Estonian Garden Shawl

I've finished knitting another lace shawl. As with the other one, it took me months to do. I don't mind. This one was knitted using Harmony 100% wool, color HC03. The pattern is Estonian Garden designed by Evelyn Clark. It is 19 in X 66 in. I hope the photos show it off well enough. I am just learning how to photograph knitted lace.

I finished earlier this month and mailed it to a friend whom I wish I could wrap my arms around. This seems so inadequate but is the best I can do at this time.

Breast Implant Deflation

Recently I had a patient call to tell me to report that her right breast implant had deflated.  She is a patient from the early years of my practice.  This is her second deflation, but this one is complicated by pregnancy.  She has listened to my “lectures” over the years and was not panicked.  She wanted to check in with me.

I reminded her

• Your body will simply absorb the IV saline that was used to fill the implant.
• It isn’t a medical emergency though it can be embarrassing.
• We can take our time and fit it into your life/work schedule (If patient is pregnant, it can safely wait until the delivery of her baby).
• Put a shoulder pad or some other padding in your bra to even it out for now.

I told her I would report the deflation to the implant company and get a file number for her case.  When she has delivered a healthy baby and finished breast feeding, then she should call me back.  At that time we will arrange a visit and decide what she wants to do (remove or replace; same size or smaller/larger; etc).

We didn’t discuss costs at this point in time.  We will later.  She unfortunately was augmented prior to the “extended warranty” offers that both Mentor and McGhan (INAMED) have now.  The programs didn’t exist prior to October 2, 2000.  The company will offer free implants for replacement.

Locally, the surgery center I use charges $840, anesthesia’s charge is $525, and my fee is $***(depends on time passed since surgery and whether I was the initial surgeon).  I began paying for the “extended warranty” for each patient out of my fee back in 2002 when I realized too many of them were failing to spend the extra $100.

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

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

Other Posts of Interest:
It Happened Again (June 5, 2007)
Breast Implants – Some History (March 3, 2008)
Silicone vs Saline Breasts Implants (March 4, 2008)
Silicone Implants and Health Issues (March 5, 2008)

Prevention and Management of Complications of Rhinoplasty – 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. 

This article is a CME (continuing medical education) article.  As such it is a review of complications of rhinoplasty.  It is a good review and worth reading.

Complications of rhinoplasty can be classified into hemorrhagic, infectious, traumatic, functional, or aesthetic problems.  Here is a  summary of the article.

Hemorrhagic Complications

Postoperative bleeding is one of the most common
complications following nasal surgery. 

Epistaxis  --  The most common causes of mild epistaxis are bleeding from the incision sites and traumatized
mucosa.

For mild to moderate epistaxis being with

• 60-degree head elevation
• gentle nostril pressure for 15 minutes
• application of topical decongestant nasal sprays such as oxymetazoline or phenylephrine.

If bleeding persists

• Remove the septal splints and gently suction the nasal passages remove blood clots and crusts.
• Cauterize focal areas of bleeding with silver nitrate or place a light hemostatic packing made of methylcellulose over the bleeding surface.

Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon.
Bleeding that persists despite anterior packing may signify
a posterior bleed from a branch of the sphenopalatine
artery.  If so, a posterior pack may be required. 

• Patients should be observed for airway compromise while a posterior pack is in place.
• Antibiotics should be administered while packing is in place to reduce the risk of toxic shock syndrome.

Serious bleeding occurs in less than 1 percent of patients, but warrants operative exploration when conservative measures fail.

Septal Hematoma -- is a potentially serious complication of rhinoplasty.  These patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever.   The typical finding on physical examination is an ecchymotic nasal septal mass.

Untreated septal hematoma may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity.

Management

• early recognition with prompt evacuation of the hematoma, either via needle aspiration or incision and drainage.
• Antimicrobial therapy should be initiated if a secondary nasal septal abscess is suspected.

Infectious Complications

Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome.

Local wound infections (such as cellulitis) -- treat with systemic antibiotics and close observation.

Abscesses require prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following
rhinoplasty include the nasal dorsum, nasal tip, and septum.

Cavernous sinus thrombosis,  meningitis, or a brain abscess may result without adequate treatment of a septal abscess.

Toxic shock syndrome is an acute, multisystem disease.  It has been described after nasal surgery with the use of both nasal packing and intranasal splints.   Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension.  Treatment requires the immediate removal of the offending object (packing or splint), intensive care unit admission, intravenous antibiotics, and supportive care.

Traumatic Complications

L-Strut Fractures  -- 
When L-strut fractures occur, they should be repaired immediately to prevent significant deformity.  If it isn’t, the  cartilaginous septal segment will tend to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.

Depending on the location of the fracture, it may be stabilized with either spread grafts or a combination of spreader grafts and
Kirschner wires.

Intracranial Injury and Cerebrospinal Fluid Leak Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty.  They can happen with the cribiform plate it violated by surgical instruments or from excessive bony septum manipulation.  Either can result in a cerebrospinal fluid leak and potential intracranial injury or infection.

Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A

Treatment requires hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations.

Epiphora  --  after rhinoplasty is most commonly occurs due to compression of the lacrimal system by the soft-tissue edema.  It normally resolves after 1 to 2 weeks.

Functional Complications

Septal Perforation -- are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no  intervening septal cartilage.   They may also result from decreased blood flow to those same flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches.

Symptoms of a nasal septal perforation include crusting, bleeding,
whistling, and nasal airway obstruction due to disruption
of the normal laminar airflow through the nasal passages.

Treatment includes

• Local hygiene with nasal saline irrigation
• Obturation with a Silastic septal button
• For small perforations, local advancement flaps with an interposed connective tissue autograft or an allograft can be
  used to close the perforation.

Intranasal Adhesions  -- (synechiae ) result from cicatrical healing of opposed, abraded mucosal surfaces.

Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall.

Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.

Postoperative Septal Deviation  -- whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon.  Any significant septal deviation that persists and causes cosmetic or functional impairment may require revision surgery.

Rhinitis – Atrophic rhinitis is due to atrophy of the nasal mucosa usually due to overresection of intranasal structures such as the middle or inferior turbinate.

Patients often present with subsequent symptoms of dryness, crusting, and nasal obstruction.  These patients will get relief with nasal saline.

Patients may also report a spontaneous clear watery nasal discharge.   This phenomenon is most likely due to  a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to
the intranasal mucosa.  These patients are often effectively treated with topical anticholinergic preparations, such as 0.03% ipratropium bromide  which act locally to decrease the watery rhinorrhea.  The recommended dosing regimen is two sprays in each nostril two to three times a day as needed.

Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.

Aesthetic Complications

Tip and Dorsal Deformities
Postoperative deformities of the osseocartilaginous framework may be caused by overresection or underresection of the osseocartilaginous framework, incorrectly performed osteotomies, incorrect shaping of grafts and their edges, and migration of grafts due to insufficient or inaccurate fixation.

Persistent tip or dorsal deformities are generally not treated until at least 1 year after the previous rhinoplasty.

Supratip (“Pollybeak”) Deformity -- is a postoperative complication of rhinoplasty in which the nasal supratip assumes a convex shape in relation to the nasal dorsum. The deformity results either from inadequate resection of the lower dorsal septum and upper lateral cartilages or, paradoxically, from overresection of these supratip structures with subsequent scar tissue formation in the resulting dead space.

Patients who develop supratip fullness should be instructed to apply compressive tape onto the supratip area nightly. This is generally effective in treating transient postoperative swelling.  Taping should be discontinued when a permanent depression is obtained.

Steroid injections can improve excessive swelling and reduce scar tissue in the supratip area.  The injections can be used in patients who continue to supratip fullness despite compressive taping.  Triamcinolone acetate,  1 to 2 mg, is injected below the
dermis in the supratip area.  The injections may be repeated at 2-month intervals until an aesthetically pleasing supratip contour is obtained.

Side effects of the steroid injections should be remembered.  The most frequent is dermal atrophy, which may lead to a contraction
deformity of the skin. Other side effects include telangiectasias, depressions, color changes, and eventual visibility of the underlying cartilages or contour imperfections, which may be enhanced by the resulting decrease of skin thickness.

Corrective surgical procedures should not be performed until
at least 1 year after the initial procedure. 

The basic principles include judicious removal of the offending cartilage or scar tissue, adjustment of the osseocartilaginous framework so that the differential between the midvault and the tip is adequate, elimination of dead space by establishing direct contact between the underlying framework and the skin, and application of a dressing with selective compression over the supratip area.

Soft-Tissue Complications
Postrhinoplasty Nasal Cysts  -- are a rare complication
of rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum.  Both may require complete excision.

• Lipogranulomas or “paraffinomas” are foreign-body inclusion cysts that are thought to arise from the use of petroleum-based
  ointments in conjunction with nasal packing.
• Mucous cysts are a second type of nasal cyst that can arise after rhinoplasty. They are thought to arise from ectopic or displaced mucosa and ointment extravasation into osteotomy sites.

Contact Dermatitis and Skin Necrosis --

Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. It usually resolves without any permanent sequelae.

Treatment of contact dermatitis

• removal of the offending agent
• application of topical and potentially systemic steroids,
  depending on the severity of the reaction.

Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing.  More problematic is partial-thickness or full-thickness skin necrosis that can occurs when the blood supply of the soft-tissue envelope is severely embarrassed. 
Treatment of minor skin necrosis should initially be conservative.

• Daily wound care, allow the wound to close by secondary intention
• Protection from the sun
• After maturation of the scar, dermabrasion, filler substances, skin care, and laser treatment may be helpful.

Telangiectasias -- are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter.  Argon and pulsed dye lasers have proven to
be an effective means of treatment.

REFERENCE

Prevention and Management of Rhinoplasty Complications;  Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 60e-67e; Cochran, C Spencer M.D.; Landecker, Alan M.D.

Post for a Friend

Dr Smak has asked me to let you all know that she has taken her blog down temporarily.  Her family is fine.  Her blog will be back in the (hopefully) near future.

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. 

TBTAM is this week's host of Grand Rounds.  Her edition features food and medicine.  Read this edition here.  

Welcome to Grand Rounds Vol 5, no 23!  We've got a wonderful pot luck menu of great posts from around the medical blogosphere, so sit right down and dig in!

The fourth edition of Change of Shift (Vol 3, No 16) for 2009 is hosted by Amanda (This Crazy Miracle Called Life)!     You can find the schedule and the COS archives at Emergiblog. 

 

Medicine for the Outdoors has a nice post on “Naturally Occurring Toxins.”

The best classification of natural toxins involves dividing the groups of toxin-containing organisms into poisonous and venomous.

° Poisonous organisms are those that are assimilated into the host either by ingestion or through the skin. Included are bacteria, fungi, plants, and some animals.

° Venomous organisms are those that have evolved specific toxin delivery systems, which usually include a venom gland and a sting, fang, spine or pore for transporting venom to the host. Venomous animals are found in every class of animals and are distributed throughout the earth's ecosystems. The first venomous member of the class Aves (birds) - the genus Pitohui, from New Guinea - was described in 1992.

Twittering in the OR – interesting, but is this the best use of a chief resident.  Shouldn’t he be learning and doing something else?

As CNN reported yesterday, physicians used Twitter to give a blow-by-blow account of removing a cancerous tumor from a man's kidney at Henry Ford Hospital in Detroit.
The surgeon's musings during the operation were dutifully recorded in real time on Twitter by the chief resident.

On a different note.  If you have read my blog for long, you know I quilt.  TBTAM sent me a link to “The Artful Bras Project.”  The bras are wonderful art pieces!

Members of Quilters of South Carolina have created one-of-a-kind bras for Breast Cancer Awareness. The exhibit consists of fifty original works of art which are unique, entertaining, humorous, and beautiful to make the public aware of breast cancer, to memorialize those lost to the disease, and to honor survivors.  

This exhibit will tour SC until Oct '09 at which time individual Artfull Bras will be auctioned and the proceeds donated to the Best Chance Network, a program to provide care and treatment of uninsured women across the state who are diagnosed with breast and ovarian cancer

And I love my dog and have even made him homemade dog biscuits.  I didn’t know there was an International Dog Biscuit Day until Johann (photo credit) told me so.  It was yesterday.  Check out all the sources (many more than the ones below) listed in this post.

This week Dr Anonymous will be have a co-host, Dr. Gwenn, as they talk to guests Vicky & Jen about parenting blogs & podcasts.   The show begins at  9 pm EST. 

You can check out the archives of his Blog Talk Radio show.   Here is the upcoming schedule:

3/5: TBA
3/12: 4th year medical student Mudphudder to talk about Match Day 2009
3/19: Respiratory therapy student Trauma Junkie to talk about the blog carnival A Source of Inspiration
3/26: Podcamp Ohio

Prevent Pulmonary Thromboembolism – 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 full title of the article is “The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap.”   The full reference is below.

Deep vein thrombosis (DVT) and pulmonary thromboembolism  (PE) are complications that may lead to fatal consequences.  For most patients undergoing plastic surgery, these complications are uncommon.  There is one exception – abdominoplasty.  The reported incidence with this procedure is reportedly 1.1 percent. 

The transverse rectus abdominis musculocutaneous (TRAM) flap has the same risk factors as an abdominoplasty (ie obesity, abdominal flap elevation interfering with venous return of the superficial venous system of the pelvis and lower extremity, long surgery time, decrease mobility postop, etc).  TRAM flap patients have the additional risk factor of cancer. 

Malignancy causes a procoagulant state, with abnormalities in blood flow and vessel wall and blood composition.  The overall risk of venous thrombosis was sevenfold higher in patients with malignancy than in persons without malignancy, and the risk of venous thrombosis was highest during the first few months after the diagnosis of malignancy.   In breast cancer patients, the adjusted odds ratio for venous thrombosis is 4.9, and up to 15 percent of breast cancer patients present with venous thromboembolism during the course of their disease.  Moreover, chemotherapy and hormone therapy, which are unavoidable, are significant precipitants of venous and arterial thrombosis.

The incidence of DVT and PE associated with patients undergoing immediate breast reconstruction with TRAM flaps has been reported to vary from 0.7 to 18.8 percent. 

The authors conducted a prospective study of the efficacy of prophylactic use of low-molecular-weight heparin to prevent PE.  They did this by looking at 650 consecutive patients who underwent immediate breast reconstruction with TRAM flaps between August of 2001 and April of 2007.   Group 1 included the first 450 patients treated prior to February 2006.  No medical prophylaxis was administered to Group 1.   Group 2 included the 200 consecutive patients treated since February of 2006.  This group was given a once-daily dose of 40 or 60 mg of enoxaparin for 7 days (depending on the patient’s weight), from the day of surgery.  All patients in group 1 and group 2 wore compression stockings until fully mobilized and began ambulation on the second postoperative day.

Fifty-four consecutive patients in group 1 (group 1c) and 68 consecutive patients in group 2 (group 2c) were routinely checked to detect asymptomatic PE on the third postoperative day.  The exams used included  serum D-dimer, pulmonary ventilation-perfusion scan, and pulmonary embolism computed tomography

The average age of the patients in both groups 1 and 2 was 42 years.  The average BMI was 22.6 kg/m² in group 1 and 23.6 kg/m² in group 2.   All patients had quit smoking at least 3 weeks before surgery, but 5.7 % of Group 1 patients and 3.5 % of Group 2 were ex-smokers.  The average stage of cancer was 1.48 in group 1 and 1.67 in group 2.  No patient had any history of coagulopathy, DVT, or PE.

Results:

Symptomatic thromboembolism was diagnosed in eight of the 450 group 1 patients (1.8 percent)

Asymptomatic pulmonary thromboembolism was detected in nine of the 54 group 1c patients (16.7 percent) who underwent routine workup for pulmonary thromboembolism.

Neither symptomatic nor asymptomatic pulmonary thromboembolism was diagnosed in group 2 patients.

Although the incidence of symptomatic pulmonary thromboembolism was lower in group 2, the difference was not statistically significant (p = 0.107). In contrast, the incidence of asymptomatic pulmonary thromboembolism was significantly lower in group 2c patients than in group 1c patients

They found the  most common symptom of symptomatic PE to be  chest discomfort (100 percent), followed by tachypnea, dyspnea, and cough. Most symptoms were developed on the second or third postoperative day.

Concerns are often raised about bleeding-related complications with the prophylactic use of low-molecular-weight heparin.  The authors  found no increases in significant bleeding-related complications, including transfusion rate. 

Clinical observation showed that enoxaparin-treated patients had more apparent bruising at the operation sites and the subcutaneous injection sites.

This is considered unavoidable, and meticulous hemostasis is required during every procedure throughout surgery, especially at the muscle stump and the deepithelialized flap surface.

REFERENCE

The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 9-12; Kim, Eun Key M.D.; Eom, Jin Sup M.D., Ph.D.; Ahn, Sei Hyun M.D., Ph.D.; Son, Byung Ho M.D., Ph.D.; Lee, Taik Jong M.D., Ph.D.

Other Blog Posts of Interest:
DVT Prevention
Graduated Compression Stockings

SurgeXperiences 218– 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 (218) of SurgeXperiences will be hosted by Vijay, Scan Man’s Notes, on March 1st.  

Scan Man is a radiologist in India.  He has a great blog.  I hope you will check it out.

The deadline for submissions is midnight on Friday, February 27th.  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.

Yes, I’ll Have Another Cup of Coffee

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

Like many people, I love coffee, so it was nice to see this article on the "coffee consumption of women" published online before print in the February 16 issue of Circulation: Journal of the American Heart Association. 

My family has a history of stroke and high blood pressure, so I was even happier to find that my coffee drinking helps protect me from strokes. 

So, yes, I’ll have another cup of coffee.

Dr Esther Lopez-Garcia and colleagues analyzed data from a prospective group of 83 076 women in the Nurses' Health Study. At the beginning of the study none of the women had any history of stroke, coronary heart disease, diabetes, or cancer. The researchers first assessed coffee consumption in 1980 and then followed up every 2 to 4 years through 2004.

They found coffee drinking to be linked to a modest reduction of stroke risk among women. Drinking three cups of coffee a day reduced the risk by nearly 20 per cent compared to drinking less than one cup of coffee a month. 

Yes, I’ll have another cup of coffee.

The study documented the number and types of strokes that occurred in these women during the years 1980 – 2004. A total of 2280 strokes occurred (426 were hemorrhagic, 1224 were ischemic, and 630 were undetermined).

The relative risks of stroke decreased as the amount of coffee consumed went up. The relative risk of stroke in a woman who drank less than one cup per month was noted to be 0.98 compared to a relative risk of 0.81 for a woman who drank 2 to 3 cups of coffee per day.

The noted protection held even in women with high blood pressure, hypercholesterolemia, type 2 diabetes, and smokers. Other drinks containing caffeine such as tea and caffeinated soft drinks were not associated with stroke.

I’ll pass on the coke, but I’ll have another cup of coffee.

Source
Coffee Consumption and Risk of Stroke in Women;
Esther Lopez-Garcia, Fernando Rodriguez-Artalejo, Kathryn M. Rexrode, Giancarlo Logroscino, Frank B. Hu, and Rob M. van Dam.; Circulation published online before print February 16, 2009. doi: 10.1161/CIRCULATIONAHA.108.826164

Four Seasons Quilt Finished

I finished the quilt I began so many years ago, then at the end of 2008 took apart and redid. I had already sewn the squares which are 16.5 in finished (after re-trimming) before I read the very nice comment by Celeste.

Anytime I do hand appliqué, I cut the blocks larger to allow for the inward shrinkage. I then use a lot of Magic Sizing to stiffen them when pressing, and square them up. Because you don't have an equal amount of white space at the edges of all of your blocks, I would suggest that you do some kind of pieced sashing that has a light background. Obviously garden maze sashing comes to mind for floral appliqué, but a twisted ribbon would look good and so would an appliqued sashing. But the light background (similar to your blocks) would help keep the more filled blocks from looking hemmed in by a dark sashing like you had. I would also lean towards a wider sashing than what you had; with only four blocks I think it will set them off better, and it will set the stage for you to consider a wider and possibly more dramatic outer border.

I had initially intended for the quilt to “look” like a window that I was viewing a different season through each of the four panes. I stuck with that choice, but love the one options that Celeste made.

The finished quilt is 49 in X 49 in. It was hand appliqued but the blocks were sewn together by machine. The quilting was done by machine.
She is also correct about the difference in the unequal amounts of white space. If I chose the blocks again, I would have chosen something other than the Dresden plate for winter. I might have still used the “wreath” of leaves for fall, but scaled it to leave more white space outside the leaves.

Overall, I like the quilt, but mostly am pleased that I finished it.
The other posts done on this quilt:
New Year's Resolution -- Finish This Quilt
Dresden Plate Block – my winter
Windblown Tulips Quilt Block – my spring
Wild Rose Quilt Block– my summer
Wreath Quilt Block – my fall

How Not to Do Buttocks Enhancement

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

In this day and age when physicians are facing being rated like the local plumber or restaurant on Zagat, it astounds me that anyone would allow a non-physician to perform cosmetic enhancement “injections” in their home.  That seems to be what women in Florida have done to the detriment of their health (ABC Action News).

Two women who wanted cosmetic injections to enhance their bottoms are now recovering in a Town N' Country Hospital with severe infections. 

Deputies say Andrea Lee and Zakiya Teagle thought they were getting injections that were safe and would provide them with the appearance they wanted.  Instead, the person who injected them apparently is on the run and detectives want to find her.

Hillsborough County Sheriff's office says Sharhonda Lindsay of Tampa is wanted for practicing medicine without a license. A warrant for her arrest was issued Monday.

They say Lindsay injected the women's buttocks several times and was paid hundreds of dollars for her efforts.   But after leaving her home, the two were in so much pain and had to go to the hospital for treatment.

On Monday night, one of the two women was in critical condition after her kidneys stopped functioning.

While there are safe ways to cosmetically enhance buttocks, silicone injections is not one of them.  Silicone injections into soft tissue in the United States has been illegal for many years now.  Silicone injections into the face and breasts were once used for enhancement in those areas, but led to many disfiguring problems.

When liquid silicone is injected into soft tissue (face, breasts, buttocks) it can migrate to other areas.  The body often reacts to the silicone by forming benign tumors called siliconomas.

Good physicians won’t do liquid silicone injections.  They will use fat injections.  They will do buttock implants.

Safe methods for buttocks enhancement include:

Micro-fat grafting

Buttock Reduction/Contouring

Gluteal Implants

Buttock Lifts

Combination of the Above

It is important to go to a well trained plastic or cosmetic surgeon.  Do not go to a friend who offers to do the injection in their home.

Sources

List of Legal Injectable Fillers (FDA)

Suture for a Living post on Buttocks Enhancement

Massive Hemorrhage in Facial Fracture Patients – 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. 

There is little in the literature regarding management of “significant hemorrhage from fractures of the midface.”   The authors of this article (full reference below) did a retrospective study to try to look at this complication and its management.

Hemorrhage from facial fractures can threaten life by causing hypovolemic shock or by contributing to airway obstruction.  They found no established definition of massive hemorrhage from facial fractures, so devised the following:

Fracture of the midface or skull base plus hemorrhage into pharynx

* Causing tachycardia (pulse rate >100) and hypotension (systolic pressure <100) with no other cause identified, or

* Necessitating acute transfusion with two or more units of packed red cells, or

* Where blood loss from that source was measured as greater than 500 ml.

Using the above definition, the authors went through the discharge data system (Australian health care system) to identify all those patients  (January 1, 1984, to December 31, 2003) who had been discharged with diagnosis codes for malar bone, maxillary, or skull base fractures (mandible fractures were not included in the population).  This list was then cross-referenced to include a diagnosis code of epistaxis or a procedure code such as  arrest of hemorrhage, nasal packing, or blood transfusion.   The medical records of these patients were then examined to see if they met the above definition of massive hemorrhage from facial fracture.

In addition to the retrospective study, the details of any new cases of massive hemorrhage in facial fractures were documented over an additional 1-year period. The incidence of cases was calculated for both the 20-year period and the subsequent 1-year period. The clinical presentation, management, and outcome data of cases were analyzed as a whole, with those of the retrospective cases being combined with those of the recent cases.

Incidence and Mortality

The retrospective study included 4501 patients with codes for maxillary, malar, or skull base fractures.  They found only 50 patients with codes for both facial fractures and at least one of the codes indicating bleeding.  Only 15 of these met the definition of massive hemorrhage from facial fractures.  That gives an incidence of 0.33% facial fracture patients with massive hemorrhage over the twenty year period.

During the one year period, 226 patients with midface or skull base fractures were treated.  Four of these had massive bleeding or an incidence  of 1.77 percent.

In the combined data set, seven of the 19 patients died during the hospital admission in which they had the facial fractures.  The patients who died had multiple injuries so it is difficult to attribute the cause of death to one pathology alone.

Clinical Presentation

Most patients were male with a median age of 48 years (range, 18 to 83 years).  Most common cause of injury was motor vehicle accident.  Most patients had other injuries besides the facial fracture, including significant head injuries.
Most patients had significant hypovolemia on presentation.
Descriptions of facial fracture patterns

Five patients were described as having skull base fractures or Le Fort III fractures, with an additional three patients reported as having fractures of individual bones of the skull base (sphenoids or ethmoids). Four of these eight patients died. Of the 10 patients identified with a Le Fort fracture, five died.

Management

The authors discuss the following at important aspects of management:
1.  Recognition of Facial Fracture Hemorrhage as Significant
2.  Arrest of Hemorrhage Method

In three patients, arrest of hemorrhage was attempted with nasal/oral/pharyngeal packing alone. All three patients died. As all three had multiple injuries, the contribution of the facial fracture hemorrhage to death was difficult to quantify.

Ten patients had insertion of balloon catheters of some sort--Foley catheters or Brighton epistaxis catheters--and no vessel ligation. Four of these patients died; again, each of the deaths occurred in the context of polytrauma.

Five patients had ligation of a vessel, either the external carotid, maxillary, or anterior ethmoidal, with or without other measures. None of these patients died. No patients had radiological embolization of vessels to the face.

3.  Airway Management

4.  Blood Transfusion

All patients were given a transfusion of packed red cells. The median number of units given was 9 and the mean number was 10.

Their Procedure for Arrest of Massive Facial Fracture Hemorrhage

• Use a head light
• Insert bite block to keep mouth open
• Place a 2/0 silk suture through the tongue to aid retraction
• Check the balloons on 2 X 30 ml Foley catheters
• Insert Foley catheter slowly into one nostril observing the pharynx for its emergence
• Use Yankaur sucker and Magill forceps to check Foley catheter is in the pharynx
• Repeat procedure on other side
• Put catheters on light bleeding stops secure position of catheters at nares with umbilical cord clamp
• Remove bite block (they can cause fracture distraction and increased bleeding if left in place)
• If bleeding does not stop – increase tension on catheters and then secure with cord clamp
• Place foam rubber under each umbilical cord clamp to reduce pressure on skin
• Inject soft palate and periosteum around posterior maxilla with lidocaine and adrenaline (1 in 80,000) and pack oral cavity with gauze if bleeding from hard palate

Their Conclusions:

Massive hemorrhage from facial fractures is an under-recognized and inconsistently managed phenomenon. Although low in incidence, its timely recognition and better management may reduce the high mortality rate in this group of patients.

Article is worth reading.

REFERENCE

Massive Hemorrhage in Facial Fracture Patients: Definition, Incidence, and Management; Plastic and Reconstructive Surgery:Volume 123(2)February 2009pp 680-690; Dean, Nicola R. Ph.D., F.R.A.C.S.(Plas.); Ledgard, James P. M.B.B.S.; Katsaros, James M.B.B.S., F.R.A.C.S.(Plas.)

Shout Outs

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

Kim, Emergiblog, is this week's host of Grand Rounds. Read this edition here.

When I was contemplating hosting Grand Rounds, did I realize that I was hosting a compilation of serious interdisciplinary dialogue relating to the practice of health care?
Did I understand the enormity of the task I had chosen to undertake?
Heck yes I did!
I chose to use a “Napoleon Dynamite” theme anyway as that is pretty much the coolest movie ever made.
If you’ve seen it, you’ll get it. If you haven’t, you’ll think I’m nuts (but I have great nunchuk skills….)!
So grab your coffee, and get ready for a good read!
Or, as Napoleon’s Grandma says, “just make yourself a dang quesa-dilluh!”
Welcome to Grand Rounds…

Our fellow medical Aussie bloggers have their own award. Voting is now open.  The finalists are:

• AEQUANIMITAS
• Degranulated
• Life in the Fast Lane
• Prn Penguin
• Vagus Surgicalis

Congratulations to all the nominees. Go vote for your favorite here. Voting is open until February 20th.

As you know, Australia has had horrible bushfires recently with loss of entire communities, businesses, homes, and lives. Knowing I quilt, Dr Cris sent this tweet out. I’ve made a few blocks already. Hope some of you will do the same.

DrCris Just found this: People piecing quilts to send to Victorians in wake of bushfires http://flickr.com/groups/bu...

The first edition of “A Source of Inspiration” is up. Trauma Junkie, Surviving RT School, who began this new carnival is off to a great start. You can read the first edition here.

Check out this story of Dr Eugene Alford in the March 2009 issue of Reader’s Digest, “His Own Medicine”. He is a facial plastic surgeon at Methodist Hospital in Houston, TX. He was paralyzed in an accident, but with a lot of physical therapy and community/family support has made it back to the OR as the surgeon.

Medgadet has a nice “farewell” to a medical giant, Dr. Willem Johan (Pim) Kolff, who died recently.

Dr. Willem Johan (Pim) Kolff, one of the most prolific inventors of new medical devices, has passed away at age 97 in Philadelphia. Dr Kolff led a long and productive life, and through his genius he saved and greatly improved the lives of thousands of others. From external dialysis machines to the CardioWest artificial heart, Dr Kolff was one of the revolutionaries that successfully introduced practical devices to the medical world.

A Repository for Bottled Monsters has this announcement:

On Saturday, February 28, from 2-5 p.m. the NMHM will host a Knitting for Marines charity event to make and distribute helmet liners to Marines stationed in Iraq and Afghanistan. The liners help to protect our Marines and keep them warm during the harsh winters in these countries.
If you don't know how to knit in the round, this is a great time to learn. Instructors will be on site to help you through the project. If you are an experienced knitter and wish to get an early start on the project, you may download the knitting pattern.

This week Dr Anonymous will be talking with From Medskool. The show begins at 9 pm EST.

You can check out the archives of his Blog Talk Radio show. Here is the upcoming schedule:

2/26: Co-host Dr. Gwenn
3/5: Podcamp Ohio
3/12: Mudphudder
3/19: Trauma Junkie

Myofascial Compartments of the Hand in Relation to Compartment Syndrome --- 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. 

Acute compartment syndrome of the hand is an emergency and  requires prompt surgical decompression.  This article (the first reference below) is a cadaveric study aimed at identifying the myofascial compartments of the hand.  As they point out

Few studies have outlined the myofascial compartments of the hand. The standard anatomy texts do not show actual anatomical specimens but instead rely on diagrams and figures to outline the various compartments. These include the thenar, hypothenar, adductor, and interosseous compartments, each encased in fascia that extended from one metacarpal to another

The ten anatomical compartments of the hand include (photo credit)

• four dorsal interossei
• three palmer interossei
• adductor pollicis
• thenar
• hypothenar

The authors dissected fourteen fresh-frozen cadaveric hands.  They found no distinct tough fascia completely surrounding any of the intrinsic muscles, but instead thin filmy fascia that partially encases some of the muscles. 

Results:
There was no well-defined tough fascia overlying the thenar muscles, the hypothenar muscles, or the adductor pollicis.
Areolar tissue was present between the individual thenar and hypothenar muscles.
A distinct band of fascia was noted over the entire length of the ulnar three dorsal interosseous muscles.
A band of fascia was noted over the distal portion of the palmar interossei but not over the proximal aspect.
The above findings were found in all 14 specimens.
A layer of loose areolar tissue was noted over the dorsal aspect of the first web space in eight specimens, whereas a distinct band of fascia was noted overlying the first dorsal interosseous muscle in the remaining six.

Interesting findings, but doesn’t explain why it is necessary to do the fasciotomies in each and every compartment.  Does the skin constrict that much?  Maybe.



REFERENCES

Myofascial Compartments of the Hand in Relation to Compartment Syndrome: A Cadaveric Study; Plastic and Reconstructive Surgery:Volume 123(2)February 2009, pp 613-616; Ling, Marcus Z. X. M.B.B.S.; Kumar, V P. F.R.C.S.

Beware: Compartment Syndrome of the Hand; JNZMA, Feb 11, 2005, Vol 118, No 1209; Warren Leigh, Vasu Pai

Compartment Syndromes of Hand and Forearm; Wheeless' Textbook of Orthopaedics; Last updated by Clifford R. Wheeless, III, MD on Sunday, December 28, 2008 8:31 pm

Compartment Syndrome, Upper Extremity; eMedicine Article, July 27, 2007; Stephen Wallace, MD and Douglas G Smith, MD

SurgeXperience 217 is Up!

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. 

This edition (217) of SurgeXperiences is hosted Dr Cris, Scalpel’s Edge.    You can read this edition here.

It’s the Learning and Teaching Surgery Edition

Welcome to SurgeXpereiences, the fortnightly blog carnival about all topics surgical. The tentative theme for this carnival is teaching and learning surgery.

As always, there is evidence that Surgeons require good teaching. Some of them certainly make bad decisions, when left to their own devices. See this report by Medical Quack, and reports on our “favourite” Queensland surgeon who is facing trial this month, Jayant Patel, and probably shown in this one, too Dubai surgeon sues hospital. It is further evidenced by the need for articles like this How to avoid surgical errors

The host of the next edition (218), March 1st will be hosted by Vijay, Scan Man’s Notes. The deadline for submissions is midnight on Friday, February 27th. 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.

Wonky Star Blocks

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

As you know, Australia has had horrible bushfires recently with loss of entire communities, businesses, homes, and lives.  Knowing I quilt, Dr Cris sent this tweet out. 

  DrCris  Just found this:  People piecing quilts to send to Victorians in wake of bushfires http://flickr.com/groups/bu...

Here are three  Wonky Star Blocks that I have made and sent.

There are two addresses to mail finished blocks:
US APO address - "local" to those mailing from the US, so postage will be much less expensive:
Tia Curtis
PSC 276 BOX 89
APO AP 96548 USA
Australian street address:
Tia Curtis
18 Forrest Crescent
Gillen Suburb
Alice Springs, NT 0870

Buckeye’s Baby’s Quilt

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 baby quilt is for our blog friend, Buckeye Surgeon.  His wife will be having a baby soon.  I have no idea whether the baby is girl or boy.  I hope I made it interesting for either, though I admit I found myself hoping the baby will be a boy.  Mostly I hope the baby is healthy.

I stumbled across this pattern while browsing through one of my quilting books.  It was a loose page I had saved from a flyer years ago.  It was called “Sunday Funshine Quilt”.  I can’t find who to credit it to.  They called the basic block – Funshine Block.  Think nine-patch.  The top and bottom row of the block is 2.5 in X 6.5 in rectangle.  The center row is made of three 2.5 in squares.  The finished block is then 6 in.

The quilt measures 42 in X 48 in.  It is made of scrapes and partial fat quarters.  It is machine pieced and quilted.

Here is a close photo to show some of the interesting fabrics.  I love the motorcycle tire in the center of the blue batik block.  I love the football player, the lion, and the “feet”.

Here’s another detail shot.  Here you’ll find a steer, a cowboy, an angel, and the front end of a race car.

This is the back.  I found this lovely flannel fabric in the remnant bin.  It was just over a yard of fabric, not quite enough for the back.  I sewed some dark green/brown flannel to each end.  Appropriate for Valentine’s Day – don’t you think?

Assessing and Managing Mammal Bites – 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 sure how I got on the list to receive Emergency Medicine journal, but I always look through it before I recycle it.  There are often decent articles in it.  The one referenced below is a nice quick review on the problem of mammal bites.  This is an issue most doctors will encounter at some point in time.

About 1% of emergency department and urgent care visits each year are for mammal bite injuries or their complications. Ten to 20 people die each year from mammal bites. In 2006, 310,710 injuries from dog bites alone were reported to the Centers for Disease Control and Prevention. The actual number of bite wounds from all mammals is estimated to be around 2 million each year, but that figure underestimates the true incidence because most animal bites are unreported.

Animal bite injuries come in many forms:  lacerations, punctures, crush injuries, tears, rips, avulsions, fractures, hemorrhage, and contusions. The type and severity of the injury will depend on the location of the bite, the animal involved, and size of the patient. 

More than two-thirds of bite injuries occur in children younger than 10 years old—boys more often than girls. Children most commonly pre-sent with bite wounds to the face, neck, and head. Adults more commonly present with bites to the extremities.

The article gives helpful “History and Physical Exam Tips”

• Patients usually seek medical care for repair of the wound or because the wound has become infected.

A thorough history of the event includes asking about the timing of the injury, the kind of animal involved, its health history (including vaccination status and current health), and its behavior. Other important information about the animal includes whether it can be observed or captured.

• Thoroughly examine patients with bites.  Especially with children, check the entire body to identify additional injuries.
• Examine the wound itself meticulously. It’s easy to miss things.
• Be alert for injuries to the vasculature, nerves, tendons, bones, and joints.
• Bites from large mammals can damage and even fracture bone.  Plain radiographs should be viewed after the exam.
• Large mammals who bite and shake can dislocate joints. Have patients perform active range-of-motion with joints that are near bite wounds.
• Use plain radiography to assess for retained foreign bodies and skeletal injuries. Computed tomography and magnetic resonance imaging have increased sensitivity for foreign bodies and subtle fractures.

The article gives a nice review of principles for reducing the risk of infection.   As with all wounds, standard wound care applies.  This means copiously irrigate and debride as needed.
Bites are tetanus-prone wounds. Review the patient’s immunization records.  Give updates, etc as needed.
Most wounds can be closed primarily.  It’s expected that a small percentage of wounds will become infected and require early suture removal. Inform patients that wound infections may occur in spite of the appropriate care. Advise all patients at discharge to look for signs of infection, such as redness, increasing pain, and purulent drainage.
Some bite wounds have a higher risk of infection.

Animal Bites With a High Risk for Infection
•  crush injuries
•  hand wounds
•  puncture wounds
•  wounds with extensive devitalized tissue
•  heavily contaminated wounds
•  prolonged time from injury to treatment:
     6–12 hours on the body
     12–24 hours on the face

The article points out some specific considerations to keep in mind.

Dog bites. A big fear with dog bites is rabies, but the actual incidence among these dogs in the United States is low.  Similarly, few dog bites actually lead to infection. 

However, significant bites are at risk for infection, which is usually polymicrobial. About 50% of infected dog bites involve Pasteurella canis. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children (see table below). Duration of therapy is not clearly established.

Cat bites. In contrast to dog bites, most cat bites do become infected.

Pasteurella multocida is present in 70% to 90% of the infections. Antibiotic post-exposure prophylaxis that is effective for P. multocida is recommended for all cat bites; unfortunately, P. multocida is resistant to clindamycin, dicloxicillin, cephalexin, and erythromycin. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily in adults, 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.

Cats have the highest incidence of rabies of all domestic animals in the United States. However, transfer to humans remains rare. 

Primate bites.  A subgroup of primates called the macaques (rhesus and green monkeys) carry B virus (Cercopithecine herpesvirus 1), usually by the age of 2.

Though asymptomatic in the macaques, B virus causes fatal encephalitis in humans; 24 of the 25 humans known to be infected have died. The incidence of transmission is unknown, but it has been documented to occur from even trivial wounds. Due to the high mortality, post-bite prophylaxis is recommended for any macaque bite. First-line therapy is valacyclovir 1 gram orally every 8 hours for 14 days.

Rodent and rabbit bites. Rodents, rabbits, and hares carry Francisella tularemia and can transmit this to humans through bites. The CDC does not recommend routine prophylaxis for tularemia from the bite of a rodent.

Domestic and wild rats in the United States carry and transmit Streptobacillus moniliformis, which causes rat bite fever. The CDC recommends post-bite prophylaxis after wild or domestic rat bites.The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.

Overall, a very nice review article.  Especially good for students and residents.  The article includes tables of appropriate antibiotics and dosages.

Related Blog Posts:

Cat Bites

Dog Bite Prevention

REFERENCE
Assessing and Managing Mammal Bites; Emerg Med 41(1):35, 2009; Lisa D. Mills, MD, and John Lilley, MD

Sulfonamide Associated Hepatic Failure

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

First off, let me say I have never seen this complication of sulfonamides.  I was only vaguely aware that it existed.  A patient came in to discuss a cosmetic procedure.  Like always, I was going through the allergy section.  She had marked yes on the sulfa drugs.  I asked what kind of reaction.   I want to know if it was a true problem or just an unwelcome side effect.

She then told me about her son who died of acute hepatic failure from a reaction to Bactrim (Sulfamethoxazole/Trimethoprim), and how a few years after his death she got very ill after taking Bactrim.  So now their family refuses to take sulfa drugs.  It prompted me to do a review.

Sulfamethoxazole/Trimethoprim (SMX/TMP) is a commonly used antibiotic for respiratory, gastrointestinal and urinary tract infections caused by a range of aerobic gram-positive and gram-negative bacteria. It also has activity against Listeria monocytogenes, Nocardia and Pneuomcystis jiroveci.

SMX/TMP is generally well tolerated in non-HIV-infected patients.  Adverse reactions occur in this group in approximately 6 to 8 percent of individuals. In comparison, the adverse reaction rate is as high as 25 to 50 percent in HIV-infected patients and many of the reactions are severe.

The most common adverse reactions include nausea, vomiting, anorexia, dermatological reactions such as pruritis, urticaria and less commonly Steven Johnson Syndrome.

Life-threatening adverse reactions include neutropenia, exfoliative dermatitis (a severe skin disorder with generalized erythema and scaling) and toxic epidermal necrolysis (an acute severe reaction with widespread erythema and detachment of the epidermis). Acute liver failure has only been reported in a few cases worldwide, and has been attributed to the sulphonamide component of the drug.

The sulfamethoxazole component of SMX/TMP is responsible for most of its' side effects including liver failure.
Three forms of SMX/TMP induced liver damage have been described.
1) hepatocellular
2)  mixed hepatocellular cholestatic
3) bile duct injury with ductopenia or Vanishing Bile duct syndrome

The onset of symptoms usually occurs within a few days of exposure, but can take up to a 1–2 months.  Patients will usually present with  nausea, vomiting, jaundice, and pruritis (if cholestatic).  Liver function tests (LFTs)  may show a hepatocellular or cholestatic pattern depending on the type of injury. Patients might have other feature of an allergic reaction such as skin rash, eosinophilia. 

Diagnosis is suspected from the clinical presentation, and absence of other causes.

The severity of SMX/TMP induced liver injury can range from mild symptoms with elevated liver enzymes to fulminant hepatic failure with hepatic encephalopathy and coagulopathy. Outcome can be favorable with spontaneous resolution or unfavorable leading to death.

Treatment is generally supportive, liver transplantation has been successful for both fulminant hepatic failure and vanishing bile duct syndrome

REFERENCES

Acute Liver Disease Associated with Erythromycins, Sulfonamides, and Tetracyclines; Annals of Internal Medicine, Vol 119, Issue 7, Part 1, pp 576-583, Oct 1993;  Jeffrey L. Carson; Brian L. Strom; Amy Duff; Anand Gupta; Michele Shaw; Frank E. Lundin; and Kiron Das

Case Report: Sulfamethoxazole/Trimethoprim induced liver failure: a case report; Cases Journal 2008, :44doi:10.1186/1757-1626-1-44; Salaheldin Abusin, Swapna Johnson
Harrison’s Online; Chapter 299 (Merck’s)-- Trimethoprim-Sulfamethoxazole Hepatotoxicity (Idiosyncratic Reaction)

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 Health Care Blog is this week's host of Grand Rounds.  Read this edition here.  

Welcome to Grand Rounds. It's been quite some time since THCB hosted the medical blogosphere's major compendium. So sit back and enjoy a stroll through the gardens of medical and health care obsession.
It's still a fresh political season, so we start with the wonks:

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

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.

 

The third edition of Change of Shift (Vol 3, No 16) for 2009 is hosted by Digital Doorway!   It’s the “fish bowl” edition. I hope you will check it out (photo credit).  You can find the schedule and the COS archives at Emergiblog. 

In the days leading up to hosting this edition of Change of Shift, I gave a great deal of thought to the phenomena of the internet, blogging, Twitter, iPhones, Facebook, and the many technological advances that now keep us all connected and communicating.

That said, as much as I love these manifestations of our Digital Age, I also see these forums as proverbial fish bowls in which we all stew ourselves in the waters of public communication, often rendering ourselves vulnerable and naked as the observing masses watch our every move.

Pallimed has begun a new grand rounds for palliative care.  The inaugural edition (Vol 1, Issue 1) can be read here.

Welcome to the inaugural edition of Palliative Care Grand Rounds, a monthly blog carnival bringing you the best and most interesting blog posts about hospice, palliative care, death and dying, grief, quality of life, communication in the medical arena, and anything else that strikes the fancy of the host that month.
If you are interested in becoming one of the upcoming hosts, please comment or email me at ctsinclair @t g-m-a-i-l d0t c0m. Here is the website with the archives and upcoming hosts.

Rhinoplasty Surgery Blog has a nice post titled "Pablo Picasso's Girl in the Mirror:  The Agony of Imagined Ugliness".  (photo credit)

Most clinicians involved in the treatment of patients with facial deformities will encounter the patient who is excessively concerned with a minor or imperceptible defect in their appearance or patients who reveal extreme dissatisfaction despite good treatment results. In cases in which such a preoccupation with appearance causes the patient marked distress in their social or occupational functioning, the patient may have nondelusional dysmorphophobia, also known as body dysmorphic disorder (BDD).

Ant Ears is back! 

It has been some time since I last posted.  Busy trauma rotation, holidays, ABSITE, killer call schedule - suddenly 3 months went by.

This week Dr Anonymous will be talking about  Podcamp Ohio.  The show will be back at it’s usual time,  9 pm EST. 

Integrating Radiation Therapy & 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.

Let me begin by saying – this review article is worth your time to read. The Medscape article examines the most recent literature on breast reconstruction in patients receiving post-mastectomy radiation therapy (PMRT) and presents it in a fashion that is meant to assist in making the best treatment decisions.

They introduce the subject by reviewing the evidence that supports the use of post-mastectomy radiation therapy.

PMRT can improve survival and local-regional control in selected patients with invasive breast cancer treated with mastectomy and systemic therapy.

Local-regional and survival benefits of PMRT for patients with lymph node-positive disease.

Survival advantage associated with PMRT was evident both for patients with 1-3 positive lymph nodes and those with 4 or more positive lymph nodes.

Accordingly, the use of PMRT for patients with stage II breast cancer is increasing

Breast reconstruction following mastectomy is also an important aspect of care for many patients with breast cancer. It is important that reconstruction does not compromise the goal of breast cancer treatment: to maximize the probability of cure and permit patients to return to a normal quality of life.

So what is the optimal timing and technique of breast reconstruction in patients requiring PMRT? It is controversial. Like most medical treatment, “one size doesn’t fit all.” This article does a nice job of making some sense of it.

Implant-Based Breast Reconstruction in Patients Receiving PMRT

Studies evaluating the outcomes of 2-stage breast reconstruction (placement of a tissue expander followed by placement of a permanent breast implant after PMRT) consistently reveal high rates of acute and chronic complications and poor aesthetic outcomes.

Capsular contracture that results from PMRT can distort the appearance of the breast and cause potentially significant chronic chest wall pain and tightness.

Many surgeons attribute the poor outcomes with implant-based breast reconstruction to older, less precise techniques of radiation delivery. However, even with modern radiation delivery techniques, complication rates with implant-based reconstruction are high.

In addition, fibrotic changes around breast implants associated with PMRT can continue to evolve years after treatment; early results of new techniques often underestimate the true incidence of complications.

Current Role of Reconstruction With a Latissimus Dorsi Flap

Evans and colleagues found that the addition of the tissue flap -- either a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi myocutaneous flap -- did not appear to protect against capsular contracture, a common complication of PMRT.

…………………………………………………………….

In 2007, Spear and colleagues concluded that in patients with unsatisfactory outcomes after 2-stage implant-based reconstruction as a result of the adverse effects of radiation, breast contour can be improved by adding a latissimus dorsi flap, generally to the inferior pole of the breast.

Effect of Immediate Implant-Based Breast Reconstruction on Radiation Treatment Field Design

Not only can PMRT adversely affect the aesthetic outcome of immediate implant-based breast reconstruction, but there is increasing evidence that such reconstructions may interfere with the delivery of PMRT.

Chest wall treatment in patients who have undergone reconstruction must be accomplished by using traditional, 2-beam tangential fields alone rather than the modern, 3-beam technique. As mentioned, this can deliver potentially harmful doses of radiation to the heart or lung.

This is something that truly needs to be considered in woman who need or may need post-mastectomy radiation therapy. The article has some nice visuals that help explain the physics for those interested.

Autologous Tissue Breast Reconstruction in Patients Receiving PMRT

Although the consensus in the literature is that autologous tissue is preferable to breast implants within an irradiated operative field, autologous tissue reconstructions may also be adversely affected by PMRT.

However, autologous tissue reconstructions can interfere with the radiation field design and can also lead to adverse changes in the aesthetic reconstruction outcome.

This issue of the reconstruction, no matter which technique, is a requiring theme. This needs to be considered. Delayed reconstruction may be the best option in patients who are known at the time of mastectomy to require PMRT.

Effect of Immediate Autologous Tissue Breast Reconstruction on Radiation Treatment Field Design

Immediate reconstruction substantially compromised treatment of the internal mammary nodes and made it less possible to use a modern, 3-beam technique with a separate medial electron beam to treat this region.

In patients with right-sided reconstructions, the chest wall and internal mammary chains were treated with deeper tangential beams (traditional, 2-beam tangential beam technique) at the expense of irradiation of more lung parenchyma.

In patients with left-sided reconstructions (accounting for 67% of the compromised treatment plans), the heart and lung were spared at the expense of suboptimal coverage of the chest wall and internal mammary nodes.

Sixty-five percent of patients with compromised internal mammary node coverage also had compromised coverage of the chest wall and suboptimal sparing of lung and epicardial heart structures (including the left anterior descending branch). Thus, even if the internal mammary nodes had not been treated, these patients' plans would not have been optimal.

Delayed-Immediate Breast Reconstruction

It is best to do delayed breast reconstruction in women who will need radiation therapy. This is not always known prior to the mastectomy as it may hinge on the receptor studies. However, by delaying the reconstruction, the benefits of immediate reconstruction are lost. These benefits include the ability to preserve of the breast skin envelope and the natural contour of the inframammary crease which give the opportunity for the best aesthetic outcome.

One option that decreases the adverse effects of PMRT through more targeted therapy and helps ensure optimal radiation delivery after immediate breast reconstruction is delayed-immediate reconstruction.

This approach involves placing a tissue expander at the time of mastectomy to preserve the initial shape and thickness of the breast skin flaps and the dimensions of the breast skin envelope until the final pathology results are available. In patients found not to require PMRT, preservation of the breast skin envelope enables the plastic surgeon to achieve optimal aesthetic outcomes. The outcomes are found to be similar to those obtainable with immediate breast reconstruction.

In patients who require PMRT, the tissue expander can be deflated before the start of PMRT to create a flat chest wall surface and permit modern, 3-beam radiation delivery. The expander can be reinflated after PMRT to permit "skin-preserving" delayed reconstruction.

REFERENCE
Integrating Radiation Therapy and Breast Reconstruction: Which Comes First?; Medscape Article, January 30, 2009; Thomas A. Buchholz, MD, FACR; Steven J. Kronowitz, MD, FACS
Related Blog Posts
Breast Reconstruction – Part I
Breast Reconstruction – Part II

SurgeXperiences 217 – 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 (217) of SurgeXperiences will be hosted by Dr Cris, Scalpel’s Edge, on February 15th.  

Dr Cris is a general surgical trainee based at the Austin Hospital in Heidelberg, Australia. She is working on her PhD in surgery: "Hyperbaric Oxygen improves survival in severe acute pancreatitis."

The deadline for submissions is midnight on Friday, February 13th.  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.

Home-Health Models in Arkansas Praised

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

There was a really nice article by Carolyne Park in my local paper on Sunday, Feb 1, 2009, that states that the National Association for Home Care and Hospice would like to use our local Baptist Home Health model as the model for a national pilot program.

Baptist Health’s home-health model for treating chronically ill patients uses technology and a team approach to identify obstacles and help patients better manage their diseases. 

Patients are provided a small telehealth computer.  The patient then must use the secure network to send daily data (ie heart rate, blood pressure, oxygen level, blood sugar levels, etc) via phone line to Baptist’s main home health office in Little Rock.   A team of registered nurses and advanced practice nurses check the results for any potential problems.  If anything is noted, a team member will phone the patient.

The Center for Disease Control and Prevent states that 45% of Americans (133 million in all) have at least one chronic disease, such as heart disease, cancer, stroke, chronic obstructive pulmonary disease or diabetes.  The percentage is 60% in older adults who often have two or more chronic conditions.  These chronic diseases are the leading cause of death and disability in the US.  They also account for more than 75% of the nation’s $2 trillion health-care costs.

The home-health model is being viewed as a possible way to lower these deaths and decrease the overall cost.  Home-health nurses have time on their side.  By working closely with the patients, the nurses help the patients learn about their disease(s), care, and prescriptions.  By making home visits, they see the conditions they patient lives in (ie food in cabinets/refrigerator), whether there are family/friends for support, and can better access the patients for depression.  By doing this, the hope is that there will be fewer hospitalizations and fewer complications from the chronic diseases.

Medicare has been collecting data for many years on home health agencies and the outcomes of the patients they serve. This data is reported on the Medicare websites. The Baptist Health website list (last updated June 20, 2008) gives their numbers:

The quality of care you will receive from BAPTIST HEALTH Home Health is demonstrated by our outcomes in these 3 crucial areas (from data reported by our Little Rock office*):

• Only 21% of our patients needed urgent, unplanned medical care.  This is among the lowest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 23%
  • National average is 21%
• Only 24% of our patients needed to be rehospitalized while under our care.  This is the lowest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 32%
  • National average is 28%
• A total of 72% of our patients were able to remain at home after they discharged from our agency.  This is the highest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 63%
  • National average is 68%

St. Vincent Health System’s Visiting Nurse Association also combines technology with home health care. It has used telehealth computers to monitor patients in their homes for several years.  The Arkansas Gazette article states that “the technology has helped St. Vincent reduce hospital visits by its 400 home-health patients in 11 central Arkansas counties. In 2007, about 4.5 percent of the association’s heart-attack patients were rehospitalized, compared with a national rate of 37 percent.”

REFERENCES
Home-health program seen as national model; Arkansas Democrat-Gazette, Feb 1, 2009; Carolyne Park (subscription required)
Baptist Health Home Health Network
St. Vincent Health System’s Visiting Nurse Association
National Association for Home Care and Hospice

Wreath Quilt Block

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

My fall block of the Four Seasons Quilt is called Wreath. Like the Wild Rose block, it comes from the “Award Winning Quilts” by Effie Chalmers Pforr book. It was submitted by Mrs Russell A Warehime of Westminster, Maryland. She states that is is a very old pattern

The pattern has been handed down from my mother, who quilted quite a few of them.”

The leaves’ center veins were machine stitched with brown or green thread prior to the block stitched into the quilt and quilted.

To enhance this quilt block, I planned the quilting to have a “leaf” that I found in Better Homes and Gardens America’s Heritage Quilts (page 23, published 1991). The “leaf” and the stems of the Wreath were done with a brown thread. The background is cross-hatched as the other blocks have been.

Related Posts

New Year’s Resolution—Finish This Quilt

Dresden Plate Quilt Block

Windblown Tulips Quilt Block

Wild Rose Quilt Block

Benefits of Quitting

 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.

This post is for Trauma Junkie, Surviving RT School,  who has recently quit smoking (applauding you) and is starting a new carnival, A Source of Inspiration.   The first edition is planned for Friday, February 13th.  You have to love this logo (photo credit)!

Yes, it may be difficult to quit smoking, but the health benefits are many.  So I would encourage you to halt your habit/kick your addiction to cigarettes. 

Mark Twain said, "Quitting smoking is easy. I've done it a thousand times."

It often takes more than one try (maybe more than a thousand) to actually quit smoking, but it will be worth the effort. 

No matter how old you are or how long you've smoked, quitting can help you live longer and be healthier.  You will heal quicker.  Your skin will age slower.  If you stop smoking before age 50, you can  cut your risk of dying in the next 15 years in half compared with those who keep smoking.

If you are a young woman who wants to have children, you can reduce the risk of having a low birth-weight baby by quitting smoking before or during the first 3-4 months of pregnancy.  The act of quitting smoking will improve not just your health, but that of your child.

Immediate Health Benefits of Quitting

Here are some of the benefits that you will notice right away if you stop smoking. 

• your breath will smell better
• your stained teeth get whiter
• your clothes and hair will smell better
• the yellow stains on your fingers and fingernails will disappear
• food will begin to taste better
• your sense of smell will return to normal

Benefits to Your Health Over Time
These are improvements you will notice to your health over time if you remain smoke free.

20 minutes after quitting:

Your heart rate and blood pressure drops.

12 hours after quitting:

The carbon monoxide level in your blood drops to normal.

2 weeks to 3 months after quitting:

Your circulation improves and your lung function increases.

1 to 9 months after quitting:

Coughing and shortness of breath decrease.

Risk of lung infection goes down.

1 year after quitting:

The excess risk of heart disease is half that of a smoker's.

5 years after quitting:

Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting.

10 years after quitting:

The lung cancer death rate is about half that of a continuing smoker's.

The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease, too.

15 years after quitting: The risk of coronary heart disease is the same as a non-smoker's.

An additional benefit is cost savings.  Smoking is expensive and becoming more so as states continue to increase the sales taxes on cigarettes.

Source
American Cancer Society

Other articles of interest:
Memorial to Virginia Johnson
Smoking:  Become a Quitter
Arkansas Proposes 56 Cents Increase in Cigarette Tax