Tuesday, June 30, 2009

Shout Outs

Dr Edwin Leap is this week's host of Grand Rounds. You can read it here. Great edition!

Today is June 30, 2009. Which means, if I’m correct, that tomorrow is July 1st. And July 1st is the day that, all across the country, recent medical school graduates begin residencies in their assorted specialties. An amazing time, indeed! I remember it well. Standing around in a suit, listening to lectures, trying to figure out who was really smart and who was more like me. None of us knowing, by a long-shot, what we were embarking upon.

The latest edition of Change of Shift (Vol 3, No 26) is hosted by ReHabRN! You can find the schedule and the COS archives at Emergiblog.

Welcome to the June 25, 2009 edition of Change of Shift. Many thanks to Kim at emergiblog for allowing me to host this edition.

'Tis the holiday season, so I thought I'd go for a holiday theme for this edition. So since I'm thinking holiday more in the sense of how our British friends and other folks around the world view holidays as Americans view vacation. Ah, relaxing and not being at work tops the list for me.

Dr Gwenn O’Keeffe, Pediatrics Now, has authored the American Academy of Pediatrics’ expert-driven "social media and sexting tips" for parents: Talking to Kids and Teens about Social Media and Sexting. The “tip sheet” is full of good information and advice. Here’s a small example:

“Sexting” refers to sending a text message with pictures of children or teens that are inappropriate, naked or engaged in sex acts. According to a recent survey, about 20 percent of teen boys and girls have sent such messages. The emotional pain it causes can be enormous for the child in the picture as well as the sender and receiver--often with legal implications. Parents must begin the difficult conversation about sexting before there is a problem and introduce the issue as soon as a child is old enough to have a cell phone. Here are some tips for how to begin these conversations with your children:

H/T to Lakshmi for this tweet which links to a wonder article:

RT @TheCuriousMind: Habitat: 15 Year Old Invents Algae-Powered Energy System http://tinyurl.com/lmsqlg; My hero

Nice story by NPR on the stigma nonsmokers with lung cancer experience.

Smoking is such a well-known cause of lung cancer that many don't realize thousands who never smoked get the diagnosis. The great majority are women. Recent research shows it's really a different disease than smoking-related lung cancer. But those with the diagnosis say they suffer the same stigma.

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

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

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Monday, June 29, 2009

Breast Implants and Lymphoma Risk

Yes, I’m behind in my journal reading. This article was published in the March issue of the Plastic and Reconstructive Surgery Journal. The article is the summary of a literature review using PubMed to review the evidence from all epidemiologic cohort studies of cancer incidence among women with cosmetic breast implants that include results on the incidence of non-Hodgkin's lymphoma, with specific attention to lymphomas arising in the breast.

The review was prompted by the article from The Netherlands (second reference below) which suggested an association of breast implants with anaplastic large T-cell lymphoma.

Primary breast lymphoma is a rare malignancy. Most of them are of B-cell origin. It is important for anecdotal reports not to alarm providers or patients. This review article found only five long-term cohort studies which had evaluated the incidence of non-Hodgkin's lymphoma following cosmetic breast augmentation surgery.

The authors looked at each study and came to the following conclusion:

The association between cosmetic silicone breast implants and non-Hodgkin's lymphoma has been examined in a number of long-term cohort and surveillance studies, based on large numbers of women with virtually complete follow-up substantially longer than the 17-year study period presented in the Dutch case-control study.

In the only cancer incidence study to include women followed for at least 25 years after implantation, including 3336 women followed for 15 years or more and 827 followed for at least 25 years, no significant excess of non-Hodgkin's lymphoma was observed overall and not one primary lymphoma of the breast was observed.

Moreover, the largest study to date, with cancer surveillance up to 24 years, actually reported a reduced incidence of total non-Hodgkin's lymphoma among almost 25,000 Canadian women with cosmetic breast implants.

Based on the epidemiologic studies published to date, there is no evidence of an excess of non-Hodgkin's lymphoma incidence overall among women with cosmetic silicone-filled breast implants.

REFERENCES

Breast Implants and Lymphoma Risk: A Review of the Epidemiologic Evidence through 2008; Plastic & Reconstructive Surgery. 123(3):790-793, March 2009; Lipworth, Loren Sc.D.; Tarone, Robert E. Ph.D.; McLaughlin, Joseph K. Ph.D. (subscription required)

Anaplastic large-cell lymphoma in women with breast implants; JAMA. 2008;300:2030-2035; De Jong D, Vasmel WLE, de Boer JP, et al. (subscription required)

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Sunday, June 28, 2009

SurgeXperiences 226 is Up!

The 50th edition of SurgeXperiences is hosted by Vijay,  Scan Man’s Notes.  You can read this edition here.

Welcome to the latest edition of SurgeXperiences, the fortnightly carnival of blog posts related to surgery.

This happens to be the 50th edition. Ironically the number 50 has acquired an altogether unwelcome significance this week due to the unfortunate and untimely death of Michael Jackson aged 50. Mr. Jackson may very well be the King of Pop to fans and music lovers, but to most of us in healthcare he is probably better known as the worst example of celebrity plastic surgery on demand or as a prominent plastic surgeon describes him, the most famous “nasal cripple.”

 

The host of the next edition (227), July 12th, will                   . The deadline for submissions is midnight on Friday, July 10th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

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, June 26, 2009

Interlaced Ribbon Quilt

I made this quilt for a lawyer friend who helped my husband several years ago.  He and his wife use it as a wall hanging rather than a bed quilt.  It is 88.5 in X 99 in.  Recently he went to visit them and I asked him to get some photos of it for me.

The quilt is machine pieced by me, but I paid Peggy Ries (Peg’s Quality Quilting, Epworth, Iowa) to do the machine quilting for me.  She does excellent work.

Because of the size, my husband wasn’t able to get a true full view photo of the quilt.

Here is a detail photo that shows some of the fabrics.

Here is another detail photo that shows some of the fabrics.

 

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Thursday, June 25, 2009

How Poland’s Syndrome Was Named

Poland's syndrome is a congenital disorder. The classic ipsilateral features of Poland syndrome include the following: absence of sternal head of the pectoralis major, hypoplasia and/or aplasia of breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of rib cage, and upper extremity anomalies. These upper extremity anomalies include short upper arm, forearm, or fingers (brachysymphalangism). (photo credit)

Additional features of Poland syndrome include the following: hypoplasia or aplasia of serratus, external oblique, pectoralis minor, latissimus dorsi, infraspinatus, and supraspinatus muscles; total absence of anterolateral ribs and herniation of lung; and symphalangism with syndactyly and hypoplasia or aplasia of the middle phalanges. (photo credit)

The name of this condition pays homage to Dr. Alfred Poland of Guy's Hospital, who in 1841 described a case of these two deformities during the autopsy of a 27-year-old convict, but as this article points out he wasn’t the first to recognize the syndrome.

If you enjoy medical history, then you will enjoy this article. It explores the historical literature to reveal the progression of knowledge about this syndrome. Here is a quick summary of different investigators who contributed to the understanding of Poland's syndrome. The article goes into more detail of each.

1826 Lallemand is first to describe the absence of the pectoralis.
1835 Bell is the first to record the absence of the pectoralis
1839 Forlep is first to describe the paired absence of the pectoralis and ipsilateral syndactyly
1841 Poland is the second to describe the paired absence of the pectoralis and ipsilateral syndactyly
1895 Thomson is the first to document an understanding that the deformities accompanied one another
1900 Furst is the first to propose that the anomalies constituted a syndrome
1902 Bing is the first to present a case series of patients with the syndrome
1940 Brown and McDowell are the first to document a thorough review of the syndrome
1962 Clarkson is the first to propose the name “Poland’s Syndactyly” for the syndrome

As the authors conclude:

Honoring physicians for notable achievements in the form of eponyms can be viewed as a harmless way to bring a little bit of warmth to an otherwise cold world of facts. The least we can do, though, is to recognize the contributions of those who endeavored to shape our current understanding of disease.

Perhaps if history took another course, Poland's syndrome would instead be called Frolep's syndrome or Furst's syndrome. Or perhaps it might simply have been called pectoral-aplasia-dysdactylia syndrome

REFERENCES

Poland's Syndrome: Current Thoughts in the Setting of a Controversy; Plastic & Reconstructive Surgery. 123(3):949-953, March 2009; Ram, Ashwin N. B.S.; Chung, Kevin C. M.D., M.S. (subscription required)

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Wednesday, June 24, 2009

Healthcare Discussion

I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest Advance (CMPIA).  In addition to him, Dr. Val Jones (Founder and CEO Better Health Network) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers.  The focus was to be on the risks of government-run healthcare.

It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term.  As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.

Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it's we the patients who are not at the policy table, and you can bet that it's the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

 

There were two links given by the CMPIA as sources for factual information on the healthcare discussion: publicplanfacts.org and biggovhealth.org.

I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link.  First this one --

  • Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.

I won’t comment on that one, but will this next one:

  • Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.

This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements.  I think this trend will only get worse.  Check out Barbara Duck’s series at Medical Quack on desperate hospitals.  Here’s an excerpt from the May 24, 2009 post:

In Chicago, Illinois

The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.

The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.

"We have been hit by a number of things," Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. "We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it."

 

In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion.   Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs.  We don’t need more rules like the Medicare’s 75% rule.

Saving money by providing an inferior “product” isn’t what any of us want.  Is it?

 

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Surgical Glove Perforation and the Risk of Surgical Site Infection – article review

H/T to ACP Internist for bringing this article to my attention (see full reference below).

It's best not to get holes in one's surgical gloves in the middle of a procedure, as this leads to a higher risk of infection for the patient, the Archives of Surgery reports in a study about the effect of ripped gloves. …… Which is, perhaps, why the surgeons put on the gloves in the first place?

For me, I found nothing new in this article.  Yes, surgeons wear gloves to both protect the patient and him/herself.  Gloves are part of the universal precautions. 

It is well known that the risk of getting a hole in one’s glove increases with the length of the surgery (especially when over 2 hours) or when dealing with spiked bone fragments.  The authors of the article felt they had a new angle --

The frequency of glove perforation during surgery has been studied extensively and found to range from 8% to 50%.  The impact of glove perforation on the risk of surgical site infection (SSI), however, is unknown. The present study was conducted to test the hypothesis that clinically visible surgical glove perforation is associated with an increased SSI risk.

 

I think most surgeons change their gloves if the hole is visible.   It is intuitive that the patients who are not on antimicrobial prophylaxis would be at the greatest risk of surgical site infection when a defective glove is involved.  This holds true with the authors’ findings: 

In the presence of surgical antimicrobial prophylaxis, the rate of SSI (6.9% vs 4.3%) was higher in procedures involving perforated gloves compared with procedures with maintained intraoperative asepsis.  After adjusting for 6 confounders in multivariate logistic regression analysis, however, the odds of contracting SSI in the event of glove puncture were not significantly higher when compared with procedures with intact gloves.

In the absence of surgical antimicrobial prophylaxis, glove leakage was associated with an SSI rate of 12.7%, as opposed to 2.9% when asepsis was not breached.  This difference proved to be statistically significant.

 

Double gloving may decrease the risk of transfer of germs (either direction:  patient to surgeon or surgeon to patient), but it is not always the answer.  I have tried all the combinations:  both gloves the same size, the outer one a smaller size, the outer one a larger size.  In all cases, my hands go numb.  Numb hands is not a good thing in a surgeon.

Routine changing of one’s gloves might capture some of the “un-caught” glove perforations and therefore decrease the risk of SSI in patients.  The authors even suggest doing so every two hours.  It would be interesting to figure up the costs of all the glove changes compared to the SSI costs.  Would it be cost effective?

The use of surgical microbial prophylaxis for all cases is still controversial.  The risk of SSI with clean surgical procedures is considered too low to be worth the risk of “side effects” from the antibiotics or the possibility of contributing to “super bugs.”  As pointed out in the article, indications for prophylactic antimicrobials approved by the CDC are clean operations involving prosthetic material and any operation in which a potential SSI would pose catastrophic risk (ie all cardiac operations, most neurosurgical and major vascular operations, and some operations on the breast).

 

 

REFERENCE

Surgical Glove Perforation and the Risk of Surgical Site Infection; Arch Surg. 2009;144(6):553-558; Heidi Misteli, MD; Walter P. Weber, MD; Stefan Reck, MD; Rachel Rosenthal, MD; Marcel Zwahlen, PhD; Philipp Fueglistaler, MD; Martin K. Bolli, MD; Daniel Oertli, MD; Andreas F. Widmer, MD; Walter R. Marti, MD

 

Related post

Needle Sticks (January 2008)

 

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Tuesday, June 23, 2009

Shout Outs

Barbara Olsen, Florence Dot Com,  is this week's host of Grand Rounds. You can read it here (photo credit).  Great edition!

Welcome to Grand Rounds! It's officially summertime, and Flo & Bo are taking you out to the ballgame! At Florence dot com, Bo, a seasoned nurse with an engineer's mind, channels Florence Nightingale, a systems thinker whose interest in public health and service gave rise to modern nursing. (Flo favors cricket, but this is Bo's gig.)

From Better Health comes “A Medical Transgender Primer”  written by DrJonLaPook.   Very nice article.

Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful……….

 

See DermDoc for the Proper Way to Pop a Pimple

As a dermatologist, I am obligated to tell you: “Do not attempt to pop your pimples.” But I know you are going to do it anyway, so here’s how to do it properly:

  1. Pick only pimples that are ready to be popped………..

If you deal with head injury patients, you’ll find this list of resources by VP Medical useful

We here at VP Medical Consulting are currently working on a life care plan for a young lady with a traumatic brain injury. In developing the plan we consult many resources and thought I would share them here. If you have a resource I have missed, please let me know and I will be sure to add it…….

VP Medical has also put together a list of resources for care givers.

 

From @drval (on twitter):  For those interested in what was discussed at the HC reform meeting at BIO today (June 17): check out the blog: http://tinyurl.com/nqowbm #hcrmtg

 

TBTAM brings to our attention “Folic Acid Supplementation – Too Much of a Good Thing?”     I must admit, folic acid is one of those vitamins (water soluble) that I never thought of as ever having a problem of too much.  I associate the water soluble ones which our bodies don’t store as having the problem of deficiency.  I stand corrected.  I hope you will read her entire post.

Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.
But too much folic acid may lead to an increased risk for colon cancer……………….

If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.

 

This week Dr Anonymous will be  doing a “summer vacation” show.  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:

July: Break
August: Two Year Anniversary of the Doctor Anonymous Show

 

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Monday, June 22, 2009

Posture

I had a patient come in last week for her yearly breast/implant exam.  I gently reminded her to watch her posture.  She then told me that her fiancĂ© who has come with her on previous visits and heard me give her the same reminder now will look at her, smile, and say “posture.”  The story made me smile.

It is something I picked up from my mother (and last week was the one month anniversary of my mother’s death).  When my sisters and I were young, Mom would have us walk around with a book on our head as a way to teach us to stand up straight.  I can’t say I liked it then, but am grateful for it now. 

The patient, the anniversary, and the recent post of JMB (Nobody Important) all came together at the right time to inspire this post.  This photo she used in her post Shrinking Woman – Arrghhh is exactly why I want all the women around me to stand straight.

JMB’s post is focused on osteoporosis, her mother, and her loss of height.

My mother suffered severely from osteoporosis, being severely bent over for many years before her death at 85. ……….

How tall were you at your tallest? Five foot six inches, I replied. Mmm. Five foot four inches now. Normal, he said. What?????

Yes it is normal to lose two inches of height without necessarily having osteoporosis. The Baltimore Longitudinal Study of Aging found that the cumulative height loss from age 30 to 70 years averaged about 3 cm (1.18 inches) for men and 5 cm (1.97 inches) for women (Sorkin, Muller, & Andres, 1999)……….

Mine is on posture.  Good posture can help you “appear” tall and thinner.  My mother had great posture.  She never developed the rolled back (dowager's hump).  So I would encourage you all to watch your posture both in standing and at your computer or sewing machine, etc.

 

 

Here is a repost of my June 3, 2007 post “Good Posture for Sewing (or Blogging)”

For comfort and to decrease the risk of strain injury, it is important to pick a good chair and to set the sewing machine at a good height for your own body. Susan Delaney Mech, M.D answered this question as follows (photo credit):

  1. The first step is to set the height of your sewing chair. The seat should be at a height that allows your feet to rest flat on the floor and your knees to make a perfect 90-degree angle. A secretarial chair makes a good, adjustable sewing chair.

  2. The next step is to lower your sewing machine table until, with your elbows bent at a perfect 90-degree angle, your fingertips can rest on the feed dog of your machine. I am 5 feet 6 inches tall, and my sewing machine table is 22 inches off of the floor.

  3. Proper chair and sewing machine height, combined with good posture of your back and neck, and hourly breaks, will go a long way toward preventing (or healing from) Repetitive Strain Injury.

Avoid slouching. Keep your neck and shoulders relaxed. Try to keep your elbow, hips, and knees at right angles (ninety degrees). Avoid pressure to the back of the knees. If your feet can't comfortably be flat on the floor, then consider a foot rest. You should also consider taking breaks every 30-60 minutes and do some stretching exercises for your wrists and hands and body. Sometimes, as in the OR, breaks can't be taken that often. Do the best you can with table/chair (computer monitor/OR table/etc) height and stretch when you are able. It will help keep the aches at bay and the joints a little more supple. That will allow you to enjoy your hobby (sewing, knitting, blogging) and maybe your work for many more years.

You may want to check out this OSHA sewing station design page. Another interesting source for prevention of injury while sewing/quilting is a PowerPoint presentation at Sport & Spine Physical Therapy website is "How to Quilt Forever"

 

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Sunday, June 21, 2009

SurgeXperiences 226 – Call for Submissions

The host for  SurgeXperience 226 (June 28th) will be Vijay (Scan Man’s Notes).  It will be the 50th edition! 

Suggested theme is surgical practices in different parts of the world.

The deadline for submissions is midnight on Friday, June 26th.  Be sure to submit your post via this form

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.   If you would like to be the host in the future, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

 

 

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Friday, June 19, 2009

Sunshine and Shadow Baby Quilt

If you haven’t noticed by the number of times I use this quilt pattern, I love the “sunshine and shadow” quilt pattern.  So once again, I have used it to make a baby quilt.  This one is machine pieced and quilted.  It measures 42 in square.

This photo shows the fabric colors better than the one above.

 
Here is a photo of the label on the back. 
 
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Thursday, June 18, 2009

Topical Fluorouracil for Photoaging?

The authors of the article referenced below looked at the use of topical fluorouracil and it’s affects on improving photoaging in skin.  Topical fluorouracil (5FU) has become a standard treatment of actinic keratoses (AKs).  For treatment of AKs it is applied to the skin once or twice daily for 2-4 weeks.  It produces significant and predictable irritation and inflammation.  When the skin is healed there is always a decrease in the number of AKs.  A “side benefit” of the AK treatment in many patients was improved skin (smoother, more even color, and a decrease in fine wrinkles).  This improvement appears to come from the wound-healing response of the skin. 

The authors end the article with this observation:

Evidence is accumulating that even minimal epidermal injury, such as that from nonablative laser resurfacing, microdermabrasion, and now topical fluorouracil, can lead to mild to moderate clinical improvement.  It is likely that other topical agents such as diclofenac gel or imiquimod that have similar skin-injuring properties in photodamaged skin may have a similar restorative effect.

Although the standard course of therapy may last only 2 to 3 weeks, the ensuing reaction can persist for several more weeks.   That reaction looks like this (photo credit):

The cost of topical 5FU is much less than ablative laser resurfacing.  It is also unlikely to achieve (at least consistently) the same degree of improvement.   For treatment of AKs, it is a great treatment with the side benefit of improved skin.

 

 

REFERENCE

Topical Fluorouracil for Actinic Keratoses and Photoaging: A Clinical and Molecular Analysis;  Arch Dermatol. 2009;145(6):659-666; Dana L. Sachs, MD; Sewon Kang, MD; Craig Hammerberg, PhD; Yolanda Helfrich, MD; Darius Karimipour, MD; Jeffrey Orringer, MD; Timothy Johnson, MD; Ted A. Hamilton, MS; Gary Fisher, PhD; John J. Voorhees, MD

 

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Wednesday, June 17, 2009

Bundling – What will it mean?

In a lot of the healthcare policy talk I feel like an outlier.  Most of the healthcare policy talk is directed more towards the primary care specialties.  As a “potential” patient and as a medical specialist, I watch and read with interest.   Often I am unsure as to the definitions being thrown around in the discussion.  Take bundling for example.  Currently, many of the surgical payments are already “bundled” in that the surgery and the first 90 days postop are linked or “bundled” together. 

When I do a breast reduction on a patient, the fee I receive covers the surgery itself and any visits during the first 90 days postoperative.   I see each of these patients the morning of surgery to do the preop marking and answer any new questions.  I then do the surgery and check on them in recovery.  Most breast reduction surgery is outpatient these days so there isn’t hospital rounds to make.   I call each of my patients the evening of surgery.  I see each of them at 5-6 days postop.  I try to get them to return at one month postop and then again at 3 months.  So the average patient will be seen 2-3 times in that post-operative time frame.  All this patient interaction, including all the office work for the insurance billing, is “bundled” into one fee.  If the patient needs or simply wants to be seen more often, it would still be included in the one fee.

So what are the policy wonks discussing in this new bundling talk?  I apparently am not the only one wondering as evidenced by this:

James Bentley, senior vice president of strategic policy planning at the AHA, says that to debate the merits and drawbacks of bundling, we need a clear definition of what bundling really is.

"Most people who talk about bundling talk about combining the physician payment and the hospital payment," but currently, the focus is on combining the acute payment with the postacute payment, he says. Bentley says fundamental questions like this spring up due to the lack of detail in the president's budget proposal, which Congress has already approved in principle. Details are expected to be worked out in conference between the two houses over the summer.

"Our membership is asking a lot of questions that we can't answer," Bentley says, including whether a new system would include all diagnosis-related groups, or just some, or whether the new formula will incorporate the historically wide disparity in Medicare payments per capita by region, for example.

One big potential problem with bundling payments is the assumption that much of the anticipated savings come from the idea that chronic care patients use lots of services and are high cost; but such chronic care services are the hardest to describe for bundling.

"If there are a lot of comorbid conditions, what's the primary condition, where does the bundle start and where does it end?" Bentley asks.

Are the new bundling talks aimed at the family practice doctors and internists?  Surgeons have been living with “bundling” for a while now.

How the policy wonks decide to “bundle” medical care for diabetics will be interesting.  What will that mean to the family practice clinics?

 

This next part is still on the health policy issue, but has nothing to do with bundling.  It is just interesting to me.

I am like Dr Bruce Campbell  who wrote in his post --Health Care, House Building and Ethics:

I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me. 

Read Dr Campbell’s entire post on his viewpoint of the recent article in the The New Yorker by surgeon-writer Atul Gawande, MD.

Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation. 

 

Then read this one (Gawande) by Dr Jeffrey Parks (Buckeye Surgeon) on his perspective of the same article by Dr Gawande:

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking…..

But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point……….

But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common.

 

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Walking

I call my dog Rusty my personal trainer.  We walk every day regardless of the weather.  He was preceded by other dogs (Columbo, Girlfriend, and Ladybug) who got me into this walking habit.  It has kept my weight down over the years without having to go to the gym.

I was reminded of this earlier this week by an article in my local paper.  This link needs a subscription, this one does not.  I especially love this part of the article as it highlights a community in Arkansas where “volunteer” dog walking has become a weekly club event.  Kudos to them!

And there's another way to dabble in dog time. In many communities, volunteers for local Humane Society shelters gather to give the friskiest residents a workout. In Arkansas, the Humane Society of Independence County has a weekly Dog Walk Club. Its volunteers walk dogs at 8:30 a.m. every Wednesday at the North Complex on 3451 E. Main St. in Batesville. Anyone can volunteer by calling (870) 251-4145 or (870) 307-5305A similar group meets in the nation's capital. Kevin Simpson, director of animal training and behavior for the Washington Humane Society, has dubbed the year-old group the People & Animal Cardio Klub, or PACK. (Because pack animals run together.)

"People love it because they're helping out and getting exercise," he says. The cooped-up canines get an even better deal: They're socializing and blowing off steam, which means they'll be better behaved and, thus, more adoptable.

 

As I have said before in previous posts, walking is a great exercise.  It is good for both you and your pets (or the ones in the humane society).  I would encourage you to take it up.

If you are just beginning a walking program, remember as summer begins here in the United States that heat becomes an issue quickly.  Walk in the early morning or evening, or consider going to the mall to walk inside in the air conditioning. 

 

 

My past related posts include:

Heat Related Illnesses (August 2007)

Pedometers and Physical Activity (November 2007)

50-Minute Strength Workout (December 2007)

Getting Back Into Shape (November 2008)

 

 

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Tuesday, June 16, 2009

Shout Outs

Acp Internist is this week's host of Grand Rounds. You can read it here (photo credit).  Great edition!

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.

 

The latest edition of Change of Shift (Vol 3, No 25)  is hosted by Barbara over at Florence Dot Com!   You can find the schedule and the COS archives at Emergiblog

Welcome to Change of Shift, nursing's vibrant blog carnival! I'm thrilled to be your guest host this week and hope you'll find the posts embedded here as interesting as I have. If you're visiting my blog for the first time, I should warn you that I channel Florence Nightingale. I don't take extreme liberties with Miss Nightingale, just try and figure out what her work might say about ours. Sometimes I hit, sometimes I miss. Today, I'm weaving the voices of front line clinicians, consumers, and other interested (and interesting) bloggers around the theme of communication, showing, perhaps, where we are ("Can you hear me? Can you hear me now?") and what enhanced communication might do for us in the future.

 

I meant to give a shout out to this post by Dr. Howard Luks earlier, but it remains relevant -- Pitching injuries can be avoided!!! Parents are usually the *problem*

The spring parade of pitching injuries is starting. Last week I saw many young kids with early signs of shoulder and elbow issues due to pitching. They all shared one thing in common:  All were throwing more than 100 pitches a week, and they were all under 15 years of age…….

 

The coverage of our country’s debate and struggle over changes to healthcare continue.  I’d like to highlight a couple of recent posts.  One is up over at Better Health and is written by GwenMayes -- Hot Topics In Healthcare Reform: A Primer 

For those who might not feel up to speed on the latest buzz on health care reform, here’s a quick primer:

Another is by Dr Wes -- Show Me The Money and one by Shadowfax -- More like capitulation than compromise in which he makes this point (the bold hightlight  is mine):

Hacker's summary line, I think, is quite accurate -- this is not a compromise, it's outright capitulation.  And it's not like we're going to get a chance to come back and re-do this in a year or two.  As Robert Reich wrote: This is it, folks. The concrete is being mixed and about to be poured. And after it's poured and hardens, universal health care will be with us for years to come in whatever form it now takes.  So it's extra-important to get it right -- or as right as possible -- this time.

 

Continuing on with difficult topics, I’d like to suggest you read these two nicely written viewpoints on the abortion issue:

Another difficult topic via White Coat -- Promises Promises …

Very poignant article in Yahoo news about how the federal government is failing to meet the needs of many patients in the Indian Health Services – and the disastrous effects the broken promises are having….

 

From Cocktail Party Physics comes a post “be nice, it’s what makes us human

Altruism is only a facet of the complex cooperative societies that humans develop, but it seems unique to us. Chimpanzees and other primates cooperate, but the difference between our behavior and that of ants or bees or marmosets or even other primates is that "awwwww" factor: our ability to empathize.

 

The Quilt of Valor Foundation has begun a new blog (Quilts of Valor Across America) to document their trip across America.  (photo credit)

If you’re traveling along, and you happen to see this blue truck pulling a trailer … then you’ve found us.  Honk, Wave, Smile, let us  know that you care !!!

 

 

This week Dr Anonymous’ guest will be  doing a Podcamp Ohio Pre-show.  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:

6/25: Podcamp Ohio Post-show
July: Summer Vacation


 

 

 

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Monday, June 15, 2009

Unused Prescription Medications

As regular readers of my blog know recently my family lost my mother (May) and my sister lost her husband (March).  Both times we were left with many unused prescription drugs at their respective homes.  What do you do with these?  What do you do with ones you or a family member have left when switched to another drug?

 

This topic was also brought up on twitter recently by  lesmorgan.

  • Handling a family request to donate dialysis meds after a death. Is it correct that Kaiser pharmacy has no post-death return policy?
  • @rlbates thanks for the comment. that's the usual answer, but some institutional systems do have giveback programs, unsure on Kaiser.
  • http://www.dhss.mo.gov/Drug... DHSS FAQ on medication donations in Missouri. Regulations vary by state.
  • http://bit.ly/aeAfv California law on recycling meds after SB 798
  • http://www.ciwmb.ca.gov/HHW... California medical waste disposal location finder. Handy!
  • @striving4more My understanding is that laws vary by state, I'm updating my own FAQ on the issue now.
  • @striving4more Best general advice is to ask the pharmacy that dispensed the meds to advise on prevailing law, which also varies by med.

I tried to take my brother-in-law’s to the pharmacist downstairs in the building my office is in.  They were not allowed to take them for recycling.  Their advise to me and to others who ask was to empty the pills into a plastic bags with cat litter, then throw that bag into your regular trash.  I did the bag/cat litter thing, but put my into my “medical waste” trash at the office.  I don’t like the thought of those drugs ending up in my drinking water, but I also find the waste sad.  I wish there were a way to donate them to charity clinics legally.  It’s much easier to donate or “recycle” the unused prescription drugs when someone dies in a nursing home or hospice.  It’s almost impossible if the drugs have made it into someone’s home cabinets.  Most states are similar to California and make no recommendations on the ones that I wanted to donate or recycle (the ones at the departed’s home).

SUMMARY

California Senate Bill 798, signed into law by Governor Schwarzenegger in September 2005, authorizes a county to establish a program to collect unused prescription medications from nursing homes, wholesalers, and manufacturers and redistribute them to low-income, uninsured people. (A copy of the law is attached. )

 

Here is a post I did early in my blogging days, May 2007 – Unused Medicines.

As I have begun to find more ways to recycle and conserve waste in my home and office, I have found that it is no longer acceptable to “flush medication” down the drain. I was taught in medical school (graduated in 1982) to educate patients to dispose of out-of-date medications (old Tylenol, aspirin, cough syrups, etc) and unused prescription (either couldn’t take them due to side effects or failed to take all of the antibiotics or HBP medication was switched) by flushing them down the toilet. That is no longer a good idea. But the information out there is not clear as to the new guidelines.

I found that the Senior Care Service website still tells our elderly and their care givers to flush the out-of-date or unused medication. I found little help at my own state’s Cooperative Extension Agency’s website on medication disposal, but it is very helpful for other household chemicals.

The two best sites I found were the American Pharmacy Association and the White House Drug Policy. Both of these give clear instructions [ Federal Guidelines ]

 

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Sunday, June 14, 2009

SurgeXperiences 225 is Up!

This edition (225) of SurgeXperiences is hosted by Jeffrey,  “Vagus Surgicalis”.  You can read this edition here.

Welcome to the 25th edition of SurgeXperiences – the one and only Surgical “Grand Rounds”, where the best surgical-related posts are gathered into one succinct post every 2 weeks. Thank you for dropping by, and because i’m in  exam mode, i shall present this edition in a Q&A fashion; enjoy!

The host of the next edition (226), June 28th, will be Vijay, Scan Man’s Notes. The deadline for submissions is midnight on Friday, June 26th. 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, June 12, 2009

Star of Bethlehem Quilt

I made this wall hanging back in 2003.  It hung in my office for a few years and then I gave it to my sister Jeanne.  She uses it on the foot of her bed.  Recently, I got her to take some photos of it and send them to me so I could share it.

The  pattern is called the “star of Bethlehem” or “lone star.”  I machine pieced the quilt which is 49 in square.  It is machine and hand quilted.

The machine quilting was done “in the ditch” around the diamonds and border.  I then hand quilted the open areas and the outline quilting of the diamonds.

My “corners” where the diamonds meet weren’t perfect, so to hide this I embroidered around the diamonds with gold metallic thread.

Here is a partial photo of the back to show the quilting.

 

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Thursday, June 11, 2009

The Dermatology Blog

If you haven’t found The Dermatology Blog, you need to check it out.  It is written by Dr Jeffrey Benabio. 

 

Here is a sampling of his advise on his blog:

Skin Care Myths: Adding Sunscreens Adds SPF

Applying two sunscreens with an SPF of 15 gives you a total SPF of 15, not 30. The SPF you end up with is only the SPF of the highest sunscreen that you applied.

Facials Don’t Treat Wrinkles

Facials can be beneficial; they extract clogged pores, exfoliate dull, scaly skin, and give you a deep, invigorating cleansing, leaving your face smooth and silky. But facials cannot treat wrinkles, broken blood vessels, or brown spots.

5 Ways to Have Beautiful Lips

Stop smoking

This seems like a no-brainer, but it is important to mention here. Smoking is bad for lips for two reasons. First, smoking causes wrinkles and lips are prone to developing fine vertical lines that give lips a crepe paper look and make it nearly impossible to get a nice smooth line of lipstick……….

 

He also gives and RT’s some great advice on twitter (photo credit):

 

"Not all rashes are ringworm." - DermDoc6:44 PM Jun 7th from web

Sunburned today? Take motrin or advil; they block the inflammation and can lessen the burn.8:03 PM Jun 7th

This will make your skin crawl : http://digg.com/d1tEco?t 7:15 AM Jun 8th

@Ann_Sieg Unfortunately, not much else you can do. The oil (urushiol) that causes Poison Ivy absorbed in 1 hour. Rash develops in 8-12 hrs 2:29 PM Jun 8th from web in reply to Ann_Sieg

@Ann_Sieg Poison ivy rash lasts about 2 weeks. Oatmeal baths, calamine, topical steroids all can help.2:30 PM Jun 8th

@Ann_Sieg The best OTC treatment for poison ivy is cortisone 1% cream or calamine lotion. No product can stop the rash or speed recovery2:54 PM Jun 8th

The rash from poison ivy is caused by an oil (urushiol) and is not spread after the first few hours.2:59 PM Jun 8th

The rash from poison ivy develops in 8 to 12 hours and lasts for 2 weeks.3:00 PM Jun 8th

Washing your skin immediately (< 1 hr!) with soap and water and washing any contaminated clothes is the only way to prevent poison ivy.3:01 PM Jun 8th

RT @goodhealth Hair tip: Never shampoo before swimming, it strips away protective oils, leaving hair vulnerable to drying chemicals and salt

DermDoc says: Ivy Block can prevent poison ivy, but only if it is applied before exposure.

They Lied To You: There is no cure for cellulite.

DermDoc says: Your risk of skin cancer doubles after 5 or more sunburns.

 

 

 

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Wednesday, June 10, 2009

Should Doctors Say How Many?

Monday the WSJ Health Blog posted “Should Doctors Say How Often They’ve Performed a Procedure?” written by Jacob Goldstein.   It references another guest post by Adam Wolfberg, M.D -- “Test Poses Challenge for OB-GYNs

Dr. Wolfberg writes:

None of the published studies of CVS pitted seasoned physicians against novices; what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle? But several reports from individual hospitals demonstrate that the miscarriage rate declined over time as the hospital's staff became more experienced.

These reports point to a dilemma: CVS mavens got that way by practicing, so their present-day patients benefit at the expense of previous patients.

When I first began my solo practice 19 years ago, patients often asked how long I had been in practice.  They ask less often these days.  I have never failed to answer. 

Patients sometimes asks how many times I have done a procedure, but not often.  Early in my practice, and sometimes even now, if it is a procedure I feel a bit uneasy with or haven’t done in a while I will bring the subject up without being asked.  After all, some procedures you just don’t do every day or even every month.  Some diseases you don’t see every month or even every year.

In my mind, many of the procedures I do are built on basic surgical principles.  I withdrew my privileges for microvascular procedures more than 10 years ago.  I didn’t get enough patients referred to me to feel that my skills were kept sharp.  In private practice, unlike at a university, there are no labs to go do practice work in to maintain those rarely used skills.  I have no doubt that I could regain them given the chance, but at what cost (financially or complications). 

Because I gave up my privileges for microvascular procedures, it means I have limited my repertoire of reconstructive procedures important in hand, breast, and other work.  I tell my patients about them.  If a breast reconstruction patient wants a free TRAM flap, then she is referred to someone who does it.  If she  wants to keep me as her surgeon, is there the possibility she is short changing herself on the outcome?  I suppose, but I try (TRY) to be upfront and fair to each patient.

 

The question asked “should doctors say how often they’ve performed a procedure?” may seem an easy one to answer.   If asked, yes.  If not asked, should it be part of the consent form?  I’m not sure it should for most procedures, but for extremely complex ones, maybe.

What if I did 100 of one type of procedure, but my last one was over a year ago?  What if I have done 50 of a second procedure that is closely related in skill-set?  What if that number is only 15? What if I have never done one and don’t wish to now, but the patient needs the procedure and is not willing to travel to another hospital?  Is it okay that I have “informed” them, but they want to take the risk?  How do I define that risk for them? 

How many of which procedure is enough to become proficient?  How often does it need to be done to remain proficient?  Who gets to define proficient?  Who gets to define the “magic” number of how many is enough to be proficient?  Who get to define how often the procedure needs to be done to remain “proficient”?

 

As Dr Wolfberg noted

what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle?

So how will these questions be answered?

 

 

 

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Tuesday, June 9, 2009

Shout Outs

The Jobbing Doctor is this week's host of Grand Rounds. You can read it here.  Great edition!

Welcome to Grand Rounds, Volume 5, Number 38. The rounds have travelled over the Atlantic to reside briefly in the green fields of England, to give an English flavour to what is going on in the Medical Blogosphere.

The advent of blogging has internationalised many issues, and we see many health care issues are very much shared throughout the world. Some of these I will touch on this week, but the Jobbing Doctor is pleased to be hosting the grand rounds.

 

Sally Church, Pharma Strategy Blog, writes “Beating malignant cancer - Yes, it can be done”  -- great story! (H/T @drval RT @scotthensley RT @maverickny)

One of the coolest things about cloud services like Twitter is that if you follow other people who tweet at cancer conferences such as ASCO, ASH and AACR, you can keep track of other parallel sessions while sitting in a different one.  Thus Kerry Wachter tweeted about the pediatric neuroblastoma session she was in earlier this week at ASCO and I couldn’t help but suddenly realize it is 32 years since I had a largish lump the size of a small football removed from my adrenal gland and kidney.  32 years is quite a long time and I haven’t really thought much about it in those intervening years.  Gilles Frydman from ACOR challenged/encouraged me to tell my story, so here it is for the first and only time, gulp.

 

Dr Isis, On Becoming a Domestic and Laboratory Goddess, continues "The Letters to Our Daughters Project".  I would encourage you to check them out.

 

Check out the Oprah-fication of Medicine by by Dr David Gorski over at Better Health.

Why Oprah? you may ask. I’m happy to tell you. Oprah Winfrey has been the host of the highest rated syndicated talk show in television history, her self-named The Oprah Winfrey Show. The show has been running for nearly 23 years, with over 3,000 episodes. Winfrey is so famous that she is one of those rare celebrities who is known instantly by just her first name. Say “Oprah,” and virtually everyone will know to whom you’re referring, and her show is often colloquially known as simply Oprah………

 

From the WSJ Health Blog:  Should doctors say how often they have performed a procedure?  Don’t forget to read the comments and read the referenced article by Dr Wolfberg.

But other procedures demand a more binary approach: Sometimes, after the books and the observation, you just have to jump in and do something yourself. That can be especially daunting when the procedure carries risks and the patient is pregnant, writes Adam Wolfberg, M.D., in a guest column on WSJ.com.

 

The Textile Museum in Washington, DC has an exhibit of Amish quilts --  Constructed Color: Amish Quilts  April 4 – September 6, 2009.   I was sent the link by a friend who recently saw the exhibit with his wife.  Compare this triple Irish chain quilt (photo credit) to the double Irish chain quilt I made.

This exhibition, on loan from the International Quilt Study Center and Museum at the University of Nebraska-Lincoln, features 29 examples from the center’s highly regarded collection. The quilts represent three specific regional groups, each with its own distinctive features, drawn from Lancaster County, Pennsylvania, from Midwestern communities and from Mifflin County, Pennsylvania.

 

The Quilt of Valor Foundation has begun a new blog (Quilts of Valor Across America) to document their trip across America.  (photo credit)

If you’re traveling along, and you happen to see this blue truck pulling a trailer … then you’ve found us.  Honk, Wave, Smile, let us  know that you care !!!

 

 

This week Dr Anonymous’ guest will be  Podcast Guru Cliff Ravenscraft.    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:

6/18: Podcamp Ohio Pre-show
6/25: Podcamp Ohio Post-show
July: Summer Vacation


 

 

 

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Monday, June 8, 2009

Cell Phone Elbow?

Last Tuesday, this tweet from @AllergyNotes caught my eye.

Call cubital tunnel syndrome a "cell phone elbow" and you make the front page of CNN.com: http://bit.ly/RaXrt and http://bit.ly/TTRfg

 

Cubital tunnel syndrome I know, but I had not heard it called “cell phone elbow.”  The first link is to the Cleveland Clinic Journal of Medicine article (full reference below).  It is an excellent article and well worth reading.  The second link is to CNN news article picking up the “cell phone elbow” line.

 

Cubital tunnel syndrome is a nerve compression syndrome (like carpal tunnel syndrome).  In the case of cubital tunnel syndrome, the nerve involved is the ulnar nerve and the location is at the elbow.  From the article

… the ulnar nerve as it traverses the posterior elbow, wrapping around the medial condyle of the humerus. When people hold their elbow flexed for a prolonged period, such as when speaking on the phone or sleeping at night, the ulnar nerve is placed in tension; the nerve itself can elongate 4.5 to 8 mm with elbow flexion……..

As with other nerve compression syndromes, the clinical picture is representative of the nerves enervation.  In the case of the ulnar nerve, this involves numbness or paresthesias in the small and ring fingers.   There may also be numbness of the dorsal ulnar hand which will NOT be present if the ulnar nerve  compression is in the Guyon’s canal at the wrist level (distal ulnar nerve compression).  If the compression is chronic enough, the symptoms progress to hand fatigue and weakness.  The small intrinsic muscles of the hand are important in hand strength needed to open jars.   More from the article

Chronic and severe compression may lead to permanent motor deficits, including an inability to adduct the small finger (Wartenberg sign) and severe clawing of the ring and small fingers (a hand posture of metacarpophalangeal extension and flexion of the proximal and distal interphalangeal joints due to dysfunction of the ulnar-innervated intrinsic hand musculature). Patients may be unable to grasp things in a key-pinch grip, using a fingertip grip instead (Froment sign).

 

It may be an old joke (Patient: Doctor, it hurts when I do this.  … Doctor: Well don’t do it.), but in the case of cubital tunnel syndrome it fits.  Prevention is key.  Prolonged extreme flexion of the elbow (elbows bent tighter than 90 degrees) is not kind to the ulnar nerve.  Switch hands or use a head set or blue tooth.

 

 

REFERENCES

Q:What is cell phone elbow, and what should we tell our patients?; Cleveland Clinic Journal of Medicine May 2009 vol. 76 5 306-308 (doi: 10.3949/ccjm.76a.08090); Darowish, Michael MD, Lawton, Jeffrey N. MD, and Evans, Peter J MD, PhD

Cubital Tunnel Syndrome: eMedicine Article, Feb 9, 2007; James R Verheyden, MD and  Andrew K Palmer, MD

 

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