Thursday, April 30, 2009

Herbal Supplements and Surgery Reviewed

I reviewed this topic in June 2007, but the recently published article in the March/April issue of the Aesthetic Surgery Journal makes it timely to review again. The article points out that many patients don’t tell their doctors about taking the herbal supplements. Many doctors forget to ask.

Patients tend to underreport the use of complementary medicines to their conventional health care providers. In fact, 40% to 70% of responders in many investigations did not report complementary medicine use to their doctors.

It is important for both doctors and patients to ask and tell. Here is a reposting of that post.

Many people take herbal supplements these days for many reasons.

Chondroitin and glucosamine (My husband swears by them. My 14 yr old labrador, Girlfriend takes them.) are supplements that are taken together. Both are components of the normal cartilaginous matrix and are used to treat osteoarthritis.

Echinacea is often used for prevention and treatment of viral and bacterial infections. It has been shown that echinacea, both in vitro and in vivo, possessing immunostimulation properties because of enhancing phagocytosis and nonspecific T-cell stimulation.

Ginkgo biloba has become widely used for its efficacy in treating peripheral and cerebral circulatory disturbances, including claudication and memory impairment (e.g., Alzheimer’s Disease).

Garlic is taken to aid in the reduction of atherosclerosis and hypercholesterolemia. It is also taken as an antioxidant, an antibiotic, a diuretic, an antitussive, to remove “evil” spirits, strengthen the stomach and spleen, and relieve diarrhea.

Ephedra is used to promote weight loss, increase energy, and treat respiratory tract conditions, such as asthma and bronchitis. It is contained in many over-the-counter “slimming preparations.”

Many people take these supplements with no thought of "side effects" or interactions with their prescriptions.

Chondrotin and heparin are similar in chemical composition and researchers speculate that bleeding complications may arise from chondroitin use, particularly when used in combination with other blood-thinning medications.

Because echinacea does have immunostimulation properties, it is contraindicated in systemic and autoimmune diorders. The immunostimulatory effects can offset the immunosuppressive actions of corticosteroids and cyclosporin. Side effects of echinacea also include GI upset, headache, dizziness, and potential allergic reactions. Prolonged use of ecchinacea (8 weeks) has been documented to cause tachyphylaxis through an unknown mechanism. Echinacea is also an inhibitor of cytochrome P450, 3A4, and sulfotransferase and can potentiate the toxicity of drugs that are metabolized by these pathways (benzodiazepines, barbiturates).

Gingko biloba has the ability to inhibit platelet-activation factor and possesses an anti-inflammatory effect. Gingko biloba has induced spontaneous hyphema (bleeding from the iris in the anterior chamber of the eye), subarachnoid hemorrage, and spontaneous bilateral subdural hematomas. It should not be used with other anticoagulants. Other side effects of gingko include headache, GI symptoms, and allergic skin reactions.

The active ingredient in garlic is allicin, which has been reported to inhibit platelet aggregation. It should not be taken with other coagulation inhibitors (e.g. warfarin, heparin, nonsteroidal anti-inflammatory inhibitors, and aspirin). Other side effects of garlic include halitosis, nausea, hypotension, headache, bloating, and possible allergic reaction.

Ephedrine, a chemical contained in ephedra, has medical uses, mostly in operating rooms and intensive care units. It is sympathomimetic agent and causes positive inotropic and chronotropic responses to raise blood pressure and heart rate, respectively; dilates bronchioles; and increases metabolic rate. Side effects such as psychiatric disturbances, heart attack, cardiac dysrhythmias associated with volatile general anesthetic agents (e.g., halothane) and cardiac glycosides (e.g., digitalis), stroke, and even death. Of note, patients taking ephedra under general anesthesia can have severe hypotension that can be controlled with phenylephrine instead of ephedrine.

It has become important to ask patients about supplements. It is important to caution them to stop them prior to surgery. Gingko biloba should be discontinued at least 36 hours before surgery. Garlic should be discontinued at least 1 week prior to surgery. The exact time for chondrotin is unknown, so recommendations are based on guidelines from the American Society of Anesthesiologists, which advises that all herbal medicines without formal study be discontinued at 2 to 3 weeks before an elective surgical procedure. Echinacea should be discontinued 2-3 weeks prior to surgery. Ephedra should be discontinued at least 24 hours prior to surgery.

Herbal supplements are being studied as medications, but still too much is unknown. If you are the patient, tell your doctor which ones you are taking. If you are scheduled for an elective surgery, stop taking the supplements for 2-3 weeks prior to surgery.

Some references:
1. Kleiner, S. M. The true nature of herbs. Phys. Sports Med. 23: 13, 1995.

2. Eisenberg, D. M., and Kessler, R. C. Unconventional medicine in the United States: revalence, costs and patterns of use. N. Engl. J. Med. 328: 246, 1993.

3. Kaye, A. D., Kucera, I., and Sabar, R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol. Clin. North Am. 22: 125, 2004

4. Ang-Lee, M. K., Moss, J., and Yuan, C. Herbal medicines and perioperative care. J.A.M.A. 286: 208, 2001

5. Heller, Justin B.S.; Gabbay, Joubin S. M.D.; Ghadjar, Kiu; Jourabchi, Mickel; O'Hara, Catherine B.A.; Heller, Misha B.S.; Bradley, James P. M.D. Top-10 List of Herbal and Supplemental Medicines Used by Cosmetic Patients: What the Plastic Surgeon Needs to Know. Plastic & Reconstructive Surgery. 117(2):436-445, February 2006.

6. Broughton, George II M.D., Ph.D., Col., M.C., U.S.A.; Crosby, Melissa A. M.D.; Coleman, Jayne M.D.; Rohrich, Rod J. M.D. Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review. Plastic & Reconstructive Surgery. 119(3):48e-66e, March 2007.

7. Perioperative Risks and Benefits of Herbal Supplements in Aesthetic Surgery; Aesthetic Surgery Journal, March/April 2009; vol 29: pp 150-157; Rowe, D.J.

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Wednesday, April 29, 2009

Melanoma Skin Screening Is Important

I’m all for finding skin cancer early.  It makes treatment so much more simple and effective.  This is reinforced in the recent article by Alan C. Geller, of the Boston University School of Public Health, and colleagues in the April issue of  Archives of Dermatology.  The study shows that routine screening for melanoma can lead to a 50% increase in detection of small back-of-body lesions.  These lesions on the back are ones that are often missed by the patients themselves.

The study surveyed 227 men ≥40 within three months of melanoma diagnosis.   They found that more than half (59%) had not received a full-body physical examination by a physician prior to diagnosis of melanoma.  

Melanoma can present anywhere on the body, but in men the back is the most common site, making up nearly a third of all cases.  The study found that back lesions made up nearly half of all physician-detected lesions, and back-of-the-body lesions comprised 63% of physician-detected melanoma.   It is also important to note that 92% of physician-detected back-of-body lesions were thinner than 2 mm, compared with 63% of self-detected and 76% of other-detected lesions. 

The authors are urging the promotion of the  " 'Watch Your Back'  education campaigns. 

Each month examine your skin everywhere, including the palms and soles. Use a hand mirror and a full length mirror to see your back.  Ask you spouse or partner to check your back.  Ask you doctor to check you skin once a year.

Look for a new growth, or any skin change, and know your ABCD’s.
“A” for Asymmetry – Basically, one side does not look like the other.

“B” for Border irregularity – Lots of moles grow, but beware of irregular jagged borders

“C” for Color Variation – Lots of moles have pigment, but be wary of different colors in the same mole.

“D” for Diameter – Moles that are larger than a head of a pencil eraser (about 6mm.) are more concerning for melanoma

The proportion of patients reporting full-body examinations in the year prior to diagnosis did not differ among men with physician-detected (43%), self-detected (41%), or other-detected melanoma (52%).




Source reference:
Factors associated with physician discovery of early melanoma in middle-aged and older men; Arch Dermatol 145(4): 409-14; Geller AC, et al


Related Posts

Melanoma Review (February 25, 2008)

Skin Cancer—Melanoma (December 8, 2008)


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Tuesday, April 28, 2009

Shout Outs

Kerry, Six Until Me, is this week's host of Grand Rounds. It is the “what’s on the menu” edition. Read it here.


The bells on the door of the diner near my office jangled as I walked in.

"Hey Kerri," said Lisa, the waitress who knows my morning coffee order by heart. "Here for lunch today?"

"Yeah, I'm looking for a little snack here at the Grand Rounds Cafe." I took a seat. "What's on the menu?"

Kevin, MD did a “Live” Question and Answer session on April 26th! Good for him! Topics included cancer screening, the swine flu, etc. You can read the session here.

Precordial Thump posted a nice poem ‘Today I do not want to be a doctor’ written by South Auckland-born medical poet, Glenn Colquhoun. You can read the entire poem here. Here are the first few lines.

Today I do not want to be a doctor.
Nobody is getting any better.
Those who were well are sick again
and those who were sick are sicker.
The dying think they will live.
The healthy think they are dying……

Dr Harriet Hall writes Is IV Sedation Over-Used?

We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients………….

The Medical Quack writes about a surgeon who performed more than a thousand surgeries on healthy people

A Seal Beach, CA doctor, who is in prison for performing an unnecessary sweaty-palm surgery billed to an insurance company, has lost his medical license, effective this week.

Dr. William Wilson Hampton is serving 10 years in federal prison in Lompoc after his conviction in 2007 for defrauding Aetna by operating on a healthy patient, who was recruited to give false symptoms, according to legal documents filed by the California Medical Board.

Sean Dent, Be the Next Step, gives “Sunburn Tips from a Bald-Headed Irish Man

I have become somewhat of a ‘field -expert’ on sunburns over the past 20 some years. I grew up a fair skinned Irish boy with blondish brown hair who evolved into an Bald-headed Irish man. So over the years I have had some ‘tactical’ training in regards to sun management. So lets start with the basics.

  1. Any exposed skin can burn. In fact, some covered areas are susceptible to burning depending on the material that is doing the covering.
  2. Sun block is your friend. (In fact it’s my best friend.. My BFF!) Use it generously. ……….

Dr Ves Dimov, Clinical Notes, has a really nice post on “Antibiotic eye drops for bacterial conjunctivitis: which one to choose?

According to the current clinical evidence, 64% of cases of acute bacterial conjunctivitis improve spontaneously and do not require local antibiotic therapy with eye drops.

When antibiotic therapy is indicated for bacterial conjunctivitis, the most cost-effective options are the eye drops listed below that are included in the Walmart $4 prescription medication program…….

This week Dr Anonymous will be discussing Podcamp Ohio. I hope you will join us. The show begins at 9 pm EST.

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

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Monday, April 27, 2009

Watch Out for Snakes

This pass Friday evening, my dog Rusty woke up from his sleep and jump up startled. He had been sleeping in the doorway of the bedroom / living room. No bark. No yelp. Just a quick move. I got up to see what had startled him and was surprised to find a snake in my house! Here’s the picture I uploaded to twitpic.

This started quite a conversation on twitter as we tried to identify the snake. Robin (Survive the Journey) finally made the definitive identification-- western rat snake

staticnrg@rlbates cousin to the corn snake... check it out.

Two weeks ago I had found this snake while raking the yard. I identified it as a western worm snake. It didn’t bother me nearly as much, as it was not inside my home.

As the weather warms, it is time once again to watch out for snakes. Most (like the two above) are non-poisonous, but others aren’t. If you are bitten by a snake, here are a few tips from a review article at Medscape (Bites and Stings: Snake Bites).

First Aid in the field (or home) consists of:

  • Preventing systemic absorption of the toxin which may be done with compressive dressings and immobilization of the bitten extremity.
  • If signs of envenomation begin to occur, a constriction band to impede lymphatic flow should be placed on the extremity, proximal to the bite. Transport to a hospital should take place immediately.
  • The site should be wiped off and cleaned. The use of field first-aid methods such as incision and suction, tourniquets, and cryotherapy has been associated with a threefold increase in the likelihood of the need for surgical intervention.
  • Although popular belief has it that snakebites kill within minutes, in fact, the toxicity from snake venom usually does not even begin to affect the body for several hours. In one review, 64% of deaths from snakebite occurred between 6 and 48 hours after the patient was bitten.

Other posts

Snake Bites (July 17, 2008)

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Sunday, April 26, 2009

Blog Rally for Free Speech

Thanks to T at Notes of an Anesthesioboist  and Paul Levy, Running a Hospital, for getting this going.

A group of bloggers is holding a blog rally in support of Roxana Saberi, who is spending her birthday on a hunger strike in Tehran's Evin Prison, where she has been incarcerated for espionage. According to NPR, "The Iranian Political Prisoners Association lists hundreds of people whose names you would be even less likely to recognize: students, bloggers, dissidents, and others who, in a society that lacks a free press, dare to practice free expression."

Hearing reports like these has prompted us to do a ribbon campaign. Blue for blogging.

Please consider placing a blue ribbon on your blog or website this week in honor of the journalists, bloggers, students, and writers who are imprisoned in Evin Prison, nicknamed "Evin University," and other prisons around the world, for speaking and writing down their thoughts. Also, please ask others to join our blog rally.

Articles of interest:

"Birthday Wishes for Imprisoned Journalist Saberi"

"Mir-Sayafi:  Iranian Bloggers Writings Bring Him to Life"

"Iran's Evin Prison Likened to Torture Chamber"


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SurgeXperience 222 – Call for Submissions

The SurgeXperience 222 will be hosted by Bongi, other things amanzi, on May 3rd.  The deadline for submissions is midnight on Friday, May 1st.  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, April 24, 2009

Crazy Quilt Project

This is an old crazy quilt top that I bought several years ago intending to repair and finish it. It got put away and time got away from me. A few months ago I read about a crazy quilt contest with the proceeds going to the Alliance for American Quilts, so got it back out. It was in worse condition than I remembered.

I apologize for my lack of skill in “putting” all the photos together, but here is the quilt in “nine” photos.

Here are a few detail photos to show some of the damage. This first one shows a ribbon from some Grand Lodge in Arkansas.

It’s sad how the beautiful old silks have worn or crumbled away.

This photo shows how the quilt was actually done on foundation squares and then sewn together.

I wish I could have used this, but the background silk is in shreds.

I know that some “purist” feel that old quilts should not be cut up, but I decided the best way to “salvage” any of this quilt would be do do just that. I struggled to find areas with good fabric. Here is the beginning of my crazy quilt entry. Later I will show you the embroidery and embellishment that I added. The finished quilt will be 16 in X 16 in as the rules demand.

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Thursday, April 23, 2009

Short Cuts to Beauty?

Interesting article recently in the New York Times written by Anemona Hartocollis and Christina Davidson, A Cheap, Fast and Possibly Deadly Route to Beauty  (April 16, 2009).  The article reports on how an increasing number of people are participating in “pumping parties” which use illegal silicone injections for cosmetic purposes.

The injections are administered at home, in motel rooms, in makeshift offices or at “pumping parties,” where the guests take turns injecting one another, officials said.


Silicone injections are not legal in the United States.  It’s use is considered by the FDA as a violation of Federal law as the use of liquid silicone injections “does not have an approved application for marketing or currently approved investigational exemption to permit scientific study. Liquid injectable silicone has been regulated as a device by FDA since 1976. It was previously regulated as a drug.”

There are many side effects that can occur which are being overlooked by the participants in the parties or maybe not even discussed with them.  These side effects include:

  • uneven distribution of the silicone resulting in a lumpy or nodular appearance
  • development of localized infections
  • formation of granulomas
  • silicone pneumonitis (rare, when large quantities are used)
  • silicone embolism  (rare)


Many who perform this injections at the “pumping” parties are not physicians or even medically trained individuals.  And  medical grade silicone is not used in all cases.

Industrial-grade silicone can be bought at a hardware store. But Dr. Graber said there have been reports of the use of substitutes like castor oil, mineral oil, petroleum jelly and even automobile transmission fluid.


I would encourage anyone looking to have liquid silicone injections to NOT do so.  If you ignore that advise, then perhaps look for a well trained physician who used medical grade liquid silicone.  You at least will have less likelihood of complications that way.


Related Posts

How Not to Do Buttocks Enhancement

Medical Lasers and the Law

Medical Spa Regulations




List of Legal Injectable Fillers (FDA)

Lip Augmentation; eMedicine article, November 12, 2008; Jorge I de la Torre, MD, FACS

Face: Liquid Silicone Injections ASAPS — Position Paper

A History of Silicone Infections (pdf) by Dr Robert Yoho



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Wednesday, April 22, 2009

Stress and Burnout Among Surgeons – an Article Review

There is an interesting article on stress and burnout in surgeons in this months issue of Archives of Surgery.  The authors state the goals of their article is to raise awareness of burnout and to encourage surgeons to “be proactive in their personal health habits.”  I will admit I sometimes struggle with trying to keep my life in balance so that I won’t become a “burned out” surgeon/human.  So I read these articles and look for that “magic cloak” that would protect me.  It’s not there.  It takes work and vigilance to prevent becoming a burned out cynic.


Their definition of “burnout”

Burnout is a form of personal distress that appears in a markedly more common fashion among physicians compared with depression, substance abuse, and suicide.

As a clinical syndrome, burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.

It is a syndrome that primarily affects individuals such as physicians, nurses, and social workers, whose work involves constant demands and intense interactions with people who have great physical and emotional needs.

Just as with “burned-out” individuals in any other profession, we need to be aware of the following symptoms:

treating patients and colleagues as objects rather than human beings

feeling emotionally depleted

physical exhaustion

 poor judgment



feelings of ineffectiveness

a sense of depersonalization in relationships with coworkers or patients

The authors make the point that burnout in physicians/surgeons not only affect them personally, but can adversely affect patient safety, the quality of care we give to patients, and may contribute to medical errors.  This in turn (the increase medical errors and the decreased patient satisfaction) can then increase the threat of malpractice litigation. 

The increased stress/distress often lead to broken marriages, substance abuse, poor health, etc.

The article points out many of the contributing causes, including a lack of autonomy, imbalance between personal and professional life, excessive administrative tasks, long work hours, financial issues (overhead, poor insurance reimbursement, etc), and isolation from colleagues.

The article points out (and I would agree) that prevention is better than treatment of “burnout.”

Although recovery from burnout is possible, prevention is a better strategy.

Physicians who actively nurture and protect their personal and professional well-being on all levels—physical, emotional, psychological, and spiritual—are more likely to prevent burnout or at least to mitigate its consequences. 

The importance of mentorship cannot be underestimated



I limited my office hours so I could try to find a balance between being a “wife” and being a “physician/surgeon.”  This affects the finances and not always in a good way.  Being in solo practice can be isolating, even though it gives me the “freedom” to set my hours and not feel “guilty about not pulling my weight.”  I covet my daily walks with my dog.




Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences;  Arch Surg. 2009;144(4):371-376; Charles M. Balch, MD; Julie A. Freischlag, MD; Tait D. Shanafelt, MD


Related Blog Posts

Doctors With Depression (September 24, 2009)



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Tuesday, April 21, 2009

Shout Outs

Amy, Diabetesmine,  is this week's host of Grand Rounds.  It is a really nice  edition.  Read it here.   

Welcome Guests! Thanks for joining me on this fine day for the Grand Rounds host Birthday Edition, Vol. 5, No. 31 — where the best of this week’s medical and health blogging comes to party.

And now straight to the festivities, where you’ll find some delightful surprises in store:


The latest edition of Change of Shift (Vol 3, No 21)  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 Change of Shift, the blog carnival by nurses, for nurses and about nurses!

This week the theme is….wait for it….nursing!


Dr Rob Oliver’s take on politics and breast cancer:

Of all medical diseases, few are surrounded by as much politics as breast cancer. After all, who doesn't want to advance the treatment of breast cancer? The problems arise when feel good political ideas triumph over evidence based medicine and you end up with legislation which is almost sure to cause as many problems as it solves…………………..


From White Coat “What’s the Diagnosis?”  (photo credit)



Via GruntDoc -- What to do when you get a leech on your eye

Per our Australasian colleagues:

The Australasian College for Emergency Medicine has reported the first case of a leech being safely removed from a human eye……………….


Interesting discussion on NPR’s Diane Rehm Show yesterday on "Controversy over Chronic Lyme Disease"


Dr. Samuel Shor, Internist in private practice and Associate Clinical Professor at George Washington University.

Pamela Weintraub, A senior editor at "Discover" Magazine and author of "Cure Unknown"

Phillip Baker, Executive Director of the American Lyme Disease Foundation and microbiologist, former Project Officer of Lyme Disease studies at the National Institute of Allergies and Infectious Diseases



The need remains, so if you quilt or sew consider making a few blocks  for the Quilts of Valor.   You can find the pattern and information for mailing the finished block(s) here (photo credit).

Thank you for participating in this Quilts of Valor Project.  We are attempting to help comfort all the war wounded from the War on Terror.  Your Autographed Star Block will be joined with other blocks that are sent to us to make a Quilt of Valor for a wounded serviceperson


Amy at Park City Girl is hosting a virtual festival of quilts.  There are links to many new (to me) blogs.  Not sure which of my quilts is my favorite but I do like this one.  You can also enjoy the quilts here on Flickr.


This week Dr Anonymous will live from Chicago.  I hope you will join us.  The show begins at  9 pm EST. 

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

4/25: Night Shift with Dr. A in Chicago
4/30: Podcamp Ohio




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Monday, April 20, 2009

Excess Sweating

I have a nephew who has excess sweating of his feet which began as a child.   The problem has not gone away as he got older, nor has it spread to other parts of his body.  He has tried the new socks that say they will absorb sweat and keep the feet dry.  None of them work for him.  So this post is for him as I look for ways to help him.



Sweating is the release of a salty liquid from the body's sweat glands.  Sweating or perspiration is important in cooling the body.   It is common to sweat under the arms, on the feet, and on the palms of the hands.

When the production of sweat is in excess of the amount needed for cooling the body (thermal regulation) it is call hyperhidrosis (excess sweating). 

Hyperhidrosis may be primary or secondary.  Primary (essential)  hyperhidrosis is excess sweating in an otherwise healthy individual, like my nephew.

When excessive sweating affects the hands, feet, and armpits, it's called primary or focal hyperhidrosis. Primary hyperhidrosis affects 2 - 3% of the population.  Less than 40% of patients with this condition seek medical advice. In the majority of primary hyperhidrosis cases, no cause can be found.   It appears to run in families.

Secondary hyperhidrosis is associated with any number of systemic illnesses.  These including pheochromocytoma, thyrotoxicosis, diabetes mellitus, diabetes insipidus, hypopituitarism, anxiety, menopause, carcinoid syndrome, and drug withdrawal.  Nocturnal sweating, in particular, may be a clue to the diagnosis of tuberculosis, lymphoma, endocarditis, diabetes, or acromegaly.  Treatment of the underlying disease will decrease or cease the excess sweating in secondary hyperhidrosis.

Several common medications occasionally produce hyperhidrosis. These include tricyclic and serotonin reuptake inhibitors, opioid analgesics, acyclovir, and naproxen.


When looking for underlying health issues, it is important to know if there are any triggers (stress, anxiety, food, etc), if the sweating occurs mostly at night or during the day, which areas of the body are involved, is there an elevated body temperature, or any other problems. 

You should see your doctor, if:

  • You sweat a lot or if sweating lasts for a long time or can't be explained.
  • Sweating occurs with or is followed by chest pain or pressure.
  • Sweating is accompanied by weight loss or most often occurs during sleep and associated with a fever.
Treatments may include:
  • Antiperspirants. Excessive sweating may be controlled with strong anti-perspirants, which plug the sweat ducts. Products containing 10% to 15% aluminum chloride hexahydrate are the first line of treatment for underarm sweating. Antiperspirants can cause skin irritation.  The strong doses of aluminum chloride can damage clothing.
  • Medication. Anticholinergics drugs, such as glycopyrrolate (Robinul, Robinul-Forte) are rarely helpful.  Beta-blockers or benzodiazepines may help reduce stress-related sweating.
  • Iontophoresis. This FDA-approved procedure uses electricity to temporarily turn off the sweat gland. It is most effective for sweating of the hands and feet. The hands or feet are placed into water, and then a gentle current of electricity is passed through it. The electricity is gradually increased until the patient feels a light tingling sensation. The therapy lasts about 10-20 minutes and requires several sessions. Side effects include skin cracking and blisters, although rare.
  • Botox. Botulinum toxin type A (Botox) was approved by the FDA in 2004 for the treatment of severe underarm sweating, a condition called primary axillary hyperhidrosis. Small doses of purified botulinum toxin injected into the underarm temporarily block the nerves that stimulate sweating. Side effects include injection-site pain and flu-like symptoms. 
  • Endoscopic thoracic sympathectomy (ETS). In severe cases, a minimally-invasive surgical procedure called sympathectomy may be recommended. The procedure is usually performed on patients with excessively sweaty palms. It is not as effective on those with excessive armpit sweating. This surgery turns off the signal which tells the body to sweat excessively. ETS surgery is done while the patient is asleep under general anesthesia.  The surgery takes about a half hour. Patients usually go home the next day, but may experience pain for about a week.  ETS requires special training so make sure your doctor is properly trained. Risks include artery damage, nerve damage, and increased sweating. New sweating occurs in about 50% of patients.



Goldman L, Ausiello D. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: WB Saunders; 2004:2365, 2446-2447.

Hyperhidrosis; eMedicine, May 2, 2008; Robert A Schwartz, MD, MPH, Rachel Altman, MD,  George Kihiczak, MD


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Sunday, April 19, 2009

SurgeXperiences 221

It is always my pleasure to be the host of SurgeXperiences. I find myself reading and looking for more to bring to you. Let me begin by welcoming Someonetc back from his tour of duty in Iraq. Now maybe he’ll rejoin us in blogging again. I have missed his posts.

I would also like to congratulate Dr Bruce Campbell, Reflections in the Head Mirror, for the recent publication of his essay, The Code, in the April 8, 2009 issue of JAMA. Unfortunately it isn’t open access. Try to get a copy of the issue and read it. Well worth the effort.

Surgeons and Medical Folk

Bongi, other things amanzi, is imparting his wisdom to us in a series of his “surgical principles”:

#1 to swear does in fact help

#2 fear nothing but fear itself

#3 all bleeding stops

#4 enjoy

#5 it is in fact always the surgeon’s fault

#6 take a moment

Buckeye Surgeon gives us some Lap Chole tips.

I love LC. If I had to do 3-4 a day for the next 20 years I would be a happy general surgeon. It's an elegant operation. I haven't done thousands, but I've done enough where it's become almost automatic. I try not to waste any moves. Every act is purposeful. Rarely is there struggling or the sort of futzing around that can occur when doing a laparoscopic colon resection. So here are my tips:

1) Never use a Veress needle. Why blindly stick a needle into your patient's belly? It's ridiculous. I do an open Hasson insertion. It's not slower. It's definitely safer. It's a no brainer……………..

T, Notes of an Anesthesioboist, writes about “Surgeons v Anesthesiologist: Why the Tension?

…………………On the whole, though, what I typically see is a lot of exasperation from surgeons whenever a medical condition precludes speedy progress to the O.R. – ……………… I always wonder: didn't they look through the chart themselves and see that the lab value was egregiously abnormal, or examine the patient and hear the lung crackles practically from across the room? Surely they, too, did a history and physical, as we're all expected to do?……………….

A good surgeon will also respect an anesthetist's or anesthesiologist’s instructions inside the O.R. when safety is at issue. Rarely have I seen this to be a problem. ………………But I did encounter one surgeon whose behavior I consider among the most appalling I’ve seen. I'll call her Dr. Myrtha Banshee…………

OR nurse Christina, Both Sides of the Mask, writes about her recent experience as a surgical patient in “please tell me

In surgery, a huge amount of time and attention is devoted to the issue of on-time starts. Extra focus is often placed on the on-time starts for first cases of the day. ……….

When I was scheduled at Giant Hospital for my own surgical experience, I was delighted to get a Tuesday at 9:15am. ………

When the procedure had to be moved to Almost Giant Hospital, I was happy to keep the same day of the week, but obviously the time had to be changed……..

On my surgery day, I lay in the pre-operative area wearing one of those stylish gowns, watching the IV drip, and wishing time would move faster. …………..

A Chance to Cut is a Chance to Cure has returned to blogging and given us a new Tales from the trauma service XIX

Gentleman working on a landscape project. The worker above him falls and drops one of these on him:

And they strike him in the neck. He arrives alert and oriented, but every time he speaks or coughs air comes out of the wound on his neck. Off to the operating room..

More trauma. This tale from Karen Little, Just Up the DoseMonday, Bloody Monday.

I was driving back to The Crater one Monday morning …….Running towards me from the other direction were a bunch of men in overalls - he'd just flown off the back of a lorry………

This guy was badly hurt. ………………. but as I did this his major injury became apparent. As we carried him, hot, sticky, bright red arterial blood pulsed out of his ear and over my hand - a textbook skull-base fracture, and a massive one at that.

(Via Uveal Blues) Eyeborg Project: An Exciting and Creepy Hack I Hope You Never Try -- Go watch this but remember

It goes without saying that experimenting with your eyesight is neither the easiest hack in the world or the safest, but apparently a few brave souls out there are driven to take it on regardless. The Eyeborg Project is the brainchild of one of those.

Bruce Campbell, Reflections in the Head Mirror, tells us about a patient in “Role Model

Nothing has come easily. Her cancer was difficult to control and she required radiation and then extensive surgery and more radiation. The side effects led to additional treatments, a feeding tube, and expensive pain medications. ………………..Of course, to hear her tell the story, she is doing fine. She feels well and has adjusted reasonably well. She celebrates her freedom from cancer every single day.

I was worried, therefore, when she arrived for a follow-up visit. She looked distracted. I moved into position to perform the examination.

“What’s this?” I blurted out. “Have you started smoking again?”……………..

KeaGirl, UroStream, talks about “redemption” in her practice.

…………………..And then just yesterday, I had a patient come into the ER with testicular torsion. He was one of the rare patients who presented in enough time for me to swiftly whisk him to the OR and save his testicle! (there is a window of 6 to 8 hours before the testis undergoes permanent damage for lack of blood flow and oxygen, at which point I have to do an orchiectomy). I felt some degree of redemption, and all was right in the world again....

SandnSurf, Life in the Fast Lane, discusses the John Thomas Sign in trauma patients.

The sign tends to be commented on by middle-aged male radiologists and orthopedists suffering from Peter Pan syndrome. Some may even suspect an occult fracture purely based on the observed radiographic penile orientation. While this can clearly be very amusing (in the same way that some people can’t help but laugh when they hear the word “Uranus”) the question remains - is the sign actually of any use?

The Sterile Eye critiques some surgical videos in “10 Gory Surgeries Reviewed -- Part 1/2.” Who better to review the filming than “our own” medical photographer?

WIRED Science has put up an article with “10 Gory Surgical Triumphs on YouTube”. Although their approach is somewhat sensasionalist, the idea to collect surgical videos available on YouTube is good. It has actually inspired me to start a series of posts where I’ll pick a surgical video from YouTube every week and review it.

And here is “10 Gory Surgeries Reviewed – Part 2/2” just in time for this edition!

Scanman’s Casebook: Case 15 --- Really nice films of a “Large Ventricular Septal Defect with Coarctation of Aorta (Tubular Hypoplasia)” Please, go view the films with Vijay as your guide.

Dr Sanjya Gupta’s twitters – check out the x-ray of the spinal fracture! - more from the OR. take a look at this cervical spine CT. can you spot the problem? 7:39 AM Apr 15th

It is teardrop fracture C6. patient ejected from a car through the windshield. now, neurologically normal. tomorrow, will show you post op! 3:43 PM Apr 15th

Check out Buckeye’s string of large bowel obstructions (photo credit).

I've had a run of large bowel obstructions (LBO) lately. ……………... Cancer, volvulus, and hernias are the usual culprits and an operation is often mandated. A colonic obstruction is technically a surgical emergency. …..

Karen Little, Just Up the Dose, makes not one BUT two really nice surgical diagnoses with x-rays in “Best Week Ever.” Go over and see why she has a “big” head (photo credit). Good for you Karen!

A CCLMC medical student writes a post on “Tips for doing well in the surgery rotation.”

I think a lot of people are pretty intimidated by surgery, especially if you don't see yourself as the surgery type. But honestly, surgery is a lot of fun if you work hard and make an effort to learn how to be useful in the OR. Here are my tips for getting more out of your OR experience.

GrrlScientist, Living the Scientific Life, writes about how pioneering stem-cell research in race horses will help people with Achilles tendon injuries.

The move from clinical veterinary to human medicine is inspiring and unusual; we normally see the translation happening the other way around," said Nicola Maffulli, a sports medicine expert and orthopedic surgeon who will help conduct the trial.

More help for humans from our animal friends with a history of xenographs by Chris Sweeney “The Beast Within: Implanting Animal Organs into Humans

Getting an organ these days is no easy task. Currently, there are more than 100,000 people on waiting lists for organ donations in the United States, but fewer than 30,000 transplants were performed in 2008. The Mayo Clinic estimates that in the United States, 17 people die each day while waiting for a suitable organ to come along………..

Still, the concept of cross-species transplantations is nothing new. As far back as 1889, physicians were shooting up slivers of dog and guinea pig testicles to study “human revitalization therapy.” Through the years, though, there has been significant progress made in the field, and biotech companies have invested heavily in developing transgenic animals and immunosuppressant drugs……………….

A public safety announcement for bloggers from Sheepish, The Paper Mask -- is a Fraudulent Scam. Go read the entire post.

I can't make it much simpler than that, can I?

and another post from Sheepish on Meeting Fatigue


Barry, An Explorer’s View of Life, describes his “First Meeting with the Surgeon

This is a preliminary meeting he tells us. He would just like to go over the probable fate that awaits me, but the specific plan will have to wait for the results of the CT scan on Monday.

The usual course of treatment involves 3 months of combined chemo and radiation therapy at Princes Margaret Hospital to shrink the tumor in my throat followed by the removal of half my esophagus and half my stomach. They will use my stomach to rebuild the missing esophagus because it is composed of the same material as my throat. The surgery will require me to be in hospital for ten days to two weeks followed by five to six weeks recovery at home.

I will need five months off work. If all goes well.
Linda has turned pale at the mention of the removal of half my stomach and I can only wonder what my face looks like.

Follow up with these posts by Barry:

* Immediately (Part 2) And Then Then News

* Answers (Part 2) And A Big New Question

* My Decision and Why I Made It


Surgeon Heals Patients and Their Violent Ways

Dr. Carnell Cooper, a Baltimore surgeon, is saving lives inside and outside the operating room.

Dr. Carnell Cooper's Violence Intervention Program provides training and support to trauma victims.

Since becoming a trauma surgeon 16 years ago, he has dedicated himself to treating the many young African-American men who've been shot, stabbed or beaten, only to see them return to the ER with another severe injury just months later…………..

Finders Keepers”, a story about a little boy who is going to have heart surgery.

Tomorrow morning,” the surgeon began, “I’ll open up your heart…” “You’ll find Jesus there,” the boy interrupted.

The surgeon looked up, annoyed. “I’ll cut your heart open,” he continued, “to see how much damage has been done…” “But when you open up my heart, you’ll find Jesus in there.”

The surgeon looked to the parents, who sat quietly. “When I see how much damage has been done, I’ll sew your heart and chest back up and I’ll plan what to do next.” ……………………

Surgical Humor

Why it’s past time for GPS in the OR (via Book of Joe)

The Mechanic vs the Heart Surgeon (via Jeffrey, Vagus Surgicalis)

Cast Anatomy (via Street Anatomy) with explanation here. You really must go see these casts. It’s enough to make you wish you had a broken arm!

News Items

* Double Hand Transplant Awakens Brain Control --

The brains of patients who've received double hand transplants can recreate lost neurological control systems, according to new brain data from a French surgical team.

* Kuwaiti surgeon succeeds in neurosurgery operation implanting two batteries in the spinal cords of patients who have difficulty in walking.

* Second U.S. Face Transplant Performed in Boston on a man who lost the middle of his face in a freak accident.

* SoCal Docs Help Woman With Severe Deformity: Rodarte's face covered in tumors

At an early age, tumors began to grow on Ana Rodarte's face. By age 25, her advanced neurofibromatosis had deformed the left side of her face, leaving her homebound and unable to see out of one eye.

* That’s Sp-early Got to Hurt

Docs had to remove a SIX INCH fishing spear from this clumsy fisherman's brain after he managed to fire it into his own head.

* Yemeni surgeon to leave Gitmo

Ayman Batarfi, 38, told a military review panel that he was a humanitarian worker who found himself at the battle of Tora Bora while Osama bin Laden was in the area, according to a Pentagon transcript. He was captured in Afghanistan and sent to the prison camps here in 2002.

* 5 cm. fir tree removed from patient’s lung (photo credit)

A five-centimeter fir tree has been found in the lung of a man who complained he had a strong pain in his chest and was coughing blood.

The 28-year-old patient, Artyom Sidorkin, came to a hospital in the city of Izhevsk in Central Russia last week,


SurgeXperiences logo created by vitum of vitum medicinus.

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. The next edition will hosted by Bongi, other things amanzi, on Sunday, May 3rd. The deadline for submissions will be midnight on Friday, May 1st. Be sure to submit your post via this form.

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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Saturday, April 18, 2009

Surgeon’s Caps

Every now and then I make caps for friends (surgeons or anesthesiologists).  These caps don’t work well for me as my hair is too long, so I just wear those blue bouffant caps provided by the surgery center.

The caps are easy to make.  I chose colorful fabric with interesting prints, prewash the fabric, and then cut and sew.  It is all done by machine.  My “pattern” is an old cap that I took apart and now use as my guide.

Rusty, my faithful companion, is a reluctant model.  :)



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Friday, April 17, 2009

Playing Puppies Baby Quilt

This baby quilt is really a “remake” of a quilt top I bought at Hobby Lobby last year. I bought three of the panels at the time and made one for my niece’s baby. I didn’t alter that panel, just quilted it. You can see it here.

This time, I cut the puppies free from the background fabrics, replaced the background fabrics with “new” fabric, and then sewed the puppies back on after I did the quilting. The quilt is machine pieced and quilted. It is 42 in X 46 in. I have sent it to a blog friend for her grandbaby.

Here is a detail shot of a very soft little puppy with a bone.

Here is a detail shot of the lower puppy. It show the butterflies in the fabric and the fish.

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Thursday, April 16, 2009

National Healthcare Decisions Day

Nathan A Kottkamp, a healthcare attorney,  is the chair and founder of the grassroots effort to promote advance care planning and healthcare decision making,  National Healthcare Decisions Day (NHDD).  This day was chosen in a nod to Benjamin Franklin and his adage “Nothing in life is certain but death and taxes."   Yesterday, April 15th, was tax day here in the United States.

More than 75 national organizations, plus 660 state and local organizations, will have teams at hospitals, nursing homes, hospices, doctor's offices and even libraries to explain the benefits of advance directives.  Those who wish will be assisted in writing / signing living wills and other medical directives. The services are free.  For a list of participants check here.

It is not only important to discuss these end of life issues, but it is important to occasionally review our decisions and make changes to them as necessary. 

Kotthamp is quoted as saying "No one likes to think about the possibility of a life-threatening injury or disease, but the simple act of creating an advance directive can turn out to be an incredible gift for loved ones in the event of an accident or severe illness.  No matter where you live, you can fill out an advance directive without hiring a lawyer. It's easy to do and is free."  


I had trouble finding any specific locations around Arkansas.  If you know of any, please, let me know and I’ll add them.

White County Medical Center (Batesville, Arkansas)

Arkansas Advance Directive; Planning for Important Healthcare Decisions (pdf file)


The National Healthcare Decisions Day website has some great resources about advance directives and how to get one.


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Wednesday, April 15, 2009

Local Hospital Discontinues Eye Surgery Service

I received my April issue of the St Vincent Health System Communiqué in Monday’s mail.  I was surprised to see this:

Eye Surgery to Close

Effective April 1, 2009 St Vincent will no longer offer surgical eye services at either Doctors or the Infirmary.  This difficult decision came after a long discernment process weighing the pros and cons of closing a service St Vincent has had for decades.  Unfortunately, shutting down the service is a sign of the times as volume has slowly decreased and many other more cost effective alternatives exist for patients and physicians alike.  Patients presenting to the hospital needing surgical intervention will need to be transferred to UAMS or Baptist Medical Center, the two remaining hospitals to offer surgical eye services.

I had missed this story earlier in March in the Arkansas Business News.  

St. Vincent will cut open positions first and then layoff workers who aren't tied to patient care, said Peter Banko, the CEO of St. Vincent.

St. Vincent Infirmary Medical Center also announced it will close its psychiatric unit for older patients, its Medicare-exempt psychiatric program and eye-surgery program by April 1.

Banko said he tries to keep up the morale of the system's 3,000 workers by keeping them informed through e-mail updates and his blog.

And here it is again on Arkansas Blog (March 24, 2009) – St Vincent Plans Job Cuts.  I have been aware of the job cuts, but had missed the surgical services cut.  And for the life of me, I have been unable to find Mr. Banko’s blog.



Other relates blog posts

Update on the Economy and its effect on BIDMC – Paul Levy, March 6, 2009

Final Budget Decisions  -- Paul Levy, March 24, 2009

How Bad is it for Hospitals?  -- Dr Wes, March 26, 2009

Desperate Hospitals Update – Medical Quack, April 12, 2009



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Tuesday, April 14, 2009

Shout Outs

Pharmamotion  is this week's host of Grand Rounds.  It is a really nice  edition.  Read it here.   

I’m excited for being part of what a would dare to say it’s by now a classic: Grand Rounds, the best of medical writing on the web! Thank you to the medical and health bloggers who submitted their posts. ALL submissions I received were excellent, but I decided to include just a few to avoid making this a too large edition.


Dr Paul Auerbach, Medicine for the Outdoors, has a wonderful post on “Teaching Children to Swim.”  In the post, he includes comments on how young to begin teaching children to swim.  He also includes some good tips on staying water safe at any age.  He concludes with:

So, teaching small children to swim is probably a good thing for many reasons. However, it is only a small part of the safety package, and in the case of children under the age of 4 to 5, may not be relied upon to confer protection from drowning.


A Repository for Bottled Monsters –check out their post/ photos,  Face Cases (photo credit)

I just posted some facial wound/reconstruction pictures on Flickr, a small part of a pretty extensive series. For me, this ties in very nicely with the Otken Collection that I've been working on for a while.



Nice article,  Nonallergenic Dog? Not Really (H/T to “AllergyNotesRT @wheezemd: See this 1997 NYT article. It is still valid today on hypoallergenic dogs.” )

Allergists say all the safe-breed theories are just wishful thinking. When people are allergic to cats or dogs, Dr. Davis said, the allergens that make them sick are the proteins in the animals' skin secretions and saliva. ''All dogs and all cats have saliva and skin,'' he said. ''So theoretically, there is no such thing as a nonallergenic cat or dog.''


From Vickie Powell, VPMedical, comes a nice article “I’m Not Sure I Like My Doctor” which discusses when it may be time to switch or find a new doctor.

When you do not care for your doctor, you should first try to do your part to improve and strengthen the relationship.  Assess whether your personal grievances are affecting the level of care you receive…….  Establish yourself as an equal in this medical team and play an active role in your own health needs.  Ask questions (prepare the in advance and write them down).

There are times when it is appropriate to seek a new medical provider.  It might be time for a change when…………….


I made two of these blocks this past weekend and mailed them yesterday.  The need remains, so if you quilt or sew consider making a few blocks  for the Quilts of Valor.   You can find the pattern and information for mailing the finished block(s) here (photo credit).

Thank you for participating in this Quilts of Valor Project.  We are attempting to help comfort all the war wounded from the War on Terror.  Your Autographed Star Block will be joined with other blocks that are sent to us to make a Quilt of Valor for a wounded serviceperson


The Doctor Diaries on PBS airs tonight.  The first part was last Tuesday.   It is a documentary that began in 1987 when producer Michael S Barnes began following the seven Harvard medical students.  Now he catches us up with them through middle age and mid-career. 


Check out this post by Mother Jones over at Better Health – “Nurse vs CIA Agent, Nurse Wins”. 

I don’t care who you are. Never get into a power struggle with a charge nurse.


This week Dr Anonymous’ guest will be Dr. M talking about End Of Life Care.    I hope you will join us.  The show begins at  9 pm EST. 

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

4/23: Dr. A in Chicago
4/25: Night Shift with Dr. A in Chicago
4/30: Podcamp Ohio



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