same way. 
• Continued use of the drug is necessary to maintain the effect.  Lashes will gradually return to pretreatment state if the use of Latisse is discontinued.

Contraindications and Side Effects

The only known contraindication for use of Latisse is hypersensitivity to the drug.

Approximately 4% of users of Latisse will have side effects such as an itching sensation in the eyes and/or eye redness.

Pigmentation of the eyelids and iris may occur.

Other less common side effects which typically occur on the skin close to where Latisse is applied, or in the eyes include skin darkening, eye irritation, dryness of the eyes, and redness of the eyelids.

Precautions

If you develop a new eye condition (e.g., trauma or infection), change in vision, have eye surgery, or develop any eye reactions (e.g. conjunctivitis and eyelid reactions), you should immediately seek your doctor's advice  and consider discontinuing use of Latisse.

Other posts you may find interesting:

Eyebrow Reconstruction

Hair for Charity

Hair Transplantation

Permanent Hair Removal

Maggot Therapy

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. 

Recently read a new article (the sixth one in the references below) on “maggot therapy” and couldn’t resist updating the one I first did in October 2007.

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization.

W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy.

A drawing of the life cycle of this fly appears below.

One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons.

It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day.

They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus).

Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Maggots must be disposed of as infectious waste in a biohazard bag when finished.  It is best to double-bag and seal the removed maggots.

From the sixth reference article regarding use of maggots in the United States:

Maggots are available only by prescription.

The Food and Drug Administration regulates the use of medical maggots, as not all species are therapeutic or safe.

Approved use currently exists for the debridement of non-healing necrotic skin and soft tissue wounds that include pressure ulcers, venous ulcers, neuropathic foot ulcers, and non-healing traumatic or postsurgical wounds.

In the United States, the supplier of Medical Maggots is Monarch Labs in Irvine, California. A vial of 250 to 500 larvae costs approximately $88 plus shipping and handling.  The number of vials needed will be determined by the wound size and duration of therapy. Many wounds require only 1 to 2 applications over a 3- to 7-day period.

REFERENCES

1.  Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

2.  From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

3.  Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

4.  Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

5.  Maggot Therapy for Wound Management; Advances in Skin & Wound Care:Vol 22(1),Jan 2009, pp 25-27; Hunter, Susan RN, MSN; Langemo, Diane PhD, RN, FAAN; Thompson, Patricia RN, MS; Hanson, Darlene RN, MS; Anderson, Julie PhD, RN, CCRC

7.  Maggots Are Enough to Gag Superbugs; Wall Street Journal Article August 8, 2008;  by Scott Hensley (Don’t watch the video in the article if you are squeamish.)

My Old Blog Posts
Maggot Therapy, October 31, 2007
Maggot Therapy Revisited, August 11, 2008

Shout Outs

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one. 

Barbara, In Sickness and In Health, is this week's host of Grand Rounds. The theme began as “connections” and organized into sci-fi films.  You can read this excellent edition here.

The (optional) theme I suggested for this Grand Rounds was connections -- connections among people, groups, ideas, opinions, facts, devices, places, events, just about anything. ………..

One area of connection that has fascinated me for decades is the realm of science fiction films. Sci-fi films connect the past, the present, and the future; our darkest fears and loftiest hopes; the devastation humans cause and the healing we bring; the divine and the utterly outrageous.

Here's a confession. For the past twenty seven years I have attended the annual 24 hour science fiction film festival. I bring my pillow and my ray gun and sit in the dark with my crew watching the sublime( Blade Runner), the drek (Plan 9 from Outer Space), the naughty (Invasion of the Bee Girls) the forgotten ( A Boy and His Dog), the political (Aelita - Queen of Mars), and the Sean Connery (Zardoz)

So the organizing theme for this Grand Rounds is sci-fi films.

The first edition of Change of Shift (Vol 3, No 14) for 2009 is up over at  Crzegrl, Flight Nurse!  Emily did a great job and I hope you will check it out.  You can find the schedule and the COS archives at Emergiblog. 

As I sat down to lay out this edition of Change of Shift, I realized how many first timers took the plunge and decided to submit blog posts. That in itself is very exciting. A few I corresponded with, giving words of encouragement and even went out and got a video blog post from another blogger who didn’t originally intend on submitting.

Trauma Junkie, Surviving RT School, is a starting a new blog carnival.  I love the logo! (photo removed 3/2017) The first edition is planned for Friday, February 13th.  If you have any posts related to lung/respiratory care than I would encourage you to submit them.  You can find the instructions here.

I'm planning a blog carnival for Respiratory Bloggers: therapists, students, patients, and anyone who has anything pertaining to respiratory care, lung disease, breaking news for respiratory therapists and modern advances in equipment. Basically, anything that has do with respiratory therapy will be included in the carnival, regardless of who submits it

On January 8, 2009, NPR ran a wonderful story called Learning to See in Stereo by Joe Palca.  You can read and / or listen to it here.

Children who are born with a crossed eye can develop a peculiar condition affecting vision called amblyopia, or "lazy eye." The eyes register two different images of the world, and the brain can't handle it — so it ignores one of them.

Surgery is commonly done to correct the crossed eye, and a patch is worn over the strong eye to force the weak eye to work harder. Conventional wisdom holds that after age 7, a child's vision isn't likely to improve.

But researchers at the University of California, Berkeley, believe that adults with the condition can improve their vision. I decided to go and meet them because I'm hoping they can help me.

There are times when we need to give presentations.  I’m not always comfortable doing so.  Allergy Notes twittered

RT @Berci: The 10 Worst Presentation Habits http://tinyurl.com/ka3ur

The article, The 10 Worst Presentation Habits (Speakers can be their own worst enemies. Here are our expert's tips on how to make a presentation sing) By Carmine Gallo, comes from Business Week.  It is worth checking out.  For example

Bad Habit #2  Avoiding eye contact

Great communicators understand that eye contact is critical to building trust, credibility, and rapport. Far too many business professionals have a habit of looking at everything but the audience -- a wall, a desk, or a computer.

Do this instead:
Maintain eye contact with your listeners at least 90% of the time. It's appropriate to glance at your notes or slides from time to time, but only for a few seconds and only as a reminder of where to go next. You are speaking for the benefit of your listeners. Speak to them, not the slides.

This week on  Dr Anonymous BTR show, he will be discussing ProMed Network.  

The ProMed Network is a site for medical and health programming producers to share their shows with other medical professionals, students in the health care fields, and members of the public interested in health related programming.  Each of the shows listed on the site is either produced by a medical professional or has been reviewed and is determined to present peer reviewed or medically relavent information.

While no program here can be used to provide specific medical advice or diagnoses, it is hoped that the general information presented here will help to provide a high quality source for medical news and content.  The ProMed Network and its member podcasts and webcasts will provide a single resource for diverse, independently produced audio and video programs by and for medical and health care professionals.

UAMS Develops Breast Cancer Vaccine

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

Scientists at my alma mater, the University of Arkansas for Medical Sciences, plan to begin clinical trials this spring on a vaccine to prevent the recurrence of breast cancer.

Thomas Kieber-Emmons, director of basic breast cancer research at the UAMS Winthrop P. Rockefeller Cancer Institute, and his team used a $2.9 million grant from the U.S. Department of Defense to develop the vaccine. It took more than a decade of study on the immune system to do so. The immunotherapy is designed to trick the body into doing something it wouldn’t naturally do - produce antibodies that fight breast cancer cells.

Traditional treatment will not be replaced by the vaccine even if it is successful. Dr Laura Hutchins who will be the principle investigator of the trial, points out that the vaccine could be additional treatment for patients along with the traditional treatment such as chemotherapy and radiation. She is a professor of internal medicine and director of the division of hematology and oncology at UAMS.

The trials will be done in phases. The first phase will last four to six months, and involve Arkansas women with cancer that is actively spreading and women whose cancer has come back after going into remission. The women will receive five doses of the vaccine.

The second phase will last about a year and include women who have had breast cancer but are in remission and considered at high risk of getting it again. The women will have to have been off chemotherapy for at least six months.

The number of patients participating in the study hasn't been determined.

SurgeXperiences 215 – Call for Submissions

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one. 

The next edition (215) of SurgeXperiences will be hosted the “founder” of the carnival, Jeffrey Leow, Monash Medical Student, on January 18th.   You can also follow him on twitter.  This is his welcome to his blog:

Welcome to my blog. Join me as I go "vagus" (latin: wandering) in the medical arena as I go through medical school down under in Melbourne.

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.

Eureka Christian Health Outreach Clinic

I’d like to sing the praises of an old medical school classmate, Dr Dan Bell, and his wife Suzie (a nurse).  They were recently on the ABC World News with Charles Gibson as part of the “Spirit of America” series.  The segment ran on January 7, 2009.

They are part of a unique approach to the health care crisis in America: all have volunteered to help their uninsured neighbors receive first-rate health care -- for free. And nearly 200 other local volunteers have joined them.

"I thought it would be more of an effort to get everybody on board," explains Dr. Dan Bell. He's the idealistic family doctor who, with his bright and energetic wife Suzie, envisioned creating a free health care clinic four years ago.

"I thought we'd be doing something in the back room of our church and seeing a dozen people," Dan said of his early vision.

Instead, the Eureka Christian Health Outreach clinic, known as ECHO, sees hundreds of patients a year. Its entire staff, which now includes doctors, nurses, pharmacists, dentists and a wide range of clerks, assistants, social workers and specialists, are all volunteers. No one receives a penny for their time and, on clinic nights, they can work six hours or more without a break. And that's after most of them have already put in a full day at their regular jobs.

Eureka  Christian Health Outreach

For more information regarding ECHO or to make a donation, e-mail echo@hbeark.com or call 253-5547.

Dresden Plate Block

My winter block of the “four seasons” quilt is a Dresden plate block. The center is a cross-stitch piece I had done with no intended use. The blue is silk that was left over from the "blue nude” quilt I had done.

The Dresden plate quilt pattern was very popular in the 1920’s and 30’s. It is also know by names such as Grandmother’s sunburst, sunflower, and friendship ring. There are usually 12 or more “petals” that are sewn together, radiating from a central circle, and then appliqued onto a block of fabric. The segments may be smooth at the outer edge of the circle or shaped into arcs or points, or a combination.

History of the Dresden Plate Block (for the full history and pictures go to the source article)

But there is indeed a much earlier example that used this configuration in the center of a wool, medallion style quilt. In fact this amazing antique is the earliest surviving American made pieced medallion quilt. It is inscribed, "ANNA TUELS HER BEDQUILT GIVEN TO HER BY HER MOTHER IN THE YEAR AU 23. 1785". ² To the right is an illustration of the medallion center of Anna Tules quilt and below is a link a photograph of it. The center Dresden Plate style motif is surrounded by hourglass and heart blocks and a wide beautifully quilted border.

Here is the block quilted. You can still see some of my “blue” washable marks.

REFERENCES
Patterns from History written by Judy Ann Breneman

Quilter's Muse Virtual Museum-- The Secret Quilt Code: Underground Railroad Quilt Blocks, The Roots and Impact of a New American Myth

CAMRSA: Dx and Tx Update for Plastic Surgeons – an Article Review

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

Beginning the year trying to catch up on some of my journals.  Reading my Plastic and Reconstructive Journals, I noticed this very nice review article on community acquired methicillin resistant Staph aureus (first article referenced below).  It seems even more timely as HHS has just issued it’s “Action Plan to Prevent Health Care-Associated Infections”.

It begins by noting that MRSA was first discovered in the 1960’s and until “recently” was considered a hospital-acquired infection.  Looking at the genes of the S. aureus bacteria has given a clearer picture of the two (hospital acquired vs community acquired) diseases.

There are five types of SCCmec. Hospital-acquired methicillin-resistant S. aureus strains contain SCCmec types I, II, III, and V4, and community-acquired methicillin-resistant S. aureus strains contain a smaller version of SCCmec type IV. The smaller size of the SCCmec type IV is responsible for the wider susceptibility of the community-acquired methicillin-resistant S. aureus to antimicrobials, as it does not carry the genes for other drug resistance. This genetic package gives community-acquired methicillin-resistant S. aureus resistance always to methicillin and almost always to erythromycin, in addition to other drugs that may be used to treat an infection……

Of clinical importance is that almost 100 percent of community-acquired methicillin-resistant S. aureus strains contain the Panton-Valentine leukocidin (PVL) gene allowing for production of a necrotizing, cell membrane pore-forming cytotoxin that targets leukocytes and erythrocytes.  Panton-Valentine leukocidin is responsible for the localized invasiveness in community-acquired methicillin-resistant S. aureus soft-tissue infections. In contrast, only 5 percent of methicillin-sensitive S. aureus and hospital-acquired methicillin-resistant S. aureus isolates contain the PVL gene.

The article compares the two HA-MRSA and CA-MRSA

	HA-MRSA	CA-MRSA
Health-care contact	yes	no
Mean age at infection	older	younger
Skin and soft-tissue infection	25%	75%
Antibiotic resistance	many agents	some agents
PVL toxin gene	5%	100%

The article reviews who is more likely (risk factors) to acquire CA-MRSA

• History of MRSA infection or colonization in patient or close contact
• High prevalence of CA MRSA in local community or patient population
• Recurrent skin disease
• Crowded living conditions (e.g. homeless shelters, military barracks)
• History of incarceration
• Participation in contact sports
• Skin or soft tissue infection with poor response to B-lactam antibiotics
• Recent and/or frequent antibiotic use
• Injection drug use
• Member of Native American, Pacific Island, Alaskan Native populations
• Child under 2 years of age
• Male with history of having sex with men
• Shaving of body hair

It is important to be more suspicious of CA-MRSA if the patient is one of those with the risk factors listed above, but also if their clinical presentation includes the following

• looks like spider bite
• folliculitis, pustular lesions
• furuncle, carbuncle (boils)
• abscess (esp. with tissue necrosis)
• cellulites
• impetigo
• infected wound

The article covers treatment  of CA-MRSA skin infections.  They make a point that not all need to be treated with antibiotics.

Abscesses should be incised and drained with material sent for aerobic culture. Abscess drainage alone suffices in patients with a soft-tissue abscess less than 5 cm in diameter and who are not systemically ill. There is no benefit in using antibiotics for cutaneous abscesses if adequate drainage is performed; however, this does not apply to patients with cellulitis.

They then go on to point out the ones who do need antibiotics.

In a patient with comorbidities, moderate illness, or a soft-tissue infection larger than 5 cm in diameter, antibiotic therapy should be started after incision and drainage.

If community-acquired methicillin-resistant S. aureus is suspected but there is not a definite abscess, antibiotic treatment should be started. If this course is chosen, the patient should follow up 48 to 72 hours after treatment has begun, as the aggressiveness of the community-acquired methicillin-resistant S. aureus may lead to development of an abscess.

The article notes that, currently, CA-MRSA is frequently sensitive to clindamycin, gentamicin, rifampin, and trimethoprim / sulfamethoxazole, as well as vancomycin.  Linezolid is also effective but very expensive.

Currently, 90-95% of CA-MRSA strains are currently susceptible to trimethoprim/sulfamethoxazole at double strength and doxycycline.

In CA-MRSA,  there is minimal evidence at this time to support decolonization protocols in the community.    There may be some benefit in decolonization of patients with recurrent methicillin-resistant S. aureus soft-tissue infections or high-risk contacts of patients with methicillin-resistant S. aureus soft tissue infections.   Topical mupirocin in the nares has been shown to eradicate methicillin resistant S. aureus colonization in health care workers and patients for a short time.   This effect may be lost over time as individuals become recolonized, and prolonged use of mupirocin has been associated with resistance.

Preventive Measures Include

Personal hygiene

• Shower daily
• Wash hands frequently
• Keep wounds covered
• Avoid contact with wound drainage

Environmental control

• Clean shared equipment (e.g., athletic equipment)
• Clean contaminated surfaces
• Use a barrier to bare skin when in contact with shared
  equipment

Health care–associated control

• Use antimicrobials judiciously
• Diagnose and treat methicillin-resistant S. aureus lesions
  early
• Educate patients about wound care
• Consider decolonization
• Consult with an infectious disease specialist when
  appropriate

REFERENCES

Community-Acquired Methicillin-Resistant Staphylococcus aureus: Diagnosis and Treatment Update for Plastic Surgeons; Plastic & Reconstructive Surgery. 122(4):120e-127e, October 2008; Stacey, D Heath M.D.; Fox, Barry C. M.D.; Poore, Samuel O. M.D., Ph.D.; Bentz, Michael L. M.D.; Gutowski, Karol A. M.D.

Community Associated Methicillin Resistant Staphylococcus Aureus (CA MRSA); Guidelines for Clinical Management and Control of Transmission; PPH 42160, October, 2005 (pdf file)

Community-associated MRSA (CA-MRSA) Information for Clinicians; CDC,February, 2005