Puss-in-Corner Quilt Top

While visiting with my husband’s cousin Bud at their family reunion in early June, he recalled me “loaning” him a quilt to use in the hospital when he had his heart surgery years ago.  He recalled it cheering him up and helping with the recovery.  I offered to make him a quilt.  Here’s the quilt top which I have sent off to be quilted.  It is approximately 58 in X 78 in in size, machine pieced.

The pattern is called “puss-in-the-corner.”  Each block is 6 in square.  I used reds, oranges, and yellows to make it bright and cheerful.

Here is a detail photo of some of the fabrics.
Here is another.  I’ll share the finished quilt when it is quilted and the binding is done.

Raynaud’s Phenomenon of the Nipple

Updated 3/2017 -- photo and all links removed as many no longer active and it was easier than checking each one.

This article would have been off my radar had it not been for the interaction on twitter.

jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis http://3.ly/CXr (via @EllenRichter)

Granted I am not generally asked about nipple pain in pregnant women.  Those questions tend to go to folk like TBTAM or ER’s Mom. 
The article describes a case report of a 25 yo woman in her 2nd trimester with “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.”

The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us.  The text with the photo:

Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.

As with Raynaud's of the hand (which I am more familiar with), the phenomenon tends to occur when the ambient temperature drops below a certain threshold that is specific to each individual.  Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors, and tobacco.
Additional treatment for Raynaud’s of the nipple:

Women with persistent pain require immediate relief to continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond within two weeks.

REFERENCE
An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe
Vasospasm of the Nipple–a manifestation of Raynaud's phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith

No Call or Card

Today is my birthday. Birthday’s have always been quietly celebrated in my family. There were too many of us to get large or numerous gifts, so the day was made special in other ways. Mom made the cake or pie of your choice. As we grew up and left home, we sent cards and made phone calls to each other.

I won’t get my phone call or card from my mom this year. This makes me sadder than I’d like to admit.

I do have a coupon for a free serving of ice cream from Cold Stone Creamery. I plan on stopping by on my way home today as I try to celebrate today rather than grieve.

Shout Outs

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

 

Captain Atopic is this week's host of Grand Rounds. You can read it here.  He calls it the “Grand Rounds 5:45 - Le Tour de France Edition!”

Where Grand Rounds is the Grand Tour of Medical Blogging, the Grand tour of Cycling is undoubtedly Le Tour de France, which concluded on Sunday in Paris. After three weeks of cycling, nearly 3,500km at an average speed above 40km/h, the peleton will ride up Paris' Champs Elysee's to the finish. Throughout the race, certain riders and teams will have reached their goals, revealed their future potential and achieved great triumphs. This week's Grand Rounds features some sterling examples of writing, all capable of Stage Victories, and some, much more. Welcome to the Tour...

The latest edition of Change of Shift (Vol 4, No 2) is hosted by Ross at Nurse in Australia! You can find the schedule and the COS archives at Emergiblog. 

The beautiful sunshine coast in Queensland, Australia is where I call home, so I’ve themed this edition the Sunshine Coast Edition. So welcome, thanks again for visiting my corner of the world!

Close your eyes for a moment and take a deep breath of that coastal air, and get ready to invigorate yourselves with some great posts for this edition of change of shift

You can read Movin' Meat’s  interview of Dr. Nick Jouriles, President of ACEP, over at The Central Line.

• Interview with ACEP President Jouriles (Pt 1)
• Interview with ACEP President Dr Jouriles (Pt 2)

Several bloggers come to Dr Regina Benjamin’s defense.  I agree with them.  It is much more important to look at her impressive qualifications.

• Dr Rob – Stone Throwing
• KevinMD  -- We should not care about Regina Benjamin’s weight
• Emily Walke -- Critcism of Regina Benjamin's Weight Nothing But Sexism

I’d like to direct you to Buckeye Surgeon’s post “The Meaning of Life.”  Be sure you read the comments.

Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?

H/T to @MedicalQuack who tweeted the following. 

Nice Mention of @GruntDoc in Houston Chronicle http://tinyurl.com/mvoymy

Interesting NPR interview of Michael Ruhlman on cooking and his new book, Ratio.

His new book, Ratio, is about learning basic ratios. For example: 3:2:1 — three parts flour, two parts fat (like butter) and one part water — makes a basic pie crust. Add a dash of salt, and it's a savory base for a quiche. Add some sugar, and you've got a shell for cherries, chocolate cream or fresh peaches.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!     

Moles Should Not Be Treated by Lasers

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

 

H/T to DermDoc who treated this news article link.  The article is “Some Laser Treatments Could Put Health At Risk, Dermatologists Say.”

dermdoc  Medical Spas Removing Moles with Lasers <-- Dangerous. Melanoma looks like a mole. http://tinyurl.com/m2pqmo  3:13 PM Jul 20th from web

He then followed up with this tweet

dermdoc  Medi-Spas are spas. Never have a mole removed without being checked by a physician. @serious_skeptic @nanarcr  3:29 PM Jul 20th from web

I agree.  It can be difficult even for trained physicians to tell the difference between moles and melanoma.  Don’t allow spas to laser them.  If there is any question, the mole should be biopsied.  That doesn’t happen with “laser treatment.”

To further make this point, check out the slide show on Medscape (free subscription required)

Mole or Melanoma? Tell-Tale Signs in Benign Nevi and Malignant Melanoma: Slideshow  Can you spot the differences between benign and potentially malignant nevi? Would you be able to tell which require a biopsy?

Related Posts
Melanoma Review (February 25, 2008)
Skin Cancer—Melanoma (December 8, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)
Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

SurgeXperiences 302

Updated 3/2-17-- all links removed as many no longer active and it was easier than checking each one.

 

Once again I it brings me great joy to expose you to surgery (via blog posts rather than actual) and the many experiences that go along with it.   I hope you find them interesting. (this -- photo credit—makes me want to quilt it-- photo removed 3/2017)

Let’s begin with this one by a non-surgeon who finds scars as fascinating as I do.  Dr Charles’ post Cicatrix is much more elegant than I could ever write about scars, but captures my feeling wonderfully.  Each scar has a story attached to it.  We all have one scar in common – the umbilicus – which tells of our attachment to our mothers.

“It looks like it’s healing well.” I told her. I didn’t know if it would be appropriate or not, but I decided to say it anyway. “Your scar is a story. I hope you can own it. Don’t ever be ashamed by it. It’s a testament to your strength, a mark of your courage.”

Dr Charles was inspired by this article in the NYTimes “Our Scars Tell the Stories of Our Lives” by Dana Jennings, as was Tara Parker-Pope “The Power of Scars.”  The comments attached to Parker-Pope’s are a very interesting  discussion on scars and their stories.

…………………………………..

Moving on to the gratitude (or lack thereof) associated with the outcome of surgery, Bongi tells us about a patient with acalculous cholecystitis.

…….some time after this the neurosurgeon got a call from the family doctor from their home country. he was indignant. he wanted to know why the gallbladder had been removed in such a young male, a group that usually does not have gallbladder problems and that in the absence of gallstones. he felt it was totally unnecessary and demanded an explanation……..

……………………………………

QuietusLeo, the Sandman, tells us of true gratitude showed by a patient’s family in the form of a gift after taking care of a “12 year old boy needed ultrasound guided drainage of perforated appendicitis with abscess.”   The father sent a touching note along with the gift which you should go read.  The child (the patient) was less grateful, but we’ll chalk that up to his age.

I called the family to thank them for their generous gift. The son answered the phone. When I identified myself he said that I had done a poor job because he didn't see the James Bond movie. I apologized and assured him that it was much more important to be healthy again.

He then passed the phone to his father. I thanked him for the gift. He said it was only a small token of appreciation. I assured him that it was much more than that.

……………………………………………

Can you imagine the story that goes with this?! (photo removed 3/2017)  Check it out over at M.D.O.D. (photo credit)


T, Notes of an Anesthesoboist, back from her vacation in France tells us about a call to the ER -- “you know it’s bad when”

One day I was giving someone a lunch break and wheeling her patient to the O.R. with the circulating nurse when we heard over the P.A. system,

"Any available surgeon stat to the emergency room. Any available surgeon to E.R. stat."

That stopped us in our tracks for a second. The nurse and I exchanged a look.

"Sounds pretty bad," I said.

………………………………………..

Buckeye Surgeon talks about tough decisions as he gets ready to put in an access port for chemotherapy.

The other day I picked up the chart of a lady who needed a port and the first thing I noticed was that she was 92 years old. I must admit, my first thought was: what the hell are we doing here? She had metastatic breast cancer with lesions seen in her lungs and liver. I was all ready to march into the room and have an honest, heart to heart talk with the patient and the family about futile care and cost effectiveness etc etc.

But I composed myself. Every situation is different. I asked questions. I listened.

Bongi tells us about the difficulties of just walking away when nothing can be done surgically.   He doesn’t do as his “teacher” taught.  Go read the entire post.

"now why did i just walk away?" he asked. we all gave the usual blank stares. "because there is nothing we can do for her." he said with a chuckle. those of us who needed to be in his good books gave the obligatory half hearted laugh. i could just manage a smile that i think came out more as a grimace.

…………………………………………….

Orac, Respectful Insolence, writes about being faced with a different kind of tough decision in “iron surgeon?”  [first posted in July 2007 and reposted recently]

The other day, Sid Schwab, surgeon blogger extraordinaire, brought up a question that, I'm guessing, most nonsurgeons wonder about from time to time when contemplating how it is that we surgeons do what we do.

What about bathroom breaks?

…………….It happened to me only once, but it provided a serious dilemma. What do I do? I'm captain of the ship of the O.R., so to speak. The entire team depends on me. The patient depends on me.

And that's the key to making the correct decision……..

……………………………………………

From WhiteCoat’s Call Room -- What’s The Diagnosis #4 – this 13 year old boy will certainly have a story to go with his scar! 

Uveal Blues tells us about Better Vision, With a Telescope Inside the Eye for people with irreversible, advanced macular degeneration.  Check out the post for photos.

……………………………………….

Vijay, Scan Man’s Notes, gives us a quiz using “three x-rays”

A small mental exercise for medical bloggers.

See the following three portable (bedside) chest radiographs that were taken in an ICU setting. They are in sequence.

See if you can guess the story that they tell.

…………………………………………

What do you do when you can’t get good IV access?  Check out Dr Michelle Lin’s post  Sneak Peak "Trick of the Trade": IO line for failed IV access.  There’s even a video showing how to do the IO (intraosseous) access in adults.

Adult intraosseous needles are coming more into favor in the United States, although they have been part of standard practice in the military and Europe. Various commercial devices exist. The one we have at SF General is the EZ IO Needle. (I have no financial ties with the company.) Needle placement is surprisingly easy and takes less than 10 seconds, especially if you channel your inner Home Depot self in using the power drill.

……………………………………….

Orac does a much better job than I did discussing “Overdiagnosis of breast cancer due to mammography” and it’s implications.  It’s a must read for all of us.

M.D.O.D talks about a surgical tragedy in the recent news in two posts – here and here where he attempts to explain how the tragedy might have happened.

Surgeon hands intern trochar. Intern, stepping up on small stool puts all her weight behind it and hubs it. Descending aorta pierced, Surgeon apoplectic, blood fills abdomen, patient's legs get blue, Vascular Surgeon scared shitless, knows it's a hopeless case, tries to punt, no one receiving, then finally gets an accepting somewhere else. Rest of story plays out.

H/T to PSP (Plastic Surgery Practice) for the link to this news article from India --  Rare surgery helps re-implant foot's thumb to write with hand.  Technically the foot does not have a thumb, so it should read “rare surgery uses foot’s big toe to give right hand a thumb.”  Still it is a nice procedure.

H/T to Barbara, Medical  Quack, who shared an update on the  German Man with Double Arm Transplant.  You can see a video of the man here.

IntraopOrate was recently an ENT patient.  Here’s the first part, read her post for the outcome.

I've been having some unpleasant pressure in my right ear and a couple of episodes of vertigo over the last six days. Today I had an appointment with my ENT Dr. He entered the exam room, we shook hands, he looked at my throat, looked up my nose (but doc, it's my ear that troubles me!) looked in my right ear and while rolling across to look in my left ear, he said "We're gonna have to get that hair out of there."

Dr Alice, 3rd year surgical resident, talks about some of the “sand traps” attending set for residents.

Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings……..

…………….

From twitter

• medpiano  RT @jonmikel: HUGE TUMOR: Radical right nephrectomy http://is.gd/1IjLH <<ENORME! (CT is image before and on wall behind)
• jeffreyleow RT @jonmikel: GIANT inguinal hernia: http://www.flickr.com/photo...
• jeffreyleow RT @ColumbiaSurgery: What You Must Know about Flesh Eating Bacteria and Superbugs from Dr. Oz. http://bit.ly/C7eRB

and for fun/education

• DrCris  I'm blue. Non-surgeons get to guess what procedure I have just done. http://twitpic.com/bavlb 
• DrCris  I like "smurf appendicectomy" but @twelveeyes hit the winner with sentinel node biopsy (for breast cancer)

MedPage Today reports that female surgeons report high job satisfaction.  I do love my work.

I agree with this news from fellow plastic surgeon, Dr Rob Oliver Jr -- Nip/Tuck gets "nipped" by FX - thank you God! 

And on that note, I wish you a wonderful day!  Enjoy the reading.   Remember if you would like to be the host  in the future, please contact Jeffrey who runs the show here.

Chasity’s Baby’s Quilt

My niece Chasity is pregnant with her first child.  She is due in December.  Chasity is my youngest brother’s first child.  We are all very happy for her and her husband.  And, yes, I’ve finished her baby quilt.

Using the same quilt block pattern and some of the same fabric as I used to make Steve and Lori's quilt, I machine pieced and quilted this one for Chasity.  It is 40 inches square.  She lives in west Texas so I went for a “cowboy” theme and hoped the red would work for a girl and the blue for a boy. 

Here is a closer view of one of the red blocks to show off the fabrics.  The red has cowboys riding broncos in it.

Here is a closer view of one of the blue blocks.  The blue fabric has cars and trucks in it.

Here is a view of the back which is a lovely yellow flora.  The quilting was done with gold colored thread in both the top and bobbin.

Bioactive Sutures

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

H/T to MedGadget who’s post introduced me to “bioactive sutures.”  What a great idea by the Johns Hopkins biomedical engineering students! 

……have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself.

The project team of 10 undergraduates focused on Achilles tendon injuries which require repair in approximately 46,000 people in the United States every year.   The surgery may fail in as many as 20%.  Recovery can take up to a year even with successful surgery.  If this new suture speeds healing and lowers failure rates – what potential! 

At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage……………

As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.

De Quervain Tenosynovitis

 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.

I love this problem though I’m sure I wouldn’t if I ever had it. It is one of those hand problems diagnosed by history and physical exam. The name can be a mouthful and is tricky to spell, but it is one that is treatable. Most often with a good outcome.

De Quervain tenosynovitis was first described in 1895 by a Swiss surgeon, Fritz de Quervain. He reported 5 cases of patients who had the now “classic” physical finding -- a tender, thickened first dorsal wrist compartment. Now this condition bears his name – De Quervain tenosynovitis.

De Quervain tenosynovitis is an entrapment tendinitis of the first dorsal compartment of the wrist. Even a small amount of swelling or inflammation of the tendons (abductor pollicis longus and extensor pollicis brevis) trying to slide through the non-elastic tunnel creates more irritation and inflammation. The involved tendons are used to move the thumb, so pain occurs with thumb motion.

De Quervain tenosynovitis is the second most common entrapment tendinitis of the hand/wrist. The most common is trigger finger (trigger digit) which is about 20 times more common. Frequently patients are mothers of infants aged 6-12 months who will have symptoms in both wrists.

Anyone with De Quervain tenosynovitis will note pain with thumb and wrist motion. These patients will also note tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Repetitive lifting/use is responsible for friction tendinitis. De Quervain tenosynovitis can also develop in individuals who have sustained a direct blow to the area of the first dorsal compartment.

Physical findings on examination will include local tenderness and swelling of the extensor retinaculum of the wrist over the first compartment. A positive Finkelstein sign confirms the diagnosis.

"Finkelstein sign” is done by tucking the thumb into the palm where it is held by the patient’s fingers. The examiner then gently deviates the wrist ulnarly. This creates a sharp increase in pain along the first dorsal compartment in any patient with De Quervain tenosynovitis.

The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling. Nonsurgical treatment should be tried first. If the tenosynovitis is associated with pregnancy, then the nonoperative treatment should be prolonged (4-6 months).

• Splints. Splints may be used to rest the thumb and wrist.
• Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
• Avoiding activities that cause pain and swelling. This may allow the symptoms to go away on their own.
• Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.
• Surgery -- recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons.
  The procedure is usually done on an out-patient basis. The surgery typically involves identification and cutting of the tendon sheath segment under local anesthesia. Care must be taken to avoid cutting the sensory branch of the radial nerve. Patients commonly return to their normal activities within 2-3 weeks. The procedure has been reported to be successful in about 90% of the cases.

REFERENCES
De Quervain Tenosynovitis; eMedicine Article, Feb 17, 2009; Roy A Meals, MD
De Quervain's Tendinitis (De Quervain's Tendinosis) -- AAOS

Shout Outs

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

Doc Gurley is this week's host of Grand Rounds. You can read it here.

Welcome to Grand Rounds Vol. 5 No. 44.  A Grand Rounds full of plot twists, drama, melodrama and yes, death (this is a medical blog roundup after all).

Just for fun, I am going to group the submissions under acts whose real names you’ll have to guess (pick from: The Hunt Is Afoot, The Law Gets Involved, Death Arrives, Clues Are Discovered, The Plot Thickens, and All Is Revealed).

Suggestions/nominations for the acts’ titles can go in the comments and the people who get the closest to the right answers can wear their imaginary Sherlock Holmes deerstalkers with pride. The rest of us can instead wear our Doctor Watson designation (also with pride).

Here are some posts on the "Patients First” meeting Dr Val put together at the National Press Club this past Friday.  I hope I didn’t miss any.

• Congressman Paul Ryan’s Speech To Medical Bloggers At The National Press Club (Better Health)
• KevinMD Addresses Crowd At National Press Club About Primary Care Crisis (by KevinMD)
• My Comments At the National Press Club, Washington DC (by Dr Wes)  
• Washington Wrap-Up  (by Dr Wes)
• Someone Who Actually Knows How to Put Patients First (by DrRich)
• Washing Tons for Boggers (by Dr Rob)
• Patients First: Twitter Transcript (by Robin)
• Better Health in D.C.: the Panel, the Politics and the Ce-Ment Pond (by Kim)
• Reflections on health-care reform (by Dr Edwin Leap)

H/T to scanman who tweeted this:  “RT @precordialthump Trick of the Trade: IO line for failed IV access http://bit.ly/4qfUl Awesome post & video. Hats off to the volunteers!!!”  This link is to this article, Sneak Peak "Trick of the Trade": IO line for failed IV access, which has a very nice video showing IO (intraosseous access)

In the video below, 3 brave (a.k.a. crazy) volunteers get an IO drilled into their proximal tibia. Apparently, the insertion is only mildly painful and the infusion of fluids is actually the more painful part of the procedure. You might consider priming the IV tubing with 1% lidocaine to minimize pain in awake patients.

H/T to MedGadget for this:  For Tender Feet, Shoes Simulate Barefoot Running Safely.   I’d love to have a pair of these FiveFingers from Vibram.   Maybe I’ll ask for a pair for my upcoming birthday. 

Check out this cake from a former ophthalmologist turned pastry chef  -- Reaching New Heights.  You should check some of her others at her blog Charmaine’s Pastry Blog.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

       

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives.

The Impact of Partial Breast Reconstruction on Postoperative Cancer Surveillance – 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. 

I wanted to share this article (1st reference below) with you.  I feel it is important as we continue to improve the treatment of breast cancer.  Our surgical treatments can change the surveillance.

The authors begin their article by pointing out breast conservation therapy has grown in popularity and scope.  In saving the majority of the breast tissue, some of the reconstructive procedures significantly alter the architecture of the breasts.  How does this affect surveillance postoperatively?  The article’s stated purpose was to look at this question.

The purpose of this review was to evaluate long-term postoperative cancer surveillance techniques in a group of patients with breast cancer who underwent partial breast reconstruction using reduction techniques. We were interested in determining whether mammographic screening remained a sensitive tool following oncoplastic reduction and whether the observed changes and diagnostic testing differed in this patient group.

We hypothesized that patients undergoing the reduction techniques might have additional qualitative mammographic changes compared with patients undergoing breast conservation therapy alone, with longer time to stability.

We further hypothesized that the mammographic changes and clinical concerns in the oncoplastic group would result in more diagnostic testing (mammograms, ultrasound, and magnetic resonance imaging) and in the need for additional tissue sampling events.

The authors did a retrospective look at charts of all patients who underwent partial breast reconstruction using reduction techniques (breast conservation therapy with reduction) at Emory University Hospital before 2004.   Their control group (breast conservation therapy alone) included women who underwent breast conservation therapy without reconstruction during the same time period.  Data points included follow-up and the number and type of breast-imaging techniques (mammogram, ultrasound, or magnetic resonance imaging).  They found 34 patients who met their criteria, 17 in each group. 

The average age in the control group was 61 years (range, 44 to 81 years).   Most in this group had diagnosis of either infiltrating ductal carcinoma or infiltrating ductal carcinoma and ductal carcinoma-in-situ. Four in this group had positive lymph nodes.  The average weight of the biopsy specimen was 71 gm.

The average age in the reconstructive group was 52 years (range, 38 to 72 years).  Two in this group had positive lymph nodes. The average weight of the biopsy specimen was 291 gm. 

Negative margins were established in all patients before radiation therapy. All patients underwent postoperative radiation therapy.  Average follow-up time was 5.9 years in the control group and 6.3 years in the study group.  The local recurrence rate in each group was 6 percent (one of 17). 

The available tools for postoperative cancer surveillance include (1) physical examination, (2) radiological imaging, and (3) tissue sampling. When local recurrence is detected, it is usually in the form of a mass, calcifications, or both.

Tumor recurrence is typically found at the lumpectomy bed (true recurrence), adjacent to it (marginal miss), or elsewhere in the treated breast.  The greatest emphasis on surveillance is in the first 5 years, as this is when the risk of recurrence is the highest; however, the risk does persist.

When breast reduction techniques are used in reconstruction, there is the potential for  additional scarring, epidermal inclusion cysts, and fat necrosis.  All these may make surveillance potentially more difficult.  In addition, breast reduction surgery displaced breast parenchyma from it’s original location. 

The authors make the point that currently there is no consensus regarding appropriate radiographic imaging protocols following oncoplastic procedures.

The main objectives are to (1) exclude residual disease, (2) rule out recurrence, (3) establish a new baseline, and (4) evaluate for metachronous disease, while minimizing misinterpretation.

Mammography following breast conservation therapy has been shown to be sensitive in about 55 to 68 percent of breast conservation patients.  Mendelson followed the mammographic changes over time following breast conservation, with the most frequent findings being skin thickening and breast edema in almost 100 percent of patients.

Other findings at 6 months after treatment include scarring and fibrosis (50 percent), fluid collections/seromas (40 percent), and dystrophic calcifications (10 percent). Skin thickening, edema, and seromas did tend to resolve with time and likely represent the changes associated with radiation dermatitis. These conditions will often peak at about 6 months after radiation therapy and resolve over 2 to 3 years in most patients.

The authors noted that it takes longer to achieve mamographic stabilization in the study group.

Since the 95 percent confidence interval for stability in the oncoplastic group was 20.5 to 30.7 months, we believe that, based on these data, biannual mammographic screening should be extended until the third postoperative year in patients who undergo partial breast reconstruction to confirm stability, and that it should be performed on an annual basis thereafter.

Accurate interpretation of postoperative images requires familiarity with these temporal changes following partial breast reconstruction. Establishing a new baseline is important and will avoid unnecessary biopsies, because many of the posttreatment mammographic findings can mimic radiographic signs of malignancy.

Even though the study is retrospective and small, it is heartening to see that with good radiologists who are aware of the surgical breast changes, surveillance and detection is possible.  Surgeons and patients can feel assured that the reconstruction procedure is not hampering follow up care.

REFERENCES

The Impact of Partial Breast Reconstruction Using Reduction Techniques on Postoperative Cancer Surveillance; Plast Reconstr Surg. July 2009 - Volume 124 - Issue 1 - pp 9-17; Losken, Albert M.D.; Schaefer, Timothy G. M.D.; Newell, Mary M.D.; Styblo, Toncred M. M.D.

Management Algorithm and Outcome Evaluation of Partial Mastectomy Defects Treated Using Reduction or Mastopexy Techniques;  Ann Plast Surg. 2007;3:235; Losken A, Styblo TM, Carlson GW, Jones G, Amerson B.

Critical Analysis of Reduction Mammaplasty Techniques in Combination with Conservative Breast Surgery for Early Breast Cancer Treatment;  Plast Reconstr Surg. 2006;117:1091-1103; Munhoz AM, Montag E, Arruda E, et al.

SurgeXperience 302 – Call for Submissions

Updated 3/2017 -- links removed as no longer active.
There is no host yet for  SurgeXperience 302 (July 26th) but don't let that keep you from making submissions.   The deadline for submissions is midnight on Friday, July 24th.  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.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.
Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Purple Quilted Tablecloth

A made this quilted tablecloth more than 15 years ago. It is not technically a quilt as it has no batting. It is a pieced top “quilted” to a backing. I left the batting out as I planned to use it as a tablecloth and thought dishes, etc would sit on it better. Over the years it got put away and not used often. I “rediscovered” it recently and thought of my blog/twitter friend Purplesque. As her name implies, she loves purple. More importantly she loves to cook and shares beautiful photos (and recipes) of the dishes she make.

The tablecloth is machine pieced and machine quilted. It is 50 inches square. It's a modified nine-patch to accommodate the amount of fabric I had.

Digital Mucous Cyst

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.

Earlier this month I received an e-mail asking for information.  I have changed it slightly:

I have been pouring over the computer, searching for information on a tumor.  I had removed last week from my left long finger (third finger).  The pathology report came back as a myxoid tumor.  I was told it was a tumor, not a cyst.  Could you help me give me more information?

To begin, most digital myxoid or mucous tumors are cystic in nature.  Very few are not.  It is difficult to find much information in the literature, especially the current literature. 

Digital mucous cysts (DMCs) are benign ganglion cysts.  They most often are located at the most distal joint of the finger or in the nail fold.  Physicians call this joint the distal interphalangeal (DIP) joints.   The fingers are most commonly involved, but DMCs may occur on the toes.

The etiology of these cysts is not known.  DMCs are also called myxomatous cutaneous cysts, periungual ganglions, mucous cysts, myxoid cysts, synovial cysts, dorsal cysts, nail cysts, cystic nodules, digital mucoid cysts, digital myxoid cysts, and digital mucinous pseudocysts.

The cyst often has a smooth shiny surface on exam.  If located near the nail, there will often be a groove in the nail as in the photo above.  The cyst's size may vary. 

If the cyst is asymptomatic, then treatment is not required.  Recurrence is common regardless of which treatment is used. 

• Aspiration of the contents (72% success rate with multiple aspirations, 2-5 treatments)
• Cyrotherapy (56% to 86% success rate)
• Steroid injection
• Surgical excision (88% to 100%)

Restriction of joint mobility, nail dystrophy, and changes to the contour of the proximal nail fold are potential drawbacks.

When considering a difference diagnosis keep in mind the following:

• Epidermoid cyst
• Heberden node or Rheumatic nodule
• Fibrokeratoma (DMCs may resemble this when they form between the proximal nail fold and the nail and protrude with a keratoticlike tip.)
• Giant-cell tendon sheath tumor
• Myxoid malignant fibrous histiocytoma
• Myxoid variant of liposarcoma (These are less likely to present as firm circumscribed masses and more likely to be deeply seated.)

REFERENCES

Digital Mucous or Myxoid Cyst

Digital mucous cyst – emedicine dermatology, the online textbook

Cystic Lesions of the Hands; Clinical Advisor, November 12, 2008; Noah S. Scheinfeld, MD, JD

Digital myxoid cysts: a review; Cutis; Feb 1986;37(2):89-94; Sonnex TS.

Myxoid Cysts; JAMA, Dec 1965; 194: 1239; Frederick A. J. Kingery

Ganglion of the Distal Interphalangeal Joint (Myxoid Cyst): Therapy by Identification and Repair of the Leak of Joint Fluid; ARCH DERMATOL/VOL 137, MAY 2001; David de Berker, MRCP; Clifford Lawrence, FRCP

Ray Amputation As A Treatment for Recurrent Myxohyaline Tumor of the Distal Extremity; Plastic and Reconstructive Surgery. 111(4):1573-1574, April 1, 2003; Mowlavi, Arian; Quinn, Brendon M.; Zook, Elvin G.; Milner, Stephen

Soft-Tissue Sarcomas of the Upper Extremity: Surgical Treatment and Outcome; Plastic and Reconstructive Surgery. 113(1):231-232, January 2004; Steinau, Hans-Ulrich; Kuhnen, Cornelius

Soft-Tissue Chondroma in the Thumb; Plastic and Reconstructive Surgery. 110(6):1599-1600, November 2002; Avc, Gülden; Aydogdu, Eser; Ydrm, Serkan; Aköz, Tayfun

Plastic Surgery for Fighters

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.

Not sure what I think about this trend of plastic surgery for fighters discussed in this New York Times article -- Cut-Prone Fighters Turn to Surgery to Limit Bleeding by R.M. Schneiderman (Published: July 10, 2009).  

In 16 years as a professional boxer and mixed martial arts fighter, Marcus Davis has received stitches above his eyes 77 times. The cuts have affected him: doctors have stopped fights, and his battered face, he says, has influenced judges’ decisions.

So last summer, Davis, 35, contacted a plastic surgeon in Las Vegas. He wanted to make his skin less prone to cutting.

The surgeon, Dr. Frank Stile, burred down the bones around Davis’s eye sockets. He also removed scar tissue around his eyes and replaced it with collagen made from the skin of cadavers.

Now, at least in theory, when Davis takes a blow to the face, he will be less likely to bleed.

Medical researchers have not analyzed the procedure, and until they do, the American Society of Plastic Surgeons will not comment on its efficacy. But Davis and several others swear by it.

I can understand why the ASPS won’t comment.  I have no problem revising scars for anyone who is realistic with what can be accomplished.  Prominent brows are smoothed down (not in my practice, as I mostly do body work) for cosmetic reasons -- orbital rim contouring or brow shave. 

It is neither of those that gave me pause when I read the article on plastic surgery for fighters.  It is the question of real or implied promise of the surgery decreasing the risk of “bleeding” or “cutting” that gives me trouble.  Possibly it does. 

Surgery always carries risk.  In this population, maybe less than the chosen occupation of boxing or martial arts fighting, but still it carries risks.  There is the risk of infection (skin and sinuses), bleeding, and scarring.   Would I tell the young man that his risk of “cutting” would be 50% less or 15% less or 65% less?  Wouldn’t he need that information in making the decision to proceed with the surgery if his reason was not for cosmetic purposes but the goal of less “cutting”?

…………………………………………………

The degree of supraorbital bossing usually falls within three groups.  X-rays or head CT scan is needed preop to determine the bone thickness over the frontal sinuses.

• Group 1 are those with minimal to moderate anterior projection of the supraorbital rims and thick skull bone over the frontal sinus and/or absence of the frontal sinus.  These deformities can be corrected by bone reduction alone utilizing a surgical burr.
• Group 2 are those with minimal to moderate anterior projection of the supraorbital rims but with relatively thin bone over the frontal sinuses of normal size. Correction requires completing as much contouring of the bones as possible without entering the sinus.
• Group 3 are those with severe anterior projection of the supraorbital rims is so excessive that adequate bone reduction contouring is impossible without entering the frontal sinus.   These require obliteration and filling of the sinuses in order to reduce the contour enough.

Shout Outs

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

Dr Joseph Kim, Medicine and Technology, is this week's host of Grand Rounds. You can read it here.

Welcome to Grand Rounds Vol. 5 No. 43 @ Medicine & Technology. The theme is this week is to look at different ways technology is changing the world of healthcare. I am your host this week and I hope you'll enjoy some of these interesting stories.

The latest edition of Change of Shift (Vol 4, No 1) is hosted by Kim who started it all three years ago! You can find the schedule and the COS archives at Emergiblog. 

Welcome to the anniversary edition of Change of Shift!

The nursing blog carnival celebrates it’s third anniversary (and the beginning of its fourth year) here at Emergiblog (aka: “home base”).

CoS has been hosted by 33 different blogs, including 31 nurses and two physicians.

(The new year begins with a new logo! I finally found out how to make one that wasn’t a banner!)

H/T to @medpagetoday  New Surgeon General named: Dr. Regina Benjamin >> The Doctor Is (Finally) In: Obama To Name Regina Benjamin For Surgeon General.  You can read her biography here (photo credit).

Regina Benjamin practices as a country doctor in rural Alabama. As founder and CEO of the Bayou La Batre Rural Health Clinic, Dr. Regina Benjamin is making a difference to the underserved poor in a small fishing village on the Gulf Coast of Alabama. It is a town of about 2500 people, about 80 percent of her patients live below the poverty level, and Dr. Benjamin is their only physician.

Dr Val Jones, Better Health, has organized a Blogger-Politician Healthcare Reform Discussion At National Press Club.  The event takes place this Friday, July 17, 9:00 a.m. to 12:00 p.m.   Check out the list of attendees:

Keynote: Representative Paul Ryan, (R-WI), House Budget Committee Ranking member
Moderator: Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health
Host: Val Jones, M.D., CEO and Founder of Better Health
Policy Expert: Robert Goldberg, Ph.D., co-founder and vice president of the Center for Medicine in the Public Interest (CMPI)
Primary Care Panelists:
Kevin Pho, M.D., Internist and author of KevinMD
Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind
Alan Dappen, M.D., Family Physician and Better Health contributor
Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor
Specialty Care Panelists:
Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog
Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr.Wes
Rich Fogoros, M.D., Cardiologist and author of CovertRationingBlog And Fixing American Healthcare
Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

H/T to @lesmorgan  End-of-Life Decision Making - A Summary and Primer: In the March 2009 issue of Clinics in Chest Medicine.

Siegel covers rationing & triage, futility, advance directives, and surrogates. But the bulk of the article is devoted to practical advice on good communication, discussing prognosis, and successful family meetings.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

H/T to @Gurdonark  for the link on “tips for photographing butterflies” 

4 - Keep your camera parallel to the butterfly’s body  You only get one plane of complete sharpness, so you always want to put as much of your subject in this plane as possible. With butterflies, you’ll want its body and wings tack sharp, so make sure your camera’s sensor is parallel to them.

6 - Shoot when the butterfly is frontlit by the sun  To highlight the butterfly’s contrast and help you get a sharp photo, photograph them when they’re frontlit by the sun. Remember: always keep an eye on the sun.

 

I just love this picture!  It is a small 150 lb black bear (photo credit) seen in west Little Rock over the weekend.  It passed through the yard of the parents of one of my brother-in-laws. 

The black bear, tranquilized by a dart from wildlife officers, was eventually transported to a wilder neighborhood. But not before he gave a bird feeder a work over. More pictures and video here.

This week Dr Anonymous will be taking July off.

Over Diagnosis of Breast Cancers

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. 

Are breast cancers over-diagnosed?  If so, how often?  Those are the questions looked at by the systematic review of incidence reported data/articles done by Karsten Juhl Jørgensen & colleagues.  Their results are published online in the June 9th issue of the British Medical Journal.   Their review shows an estimated 52% over-diagnosis of breast cancer.

The researchers’ objective was to estimate the extent of over-diagnosis.  Screening for breast cancer is meant to detect lethal cancers earlier.  Unfortunately it also detects harmless ones that will not cause death or symptoms. As it is not possible to distinguish between lethal and harmless cancers, all detected cancers are treated. Over-diagnosis and overtreatment are therefore inevitable.

They begin their review of incidence reported data from 7 years before routine screening programs were implemented and 7 years after full screening was implemented.  They included screened and non-screened age groups.  Data was available from United Kingdom; Manitoba, Canada; New South Wales, Australia; Sweden; and parts of Norway.

This data came from a PubMed search (May 2006) which yielded 2861 titles, 2546 of which were not relevant.  That left 315 articles which were evaluated. Four were included as core articles and one was added when the search was updated in April 2007, presenting data from the United Kingdom; Manitoba, Canada; New South Wales, Australia; Sweden; and parts of Norway.  A meta analysis was done on the data.

Looking at the United Kingdom data, they found that the screening program began in 1988 for women aged 50-64.  National coverage began by 1990.  The screening was expanded to women aged 65-70 in 2002.   There was a 41% higher than expected rate of invasive cancer found in women aged 50-64 during the 1993-1999 period with no compensatory drop during the 7 yrs after full screening was implemented.  This is interpreted as over diagnosis of breast cancer.  This chart (photo credit) shows the incidence of invasive breast cancer per 100,000 women in UK.

This same trend was found in the data from the other countries.  Combining the data, the researchers estimated 52% over diagnosis of breast cancer in a populations of women who are offered organized mammography screening.  That amounts to one in three breast cancers being over diagnosed.

We need improved screening methods to decrease this number to less than 10% over-diagnosis.   Each “un-necessary” surgery for one of the over-diagnosed cancers puts the patient at risk for complications.  Not to mention the increased cost to the healthcare system of each country.

REFERENCE

Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends; BMJ 2009;339:b2587;  Karsten Juhl Jørgensen, researcher, Peter C Gøtzsche, director

A Few Other Breast Cancer Related Posts

Breast Self Exam (BSE) (October 2008)
Mammograms (October 2008)
Breast Cancer Screen in Childhood Cancer Survivors – An Article Review (February 2009)
Indications for Breast MRI – an Article Review (March 2009)

SurgeXperiences 301 is Up!

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

The 1st edition of SurgeXperiences’ third season is hosted by Buckeye Surgeon.  You can read this edition here.

Welcome to another tardy edition of SurgeXperiences! It's been a killer week for me so this is probably going to be a little substandard. Apologies will be forthcoming. Operating three nights in a row after 2AM while your partner is out of town will do that to you. So excuse the spelling errors, the fractured syntax, the incoherence, the lack of any semblance of organization. Which seems to fit perfectly in the context of the former Alaskan governor's rambling resignation speech....So here it goes, just follow the damn links.

Quilt Top for Steve and Lori

This quilt is in progress.  It is for my brother Steve and his wife Lori.  I finished the top in mid-June.  It measures 56 in X 76 in.  I could quilt it, but would end up with major neck and should spasms as I use a simple sewing machine to do my machine quilting.  I have contacted a friend with a long-arm quilting machine whom I will pay to do the quilting.

The block pattern is one I have used before – Alabama quilt block.

Here is a detailed photo of the fabrics.  You can see the turquoise blue dots in the dark chocolate brown fabric here.

I’ll share the quilt with you once it is finished.  My friend is backed up a month or two.  I will need to do the binding once the quilting is done.

Use of Zafirlukast for Capsular Contracture

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. 

I first read of the off-labeled use of zafirlukast back in 2002.  I had one patient with a unilateral Baker’s Grade IV capsular contracture who wanted to avoid surgery (open capsulectomy).  I told her it wasn’t proven (only 30 patients) but that half experienced softening of their capsules.  I went over the possible side-effects of the drug with her.  She wanted to give it a try.  So I prescribed  zafirlukast 20 mg twice daily for 3 months.  She responded with softening of her capsule.  After 3 months she asked for a refill to try to achieve more softening.  She now had a Grade II-III capsular contracture.  I agreed.  It softened to a Grade II and she was happy.  

I now have another patient who is in the same state.  I have decided to try to review the literature and see if the early study has been confirmed.  The first six articles referenced below are the ones I found.  All were small in number, ranging from 20-120 human patients or 40 rats. 

The last article cautions us to remember the adverse side effects which can sometimes be worse than the problem being treated.  In this case – liver injury with zafirlukast.  Dr James L. Baker, Jr in a commentary (7th article referenced below -- 3/2017 link removed as no longer active) gives this caution:

The effectiveness of Accolate and Singulair in treating
capsular contracture remains anecdotal. It is quite  possible that while acting as an antagonist against the
leukotriene receptor, Accolate and Singulair may in reality work as a histamine receptor site antagonist and cause the relaxation of the myofibroblast, with improvement in capsular contracture in some patients. However, the increasing evidence of an association between treatment with Accolate and liver dysfunction in patients with asthma, as reported by Dr. Gryskiewicz, is a powerful argument against widespread off-label use of asthma medications to treat capsular contracture without further investigation. In addition to liver toxicity, Churg-Strauss syndrome (systemic eosinophilic vasculitis) has been reported with both drugs, more frequently with Singulair. This syndrome can have permanent ramifications, including limitation of lifestyle.

Surgeons treating patients for benign conditions with
medications carrying potentially lethal side effects should thoroughly advise patients of the off-label status and the serious risks. I discourage the use of Accolate and Singulair in the treatment of capsular contracture until such time as we can prove through laboratory research exactly how these drugs work on the myofibroblast and capsular tissue and better determine the risk-reward ratio of the therapy.

The six articles which looked at the effectiveness of zafirlukast for treating capsular contracture while noting the positive response in many of their patients also note that further studies need to be done.

Conclusions

Zafirlukast appears effective in treating early capsular contracture after primary submuscular breast augmentation using saline-filled, smooth-walled implants. Further prospective studies with control groups and long-term follow-up will be needed to address many unanswered questions, including whether leukotriene inhibitors have long-term effects on capsular contracture following breast augmentation.

If this patient and I decide to proceed with zafirlukast treatment, I will be sure she is aware of the potential side effects (minor and major) of the drug.


REFERENCES

1.  A new treatment for capsular contracture. (Letter to the editor);  Aesthetic Surg. J. 2002; 21: 164-165; Schlesinger SL and Heck RT.

2.  Zafirlukast (Accolate): A new  treatment for capsular contracture;  Aesthetic Surg. J. 2002; 22: 329-336; Sclesinger SL, Ellenbogen R, Desvigne MN, Svehlak S, and Heck R. 

3. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: A pilot study; Aesthetic Surgery Journal, Volume 25, Issue 1, Pages 26-30 (January 2005); R.Reid, S.Greve, L.Casas

4.  The Effects of Zafirlukast on Capsular Contracture: Preliminary Report;  Aesthetic Plastic Surgery, Volume 30, Number 5, October 2006 , pp. 513-520(8); Scuderi, Nicolò; Mazzocchi, Marco; Fioramonti, Paolo; Bistoni, Giovanni

5.  Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance; Int J Immunopathol Pharmacol 2007 Jul-Sep; 20(3):577-85; Scuderi N, Mazzocchi M, Rubino C

6.  Reduction of Capsular Thickness around Silicone Breast Implants by Zafirlukast in Rats; Eur Surg Res 2008;41:8-14 (DOI: 10.1159/000121501); A. Spano, B. Palmieri, T. Palmizi Taidelli, M.B. Nava

7.  Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns;  Aesthet Surg J. 2003 Mar;23(2):98-101; Gryskiewicz JM

Macrodactyly

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. 

Macrodactyly is an uncommon anomaly of the extremities.  It can affect both the fingers or toes which become abm=normally large due to overgrowth of the tissues composing the digit.  All the tissues are involved:   bone and soft tissue-particularly the nerves, fat and skin.

Other names used for macrodactyly include megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis.

Hands are more commonly involved than feet. Most of the time (~90%) patients present with unilateral (one side affected) macrodactyly.  Often more than one digit is involved.   The most frequently involved digits of the hand are the index finger, followed by the long finger, thumb, ring, and little fingers.  Syndactyly may be present in 10% of patients.   Men are more often affected than women.

It is not known why macrodactyly occurs.  It does not appear to be an inherited anomaly, but there are some syndromes (ie Proteus Syndrome, Maffuci syndrome, and tuberous sclerosis) which may be associated with enlarged digits. There are some surgeons who believe that macrodactyly is a variant of neurofibromatosis. 

Macrodactyly may be either static or progressive.   The progressive type is more common than the static.

• In static the enlarged digit (finger or toe) is present at birth and continues to grow at the same rate as the normal digits of the hand.  The involved digits are generally about 1.5  times the normal length and width of the normal digits.
• In progressive the affected digits begin to grow soon after birth and continue growing faster than the rest of the hand.  The involved digit or digits can become enormous.

There is no medical treatment for this disorder.  It is treated by surgery.   In the hand, the indications for surgery can often be cosmetic in nature as the hand can functionally tolerate a digit with some increased width and length.  In the foot, the enlarged digit can make shoe fitting/wearing difficult.

Surgical treatment of macrodactyly is complex as multiple tissue layers are involved.  It typically will involve debulking, epiphyseal arrest, and shortening.  Multiple surgeries are the norm.

Soft tissue debulking:

• This is done to help correct the width of the digit. This is often done at the same time as the epiphyseal arrest.   The affected fingers are approached volarly with Bruner-type incisions/flaps. The fat is removed from the skin and the tissues are debulked.
• Care is taken to preserve the ulnar and radial digital neurovascular bundles. Sometimes the enlarged nerve branches will need to be sacrificed along with the enlarged subcutaneous tissues.
• When a sufficient amount of tissue has been removed, the skin flaps are overlapped and excised, which allows for tension-free closure.  It needed, skin grafts using healthy skin will be done.
• Debulking is often need to be done in staged procedures.

Shortening procedures:

• This is done to help correct the length of the digit.  Shortening procedures usually involve either surgical excision (removal) of one of the phalanges of the finger or toe, or removal of a metacarpal (hand bone) or metatarsal (foot bone).  
• Barsky and Tsuge originally introduced the two most described methods. Barsky’s technique involves removing the distal portion of the middle phalanx and proximal portion of the distal phalanx, thereby reducing the length of the finger while preserving the nail. Tsuge’s technique also preserves the nail by overlapping the dorsal portion of the distal phalanx with the volar portion of the middle phalanx.

Ray resection:

• This may be done in progressive macrodactyly.  It involved the complete removal of the digit or digits.  It is also an option if there is excessive widening of the forefoot, where digital shortening and debulking procedure may not be effective.

Epiphyseal Arrest:

• The timing of the this surgery is critical.  An attempt to “guess” the adult finger length is done by comparing the child’s digits with those of his/her parents.  When growth of the affected digits matches those of the parent, epiphyseal arrest can be performed.   This in effect will stop the bone growth of the digit.
• The epiphyses of the proximal and distal phalanges  are the ones treated by disruption or removal.   The middle phalanx epiphyses is not treated to help preserve motion at the proximal interphalangeal joint.

Other surgical options include amputation and wedge osteotomies.  Amputation is reserved for patients with nonfunctioning digits or digits that are extremely difficult to correct.  Wedge osteotomies are performed in patients who have digits that are grossly deviated.

Complications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.

REFERENCES

Wood VE. Macrodactyly. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingston; 1998:533-544.

Treatment of macrodactyly;  Plast Reconstr Surg. 1967; 39:590-599; Tsuge K.

Congenital anomalies of the hand; Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New York, NY: Little, Brown and Company; 1994; Upton J, Hergrueter C.

Macrodactyly; Boston Children’s Hospital website

Macrodactyly; Wheeless’ Textbook of Orthopaedics

Shout Outs

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

Pharmamotion is this week's host of Grand Rounds. You can read it here.  It comes to us from Argentina!  Check it out:

I’m starting this Grand Rounds with a confession: I completely suffered of lack of time for this Round’s preparation. Maybe you are wondering why, since this blog carnival is perfectly scheduled. Well, the thing is that here in Argentina winter has arrived and things are starting to get a bit more complicated than we thought. I think that most of you guessed what I am talking about. Yes! The current pandemic of Influenza A(H1N1) has settled in South America and I was hired to cover night shifts in a local hospital

#1 Dinosaur comes out of anonymity as she announces the publishing of her first book!  Congratulations!

Question: What do anonymity and virginity have in common?
Answer: You can only lose them once, so make it count.
I am pleased, proud and thrilled to announce the upcoming release of my first book. From Kaplan Publishing, on August 4, 2009:

GrrlScientist is trying to win a trip to Antarctica!    She needs your help.  Here’s how:

I've posted a picture and written a 300 word essay (which I will no doubt revise over time) and my entry is now public. Voting ends on 30 September 2009, and the Official Quark Blogger will travel to Antarctica in February 2010 to blog about the experience, chronicling the action, the emotion, and the drama as their polar adventure unfolds.

My official essay where you can vote for me.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

Addicted to Medblogs’ calendar continues.  Dr June is … Whitecoat!  I agree with the answer he gave on this question, but go read the rest of the interview.  Oh, yeah, listen to his singing.

12. If you could be reincarnated, what would you like to come back as?
A dog with a really cool owner whose back porch backed up to a beach.

H/T to A Respository for Bottled Monsters

In one of those strange, how-did-I-get-here moments on the internet, I came across the abcnews website that shows some oddball x-rays. As they say, Viewer Discretion is Advised.

H/T to MedGadget for the link Theories of Mind Art Gallery...  The work is absolutely amazing!  It is from a Tel Aviv University physics professor named Eshel Ben Jacob.  Here’s one used in the MedGadget post.

The International Quilt Study Center &Museum shows off one of the amazing quilts from our collection each month in their “quilt of the month” section.  This month the quilt is one created by Gail Belmont, Cathy Morris, and Marie Aquino for the Quilts of Valor Foundation.

 

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives.

Preventing and Treating Skin Tears

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. 

If you work with elderly patients, then you have probably seen “skin tears.”  There is a nice basic article (see full reference below) on the topic that recently crossed my desk.  I’d like to share some of the information with you. (photo credit)

In considering the mechanism of skin tears, I love the way Dr Salcido (2nd reference below) puts it.  His paper explanation could be useful in explaining the problem to patients.

I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions:  pathomechanical & pathophysiological.

The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears.

To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will.

Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.

The main article has a nice list of risk factors for “skin tears” that should be considered when dealing with patients:

• Advanced age (>85 years of age)
• Sex (female)
• Race (white)
• Immobility (chair or bed bound)
• Inadequate nutritional intake
• Long-term corticosteroid use
• History of previous skin tears; presence of ecchymoses
• Altered sensory status or cognitive impairment
• Stiffness and spasticity
• Using assistive devices; Visual impairment
• Applying and removing stockings
• History of vascular, cardiac, and/or pulmonary problems

Many of the prevention strategies shared are common sense and focus on fall prevention – ie adequate lighting, removing clutter from a pathway, avoiding scatter rugs, making the bathroom safe for bathing.  Other strategies focus on removing sources of skin trauma – ie padding edges of furniture and equipment, avoiding adhesive products on frail skin, keeping fingernails and toenails cut short. 

Lift patients, do not drag them across sheets or surfaces.  Reduce moisture from incontinence or other sources.

Improved nutrition and hydration are important in prevention, as well as being gentle with the skin.

Once a skin tear has occurred, the same principles used to manage other wounds should be used.    First, the wound has to be assessed.  They suggest using the Payne-Martin classification of the skin tear.   However, the STAR consensus does not

Once again, the STAR consensus was to simplify the parameters of assessment and

a category 1a or 1b skin tear is one ‘where the edges can be realigned to the normal anatomical position
(without undue stretching)’.

A category 2a or 2b skin tear presents ‘where the edges cannot be realigned to the normal anatomical position (without undue stretching)’.

Whichever classification you use, remember these are acute wounds and have the potential to close by primary intention.

 Next,  the wound has to be cleaned -- removing bacteria and necrotic tissue.  When thinking about repair, it is usually best to avoid staples and sutures as the fragile tissue won’t hold.  So go straight to the next step – the dressing.

Most skin tears tend to achieve wound closure within 7 to 10 days using the following treatment plan:

• Category 1a or b skin tears can be treated with adhesive strips anchor or Dermabond to the re-approximated edges
• Category 2a or b skin tears can be treated with soft silicone or low tact foam dressing. 

All can be treated by using a  transparent film dressing (ie POLYSKIN* II) if there is minimal moisture.  The longer the dressing can be left unchanged, the better for the fragile skin.  It will often need changed every 3-7 days, but if the wound looks fine underneath consider leaving it another day or so.  If fluid develops under the transparent film dressing, then it will need to be changed promptly.

REFERENCES

Prevention and Management of Skin Tears; Advances in Skin & Wound Care, 22 (7):  325-332, July 2009; LeBlanc, Kim BScN, RN, ET, MN; Baranoski, Sharon MSN, RN, CWOCN, APN, DAPWCA, FAAN

Deconstructing Skin Tears; Advances in Skin & Wound Care,  22(7):294-295,July2009;  Salcido, Richard MD

STAR: a consensus for skin tear classification; Primary Intention Vol. 15 N o. 1 FEBRUARY 2007; Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P

SurgeXperience 301 – 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 host for  SurgeXperience 301 (July 12th) will be  Buckeye Surgeon.  This is the beginning of the 3rd season!

The deadline for submissions is midnight on Friday, July 10th.  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.   If you would like to be the host in the future, please contact Jeffrey who runs the show here (3/2017--link no longer active).

Lou Gehrig's Speech 70 Years Later

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

This is the 70th anniversary of Lou Gehrig’s famous farewell speech (http://baseballhall.org/discover/lou-gehrig-luckiest-man).   It is still very inspiring.

For more information on ALS (Amyotrophic Lateral Sclerosis):
Lou Gehrig:  the Official Website
ALS Association
National Institute of Neurological Disorders and Stroke

Patriotic Sampler Quilt

One thing my blog has helped me do is better documentation of my quilts.  My husband has been after me for years to take better pictures of them before giving them away.  He wanted me to keep records of the each one.  Unfortunately, I didn’t do a good job of that in the past.  I found two Polaroid photos of this patriotic sampler quilt that I made after September 11, 2001.  I quickly took the photos before mailing it in the spring of 2003 to Laura and George W Bush.  

Anyway, I had the four churn dash blocks and the small pinwheel and pineapple blocks as my start.  If my memory is correct the blocks are 12 in square.  I think the sashing is 3 in wide.  I think the borders are 5 inches wide.  If my memory is correct, then the quilt measures 52 in X 67 in.

I’m not sure if I have the names of all the blocks correct, so feel free to correct me if not (Celeste).  Starting at the top from left to right, then the second row from left to right, and so on:

1.   Evening Star with Pinwheel in center
2.   Churn Dash
3.   Stepping Stones
4.   Odd Fellow’s Cross
5.   Grecian Cross (rotated 45 degrees)
6.   Many Pointed Star
7.   Churn Dash
8.   Ribbons
9.   Churn Dash
10.  Eight-pointed  Star with Pineapple Square in center
11.  Churn Dash
12.  Mosaic Star

I added several rosettes which you can see (though not well – I wish I’d taken better pictures.).  The one with the gold base began as a strip of black & white striped ribbon folded into the rosette.  The small black one on the “ribbons” block is a rushed rose.

The fabric on the left side border has frogs holding American Flags which I just loved but didn’t have enough of to do all four borders.  It is on two borders.  The other two have red fabric with roses.

Don’t Forget HIPAA Privacy Rules

 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 we move towards EMR’s, the ability to know who has looked at the medical record may get more and more in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story (3/2017-- link no longer active) shows the importance of this respect.

Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.

I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.

I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.

The hospital said in November that it fired up to six people for looking at Pressly's records after a routine patient-privacy audit showed that as many as eight people gained access to them.

It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.

With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….

If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.

My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressley case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.

We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.

Dr Holland had no malicious intent, just curiosity. Be careful.

Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter

3 charged with getting TV anchor's medical records by Jon Gambrell (no subscription required)