Thursday, December 31, 2009

Blog Review of 2009

This year seems to have gone by so quickly.  It was great fun meeting so many of you at the Blog World Expo which stands out as a great highlight of the year.  It was also a year of losses for my family – a brother-in-law, my mother, a cousin.

 

Here are a few posts that stand out for me:

Wednesday, December 30, 2009

Appearance Is A Function of the Face

I noticed this article title on MDLinx, then went to the Journal of Plastic and Reconstruction website to read the full article.  The abstract is free to read, the full article requires a subscription.

The study was prompted by the authors noticing third party insurers increasingly deny coverage to patients with post traumatic and congenital facial deformities.  This denial is often cited as due to the deformities not being seen as "functional" problems.  The authors cite the recent facial transplants patients as having demonstrated  that the severely deformed are willing to undergo potentially life-threatening surgery and extended chemotherapy in an attempt in look normal.

The authors also noted that very little research exists which objectively documents appearance as a primary “function” of the face.  To this end, they designed their study to “establish a population-based definition of the functions of the human face, rank importance of the face among various anatomic areas, and determine the risk value the average person places on a normal appearance.” 

Their method involved using  210 voluntary adult subjects in three states aged 18 to 75 years who then completed study questionnaires.  Quota sampling technique was used to select the subjects.  The study questionnaires of demography and bias were done using Gamble Chance of Death Questionnaire and Rosenberg Self-esteem Scale.

Their results:

Subjects ranked appearance as number 5 above expression (number 6), and smell was least important.

Subjects ranked the face as the most important body part to restore after an injury followed by the hand, leg, arm, knee and breast.

Chewing was regarded by most subjects (88%) to be a basic function of the face with over half of subjects (57%) rating appearance as a basic function, and 43% of respondents rating beauty.

68% disagreed with the statement  “Normal facial appearance is not important to be a normal functioning member of society.”

17% of subjects agreed with the statement “Normal facial appearance is irrelevant to being a normal functioning member of American Society”.

A large majority of subjects (72%) determined that surgery to normalize the appearance of facial scars from an accident was functional, as compared to those subjects who thought it was non-functional or not necessary (28%).

Most subjects (79%) reported that surgery to normalize the appearance of facial birth defects was functional, while 21% reported that it was not necessary or non functional; and 72% of the respondents agreed that surgery to normalize the appearance of facial scars from an infection was functional.

The highest ranking of agreement regarding surgery was to normalize the appearance of facial nerve injury; 90% of subjects agreed it was functional while only 10% of subjects agreed it was non-functional.

 

The authors call this a large sampling, but I don’t feel that 210 subjects is a large sampling.  I would like to see this study repeated with minimally 10 times the number of subjects.  If they want to change insurance policy, I think bigger numbers will be needed. 

 

 

REFERENCE

Appearance Is A Function of the Face; Plastic and Reconstructive Surgery: POST ACCEPTANCE, 1 December 2009; Borah, Gregory L. MD, FACS; Rankin, Marlene K. PhD; doi:10.1097/PRS.0b013e3181cb613d

 

Related posts

Face Transplantation – First in the US Done (December 18, 2008)

Cleveland Clinic’s Connie Culp (May 6, 2009)

The Technical and Anatomical Aspects of the World's First Near-Total Human Face and Maxilla Transplant—an Article Review (December 7, 2009)

Tuesday, December 29, 2009

Shout Outs

 Dr. Ottematic is this week's host of Grand Rounds. You can read this week’s edition here (photo credit).

The end of the year is a time of reflection. We look forward to the years to come and look backwards, pondering our triumphs and tragedies. And, if you are anything like me, you might also look behind the dryer for that missing sock.

In late December, the tradition is also to formalize our best intentions for the future, even if we know the process is futile. Though considered nearly a pointless exercise, with failure resulting in an even worse state than before we started, we make these resolutions annually. So, onto the blogs, grouped according to some of the classic New Year’s resolution themes.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 13) !   It is the “Merry Christmas” edition.  You can find the schedule and the COS archives at Emergiblog. (photo credit)

It’s Christmas Eve and time for a new Change of Shift!

Between the hustle and bustle of the holiday rush (and the ending of fall semesters), the nurses of the blogosphere put fingers to keyboard and busted out a joyful Change of Shift!

Grab an Egg Nog (spiked, of course), and settle in for some nursing stories!

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H/T to @EvidenceMatters for the link to this WSJ article:  A Downside of Organ Donation by Laura Landro (photo credit)

Most transplants do indeed save lives. But as demand grows for donated organs and tissues, so do concerns about the risk of disease transmission, including deadly bacterial infections and viruses, tuberculosis, rabies, parasites and even cancers. Some experts are calling for better testing and tracking of organ donors in order to limit the number of infections, though others warn that this could have the effect of delaying transplants, producing false-positive results that would eliminate safe organs and adding costs to the health-care system.

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The “downside of organ donations” has prompted a re-exam of transplantation rules.  Denise Grady reviews this topic in the NY Times article:  Officials Re-examining Organ Transplant Rules

……….The case highlights the lack of a national policy on whether to bar people with poorly defined neurological disorders as donors. For now, the decision is up to individual transplant centers, said Dr. Michael G. Ison, ………..

Dr. Kuehnert said he wondered whether there should be a registry for donors who have brain inflammation, or encephalitis, from an unknown cause.

“It would be difficult to say, ‘Don’t ever recover a donor with encephalitis,’ ” he said. “Some may be O.K. But we don’t know how many times it’s a successful operation, and how many times a tragic operation.”

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H/T to @ChrisCoppola and @DrSonnyO  for the link to this CNN article which shows the good outcome of organ transplantation:  Pediatric heart transplant survivor: 'I thank God every day' by Madison Park.

"Not a day or minute goes by where I don't think about how lucky I am just to be here," said Farley of Hasbrouck Heights, New Jersey. "I thank God every day when I wake up that I woke up."

Around Christmas time, 24 years ago, Farley's heart was deteriorating.

Farley was 12 and couldn't walk without feeling exhausted. She'd stop to catch her breath after taking a few steps. During gym class, her lips and fingers turned purple from low blood oxygen levels. She often felt listless, and she had chronic bronchitis and respiratory infections…………

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Margaret Polaneczky,MD, TBTAM, has done an exception job explaining The New Mammogram Guidelines - What You Need to Know

Unless you've been living on another planet, you know that in mid-November, the US Preventive Services Task Force released new recommendations on screening mammography, in which they recommended against routine mammogram screening in women under age 50, and recommended that mammograms now be every two years in women ages 50-74.

What you may not have heard is that the Task Force has acknowledged that the mammogram guidelines were poorly worded, and have revised their original statement to clarify their intentions, mostly by removing those two little words "recommends against"…………..

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The Diane Rehm Show rebroadcasted their show on the "goat gland man” John Brinkley yesterday morning.  Brinkley was an amazing charlatan who was born in North Carolina, but much of his medical career was spent in Arkansas.  Her guest on the show is Pope Brock talking about his book on Brinkley:  Charlatan: America’s Most Dangerous Huckster, the Man Who Pursued Him, and the Age of Flimflam.   You can listen to the show here.

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The Dr Anonymous’ show this week will be New Year’s Eve, 10:30 pm ET.   

Upcoming Dr. A Shows (9pm ET)
1/2 : Saturday Night w/ Dr. A
1/5 : Maybe Tuesday Night Show
1/7 : Maybe Thursday Night Cancelled
1/9 : Saturday Night w/ Dr. A

You may want to listen to 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

Monday, December 28, 2009

SurgeXperiences 313 is Up!

Jeffrey, Vagus surgicalis, is the host of this edition of SurgeXperiences. Here is the beginning of this edition which you can read here (photo credit).

Most readers here would have had enjoyed numerous festive seasons. For me, the Christmas season is most meaningful of all festivities, perhaps by virtue of my Christian faith. It is a timely reminder of why Christmas existed in the first place and the implications the birth of Jesus Christ, His life and the reason why He died on the cross, have for the entire human race.   A.D. 2009 will be over in a few days. It might even be over by the time you chance upon my humble little blog. A.D. is medieval Latin  for Anno Domini and can be translated as In the year of (the/Our) Lord.

For medical professionals, the duty of care to patients does not cease just because of a festive season. Patients do not cease to require medical attention just because everyone is enjoying their holiday……

The host of the next edition (314) has not been announced, but don’t let that keep you from making your submissions. The deadline for submissions is midnight on Friday, January 8th. 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.

Smoking in Facial Aesthetic Surgery Patients

Just finished reading a CME article on “Aesthetic  Surgery of the Face and Neck” in the Nov/Dec issue of the Aesthetic Surgery Journal (the first article referenced below).  Nice review article, but I want to just concentrate on the section on smoking.  This is the time of year when many resolutions are made, and often to quit smoking is one of them. 

One of the major things to avoid pre- and post-facial surgery is smoking.  The other major one is platelet inhibitors (ie aspirin, NSAIDs, and certain herbals).

The logic for smoking avoidance is because “tobacco smoke is an aerosol of particulate matter, volatile acids and gases.  The overall cellular effect of these inhaled or absorbed byproducts is to produce an environment of relative tissue hypoxia, and delayed wound healing mediated by vasoconstriction, abnormal cellular function, and thrombogenesis.” [second reference]

The reported incidence of facelift skin flap necrosis is 12.5 times greater in smoker than nonsmokers.  This risk is too high for elective surgery, so no surgeon will knowingly operate on the face of a smoker electively.

Even smoking one cigarette has been shown to cause temporary vascular spasm which can last up to one hours.  This vascular spasm can result in 24-42% decrease in blood flow.  This can lead to skin necrosis, poor wound healing, and increase infection.

The current recommendation for elective facial surgery is smokers is patients remain nicotine-free for four weeks before surgery and for four weeks after surgery.

Patients often underreport their smoking.  To “test” their truthfulness, a salivary rapid test (NicAlert) has been developed which test for cotinine, the metabolic breakdown product of nicotine.

I would encourage all smokers to quit just for general health benefits.  Keep trying.  If one method doesn’t work for you, work with your primary care physician to find one that does.

 

 

REFERENCE

Aesthetic Surgery of the Face and Neck; Aesthetic Surgery Journal, November 2009, Vol. 29, Issue 6, Pages 449-463; Fritz E. Barton (DOI: 10.1016/j.asj.2009.08.021)

Clearing the Smoke:  the Scientific Rationale for Tobacco Abstention with Plastic Surgery; Plastic and Reconstructive Surgery. 108(4):1063-1073, September 15, 2001; Krueger, Jeffery K.; Rohrich, Rodney J.

The Effect of Cigarette Smoking on Skin-Flap Survival in the Face Lift Patient; Plastic and Reconstructive Surgery. 73(6):911-915, June 1984; Rees, Thomas D.; Liverett, David M.; Guy, Cary L.

Planning Elective Operations on Patients Who Smoke: Survey of North American Plastic Surgeons; Plastic and Reconstructive Surgery. 109(1):350-355, January 2002; Rohrich, Rod J.; Coberly, Dana M.; Krueger, Jeffery K.; Brown, and Spencer A.

Friday, December 25, 2009

May You Be Warm This Christmas

Earlier this fall, I knitted my first pair of sock at the urging of Dr Smak, Dr Cris, and Geek2Nurse.  Those are my feet as I “modeled” them for a photo.

I gave them to my stepmother-in-law for her birthday.  She and my father-in-law were so impressed with them, they both began hinting that he needed a pair as his feet get cold.   He’s getting this pair for Christmas, modeled here by his son/my husband who now wants a pair.

I wish you all a very Merry Christmas filled with warm feet, warm wishes, and warm hearts!

Thursday, December 24, 2009

Hand Rejuvenation

I took this photo when my mom was in the hospital earlier this year. My hand looks like I wash dishes for a living. Her hand shows many of the spots that come with age and sun exposure: actinic keratosis, liver spots, etc.

There is a decent article that gives an overview of hand rejuvenation in the Sept/October issue of the Aesthetic Surgery Journal.

The epidermis thins as we age. Lentigines, actinic keratoses and seborrheic keratoses, general dyschromia, and textural roughness appear. Capillary fragility may make bruising common. Fat atrophy may make tendons and bony prominences more noticeable and the veins appear to bulge.

The article goes through the available treatments: chemical peels, vein sclerotherapy, fillers, laser therapy, intense pulsed light (IPL) therapy, fractional skin therapy, and Thermage.

It also reminds us that caution must be exercised as hand skin has relatively few adnexal structures and therefore has less capacity to replace the epidermis

All of the procedures discussed are on an out-patient basis and some may be performed with local anesthesia.

Prescription-strength skin care like Retin-A can help repair sun-damaged skin, cause spots to fade, improve transparent skin, and stimulate the production of collagen. As with the face, use of sun protection is extremely important to protect the improvements gained and to prevent further sun-damage.

Chemical peels are available in a variety of forms: glycolic acid, Jessner’s solution and trichloroacetic acid (TCA). These are useful in addressing the mild pigmentary and texture changes of the skin. Dr Shamban likes to use pre-formulated peels to avoid worrying about acid concentration changes that can occur due to evaporation when bottles are opened and re-stored. Mentioned is SkinMedica peel which is a combination of tretinoin and glycolic acid.

Fractional skin resurfacing, IPL treatments, and Laser treatments can be used to treat spots, spider veins (IPL), and improve the texture of the skin.

Soft tissue augmentation can be performed with fat cells taken from other parts of your body and transplanted to your hands. Synthetic fillers can also be used (Sculptra, Restylane, Juvederm, Radiesse). Results are immediate. The duration of improvement depends on the size and location of the area treated, as well as on the material used.

Sclerotherapy can be used to address the veins, but Dr Shamban states that often the veins do not need treatment if appropriate soft-tissue volume is replaced.

Microdermabrasion is a superficial skin polishing that improves the appearance of aging skin and spots. The results are immediate. Maintenance treatments are required.

Thermage is a non-surgical procedure that uses a radio frequency (RF) system to gently cause the collagen in your skin to contract and tighten. The result is smoother, softer looking hands.

Use of sun protection before and after is important, but difficult as the hands are washed frequently during each day.

REFERENCE

Combination Hand Rejuvenation Procedures; Aesthetic Surgery Journal, Vol 29 (5), pp 409-413, Sept/Oct 2009; Shamban, Ava T. MD

Dr Demar Dermatology – Hand Rejuvenation

Wednesday, December 23, 2009

When Does Death Start?

H/T to @ctsinclair and @doclake  for the link to this December 16th NY Times article.  If you haven’t read it, it is worth the time, especially if you have any interest in this topic.

When does death start? from NYT http://bit.ly/8xGXjL

The article, "When does death start?",  was written by Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, is Slate’s health care columnist and the author of “A Map of the Child: A Pediatrician’s Tour of the Body.”

The article uses the story of Amanda to discuss “brain death” and “death after cardiac arrest”  in conjunction with organ procurement.   No organs can be procured until a person has been declared dead (the so-called dead-donor rule). 

The question of “when does death start?” comes from the 5 minute of no heart activity after cardiac arrest.

In procuring organs from patients like Amanda, doctors have created a new class of potential organ donors who are not dead but dying. By arbitrarily drawing a line between death and life — five minutes after the heart stops — they have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?

The article takes the reader through the history of transplantation and the need to define “when death starts.”

Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association.

President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.”

The 1981 Uniform Determination of Death Act also defines death as the “irreversible cessation of circulatory and respiratory functions,” which left an opening for another source of donors.

In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity.

In 1997, the federal government asked the Institute of Medicine, an independent advisory body, to gather experts to determine how a dying donor might be treated. The experts ended up endorsing the procedure for donation after cardiac death, in which death occurs through a process of withdrawing life support and allowing the heart to develop “irreversible cessation.”

In 2004, pediatric cardiologist Mark Boucek at Denver Children’s Hospital, financed by a federal grant,  wrote a far more aggressive D.C.D. protocol that would save the heart, which was adopted after going through the hospital’s review process. His version …..most controversially, rejected the five-minute rule imposed by the Institute of Medicine and initially picked three minutes instead.

David Campbell, the pediatric cardiac surgeon at Denver who procured the first heart using the (Boucek) protocol, realized that even three minutes was too long. ….. In reviewing the medical literature, Boucek found the longest recorded time that a heart had ever stopped and then spontaneously restarted without medical intervention was 65 seconds.

 

The article goes on to discuss the current needs for organ donation.  It is estimated that at least 18 people on the transplantation list die each day before the needed organ becomes available.  This need makes the need for an answer to the question of “when does death start?’ extremely important.  The answer could increase the availability of viable organs.

The Institute of Medicine created a new class of potential organ donors: living patients with little hope of recovery who could be declared dead soon after life-support removal. Within a decade, the number of such donors increased tenfold; they now account for 8 percent of organ transplants nationwide, up to 20 percent in certain areas. Still, many hospitals were slow to adopt the practice.

Tuesday, December 22, 2009

Shout Outs

Teen Health 411 is this week's host of Grand Rounds. You can read this week’s edition here (photo credit).

Welcome to Grand Rounds 6.13 and blessings from Teen Health 411 for your holidays (the bizarre ones were provided by my teenagers) which may include: Hanukkah, Solstice, Boxing Day, Christmas, Kwanzaa, New Years, St. Lucia, National Date Nut Bread Day, Pumpkin Pie Day, International Children's Day, Go Caroling Day, Saturnalia, Humbug Day, Bathtub Party Day, National Noodle Ring Day, Eggnog Day, and Repeal Day (which FYI undid prohibition)!

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  H/T to @ctsinclair for the link to this story:  Hospice Santa volunteers face grief, kids' hard questions by Marcia Manna Special for, USA TODAY (photo credit)

A Santa Claus volunteer leans in for a girl who just received a candy cane at a hospice care center. John Scheuch, Santa-America's executive director, says these kids sometimes ask difficult questions. "I visited a 6-year-old who asked Santa, 'What is it going to be like when I die?' After a gulp and a deep breath I said, 'I don't really know, but I do know you will not be hurting or in pain anymore and that can only be more pleasant.' Then we spoke of other things."

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H/T to @ChrisCoppola for this amazing story from the LA Times:  Wounded soldier's shattered pancreas gets replaced in a whole new way

On Tuesday, Dr. Camillo Ricordi, director of the University of Miami's Diabetes Research Institute, told the story of a long-distance islet cell transplant …... The transplant involved flying Porfirio's shattered pancreas — now removed — from an operating room at Walter Reed Army Medical Hospital in Washington to Ricordi's specialized laboratory, more than 1,000 miles away, at the University of Miami's Miller School of Medicine. ………

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Interesting article from WSJ Health Blog:  How to Create More Organ Donors: Sweeten the Deal  by Jacob Goldstein

Getting more people to become organ donors would save lives, but driving up the number of donors is tough.

Israel, which has an unusually low rate of organ donation, is about to try a new tack. Starting next year, people who volunteer to donate their organs when they die will be higher on the waiting list if they ever need a transplant.

There are lots of details (see below), but the basic idea here is interesting. …………

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Jessica, Endless Knots, wrote a nice post:  Self and non-self: Voices of MS and in a follow-up post reports that the edition has sold out.  Here is a short segment from the first post:

It's not easy to write about illness. Writing "Feeling Numb," my essay, which originally appeared in Ars Medica and whose excerpt appears in this volume, was the second most difficult writing I can remember (the most, my mother's eulogy). I never wanted to write about it, recalling the details too painful, waiting for the words to come close to excruciating, but, at a friend's urging, I forced myself. When the first draft was done, written by hand, itself a departure from nearly everything I've ever written, I put it in a pile of unfinished material (now about a foot tall) and tried to forget about it……

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A good post from David Gorski, Science-Based Medicine , discussing the risks/benefits of medical imaging:  Radiation from medical imaging and cancer risk.

……..However, if there’s one area where even physicians tend to forget that there is potential risk involved, it’s the area of diagnostic tests, in particular radiological diagnostic tests, such as X-rays, fluoroscopy, computed tomography (CT) scans, and the variety of ever more powerful diagnostic studies that have proliferated over since CT scans first entered medical practice in the 1970s. …….

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Doc Gurley gives us her 3rd Annual Guide Homeless Gift Guide:

with tips for how you too can safely give an affordable, life-saving gift to the neediest among us. Because when it comes to the homeless, that's when, truly, The Giving Is Easy. And once you see how simple and rewarding it can be to drop a gift with a homeless person, be sure to pass the word along. Email friends, post your efforts on Facebook or MySpace. Put together gifts to have in your car for those awkward moments when you're waiting at an intersection, staring at a scrawled "anything helps, even a smile" cardboard sign. It will change the whole tenor of your life.

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There will be no Dr Anonymous’ show this week.  You may want to listen to 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

Monday, December 21, 2009

i-Surgery Notebook App Review

Thanks to Vijay for suggesting I do a review of this rare iPhone app for surgeons:  i-Surgery Notebook

@scanman RT @rilescat: A rare find! An iPhone app for Surgeons http://bit.ly/58MtJR - Maybe @rlbates will review it?

The app was developed by Justin Steullet.  It has been available at iTunes since October 28, 2009.  There are six reviews on iTunes as of this writing which range from “don’t buy this app it’s fatally buggy” to “nice app” to “good, not great yet.  would like to be able to add categories:  ie tourniquet time, implants used, and coding (ICD-9/CPT)”  The app costs $$4.99 but is currently on sale for $2.99.  I paid for mine.

I added the app this past week and have played around with it enough to decide on several good and weak points from my standpoint.   All the screenshots come from here.

After signing into the app, it is fairly simple to add a case.  It has crashed on me twice.

I like that as I have added the names of my hospitals/surgery centers they become a menu choice rather than needing to enter the name each time.

I like that the same happens with procedure choices, but wish that it did for the diagnosis.  It would be nice to have the ICD-9/CPT codes available.

I wish that you could add more than one diagnosis and assign the corresponding diagnosis to the correct procedure when more than one thing is done for a patient on the same day.  For example, a patient with breast ptosis who has a mastopexy but during the same encounter she has two moles removed from her face.  The only way I see to do this is to enter the patient twice with the correct diagnosis for each single procedure.

I wish the default for Emergency was no rather than yes.  There is a notes section which I used for implant type used and implant volume  (RT/LT).  I, also, used this for Tumescent volume used in liposuction along with fat aspirated.  It’s good enough for me that there is a note section for those, but if I wanted that info to be a searchable database then it wouldn’t be.

I wish there was a way to edit information once you have “saved” it for that patient.  For instance, I didn’t add anything under “service” as it’s just me in my solo practice.  That turns out to be one of the options in exporting cases, so I went back to add one like “plastics” and was unable to do so.

Because there is no way to edit the information, I would suggest you make sure you have time to get it all entered without interruption or the information will be incomplete and you won’t be able to correct it.  Editing should be allowed.  After all this is notebook to aid in dictation or billing, not a medical record.

Exporting is not completely intuitive, but turned out to be easy once I played around a little.  To export all the cases rather than just one procedure type for the day or week, you need to select the date and then hit export.  Don’t bother with filling in all the options, just the date >>export.  The information will be sent via email.  It would be nice if it was sent in the form of an Excel spreadsheet.  Still it would be useful to get information to your billing person. 

 

I did not try the photo section, but have feedback from a twitter acquaintance @gastromom who did:

@rlbates Review of #Isurgeon notebook. Needs a lot of work. Photo did not show up. I see potential though. Love to help customize for GI.

A previous tweet from her:

@rlbates Just downloaded the Isurgery app for the iPhone. So far,crashed twice. If it works it will be perfect for GI... Update tomorrow:)

 

Overall, I think it is a useful app with potential.  Good, not great.

Sunday, December 20, 2009

SurgeXperiences 313 – Call for Submissions

There is no host for SurgeXperiences 313 (December 27th) yet, but don’t let that keep you from submitting your posts.   The deadline for submissions is midnight on Friday, December 25th.  Be sure to submit your post via this form

If you would like to be the host  for SurgeXperiences313 or a future edition, please contact Jeffrey who runs the show here.

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.

Friday, December 18, 2009

"This One's For Me"

I love Baltimore Album Quilts but am more of a piecer than appliquér when it comes to quilting. I found some fabric in the remnant bind at JoAnne’s years ago that was a pre-printed Baltimore Album panel. There were seven or eight whole blocks and some partial blocks in the piece. I machine pieced the six best blocks together with sashing, then hand quilted it.

I then entitled this “cheater” Baltimore Album Quilt “This One’s for Me”. I even embroidered it on the label along with the date I finished it. The quilt is 52 in X 68 in. It resides on my couch.

Here is a close up view of one of the blocks.

Here is a close up of another of the blocks.
Here is a view of the back of the flowers and vase block to show the quilting. I treated the blocks as if they were true Baltimore Album blocks and quilted around each leaf, each flower, etc.

For more information on Baltimore Album Quilts:

Thursday, December 17, 2009

Chest Wall Contouring in Female-to-Male Transsexuals

I’ve been in solo practice for 19 years. I’m getting ready to do my first female-to-male (FTM) chest wall contouring. [Yes, I told the patient he was my first FTM though not my first mastectomy.]

I recalled having seen the fifth referenced article below and used it’s bibliography to find other articles which gave me nice tips on the “male” chest.  Here is the algorithm I scanned in from the fifth article.

In the normal female mastectomy, the inframammary fold is maintained. In the FTM chest-wall contouring mastectomy it is not. In the 5th article, it is explicitly pointed out: “The inframammary fold is always released, and this is an especially important maneuver for patients with large breasts.” Also,

Regardless of the technique chosen, we feel it is extremely important to preserve all of the subcutaneous fat when dissecting the glandular tissue from the flaps. This ensures thick flaps that produce a pleasing contour and do not subsequently become tethered to the chest wall. For the same reason, we preserve the pectoralis fascia and definitely do not perform liposuction at the anterior aspect of the breast. However, the judicious use of liposuction can occasionally be indicated laterally or to attain better symmetry at the end of the procedure.

Information on the male nipple gathered from the 4th reference below:

Measurements on the configuration of the nipple-areola complex revealed that 91 percent of the complexes were oval and only 7 percent were round.

Describing the localization of the nipple-areola complex on the thorax by various measurements, the average distance from sternal notch to nipple was 20 cm. The average horizontal distance from the midsternal line to the nipple was 11 cm and the average distance from the sternal notch to the xiphoid was 20 cm. (photo scanned in from 2nd article below)

Our results concerning the localization of the nipple with respect to the intercostal space showed that most of them were located in the fourth or the fifth intercostal space.

Our findings in a European population showed a slightly smaller nipple-areola complex, with a mean diameter of 23 mm for round complexes and 27:20 mm for an oval complex.

Marking tips for the concentric circle technique from the 2nd referenced article:

The vertical excess of skin is determined by comparing the distance (“ground” distance, not “air” distance) from the inframammary crease to a horizontal line 4 inches below the middle of the clavicle. This measurement is made over the fullest portion of the breast, and it is compared with the corresponding vertical distance measured over the sternum. The difference between these measurements, added to the diameter of the areola, determines the vertical height of the larger (outside) “circle.”

The horizontal excess of skin is determined by comparing the “ground” distance from the lateral border of the sternum to the anterior axillary line over the fullest portion of the breast with the corresponding horizontal distance at the level of the inframammary crease. The difference between these measurements, added to the diameter of the areola, equals the horizontal width of the larger (outside) “circle.”

The smaller (inside) circle is the periphery of the areola. The larger “circle” is placed concentrically outside the areolar circle.

If he allows, I’ll let you know how it all turns out as he heals.

REFERENCES

1. Chest-wall Contouring in Female-to-Male Transsexuals: Basic Considerations and Review of the Literature; Plastic. Reconstr. Surg. 96(2):386-391, August 1995; Hage, J. J. and Bloem, J. J.

2. Concentric circle Operation for Massive Gynecomastia to Excise the Redundant Skin; Plast. Recontr. Surg. 63(3):350-354, March 1979.; Davidson, B. A.

3. Transareolar Incision for Gynecomastia; Plast. Reconstr Surg. 38(5):414-419, November 1966; Pitanguy, I.

4. Configuration and Localization of the Nipple-areola Complex in Man; Plast. Reconstr. Surg 108(7):1947-1952, December 2001.; Beer, Gertrude M.; Budi, Srecko; Seifert, Burkhardt; Morgenthaler, Werner; Infanger, Manfred; Meyer, Viktor E.

5. Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm; Plast. Reconstr. Surg 121(3):849-859, March 2008; Monstrey, Stan; Selvaggi, Gennaro; Ceulemans, Peter; Van Landuyt, Koen; Bowman, Cameron; Blondeel, Phillip; Hamdi, Moustapha; De Cuypere, Griet

Wednesday, December 16, 2009

“A Day in the Life”

I was going to include this yesterday in my “Shout Outs” but was afraid it would get lost in the middle of it all.  The blog, Mothers in Medicine, has done a topic week devoted to “a day in the life.”  The posts have been amazing! 

I included a couple written before the official topic week.  Here is a list.  Enjoy!

Tuesday, December 15, 2009

Shout Outs

Florence dot com is this week's host of Grand Rounds. You can read this week’s edition here (photo credit).

Welcome to this holiday edition of Grand Rounds! It's the time of year when friends and family gather, when stories are told and memories are made. But the winter weather and short days here in the northern hemisphere seem to prompt brevity in our everyday comings and goings. It seems like the right time to combine storytelling and brevity and channel Charlotte, one of the most masterful storytellers I met during a childhood spent with my nose in a book…………..

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 11) !   It is the “Light” edition.  You can find the schedule and the COS archives at Emergiblog. (photo credit)

That had to be the fastest two weeks on record!

It’s time for another Change of Shift!

There is some rumor going around that a holiday is coming up, but the only decorations around here consist of APA handbooks and nursing texts.

Apparently the nurses of the blogosphere are all busy, because this week it’s Change of Shift “Light”! You know, like those little 100 calorie packs of snacks you love? Well think of this as a 100 calorie Change of Shift!

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MedGadget presents the 2009 Medical Sci-Fi Contest: Please Meet the Stories!  These are very good!

1.  HeartPlus by Evan Perriello

2.  Mars Rescue by James H. Dawdy

3.  What’s More Affordable than Free? by Hans Patrick Griesser

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H/T to @dermdoc for the link to this NY Times story:   Shaving the Head of a Cancer Patient written by nurse by Theresa Brown.

It was a slow day on the floor and my patient, whose hair was falling out from chemo, had just asked me to shave his head.

“Sure,” I said, even though, despite the two years plus I’ve spent in oncology nursing, I had yet to shave anyone’s head……….

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H/T to @ChrisCoppola for the following tweet which links to the Military Pathways Screening Program for PTSD

PTSDConference RT @militarypathway Only 51% of OIF/OEF vets w/ reported symptoms of PTSD have sought treatmnt (Tanielian & Jaycox, 2008) http://tr.im/FBoU about 15 hours ago from Twitterrific

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Over the past three years as a charity partner for the NYC Half-Marathon, The Fresh Air Fund and its 210 Fund-Racers have raised more than $300,000!  They are looking for fund-racers for the 2010 NYC Half-Marathon which will take place on March 21st.  If you'd like to get involved with the race in any way, please email kbrinkerhoff@freshair.org.  (photo credit)

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I love orgami, so this piece last week on NPR caught my “eye (or rather ear)”:  Orgami Unfolded.  Another NPR article also discusses, shares video and photos of the art:  The Most Exciting New Art Medium: Paper.  If I get a chance, I’d love to watch the show:  Between the Folds.

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The winner in the US Healthcare Reform Photoshop Contest is  "Elisabeth."  She received an 8Meg iPod Touch.

Polling for the favorite finalist stopped at 11:59 PM on 11 Dec 2009 and, like American Idol, the blog-o-sphere tallied the most votes for "Taking Care of the Healthcare Pest," submitted by "Elisabeth" of Peidmont Healthcare.

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There is no guest listed for the Dr Anonymous’ show this week, but don’t let that keep you from joining us.   The show is Thursday night,  9 pm EST.

You may also want to listen to 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

Monday, December 14, 2009

Skin Cancer: More than Skin Deep – an Article Review

It’s winter so why think about skin cancer?   One of the major risk factors is UVA and UVB rays from sun exposure which is much more common in the summer.  Tanning beds never cease being used, regardless of season and may even be used more in the winter than summer.

There is never a wrong season to be reminded of the prevalence of skin cancer or the risk factors for skin cancer or ways to prevent skin cancer.

Having read this short article (full reference below) in the “throw away” December issue of the journal Advances in Skin & Wound Care it seemed a good time to again discuss skin cancer.  The article is a good overview of skin cancer which is the most common carcinoma in the United States.  The article quotes statistics from the American Cancer Society:

Statistics show that 1 in 5 Americans and 1  in 3 whites will develop skin cancer in their lifetime; 1 person dies of melanoma almost every hour.

The American Cancer Society (ACS) predicted an excess of 1.1 million new cases of cutaneous malignancy ending in 11,200 deaths in 2008.

The ACS predicted 62,480 new melanoma cases diagnosed in the United States in 2008, resulting in 8420 deaths.

The article gives a brief overview of skin changes seen with Actinic keratoses (AKs), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM).

Actinic keratoses are precancerous or precursor lesions to 10% of SCCs.

Scaly lesions on sun-exposed skin that do not respond to moisturizers, itch, or bleed with minimal provocation need medical attention. The length of time for an AK to progress to an SCC can be as early as 24.6 months.

Basal cell carcinoma (BCC) represents 65% to 75% of all skin cancers.  Most occur on sun-exposed parts of the face, ears, scalp, shoulders, and back.   Intense short-term UVB exposure is important in the formation of BCC.

Clinical features include pearly translucent flesh-colored papules or nodules with superficial telangiectasias (broken blood vessels). More active lesions may have rolled edges or ulcerated centers.

Squamous cell carconoma (SSC) represent 30% to 65% of all cutaneous malignancies.  SCCs are most attributable to UVB exposure, long-term or accumulative exposure over years.

Clinical features include crusted papules and plaques that may become indurated, nodular, or ulcerated. SCC may arise in chronic wounds, scars, and leg ulcers.  Recurrent SCC development within 3 years is 18%, a 10-fold higher incidence compared with initial SCC diagnosis in the general population.

Malignant melanoma (MM) represents the most serious of all cutaneous malignancies.  It is estimated that approximately 65% to 90% are caused by UV exposure, predominantly UVA.  Roughly 10% of all melanoma cases are strictly hereditary.

The ABCD rule outlines the clinical presentation and warning signals of the most common type of melanoma.

"A" is for asymmetry (one-half of the mole does not match the other half);

"B" is for border irregularity (the edges are ragged, notched, or blurred);

"C" is for color (the pigmentation is not uniform, with variable degrees of tan, brown, or black);

"D" is for diameter greater than 6 mm (about the size of a pencil eraser).

Some clinicians now include "E" regarding evolution, elevation, or enlargement of a lesion

The article very briefly touches on management, but devotes more space to prevention and need for continued education of the public.

A key determinant of skin cancer in adulthood is the exposure to UV as a child. Sun protection messages should be linked with other health promotion messages targeting children

Prevention Tips:

  • Children should be taught the correct use of sunscreen.
  • Select a product that contains the highest allowable percentage of zinc oxide (25%) and titanium dioxide (25%). Both do not undergo significant chemical change or photodegradation with exposure to UV light. Avobenzone (3%) is the only truly effective UVA absorber available and offers the greatest photostability.
  • Sunscreen should be applied to all exposed skin at least 20 minutes before going into the sun, even if it is cloudy outside, and needs to be reapplied every 2 to 3 hours or more frequently if swimming or exercising.
  • Use at least 1 oz per application, roughly equivalent to the volume of a shot glass.
  • Everyone needs to wear a hat and sunglasses with 99% to 100% UVA absorption.
  • Patients should be instructed to avoid exposure between the hours of 10 AM and 4 PM when the sun is the strongest, wear sun-protective clothing, and seek shade whenever possible.
  • There is no such thing as a safe tan.  This includes those gotten in tanning salons.

Related posts:

Sun Protection (March 19, 2009)

Melanoma Review (February 25, 2008)

Skin Cancer—Melanoma (December 8, 2008)

Melanoma Skin Screening Is Important (April 29, 2009)

Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)

Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

Moles Should Not Be Treated by Lasers  (July 27, 2009)

Tanning Beds = High Cancer Risk (August 3, 2009)

 

 

REFERENCES

Skin Cancer: More than Skin Deep; Advances in Skin & Wound Care. 22(12):574-580, December 2009.; doi: 10.1097/01.ASW.0000363470.25740.a2; Gordon, Randy M.

Sunday, December 13, 2009

SurgeXperiences 312 is Up!

Steve, Adventures of a Funky Heart, is the host of this edition of SurgeXperiences.  Here is the beginning of this edition which you can read  here (photo credit)

We open this edition of SurgeXperiences with an explanation and an apology: Apparently the software behind Blogcarnival.Com – the company that gathers submissions and forwards them to the carnival host – had a hiccup and vaporized all of the SurgeXperiences submissions.

So most of the posts that appear in this edition were selected from the blogs that appear on Jeffery Leow’s blogroll. If you sent in a submission and it does not appear here, I apologize. And if you did not submit, or submitted something else, again I apologize.

The host of the next edition (313) has not been announced, but don’t let that keep you from making your submissions.  The deadline for submissions is midnight on Friday, December 25th. 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.

Friday, December 11, 2009

Sampler Quilt in Blue, Green, and White

This sampler quilt began as a way to do something with three of the blocks I had made over the years for various projects and not used. Those three blocks are (#2, #8, #11). More recently were the left over autograph blocks which I used in 9-patch blocks #5, #10, and #12.

Blocks #1 and #9 are rail fence blocks using up strips of blue fabrics. Blocks #2, #6, and #7 are Ohio star blocks with working pockets as the centers. Blocks #4 and #11 are shoo fly blocks.

The quilt is 51 in X 65.5 in. It is machine pieced and quilted. I have given it to a friend’s mother.

I used a navy blue fabric for the back and the sashing. I decided (still not sure if it was a bold move or dumb as minor mistakes show up easily) to use a light gray thread in the bobbin so the quilting would show on the back. The next two photos show the front block and the corresponding back.

I love to recycle pockets into quilts. The Ohio star block is a nice one for showing off the pocket. I had to tie the center of the pocket area so the pocket would still function.

This back photo shows the quilting of #11 block.

Thursday, December 10, 2009

Microcystic Lymphatic Malformations of the Tongue – an Article Review

I stumbled across this article while previewing JAMA & Archives CME articles (full reference below). The article gives an overview of lymphatic malformations, noting that both sexes are equally affected, and there is no predilection for any race.

Lymphatic malformations are vascular malformations with an unknown cause. They are estimated to make up 6% of all benign soft-tissue tumors in children. While they may be rare, 50% of all lymphatic malformations are already obvious at the time of birth. Most (90%) are diagnosed by the end of the second year of life owing to clinical symptoms.

About 60% of all lymphatic malformations are found in the head and neck region. Regarding the mouth, the tongue is most commonly affected.

When the malformations occur in the tongue, the symptoms may include hemorrhage, excessive salivation, speech disturbances, difficulties chewing and swallowing, airway obstruction, and orthodontic abnormalities such as mandibular prognathism and malocclusion. Functional impairment and cosmetic deformity significantly affect the quality of life of patients with lymphatic malformations of the tongue.

Along with the overview, the authors present the review of their patients between January 1, 1998, through December 31, 2008, with respect to age and sex distribution, symptoms, clinical presentation, management, treatment outcome, and follow-up.

Twenty patients (13 male and 7 female) with microcystic lymphatic malformations of the tongue were included in the evaluation. Their ages at initial presentation ranged from newborn to 20 years (mean age, 7.4 years). Thirteen of them had been treated at another hospital before the initial presentation at our department. The treatment methods included surgical reduction, laser therapy, corticosteroid therapy, and OK-432 (Picibanil; Chugai Pharmaceutical Co, Ltd, Tokyo, Japan) injections.

The authors present the classification of lymphatic malformations (photo credit)

  • Isolated superficial microcystic lymphatic malformations of the tongue (stage I)
  • Isolated lymphatic malformations of the tongue with muscle involvement (stage II; stage IIA, involving a part of the tongue; stage IIB, involving the entire tongue)
  • Microcystic lymphatic malformations of the tongue and the floor of mouth (stage III)
  • Extensive microcystic lymphatic malformations involving the tongue, floor of mouth, and further cervical structures (stage IV)


The article discusses treatment options:

In the present series of patients with microcystic lymphatic malformations of the tongue, it was possible to perform complete excision with a CO2 laser in all patients with stage I disease and in 3 patients with stage IIA disease. …….. The advantages of the CO2 laser compared with conventional surgery include less postoperative edema, tissue trauma, and blood loss……... For stages I and IIA microcystic lymphatic malformations of the tongue, CO2 laser surgery seems to be an excellent curative treatment option. In stages IIB, III, and IV disease, CO2 laser surgery seems to be useful as a part of a combined or staged approach.

Other treatment modalities discussed include radiofrequency ablation, sclerotherapy (specifically OK-432 injections), and other surgical options, including wedge resection, bilateral marginal resection, U-shaped resection, and Jian or Dingman glossectomy.

Treatment of infected cysts before surgery:

The combination of antibiotics and short-duration systemic corticosteroids usually leads to a reduction of symptoms and a decrease of swelling and inflammation as described in patient 2.

I think the article is well written and well worth reading.

REFERENCE

Microcystic Lymphatic Malformations of the Tongue: Diagnosis, Classification, and Treatment; Arch Otolaryngol Head Neck Surg. 2009;135(10):976-983; Susanne Wiegand, MD; Behfar Eivazi, MD; Annette P. Zimmermann, MD; Andreas Neff, MD, PhD; Peter J. Barth, MD, PhD; Andreas M. Sesterhenn, MD, PhD; Robert Mandic, MD, PhD; Jochen A. Werner, MD, PhD

My post: Vascular Birthmarks (July 15, 2007)

Wednesday, December 9, 2009

Help Fight the BoTax: Send Your Senator a Letter

I am against the Cosmetic Surgery Tax (or BoTax). I feel it is an unfair tax which will heavily affect women more so than men. It will also affect many more in the middle class than in the wealthy class. I’d like to join the Aesthetic Society and all of organized Plastic Surgery in fighting this unfair tax.

For more on how the tax is a bad idea, check out this article Breast-Enlargement Tax That Failed in Jersey Taints U.S. Plan by Nicole Gaouette over at Bloomberg.com (H/T to Jeff Frentzen, PSP Blog)

”It was a real education,” said Cryan, a Democrat who now wants the levy repealed, in a telephone interview. “We essentially discouraged the business from happening at all.”

Susan Hughes, a Cherry Hill, New Jersey, facial surgeon, said her business dropped by 10 percent when patients began crossing the state line to Pennsylvania. Administering the tax strained relationships with patients, and created extra work and costs for her office, she said.

‘You Idiots’

“We become the tax collector,” Hughes said in a telephone interview. “Now you’re going to repeat that on a national level? You idiots!” Hughes’s office manager, Jaime Castle, said she’s also concerned about layering the taxes, making New Jersey residents pay a combined 11 percent. ………….

The following is the template for a letter that patients can use to express their opinion and dissent toward the proposed cosmetic surgery tax:

Dear Senator ______,

HEALTHCARE PLAN IN THE SENATE WILL UNFAIRLY DISCRIMINATE AGAINST US!

I am writing you today about an issue that affects everyone who utilizes plastic surgery services for anything from Botox to Tummy Tucks.

The healthcare bill approved by the US Senate this weekend, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act.

This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.

The problem is that we would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. This Bill is objectionable in many ways, including:

· This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women

· This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. We working women, soccer moms, and scores of others who carefully save and budget to improve our appearance and self esteem will be penalized for doing so.

· Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well.

· Our doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. That is not the relationship we want with our medical provider!

Please, do not allow this portion of the tax bill to pass!

Sincerely,

______________________

You can find your elected representative by clicking here.

Tuesday, December 8, 2009

Shout Outs

Nuts for Healthcare is this week's host of Grand Rounds. You can read this week’s “Broadway” edition here.

I’m excited to be hosting Grand Rounds this week and feel refreshed to read all the submissions and stories that came my way. Health care has always been a deep, personal passion of mine, as I continue to be both a student and voice in the various ways that the field is taking shape today.

Another passion of mine is the music and fanfare, dramaturgy and razzle-dazzle of Broadway theatre. …

And then I thought: why not make this edition of Grand Rounds an intersection of my two favorite things? So let me raise the curtains

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Medgadget discussed the Lancet article on Scientists Grow Skin Tissue in Preclinical Study. Their discussion includes the Lancet podcast discussing the research with two of the study authors, Marc Peschanski MD and Dr Christine Baldeschi PhD.

A team of researchers from France and Spain managed to grow complete human skin epidermis from skin-derived stem cells on laboratory mice. The finding could lead to the rapid production of one's own skin patches for people with burns and other severe skin problems.

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Chris, Life in the Fast Lane, wrote about A Philosophical Death with a video of Simon Critchley’s lecture. Good listening!

When pondering death I sometimes wonder how the great philosophers faced death, and what we the living might learn from them…

We need wonder no more.

Listen to ‘From Cow Dung to Poison: A History of Philosopher’s Deaths’, an excerpt of a longer talk by Simon Critchley titled ‘To Philosophize is to Learn How to Die‘ (hat tip to Berto: Philosophy Monkey).

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H/T to @amednews for the following tweet/link (above photo credit):

RT @PSeditor RT @HospitalSafety: Advice about allowed holiday decorations in hospitals http://bit.ly/Q4mhJ

The article gives these tips for safe holiday decorating in hospitals/offices:

There are certainly simple things you can do:

  • No “gift-wrapping” of corridor doors
  • No hanging ornaments or other stuff from sprinkler heads
  • Limited amounts of lighting (one or two strings, UL approved, etc.)
  • No fresh-cut live stuff
  • Nothing that obstructs egress

And as a reminder, you can download a free holiday decoration monitoring checklist at the Hospital Safety Center.

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Check out @headmirror's radio essay -- The Christmas Letter: WUWM: Lake Effect - Thursday December 3, 2009

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It’s time to vote for the winner in the US Healthcare Reform Photoshop Contest. Winner will receive an 8Meg iPod Touch.

Okay, the entries for the 2009 US Health Care Reform Photoshop Contest are in and it's time to vote! The idea was to create a single picture using your snark, your wit, your creativity to encapsulate your feelings about the US Health Care Reform efforts underway in a single photograph.

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Isn’t this dog sweater adorable? cal patch shared a tutorial on “ How to Make a Recycled Dog Sweater” over at CraftStylish (photo credit)

Refashioning old or thrifted sweaters into dog sweaters is easy and fun. You'll be amazed at how even the ugliest sweater can take on a whole new look as canine couture! Case in point: this vest. I picked it up at the thrift store because the details in the knit are adorable, but this style would flatter no human! My little Gertie, on the other hand, will look smashing in it.

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There is no guest listed for the Dr Anonymous’ show this week, but don’t let that keep you from joining us. The show is Thursday night, 9 pm EST.

You may also want to listen to 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