Tuesday, March 31, 2009

Shout Outs

Paul Levy, Running a Hospital, is this week's host of Grand Rounds.  It is a the “when things go awry” edition.  Read it here.   

Welcome to this week's edition of Grand Rounds, the weekly rotating carnival of the best of the medical blogosphere. (The host next week is Leslie at Getting Closer to Myself.) Our theme draws on my desire to encourage greater transparency in the delivery of clinical care. In the spirit of Dr. Ernest Codman, I asked doctors, nurses, and other providers to write about incidents in which they made or were present for a medical error. What were the circumstances, and what did you do in response to the situation? How did you feel about the event, and how did it change your practice of medicine afterward


What is acceptable dinner conversation?  Well, we doctors don’t always seem to know.  Check out this nice post by Artemis “No Mom, Billy Doesn’t Want to Stay for Dinner

I looked up from my plate to see three faces staring at me in horror. Mouths agape, eyes wide, silverware down; my family finally burst out as one: “That’s revolting!


A plea from “A Chance to Cut is a Chance to Cure” who has returned to blogging.

Now if Grunt Doc will only take me off the dead blog list.


In Case of Emergency:  How to Be Prepared for the Unexpected”  is the beginning of a series that will provide a look at a patient’s trip through the “unexpected emergency”.    Be sure to watch the video that accompanies the post.

During the next two segments, I will take you way behind the scenes and give you tips on how to be prepared in case the unexpected happens and you end up on your way to an emergency room.  This week I play the part of a patient with chest pain and take you inside a New York City ambulance with paramedics Ray Cordi and Hanan Cohen.  Next week my colleague, Richard Schlesinger, and I continue your tour inside the emergency room at New York Presbyterian Hospital/Columbia University Medical Center, the first time this institution (where I am on staff) has ever allowed such inside access to the media.


I participated in the first two “Another Little Quilt Swap” rounds.  I am still deciding about this next one as it leans more to “Art” quilts.  It would force me out of my comfort zone, so maybe I will.  We’ll see.  Anyway, anyone interested in participating are encouraged to head over here and read the rules (photo credit).



This week Dr Anonymous’ guest will be Victoria Powell whose blog is VP Medical .   She is a nurse who lives in Benton, Arkansas.   Check out her post “I am a Nurse” which tells how she became one.  The show begins at  9 pm EST. 

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

4/4: Night Shift with Dr. A



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Monday, March 30, 2009

Happy Doctor’s Day

History of Doctor's Day

The first Doctor's Day observance was held on March 30, 1933, by the Barrow County Alliance, in Winder, Georgia. Eudora B Almond, the wife of Dr Charles B Almond, conceived the idea of setting aside a day to honor physicians. The day set for the recognition occurred on the anniversary of the first administration of anesthesia by Dr. Crawford W. Long in Barrow County, Georgia, in 1842. (photo credit)

This first observance included the mailing cards to the physicians and their wives, placing flowers on graves of deceased doctors, and a formal dinner in the home of Dr. and Mrs. William T. Randolph.

The full history of how it went from a locally observed day (1933) to a national observed day (1990) can be found here.

Through the years the red carnation has been used as the symbol of Doctors' Day.

Meanings of the Carnation Flower : Fascination, devoted Love

Deep Red Carnation : My heart aches for you or I admire you

Happy Doctor's Day to all of you!


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Sunday, March 29, 2009

SurgeXperiences 220 is Up!

This edition (220) of SurgeXperiences is hosted by Jeffrey, Vagus Surgicalis. He’s the one who began and keeps this blog carnival going. You can read this edition here.

To a medical student like me, the field of surgery is very intriguing, to say the least. The daily working life of a surgeon, or even that of a surgical trainee, can be jam-packed full of action, blood, guts and gore. Dull moments in surgery are hard to come by. Surgeons are able to test their hypotheses and see rapid, graphic results from their work. Students are often awed by this process. What also draws me to surgery is the immense satisfaction of being able to completely excise a cancer (hence providing a definitive cure), or relieve the pain of an intra-abdominal catastrophe, e.g. perforated appendix.

The host of the next edition (221), April 12th will be Lisa from InsideSurgery.com. The deadline for submissions is midnight on Friday, April 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.

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

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Friday, March 27, 2009

Alzheimer Donation Quilt

I learned about this initiative from two places:  the Quilting Gallery and Jude (Spirit Cloth).  

The Alzheimer’s Art Quilt Initiative (AAQI) is an Internet-driven, grassroots, totally volunteer effort to raise awareness and fund research through art.

It has taken me quite a while to get around to doing one for them.   The requirements for one of the donation quilts

mini art quilts in any theme

with a maximum size of just 9" x 12" (so that it fits a USPS Priority Mailer without folding)

Auctions are held during the first 10 days of each month.  All profit is used to fund Alzheimer's research.
This project is ongoing.

We welcome your quilt at any time.

In the later part of February I got one finished, registered, and mailed.   Here it is.  It is a whole cloth quilt that I hand quilted.  It is 8 in X 11.5 in.  If you want to bid on it, it is quilt #3528.


I used the “quick triangle” method for the “sleeve” to allow hanging.  I will use this method again on small quilts.



This link gives you the instructions and some good tips on binding and making a sleeve for the small quilt.


I made a second one and mailed it to my friend Herbie Krisle.  She runs an adult day care for people with Alzheimer’s (Page Robbins Adult Day Care).  I learned recently that part of her responsibility is raising several hundred thousand of dollars each year to keep it running.  She has several quilters in her community that might help her get their own up and running as a way to raise money.  If not, then she’ll have it for her own wall.



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Thursday, March 26, 2009

Medical Spa Regulations

As mentioned yesterday*, the “throw away” journal, MedEsthetics, has had a couple of nice articles recently.  I looked at the first one yesterday, Medical Lasers and the Law, and today will look at the second.  I am impressed with the Massachusetts Task Force and would love to see these same findings implemented in my state.


The second article looked at how state officials are struggling to address the need for appropriate regulations governing the use of laser and light technologies in medical practices, laser centers, and medical spas.  The article reviews how the Massachusetts Legislature asked their Board of Medicine to convene a task force to study and draft some standards and regulations.  They wanted these to cover not just the use of laser and intense pulsed light devices, but also microdermabrasion, chemical peels, soft tissue fillers, sclerotherapy, BOTOX injections, etc.

Massachusetts Medical Spa Task Force represented everyone:

      • Representatives from the Boards of Medicine, Nursing and Cosmetology
      • Two ranking members from the state Legislature (one from the House and one from the Senate) with experience in the public health sector
      • Four physicians – one internist, one plastic surgeon, and two dermatologists
      • One nurse
      • One registered electrologist
      • One consumer


The Medical Spa Task Force gather information from their state and others on current regulations, practices, and safety concerns.  They reviewed relevant national standards.

Representative from the Boards of Medicine, Nursing, Cosmetology and Electrology provided overviews of permitted practices and related education and training requirements.  Industry representatives provided input on the medical spa marketplace and the training of estheticians.  Finally, concerns related to patient safety were identified by a physician from a leading dermatological association and a 2007 survey of American Society for Dermatologic Surgery members, which reported a steady increase in complications caused by non-physicians performing aesthetic procedures over the past five years.


Three big questions were focused  on for the proposed regulations:

  • Who should perform medical spa services?
  • What services should be offered and how should they be regulated?
  • In what environment should these services be provided?


The Task Force developed a three-tier classification system which considered the level of risk, type of supervision needed, and training requirements.

Level I Procedures are noninvasive and demonstrate low risk.  LED therapy and microdermabrasion are examples of procedures at this level.  Since Level I procedures are not considered the practice of medicine, they are overseen solely by the Board of Cosmetology.

Level II Procedures represent a moderate level of risk and include nonablative and nonvaporizing lasers, intense pulsed light devices and radiofrequency devices.

Level III Procedures are the highest level of risk and include ablative and vaporizing devices, chemical peels, and the use of injectables.  Procedures performed using Level III devices can only be administered by a physician. 

Facilities providing Level II and III procedures would require a medical spa license.


Another goal of the Task Force was to look at the appropriate supervision of medical spa procedures.  Existing regulations often permit physicians to act as medical directors even when they know little about aesthetic procedures  and / or spend little time overseeing the spa personnel.  The Task Force proposed changes to put an end to this.

Medical directors and personnel providing medical spa services must meet certain licensure and training requirements. 

On-site supervision by a qualified healthcare provider would be required for Level II and III procedures.

While the medical director is not always required to be onsite to oversee delegated procedures, he/she must be located within four hours of the medical spa and be present on-site 10% of the time each month for each site supervised.


After grappling with the issues of ownership, the Task Force determined that anyone can own a medical spa, but they must hire appropriate medical personnel for clinical supervision.  It was determined that the Department of Health would be responsible for licensing and inspection of medical spa facilities.  It was determined that individual licensing boards would have jurisdictions over appropriate practiced by their licensees.  It was determined that a separate advisory committee should be created to provide future oversight in this constantly changing field of medical aesthetics.

The article indicated that the participants in the Task Force hope their findings will be introduced as a formal bill in the Massachusetts stat legislature sometime this year.


*Medical Lasers and the Law (March 25, 2009)



Medical Spa Regulations;   MedEsthetics, Mar/April 2009, pp 14-16; Andrea Nadai, MHP

Arkansas Medical Board:  Arkansas Medical Practices Acts & Regulations (pdf file) – page 57, Regulation No. 22, Laser Surgery Guidelines


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Wednesday, March 25, 2009

Medical Lasers and the Law

The “throw away” journal, MedEsthetics, has had a couple of nice articles recently.  I will look at one today and the second tomorrow.


The first one on the laws governing the use of lasers in a medical practice.   Lasers:  Aesthetic or Medical?  This one discusses and answers the question:  Who can own and operate a laser?

The Food and Drug Administration regulates all medical lasers.  Most efficacious aesthetic lasers are classified as medical devices and , as such, must be owned (or leased) by a physician.  Yes, some medical devices are legally available to other professional, but these are exceptions.

The article points out that the question of who can own a laser is more clear than who can legally operate one.  They point out that a physician can legally delegate the operation of some lasers or light devices to others.  If the physician does delegate, he/she raises a whole litany of other issues.

What is the non-physician treating?  There may be a difference between using a light-based device for hair removal and treating a medical condition.  The law is clear that only a physician or an appropriate allied health provider can make a medical diagnosis.  Diagnosis cannot be delegated by a physician.

This article also covers the “misconception that devices used to treat fat  or cellulite are not medical devices.”    The Endermologie was the original device cleared by the FDA for cellulite reduction.  It is safe to utilize it as a nonmedical device as long as one is careful with the claims made for its effectiveness. 

However, newer generation products that contain light-based components are federally classified as medical devices.

The article continues to discuss the question “Who is performing the treatment?”  This quickly can become a quagmire as the physician gets further away from medical personnel.  Estheticians are not considered medical personnel.  Estheticians are governed by a state board of cosmetology and not by the state medical board. 

While it can be argued that nonmedical staff can perform purely aesthetic procedures, such as laser hair removal or tattoo removal, bear in mind that the devices being utilized are still federally classified as medical devices and their use (and ownership) may be limited by that concept.

Another issue where care is needed is “post-procedure care.”   It should be well known by now that any of the lasers or light devices can cause problems – burns, pigmentation problems, etc.  If a nonmedical personnel is doing the treatment, it must be remembered that she/he can not make the medical diagnosis of the problem (ie burn). 

Nonmedical personnel may make an initial review and listen to the patient’s concerns, but the minute there is any irregularity or subjective complaint from the patient, a physician or appropriate medical provider should be brought in to manage patient care.

I love the last line of this article:

“Owning a laser does not give you the legal right to use it.”


It is important to check your own state’s laws.  It is also prudent to have good written protocols and to utilize medical personnel rather than simple training a “lay person” to save money.

Here  are my state’s guidelines (Regulation No 22, Laser Surgery Guidelines):

Pursuant to Ark. Code Ann. 17-95-202, the practice of medicine involves the use of surgery for the diagnosing and treatment of human disease, ailment, injury, deformity, or other physical conditions.  Surgery is further defined by this Board as any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical means, to include the use of lasers.  The Board further finds that the use of medical lasers on human beings, for therapeutic or cosmetic purposes, constitutes the practice of medicine.

Under appropriate circumstances, that being the performing of minor procedures, a physician may delegate certain procedures and services to appropriately trained non-physician office personnel.  The physician, when delegating these minor procedures, must comply with the following protocol:

  • The physician must personally diagnose the condition of the patient and prescribe the treatment and procedure to be performed.
  • The physician may delegate the performance of certain tasks in the treatment only to trained non-physician personnel skilled in that procedure.
  • The physician must make himself available to respond to the patient should there be any complications from the minor procedure.
  • The physician should ensure and document patient records that adequately describe the condition of the patient and the procedure performed, and who performed said procedure.

A physician who does not comply with the above stated protocol when performing minor procedures will be considered as exhibiting gross negligence, subjecting the physician to a disciplinary hearing before the Board, pursuant to the Medical Practices Act and the Rules and Regulations of the Board.

History:  Adopted June 5, 1998; Amended June 2, 2005





Lasers:  Aesthetic or Medical?;   MedEsthetics, Jan/Feb 2009, pp16-19; Padraic B Deighan, MBA, JD, PhD

Arkansas Medical Board:  Arkansas Medical Practices Acts & Regulations (pdf file) – page 57, Regulation No. 22, Laser Surgery Guidelines

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Tuesday, March 24, 2009

Shout Outs

Code Blog is this week's host of Grand Rounds.  It is a really “grand” edition.  Read it here.   

Welcome!  This is fifth time I’ve hosted Grand Rounds here at code blog.  Although my previous four attempts were fairly creative, I decided to keep this edition simple.  All submissions were included - if you do not see yours here, I did not get it for some reason!

The first post is one that I immediately balked at even including because the opening paragraph sounded absurd to me.  But the more I read, the more I realized there were some good points and it quickly became one of the more intriguing posts submitted.  Head over to Duncan Cross to read Don’t Walk and find out why research/fund-raising organizations are not as helpful to those they purport to assist as we’d like to think.


The latest edition of Change of Shift (Vol 3, No 19)  is hosted by none other than Kim, Emergiblog!    I hope you will check it out.  You can find the schedule and the COS archives at Emergiblog

Welcome to the Emergiblog version of Change of Shift!

It’s been a while since I have hosted, and it’s fun to check out the posts as they arrive! Oh who am I kidding, I wait until almost the last minute!

Check out the calendar, if you are interested in hosting our esteemed carnival there are openings available.

Send me a postcard, drop me a line…all together now….and let me know what date you would like to host!


Check out this post over at Better HealthNeuroticism Versus Hypochondria: Dr. Jon LaPook Explores The Differences

In this week’s CBSdoc.com video, Dr. Jon LaPook conducts a two-part interview with a colleague who thinks he might be a hypochondriac.


H/T to Cathy who twittered this link (photo credit)

A computer programmer who lost half his finger after his motorbike crashed into a deer has had the finger replaced with a USB drive.


A Respository of Bottled Monsters links to an article that used their photos from the Civil War.

Michael Hughes called in the other day and mentioned an article he wrote on Civil War ophthalmology that he used some of the museum's pictures in - Eye Injuries and Prosthetic Restoration in the American Civil War Years


The  Literature, Arts, and Medicine Blog has a nice post on the “Ethics and Aesthetics:  Photographing Patients.”   Here is a small exert:

At first, I started taking Polaroids to help inform the medical history. We are a group practice and often care for each other’s patients over the phone, and in such a setting a photograph can be an invaluable aide in medical decision-making. The photos also helped me recall my patients when I was new on the job. I didn’t think twice about the propriety of taking these pictures, they were an invaluable part of the medical record and were only used as such. The consent form was signed as a bureaucratic formality.

Almost immediately, I started to appreciate the Polaroids aesthetically. There was something touching in my patient’s expression, something timeless in the corners of the room that were visible in the background. I found myself composing the images deliberately; I tried to include a colorful quilt, a glowing Christmas tree, a stuffed animal collection.


Peggikaye Eagler is a MDA's MOST WANTED CITIZEN!  She needs your help to “get out of jail.”  The money raised is for the Multiple Dystrophy Association.

If you know me, if you're a friend of me ... then you've been touched in some way by one of these 40 neuromuscular diseases. I cannot imagine how different my life would be without the research and services that the MDA has provided for those of us with Myasthenia Gravis. I know for sure, they have made a difference, both in my health, and my learning about the disease when I first got sick. PLEASE give to MDA so other families can benefit from their desperately needed services!


This week Dr Anonymous’ guest will be Brandice as they talk about Podcamp Ohio.   The show begins at  9 pm EST. 

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

3/30: Special Monday show celebrating Doctor's Day
4/2: VP Medical
4/4: Night Shift with Dr. A



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Monday, March 23, 2009

Be a Potential Hero – Learn CPR

Earlier this month the Arkansas Legislators passed a bill to put AED devices in all public schools in our state. The bill was sponsored by Senator Tracy Steele. It is estimated that about $1 million dollars will be needed to pay for the devices. The money is expected to come from the recently passed increased tobacco tax (an extra 56 cents per pack).
The Antony Hobbs III Act was named in honor of 17 yr Parkview High School basketball player who died after collapsing at a game. He died of complications from an undiagnosed heart defect.
I renewed my ACLS this past Thursday evening. Some of my nurse friends ask me to go with them as a way of getting together. They needed to recertify and assumed I might. We meet for dinner before the class and enjoyed the time together.
During the evening, the EMT who reviewed the AED devices with us mentioned having responded to the collapse of Antony Hobbs. He wanted to stress the importance of knowing basic CPR and BLS as most arrthymias are not shockable. He ask if we wanted to guess how many people at the basketball game attempted to help.
Can you guess?

When the crowd was asked if there were any medical folks there, one nurse stood up and responded. None of the teachers, coaches, parents responded “I know CPR. Can I help?”
I found that sad. CPR is much more important in most life situations than ACLS. I would like to encourage all to learn CPR. Even if the AED finds a shockable rhythm, the recommendation is a minimum of 2 minutes of good quality CPR immediately after the shock even if a normal rhythm is seen.
So having the AEDs in airports, in schools, at your work place does not replace the need for CPR. We all need to know how to do good quality CPR. It is the CPR that is most likely to save some one.
It is easy to find classes. Look to your local Red Cross chapter. They have classes on a regular basis to teach basic CPR and AED use. Or contact a group like America First Response.
Get your entire family to take the class. Learn CPR --you might end up being a hero.


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Sunday, March 22, 2009

SurgeXperiences 220 – Call for Submissions

The host for the next edition (220) of SurgeXperiences has not been announce, but don’t let that keep you from writing and submitting. The next edition will be on March 29th.

The deadline for submissions is midnight on Friday, March 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.

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Friday, March 20, 2009

One-Patch QOV Quilt Top

I have continued to make quilt tops for the Quilt of Valor organization.  This one I sent to a long-arm quilter earlier this year.  It is 51 in X 66 in.  The pattern is a one-patch pattern.



This top was made of several floral fabrics I bought at a garage sale.  Each square is 3 in.  Florals are okay because many of the soldiers are female.


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Thursday, March 19, 2009

Sun Protection

H/T to the Medgadget guys (photo credit). This post of theirs reports on a new device to help protect skin from sun damage.

Researchers from University of Strathclyde, Glasgow have developed a skin patch that measures a person's exposure to the sun. Chemical compounds inside the patch react to ultraviolet light and change color to warn of a potential skin burn.

Since the device isn’t available just yet, remember to use sun screen.

The best sunscreen is the one you will use. It has to "feel" good to them--not be too greasy, not have the wrong scent, be the right consistency (lotion vs cream).

It will not matter if it is SPF 15 or 3o if it never gets used. It is best to use sunscreen daily, all year around, especially on the face and neck. If you are in the habit of applying sunscreen to your face daily (even on overcast days), it won't be forgotten.

You need both UVA and UVB protection. It is the UVA rays that are most responsible for wrinkling and aging the skin. It is the UVB rays that are the most responsible for the sunburn. The best sunscreen is at least an SPF 15 and has a sunblock component also. The SPF rating reflects the product's ability to screen or block UVB rays only. SPF 15 blocks approximately 93 percent of all incoming UVB rays. SPF 30 blocks 97 percent; and SPF 50 blocks 99 percent. To protect against the UVA rays, the product needs to have avobenzone (Parsol 1789), ecamsule (Mexoryl), titanium dioxide, or micro-zinc oxide.

  • Apply the sunscreen 20-30 minutes before going outside.

  • Use enough. To ensure that you get the full SPF of a sunscreen, you need to apply 1 oz – about a shot glass full.

  • Reapply after getting out of the water or toweling off. Even "water-proof" sunscreens are not usually "towel-proof".

  • Reapply every two hours when outside at a beach, etc. for adequate protection.

  • Use even on a cloudy day. Up to 40 percent of the sun's ultraviolet radiation reaches the earth on a completely cloudy day.

  • Shield your eyes with UV-blocking sunglasses. Squinting caused wrinkles around the eyes. The UV rays can cause cataracts.

  • Wear a wide-brim hat to help protect your head & neck.

  • Don't forget to apply lip balm with SPF 15 or higher.

The Skin Cancer Foundation grants its Seal of Recommendation to products that meet the Foundation's criteria for effective UV sun protection products. If you use a product make especially for the face (ie MD Forte Total Protector SPF 30 or Clinique's Super City Block Oil Free Daily Face Protector SPF 25) it will be less likely to cause skin irritation or acne outbreak with daily use. So spend more money on the face and then if you need to save money, do so on the body sunscreen (ie NO-AD SPF 30 Sport Ultra Block Lotion, Coppertone Water Babies Sunscreen SPF 45).

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Wednesday, March 18, 2009

Exercise Only Good if Done

This isn’t really plastic surgery related, but considering that I am always trying to get patients to get more active or to remain active, then maybe it is.  I like to tell my patients that I have the easy part, they have the hard part of maintaining the results.  This is especially true for the liposuction or abdominoplasty patients where keeping their weight in line is an issue to outcome in years to come.


There is a new article published in  Circulation: Journal of the American Heart Association earlier this week which looked at different types of exercise after a myocardial infarction (MI). 

The authors,  Dr Margherita Vona et al, did a controlled trial using 209 patients who were referred to cardiac rehabilitation after having an MI.  These patients were then randomly assigned to one of four groups:  aerobic training, resistance training, both combined, or no exercise.  

The researchers looked at flow-mediated dilation (improve blood vessel function) at baseline after 4 weeks of exercise, and then again one month after stopping training.  The flow-mediated dilation more than doubled with exercise, from about 4% to about 10% in all three exercise groups.  Those in the no exercise group had a small increase from the baseline 4% to about 5%.

The benefits of physical activity did not last when the activity ended.  Within a month of no exercise, the flow-mediated  function returned to baseline levels.

The important finding of this study is as Dr Vona said, "Long-term adherence to training programs is necessary to maintain vascular benefits on endothelial function." 

Exercise / physical activity has to be like “brushing your teeth”.  It needs to be something that you do regularly and not just once or this week, but for life.

It is not important which physical activity you choose to do, it is important that you do it.  It is important that you continue to be physically active on a regular basis.



"Effects of different types of exercise training followed by detraining on endothelium-dependent dilation in patients with recent myocardial infarction"; Circulation 2009; DOI: 10.1161/CIRCULATIONAHA.108.821736; Vona M, et al


Other Blog Posts

50-Minute Strength Workout

Pedometers and Physical Activity

Getting Back Into Shape


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Tuesday, March 17, 2009

Shout Outs

ACP Internist is this week's host of Grand Rounds.  Their edition is a salute to newspapers.  Read it here (photo credit).  

Welcome to Grand Rounds at ACP Internist, a newspaper serving internal medicine. We're paying tribute to the daily newspaper. Read on for the latest headlines, opinions, features and even the funnies.


He’s back and he’s bald!  Check out the post which included video of Shadowfax raising money for St Baldwick’s

Enjoy the video, but be advised that if you watch it, you are morally obligated to donate! Otherwise, you're just a common thief!
I joke -- enjoy the clip, but if you can, it is not too late to make a gift:  Click here to Donate



Check out the publication “Welcoming Guests with Food Allergies to Restaurants” at the Food Allergy & Anaphylaxis Network.  The guide is free.


Pharyngula posts “Shermer at the Creation Museum

Feel in need of a purgative? Watch this video of Michael Shermer interviewing a creation "scientist" at the Creation Museum. I could only make it halfway through before closing it in disgust.


Steve Lopez was a guest on The Diane Rehms Show yesterday discussing his new book,  "The Soloist" (Berkley).  He is an L.A. Times columnist who “set out to save a mentally-ill homeless musician and found his own life profoundly changed. A true story about an unlikely friendship and the redemptive power of music.”  You can listen to the interview here.



This week Dr Anonymous’ guest will be  will be respiratory therapy student Trauma Junkie to talk about the blog carnival A Source of Inspiration.   The show begins at  9 pm EST. 

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

3/26: Podcamp Ohio



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Monday, March 16, 2009

Requirement of Perioperative Stress Doses of Corticosteroids -- an Article Review

If you refer back to my November 3, 2007 post you will see that I was taught that patients on long term corticosteroids need to have “extra” doses or “stress” doses of corticosteroids perioperatively. It was nice to see this recent article in the Archive of Surgery Journal (full reference below). The logic of the perioperative stress doses is to cover the impaired response to the stress of surgery and anesthesia due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use.

Their stated objective was

To determine the requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure.

They chose to do a review of the literature, looking for all relevant clinical trials that studied the role of perioperative corticosteroids and adrenal crisis in patients taking long-term therapeutic doses of corticosteroids. They searched the National Library of Medicine's MEDLINE database for relevant studies in any language published from January 1, 1966, through July 31, 2007. Keywords for the search were perioperative care or perioperative or surgery and adrenal cortex hormones or corticosteroids. The search was limited to studies involving humans and adults.

They found nine studies that meet their requirements. They studies involve a total of 315 patients who underwent 389 surgical procedures.

Two of the studies were prospective, double-blind, randomized, placebo-controlled studies in which patients received perioperative stress doses of corticosteroids or placebo together with their usual maintenance dose of corticosteroid.

In 2 studies, corticosteroid therapy was stopped before surgery (18 and 36 hours before surgery). Stress doses of corticosteroids were not administered.

In an additional 5 studies patients were followed up after receiving only their usual daily maintenance dose of corticosteroid. Stress doses of corticosteroids were not administered.

Their results

The 2 randomized placebo-controlled studies included in this review did not detect a difference in the hemodynamic profile of patients treated with stress doses of corticosteroids compared with patients treated with their usual dose of corticosteroid alone.

These results are supported by the 5 cohort studies in which patients received their usual daily dose of corticosteroid without the addition of stress doses of corticosteroids; none of the patients in those 5 studies developed an adrenal crisis.

One patient in each of the studies by Jasani et al and Kehlet and Binder developed a possible adrenal crisis that responded rapidly to hydrocortisone treatment; in those patients, corticosteroid therapy was stopped 36 and 48 hours before surgery.

Their conclusion is that the data suggest patients receiving long-term corticosteroid therapy do not require stress doses of corticosteroids. They stress that these patients should continue to receive their usual daily dose of corticosteroid.

They also stress

These recommendations do not apply to patients who receive physiologic replacement doses of corticosteroids because of primary dysfunction of the HPA axis (eg, patients with primary adrenal failure due to Addison disease, with congenital adrenal hyperplasia, or with secondary adrenal insufficiency due to hypopituitarism). It is likely that these patients are unable to increase endogenous cortisol production in the face of stress. These patients require adjustment of their glucocorticoid dose during surgical stress under all circumstances.


Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Literature; Arch Surg, Dec 2008; 143: 1222 – 1226; Paul E. Marik; Joseph Varon

Perioperative Steroid Coverage (my blog post; November 3, 2007)

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Sunday, March 15, 2009

SurgeXperiences 219 is Up!

This edition (219) of SurgeXperiences is hosted by Oystein, The Sterile Eye, a medical photographer in Norway. You can read this “anatomy” edition here.

Suggested theme:

noun (pl. anatomies)
1. the branch of science concerned with the bodily structure of humans, animals, and other living organisms, especially as revealed by dissection and the separation of parts.
2. a study of the structure or internal workings of something: a detailed anatomy of a society and its institutions.
- origin late Middle English: from Old French anatomie or late Latin anatomia, from Greek, from ana- ‘up’ + tomia ‘cutting’ (from temnein ‘to cut’).

- Oxford English Dictionary

The host of the next edition (220), March 29th is yet to be named. The deadline for submissions is midnight on Friday, March 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 SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

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Friday, March 13, 2009

Double Irish Chain Baby Quilt

This is a double Irish Chain I made for the daughter of a blog friend. He happens to be Irish. Instead of just using two colors, I added the pink and dark green and interlaced them. The medium green was added because I didn't have quite enough of the background fabric. The quilt is 50 in X 50 in. It is machine pieced and quilted.

Here is a detailed photo which doesn't really do justice to the lovely light green background fabric. The chains are cross-hatched quilted. The "centers" have clovers quilted into them.

And another detail photo to try to share the fabric with you.


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Thursday, March 12, 2009

Monkee Peter Tork Has Mouth Cancer

Do you remember the Monkees?  They were a rock group in the 1960’s.  Their  TV show first appeared on NBC in 1966.  One of their biggest hits includes chart-topper I'm A Believer.  The group toured following the success of their TV show.

Former Monkee, Peter Tork, 67, has a rare form of head and neck cancer.  He underwent surgery last week in New York.  He is reported to be doing well and will have radiation treatment when healed from the surgery.

According to Tork’s website, he has adenoid cystic carcinoma of the tongue.  The cancer was found early and has not spread.


Anatomically, the tongue is actually divided into two separate areas.  The oral tongue (the part you can "stick out" at somebody) is the front of the tongue and extends backward to a V-shaped group of lumps (specialized taste buds) on the back of the tongue.  The base of tongue is behind these.  (photo credit)

The oral tongue and the base of the tongue comprise the whole tongue but develop from different embryonic tissue.  The tongue is the second most common site of cancers of the head and neck.  The first is the skin.


The most common type of cancer of the tongue is called Squamous Cell Carcinoma.  Adenoid cystic carcinoma is a rare cancer of the tongue.  It is a common malignant cancer of the salivary glands.  It accounts for nearly 2% to 4% of head and neck area tumors.  In minor salivary glands, adenoid cystic carcinoma  usually affects the palate.

The most common symptoms of tongue cancer are a painful area or a non healing ulcer on the tongue.  Other symptoms include bleeding, ear pain, difficulty with swallowing and/or speech, pain on swallowing, difficulty opening the mouth, or a presence of a mass in the neck.

Most tongue cancers occur in older patients who have extensive histories of tobacco and/or alcohol use, but can arise in a person under forty years of age and/or have no significant history of tobacco or alcohol use. 

When found early, tongue cancer lesions are usually treated by surgery only.  For all but the smallest lesions, a lymph node dissection will also be done the side of the neck on which the tumor has arisen.  The neck dissection gives additional staging information about the tumor and its aggressiveness.  More advanced lesions require radiation therapy and sometimes chemotherapy in addition to the surgery. 

Surgical removal of small lesions often cause little functional impairment.  Removal of larger portions of the tongue can leave the patient with difficulty with speech and/or swallowing.  Aggressive rehabilitation by a speech pathologist can result in excellent results for both speech and swallowing. 

The prognosis for patients with tongue cancer is generally good.    Early diagnosis and treatment are important.



Information About Tongue Cancer

MD Anderson Medical Center

Adenoid cystic carcinoma of the tongue: case report and literature review; Med Oral Patol Oral Cir Bucal. 2008 Aug 1;13(8):E475-8; Soares EC, Carreiro Filho FP, Costa FW, Vieira AC, Alves AP.

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Wednesday, March 11, 2009


I find this to be a fascinating instrument. It is to be used during the de-epithelization of the breast pedicle of a reduction mammoplasty. (photo credit)

I was taught to use an Esmark bandage to wrap the base of the breast to aid in the de-epithelization. It acts as both a tourniquet and makes the process simpler as the breast remains “fuller.”

I saw the ad in a journal recently and went to their website. The site shows how to use the Mammostat. I wonder if it is easier to use than the Esmark (which is very easy to use). Curious about the cost, I called and was told it is $299. It is reusable which the Esmark is not. So it might have long term cost savings.

Other Posts:

Breast Reduction (December 19, 2007)

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Tuesday, March 10, 2009

Shout Outs

Doc Gurley is this week's host of Grand Rounds.  Her edition is a webinar.  Read it here.  

Doc Gurley is hosting Grand Rounds March 10 - and it will be our first Grand Rounds LIVE! with hosts Doc Gurley, Colin Son (our Medscape Grand Rounds Guru) and a mystery guest.

Grand Rounds will be a webinar in which you can participate! The optional theme? Improv, of course. Feel free to stretch the topic past the breaking point [Do you improvise when it comes to healthcare? Should you? Do you flourish in the unscripted moments we all face? Will we as a nation improvise a healthcare plan?].


The fourth edition of Change of Shift (Vol 3, No 18) for 2009 is hosted by Jen (The Nurse Practioner's Place)!   It’s the “Oh, No You Didn’t” edition. I hope you will check it out (photo credit).  You can find the schedule and the COS archives at Emergiblog

Welcome to The Nurse Practitioner's Place's first attempt at the Change of Shift!

Due to not having very many submissions this week, I went surfing for something to put on this edition. Thanks to those took the time to submit and without further ado, here's this week's entries.


March 10 is National Women and Girls HIV/AIDS Awareness Day.  The U.S. Department of Health and Human Service, Office on Women's Health is the lead for this day. The 2009 theme is "HIV is Right Here at Home".  (photo credit)


Check out the “Brought to Life, Exploring the History of Medicine”  website and exhibit.  (h/t of A Repository of Bottled Monsters) It is a great site!

The earliest form of surgery was trephining, which involved cutting a small round hole in the head. It was practiced as early as the Neolithic period, for reasons that remain a mystery. There are many theories about the reasons behind this practice. The only thing we know for sure is that some patients survived the procedure, and sometimes even had more than one performed. Later, the Egyptians practiced trephining in an effort to cure migraines - the idea was to ‘let out’ the illness that was causing the headaches. (photo credit)


Let’s support Shadowfax again this year as he  gets ready to shave his head for pediatric cancer research (photo credit).  He is raising money in Henry’s (Dr Smak’s son) name.  Please, consider donating even just a small amount.  Thank you.

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.


Check out the interview of Dr Val by Diariomedico on twitter last Wednesday.  You can read it here.   This time she was interviewed rather than doing the interview.  Nice job, Dr Val!  (photo credit)



This week Dr Anonymous’ guest will be  will be 4th year medical student Mudphudder to talk about Match Day 2009.   The show begins at  9 pm EST. 

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

3/19: Respiratory therapy student Trauma Junkie to talk about the blog carnival A Source of Inspiration

3/26: Podcamp Ohio



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Monday, March 9, 2009

Indications for Breast MRI – an Article Review

The full title is “Indications for Breast MRI in the Patient with Newly Diagnosed Breast Cancer.” It is a Medscape CME article. The article discussed exactly what the title implies. It does so by looking at the published research.

Some of their findings:

  • MRIs have a high sensitivity for detecting otherwise occult cancers in women recently diagnosed with breast cancer.
      • MRIs can improve assessment of disease extent in the breast known to be affected with cancer and may detect mammographically occult cancer in the contralateral breast.
  • Nothing published suggests that breast MRI should be used as a substitute for screening or diagnostic mammography.
  • MRIs should be used as an adjunct to mammography and not in lieu of standard breast imaging with mammography and, when indicated, diagnostic breast ultrasound.
  • MRI detects the primary cancer in up to 70% of these patients with adenocarcinoma meta states in the axillary lumph nodes without an identified primary source, changing the staging from T0 (unknown primary) to the defined T1 to T3.
  • To address the current lack of standardization in MRI technique, the American College of Radiology (ACR) is developing a voluntary Breast MRI Accreditation Program, which will include minimum standards for breast MRI.

Other Blog Posts of Interest:

Breast Self Exam (BSE) (Oct 6, 2008)

Mammograms (Oct 13, 2008)

Breast Cancer Screening in Childhood Cancer Survivors (Feb 4, 2009)


Indications for Breast MRI in the Patient With Newly Diagnosed Breast Cancer; Medscape Article, posted 02/16/2009; Constance D. Lehman, MD, PhD; Wendy DeMartini, MD; Benjamin O. Anderson, MD; Stephen B. Edge, MD

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Sunday, March 8, 2009

SurgeXperiences 219 – Call for Submissions

The next edition (219) of SurgeXperiences will be hosted by Sterile Eye on March 15th.  

He is a medical photographer in Norway.  He has a great blog.  I hope you will check it out.  His suggested theme:

Suggested theme:

noun (pl. anatomies)
1. the branch of science concerned with the bodily structure of humans, animals, and other living organisms, especially as revealed by dissection and the separation of parts.
2. a study of the structure or internal workings of something: a detailed anatomy of a society and its institutions.
- origin late Middle English: from Old French anatomie or late Latin anatomia, from Greek, from ana- ‘up’ + tomia ‘cutting’ (from temnein ‘to cut’).

- Oxford English Dictionary


The deadline for submissions is midnight on Friday, March 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.

Bookmark and Share

Friday, March 6, 2009

Double Four-Patch QOV Quilt Top

I have continued to make quilt tops for the Quilt of Valor organization.  This one I sent to a long-arm quilter earlier this year.  It is 50 in X 70 in.  The pattern is a double four-patch.


Here is a close photo of some of the fabrics.  It is made of several reds, blues, yellows, and tans.


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Thursday, March 5, 2009

Breast Surgery

The “throw away” journal Plastic Surgery Practice has two really well written informative article on breast surgery in the February 2009 issue. 

The first is “Reconstructing the Radiated Breast” written by Dr Jane Petro.  The article makes the point that surgery on the radiated breast includes “all the pitfalls of any breast procedure.”  The topic is important as many women opt for breast-conservation therapy (ie lumpectomy followed by radiation therapy) hopeful that they will maintain breast integrity and not need reconstruction.

This works for many, but not all. 

In reality, the appearance of the breast after this treatment may be unsatisfactory, due to a number of factors. Lumpectomy may deform the breast, leaving unsightly and poorly planned scars in the upper visible quadrant. Scars from port placement for chemotherapy are often midway between the clavicle and the breast. Resection of lower-quadrant tumors may deform the nipple location, increasing the appearance of breast asymmetry.

Radiation may cause soft-tissue contraction, skin discoloration, and scar-related exaggerated deformity. Reconstruction with an implant has one of the highest complication rates, severely affecting the result due to radiation. Reconstruction with well-vascularized flap tissue, such as a TRAM, is not immune to radiation damage, either. Women disappointed by their result then seek consultation regarding options for achieving a more aesthetically satisfactory result.

If you are interested in this topic, I would encourage you to read the entire article.  Dr Petro writes clearly and has included photos of some of the issues and what is possible.


The second article is “Beware the Breast Augmentation and Lift Combo” written by Dr Laurie Casas.  The article is a reminder that even for skilled surgeons “this combination may be the most complex plastic surgery procedure to perform.”  She makes the point that it is important  to understand the patient’s desires, to inform the patient well, and to make sure the patient is realistic in their expectations.

She reminds us all of the following:

The FDA has reported that breast augmentation leads to an 18% to 22% rate of reoperation. The number of complications that can grow out of an augmentation-lift combination procedure makes informed consent a top priority for any woman interested in breast surgery.

These risks from combination augmentation-mastopexy procedures include the following:

Risk of breast implant exposure;

Risk of infection; and,

Risk of excessive scarring.

For women having an augmentation-mastopexy combination surgery:

In 2004, Spear et al produced augmentation-mastopexy outcome data involving 34 patients over a 6-year period. Of the 34 patients, 41% had grade 1 ptosis, 41% had grade 2 ptosis, 3% had grade 3 ptosis, and 12% had grade 4 ptosis.

With 50% of the participants responding, 54% desired revision surgery with an expressed desire for a greater lift of the breasts.

Once again, if you are interested in the above topic, I would encourage you to read the entire article.  There are good photos included.



Related Posts

Breast Implants – Some History (March 3, 2008)

Silicone vs Saline Breasts Implants (March 4, 2008)

Silicone Implants and Health Issues (March 5, 2008)

Breast Implant Deflation (Feb 26, 2009)

Mastopexy (November 2007)

Breast Reconstruction – Part I

Breast Reconstruction – Part II

Integrating Radiation Therapy & Breast Reconstruction (Feb 9, 2009)



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