Chinese Boy with 31 Fingers and Toes

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.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

Daily Mail ran a story recently on a Chinese boy, 6, who was born with 31 fingers and toes (15 fingers and 16 toes).  The story reporting on the child having surgery to correct the congenital anomaly.  (photo credit)

Polydactyly is a condition in which a person has more than five fingers per hand or five toes per foot.  Rarely is it more than one or two extra.  Polydactyly  occurs in approximately 1 out of every 1,000 births. Usually, only one hand is affected.

In the hand, the extra digit(s) may be located on the thumb side  (radial), the small finger side (ulnar), or in the middle (central). 

In the black population an extra finger on the little finger side (ulnar polydactyly) is most common. The most common congenital hand difference in the Asian population is an extra thumb (radial polydactyly).

Central polydactyly is inherited as an autosomal dominant condition with variable expression, meaning that it may be more or less severe from one generation to the next.

This young Chinese boy’s extra fingers were located centrally and the skin fused together (syndactyly).  This is much more rare than either radial or ulnar polydactyly.  (photos credit)

In Memory of Robert M Goldwyn, MD

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.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

I signed onto the Plastic and Reconstructive Surgery website this morning to look up an article and found this tribute to Robert M. Goldwyn, MD who served as Editor-in-Chief of Plastic and Reconstructive Surgery from 1979 to 2004, died on Tuesday, March 23, 2010.   I was privileged to meet him while doing my plastic surgery residency in Boston.  He and the head of my program (Dr. Gaspar Anastasi) were friends.  He was a giant in the field of plastic surgery who will be missed.

 

Please join us in remembering Dr. Goldwyn by reading his collected editorials, immortalized in the pages of PRS and gathered together in October 2004 in a special supplement.

In 2004, the supplement of editorials by Dr. Goldwyn and tributes by a few of the people who had been close to him represented a small token of appreciation. Today, the supplement will serve as an enduring tribute to a wonderful scientific journal editor, physician, role model and friend.

The supplement is complimentary and only available online at PRS.

25 Years of Selected Editorials by Robert M. Goldwyn, MD

Join PRS in the weeks and months to come for further tributes to Dr. Goldwyn.

From PRS October 2004 - Volume 114 - Issue - p v
Biographical Note:  Robert M. Goldwyn, M.D

Robert M. Goldwyn was born in Worcester, Massachusetts, in 1930. He attended Worcester Academy, Harvard College (A.B., 1952; Phi Beta Kappa, Magna cum Laude), and Harvard Medical School (M.D., 1956).

He did his internship and residency in general surgery at the Peter Bent Brigham Hospital in Boston from 1956 to 1961. During this time he was the Harvey Cushing Fellow in Surgery at the Peter Bent Brigham Hospital. In 1960, he worked with Dr. Albert Schweitzer in Lambarene, Gabon.

His plastic surgical training was at the University of Pittsburgh Medical Center from 1961 to 1963. He returned to Harvard Medical School and became Senior Surgeon at the Peter Bent Brigham Hospital and at the Beth Israel Hospital, where he was Chief of the Division of Plastic Surgery from 1972 to 1996. Since 1979, he has been the Editor of Plastic and Reconstructive Surgery and has authored or co-authored more than 300 articles and has edited several books: The Unfavorable Result in Plastic Surgery: Avoidance and Treatment (now in its third edition), Reconstructive Surgery of the Breast, Long-Term Results in Plastic and Reconstructive Surgery, and Reduction Mammaplasty.

He has written The Patient and the Plastic Surgeon (two editions) and The Operative Note, a collection of his editorials, as well as a book for the general public: Beyond Appearance: Reflections of a Plastic Surgeon. With J. Saxe as translator, he wrote an introduction to G. Baronio's Degli Innesti Animali, 1804 (On Grafting in Animals). He also wrote the introduction for the first complete English translation by J. H. Thomas of G. Tagliacozzi's De curtorum chirur-gia per insitionem, 1597 (On the Surgical Restoration of Defects by Grafting, a facsimile edition).

Dr. Goldwyn has served as President of the Massachusetts Society of Plastic Surgeons, the New England Society of Plastic Surgery, the American Association of Plastic Surgeons, which made him an Honorary Fellow, and the Harvard Medical Alumni Association.

In 1972 he founded the National Archives of Plastic Surgery, housed at Harvard Medical School, and has since served as Chairman of the Archives Committee of the Plastic Surgery Educational Foundation.

He was a founding member of Physicians for Social Responsibility and has written articles on world peace, opposition to chemical and biological warfare, and medical ethics.

He has been Visiting Professor to more than 70 institutions, universities, and hospitals in this country and abroad and is an honorary member of more than a dozen national and international societies of plastic surgery. His other awards include the Dieffenbach Medal, the Honorary Kazanjian Lectureship, Clinician of the Year of the American Association of Plastic Surgeons, and the Special Achievement Award and the Presidential Citation of the American Society of Plastic and Reconstructive Surgeons. He has received numerous recognitions for his teaching and writing.

 

More information on this amazing man:
Boston Globe Obituary
Leonardo’s Hand – Dr. Robert Goldwyn

Keeping Patients Warm Perioperatively

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

Last week I read this article in the Medical Industry News written by Kaye Spector: Warm wakeup from surgery has roots with Cleveland doctor. I am impressed with this new patient gown that works with the Bair Hugger System (photo credit)

It would work well to pre-warm patients in the holding area. It would work well for facial, abdominal, or extremity surgery as shown in the photo. For chest case, perhaps it is possible to roll the gown downward covering the abdomen and legs. If not then the traditional lower-body Bair Hugger blanket could still be used.

If kept clean in the operating room, then it could be used in recovery to continue warming the patient there.

The 2006 article by Dr. Leroy Young on preventing perioperative hypothermia in plastic surgery patients is a very good article – well written, easy to read, covers the topic thoroughly. Here are the big suggestions for prevention given:

• Actively prewarm patients in preoperative area for approximately 1 hour with forced-air heating or resistive-heating blanket.
• Keep the ambient temperature of the operating room at a minimum of 73°F.
  
• Monitor core temperature throughout administration of general and regional anesthesia.
  
• Cover as much body surface area as possible with blankets or drapes to reduce radiant and convective heat loss through the skin.
  
• Actively warm patients intraoperatively with forced-air heaters or resistive-heating blanket to prevent heat loss and add heat content. Rearrange covers every time patient is repositioned to warm as much surface area as possible.
• Minimize repositioning time as much as possible so that the active warming method can be quickly continued.
  
• Warm intravenous fluids and/or infiltration fluids if large volumes are used. Warm incision irrigation fluids.
  
• Aggressively treat postoperative shivering with forced-air heater or resistive-heating blanket and consider pharmacologic intervention.

Perioperative hypothermia is associated with increased surgical site infections, slower wound healing, coagulation disorders, and increased bleeding. So it is very important to keep patients warm. It also makes them more comfortable, so improved hospital and surgeon ratings.

As the surgeon (and one with the occasional hot flash), I can tell you it is difficult to work in an OR with temperatures higher than 70°F. My fellow female colleagues (scrub nurses, circulating nurses, etc) at the surgery center I work most frequently often want the temperature even lower. It is a struggle to keep everyone happy and comfortable.

The article referenced below states

The minimum OR temperature recommended in the literature is 22°C (71.6°F), and most researchers agree that an ambient temperature of at least 23°C (73.4°F) is better. Sessler recommends an OR temperature of 25°C (77°F). One study by El-Gamal and colleagues determined that nearly all cases of perioperative hypothermia could be eliminated if OR temperatures were 26°C (79°F).

REFERENCES

Prevention of perioperative hypothermia in plastic surgery; Aesthetic Surgery Journal September 2006, Vol. 26, Issue 5, Pages 551-571; V. Leroy Young, Marla E. Watson

Shout Outs

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

Evan Falchuk, See First Blog, is this week's host of Grand Rounds.   You can read this week’s edition here.

Welcome to Grand Rounds – the health care blogosphere’s ultimate blog carnival.

This week’s version is something special.  I asked for posts only about health care reform, and I am overwhelmed by the response.  Below are the leading voices of the health care blogosphere.

It is the Mother of All Health Care Reform Blog Round-Ups.

So, evacuate the dance floor- you’re about to be infected by the sound of health care reform blogging.

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Nursing Student Chronicles  is the host of the latest edition of Change of Shift (Vol 4, No 19) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Howdy everyone! Welcome to Change of Shift, here for the very first time! And we’ve got a mini-party here today, just as promised.

So, domo arigato! How would you feel with a New Robotic “Coworker“? He speaks to you, moves around you, and even prefers to ride the elevator alone! He’s sitting at the Man-Nurse Diaries and he’s waiting to help you lift a saline bag or fifty.

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The Patient Protection and Affordability Act was signed into law last week.  Here are the parts that go into effect immediately (or more accurately within the first year).

Small Business Tax Credits
 Offers tax credits to small businesses beginning in 2010 to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. ….

No Pre-existing Coverage Exclusions for Children
 Prohibits health insurers from excluding coverage of pre-existing conditions for children. Effective six months after enactment, applies to all employer plans and new plans in the individual market. (This provision will apply to all people in 2014)……….

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NPR had a very interesting story (audio available) last week:  Former Bullies Share What Motivated Behavior.  Host Neal Cohen was joined by guests Aileen Dodd, education and family reporter for the Atlanta Journal Constitution and Rosalind Wiseman, author, Queen Bees and Wannabees. 

In Georgia, a young man killed himself because he could no longer endure his bullies. And in Mass., bullies left a 13-year-old paralyzed.

These cases and others like them have focused attention on bully behavior: Why do they do it, and do they change?

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 Dr. Gwenn covered the topic of bullies too:  Victims of Bullying Must Be Heard!!

You likely heard that Massachusetts is finally considering an anti-bullying law. It’s about time!

My kids have both been bullied over the years…have yours? It is one of the most challenging situations to handle in all of parenting and the dramatic increase in technology among today’s kids and teens and made bullying via technology a contributing factor. 25% of kids being bullied is too many already. 42% of kids being cyber-bullied is unthinkable…but is the estimated number being victimized via technology…….

In addition, Dr Gwenn has a series of BTR shows on the bulling topic.  Please, note part 2 & 3 are both upcoming.

Show 17: Bullys In Your Back Yard 1, Take 2! Stopping It Today!! (March 26, 2010)

Show 18: Bullying In Your Back Yard 2: Bully-Proofing Your LIfe  (April 1, 2010; 12 PM)
Show 19: Bullies In Your Back Yard 3: An Ounce of Prevention by Becoming Great Digital Citizens (April 9, 2010; 11 AM)

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I wish all of you could see the documentary aired by AETN last week on architect Fay Jones:  Sacred Spaces: The Architecture of Fay Jones.  (photo credit)

an Arkansas native who was in the first class of architecture students at the university, taught at the architecture school for 35 years and served as its first dean. In 2000, the American Institute of Architects named Jones one of the 10 most influential architects of the 20th century and recognized his Thorncrown Chapel as the fourth most significant structure of the 20th century.

You can take a virtual tour of his Thorncrown Chapel.  It is a breathtaking place.

Nestled in a woodland setting, Thorncrown Chapel rises forty-eight feet into the Ozark sky. This magnificent wooden structure contains 425 windows and over 6,000 square feet of glass. It sits atop over 100 tons of native stone and colored flagstone. The chapel's simple design and majestic beauty combine to make it what critics have called "one of the finest religious spaces of modern times."

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Another Little Quilt Swap (ALQS) 4  is now open to those who would like to participate.  For the complete rules and deadline (July 1, 2010) go here:

Unlike the ALQS3, Round 4 will allow all quilt types - traditional, modern, contemporary, art and any other designation you can think of.

All quilts should be roughly between 16"x16" and 24"x24". They do not have to be square, but the total area should be approximately the same.

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Dr Anonymous’ guests this week will be Psychiatric Social Worker Brandice Schnabel.  Come join us.

Upcoming Dr. A Shows (9pm ET)

4/22: DG & Tiffany Hollums and their adoption journey

Donating…..

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


The earth quakes.  Haitians suffer. 
The world tweets updates, texts donations, waits anxiously wanting to do more.
The woman extends her arm willingly, squeezing a fist in gentle rhythm as the life giving blood flows.



*** Found in my blog drafts, decided to go ahead and publish it. 

Bathing, a Source of Water Pollution from Medicines

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

I have written two posts in the past on proper disposal of unused medications.  I have always been mindful of the medicines as a source of environmental water pollution.

This past week the American Chemical Society reminded (head-slapped me) that topical medications are a source of environmental water pollution from their active pharmaceutical ingredients (APIs).   

Yes, the simple act of bathing washes hormones, antibiotics, and other pharmaceuticals down the drain into the water supply.

Ilene Ruhoy, M.D., Ph.D. and colleague  Christian Daughton, Ph.D. looked at potential alternative routes for the entry into the environment by way of bathing, showering, and laundering.  These routes may be important for certain APIs found in medications that are applied topically to the skin -- creams, lotions, ointments, gels, and skin patches.   These APIs include steroids (such as cortisone and testosterone), acne medicine, antimicrobials, narcotics, and other substances.

Ruhoy feels some APIs in topical medications have the potential of having a greater impact than those released in feces and urine.  Topical medications are un-metabolized and full-strength when washed off.  Those in feces and urine have been metabolized and are not full-strength.

APIs may go right through the disinfection process at sewage treatment plants, and enter lakes, rivers, and oceans.  Trace amounts of the active ingredients of birth control pills, antidepressants, and other drugs have been found in waterways. Some end up in drinking water – at extremely low, trace levels.

"We need to be more aware of how our use of pharmaceuticals can have unwanted environmental effects," Ruhoy said. "Identifying the major pathways in which APIs enter the environment is an important step toward the goal of minimizing their environmental impact."

Things you can do as a responsible citizen:

*  Use the topical prescription as directed, in the amount needed (more is not better, especially for the environment).

*  Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so.

*  To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take‐back programs or other programs, such as household hazardous waste collection events, that collect drugs at a central location for proper disposal.

*  Call your city or county government’s household trash and recycling service and ask if a drug take‐back program is available in your community.

 
Related posts
Unused and Old Medications (January 1, 2008)
Unused Prescription Medications (June 15, 2009)

 
Sources
American Chemical Society
American Pharmacy Association
White House Drug Policy

SurgeXperiences 320 – Call for Submissions

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

There is no scheduled host for SurgeXperiences 320 (April 4th), but don’t let that keep you from making your submissions.  If you would like to host edition #320 or any future editions, 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. You are encouraged to submit your surgery related posts.

The deadline for submissions to be included in the 320 edition is midnight on Friday, April 2nd.   Be sure to submit your post via this form.

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

Don’t Think So

Desires change to her abdomen.

Here for her third consultation in the past two years.

Worried about the drains, the scar, the pain, the recovery time.

“I have two weeks between trips here.   Can’t we schedule it then?”

“No, I don’t think so.  You’ll need more recovery time.”

Abstract Art Mini-Quilt

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

The inspiration for this miniature quilt came from feedly. When there is no photo in the blog post, feedly will use stock photos. I liked this abstract one and “saved” it on my posterous blog.  I enlarged the small feedly photo and printed it out. I then used freezer paper to make my pattern pieces.

I hand sewed the pieces together.

I used the back fabric to self-bind the quilt, creating a mitered border. The miniature quilt is 13 in X 9.75 in. It is hand quilted.
The back has a 4 in sleeve sewn for hanging the quilt. 

The Barbie Syndrome

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

Interesting article in the Huffington Post last week by Dr. Glenn D. Braunstein:  Oh, You Beautiful Doll: Plastic Surgery Risks and Rewards.  The article discusses the “Barbie Syndrome” or more accurately “Body Dysmorphic Disorder.”   I love this line

And, finally, try to have realistic expectations--it is unlikely that cosmetic enhancement is going to drastically change your life--after all, you are human, and not a plastic doll.

The article reminded me of my post Suitability.  Not all patients should have surgery.  Their reasons for desiring surgery, goals, and expectations should be discussed during the consultation.  Risks and benefits must be weighed.

 

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.

Skin Cancer

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

The entire March issue of Archives of Dermatology appears to be dedicated to skin cancer – non-melanoma and melanoma. 

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 carcinoma (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).

Prevention Tips:

• Children should be taught the correct use of sunscreen.   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.
• 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.
• Everyone needs to wear a hat and sunglasses with 99% to 100% UVA absorption.
  
• Exposure should be avoided between the hours of 10 AM and 4 PM when the sun is the strongest.  Sun-protective clothing and shade are helpful in avoiding exposure.
  
• There is no such thing as a safe tan.  This includes those gotten in tanning salons.
  

Recent News Stories

Non-Melanoma Skin Cancer Cases Jump:  Dr. Jennifer Ashton Discusses Most Common Cancer, Risk Factors, When to Go to the Doctor

Skin Cancer Epidemic?  -- Dr Sanjaya Gupta, CNN

 

Melanoma Related News:

A mother's inspirational skin cancer battle By Jane Elliott, Health reporter, BBC News

Katie’s Fight  -- the blog of the woman featured in the BBC story

Related blog 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
Incidence Estimate of Nonmelanoma Skin Cancer in the United States, 2006; Arch Dermatol. 2010;146(3):283-287; Howard W. Rogers; Martin A. Weinstock; Ashlynne R. Harris; Michael R. Hinckley; Steven R. Feldman; Alan B. Fleischer; Brett M. Coldiron
Increased Risk of Second Primary Cancers After a Diagnosis of Melanoma; Arch Dermatol. 2010;146(3):265-272.; Porcia T. Bradford; D. Michal Freedman; Alisa M. Goldstein; Margaret A. Tucker
Economic Burden of Melanoma in the Elderly Population: Population-Based Analysis of the Surveillance, Epidemiology, and End Results (SEER)–Medicare Data; Arch Dermatol. 2010;146(3):249-256; Anne M. Seidler; Michelle L. Pennie; Emir Veledar; Steven D. Culler; Suephy C. Chen

$250,000 for Loss of Consortium?

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

Why should the husband of  a woman who was disfigured by her facelift get $250,000 for pain and suffering?  Actually, his is for “loss of consortium.”

President Barak Obama is scheduled to sign the new healthcare bill into law today.  No tort reform was included.

According to the Georgia Supreme Court ruling

In January 2006, Harvey P. Cole, M.D., of Atlanta Oculoplastic Surgery, d/b/a Oculus, performed CO2 laser resurfacing and a full facelift on appellee Betty Nestlehutt.  In the weeks after the surgery, complications arose, resulting in Nestlehutt’s permanent disfigurement. Nestlehutt, along with her husband, sued Oculus for medical malpractice. The case proceeded to trial, ending in a mistrial. On retrial, the jury returned a verdict of $1,265,000, comprised of $115,000 for past and future medical expenses; $900,000 in noneconomic damages for Ms. Nestlehutt’s pain and suffering; and $250,000 for Mr.
Nestlehutt’s loss of consortium.

The Georgia Supreme Court ruled the 2005 Tort Reform Act was unconstitutional and that the state legislature may not limit the amount of money that juries award to victims of medical malpractice.   So the above amounts stand rather than being reduced to $115,000 for medical expenses and $350,000 for noneconomic damages.

The 2005 Tort Reform Act was part of a legislative package that capped jury awards at $350,000 for the “noneconomic damages” of malpractice victims.  The Georgia Supreme Court has ruled that the cap improperly removes a jury’s fundamental role to determine the damages in a civil case.

Chief Justice Carol W. Hunstein wrote in the decision,“The very existence of the caps, in any amount, is violative of the right to trial by jury.”

The current healthcare bill to be signed into law today by President Obama fails to address tort reform.

Grand Rounds Vol 6, No 26

I want to thank you all for contributing such wonderful posts for this week's Grand Rounds. And, thank you for allowing me to make it a "women’s” theme as March is the month of International Women’s Day and Women’s History Month (here in the United States).

Sterile Eye tells us the story of Jan van Rymsdyk – Drawer of Wombs. Here is one of the beautiful sketches included in the post.

In October 2008 I visited the Hunterian Museum in Glasgow, where William Hunter’s great book of obstetrics was on display. Published in 1774, The Anatomy of the Human Gravid Uterus did much to advance the understanding of human pregnancy. The book contains 34 copper engravings. 31 of these magnificent medical illustrations were made by a mysterious man called Jan van Rymsdyk.

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Our medical librarian Laika, Laika’s MedLibBlog, tells us about a wonderful woman scientist in her post Stories [1] – Polly Matzinger, the Bunny & the Dog.

….He continued with his typical Czech accent, serious but with a twinkle in his eyes.

“It is a SHE” …….

“It is a she and ….… a very beautiful one”

Then he told us that Polly Matzinger, for that was her name, was once a Playboy bunny and a waitress at a bar frequented by scientists………..

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Captain Atopic’s beautifully written post tells us about a woman and her tattoo: Freedom.

The building had four stories. In a narrow street in Baoji, west of Xi'an, the damp shell of a structure housed backpackers on its top three floors. The dorms exuded marijuana, travel must and provided many visitors with a fresh case of athletes' foot or worse. The occupants sat, huddled in the subzero temperatures playing cards and sharing a bong, partly for warmth, partly just to negate the feelings of loneliness and despair Baoji seemed to extract from twenty-something global travelers. …….

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Julie, Bedside Manner, helps us with Making Sense of Suffering Through Poetry. She presents a poem written by her friend and colleague Beth Lown, MD.

…... The poem is about Beth’s effort to imagine this patient’s experience and to empathize with her suffering…….

Let me know what you think of the poem.

Leylo and the Land Mine *

An ebony leg leaned
against the clinic wall,
snow melting
on its sandal-clad foot

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CancerDoc write a powerful post about the impact of a patient on a doctor: Denmark

R.N. just died.
She was my first breast cancer patient out of fellowship and training. My first breast cancer patient where I was the "doctor". No backup. Nobody to turn to for advice. I write the orders, I explain the side effects. I hold the hands.

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From Mothers in Medicine comes the first Topic Week post: Tips for Surviving Call while Pregnant. There are actually, good tips for non-preggers folks too. There are ten great tips. Check them out and check out the blog.

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Laurie, A Chronic Dose, asks how effective Doctors as Advocates? are as she discusses communication skills in advocating for their patients.

……….An advocate is someone who realizes there is a lot more to a successful outcome (surgical or otherwise) than simply what data reveals.

We all deserve advocate

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Kevin,MD feels Pelvic exam simulators do medical students a disservice due to the missing communication (feedback) between patient and doctor

….no matter how good the simulator is, it cannot replicate an actual person. Especially for men, doing a pelvic exam is more than the procedure itself, but learning how to interact with the female patient from beginning to end……

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Dr Am Ang Zhang, The Cockroach Catcher, notes this is the 30th Anniversary of the National Women’s History Project with her post: NWHP: Writing Women Back into History. “It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century.”

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I’d like to introduce you to a fairly new medical blogger, Deborah L. Benzil, MD who blogs at Women Neurosurgeon: Heart and Hands. Here’s the beginning of her poem: First Meeting.

Wash hands

Step over the red line

Irish gentleman

Stripped of dignity and clothes…

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Dr Shock tells us about women and anorexia nervosa in his post, The Neuroscience of Anorexia Nervosa.

One of the most striking features of those suffering from anorexia nervosa is their perception of their bodies. You can put them in front of a mirror and they will still tell you they’re to fat when in fact they’re skinny. A recent publication in Nature Proceedings has an explanation

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Dr. Charles, The Examining Room, tells us how Non-Homogenized Milk is Better Than Disneyworld

Mmmm. I just discovered non-homogenized milk – the kind with the thick layer of cream on top and more watery milk below. You have to shake it up before each serving, and the little flecks of buttery cream never quite disappear. …. But the taste is far superior to homogenized milk. Think milk with a hint of butter.

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And while Dr Charles makes the point “In terms of diet, weight loss, and optimal health, moderation seems prudent” Bob Vineyard, InsureBlog, writes about a woman who doesn’t seem to believe in moderation. Bob ask Who is the Biggest Loser?, the woman who wants to gain weight or society who will end up paying for her efforts. (photo credit)

Donna Simpson is proud of her plus size 600 pound figure and wants everyone to know it. Her 150 pound husband not only approves but is encouraging her to continue her pursuit of tipping the scales at 1000 pounds.

Happy Hospitalist weighs in on the same woman in his post: Super Morbid Obesity: Woman Proclaims "I Want To Be 1000 pounds. Happy and I both see this as a sad story of a woman who's main goal in life is to weight 1000 pounds so men can watch her eat in bikini.

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It seems apparent that Mrs. Simpson doesn’t care to exercise, but I am a fan of exercise. I believe it is important for good health. So does Dr. Ves Dimov, Clinical Cases and Images: CasesBlog, who tells us How to Exercise While Blogging or Doing Other Computer Work. Good information!

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Dr. Jolie Bookspan, The Fitness Fixer, relays how New Healthy Employment Programs for Developmentally Disabled can be accomplished.

Peggy Santamaria is bringing my healthy daily life techniques to developmentally disabled adults. She has made a new program to transition developmental disability to Developmental Ability. After her success story appeared - Shoveling Snow - Reader Wins Mother Nature's Fitness Challenge with Fitness Fixer,…

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How to Cope with Pain tells us about the Connection Between Headaches and Abuse.

Did you know that a history of abuse - emotional, physical and sexual – is common in women who have headaches. A history abuse is also associated with depression and stress. So reports a new study by Gretchen Tietjen, a Professor of Neurology at the University of Toledo and Director of their Headache Treatment and Research Program.

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David, Health Business Blog, writes More on the overuse of mammography in elderly women

An oncologist friend spotted my blog post (Overuse of mammography in elderly women with cognitive impairment) …..…..

I’d like to see the debate broadened to include a frank discussion of the potential harm from too much screening. Excessive screening and associated harm to the frail elderly population is one aspect of that story.

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Nancy, Teen Health 411, sends us a post regarding a new marketing campaign by Kotex that pokes fun at the previous tampon ads: Feminine Care Rebellion - Period! (photo credit)

Women are talking about their bodies and their health - which is good! Right?
You would not think so if you are following the debate around the new UbyKotex.com marketing campaign, which I think is brilliant! …….

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Joseph Kim, NonClinicalJobs.com, ask if the question To CME or not to CME?

The other day, I was speaking with a physician about job opportunities in the CME (continuing medical education) industry. There are fewer jobs in CME compared to 5 or even 3 years ago. Why?

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GeriPal feels that Social Workers are Awesome

….I know we should avoid generalizations, but isn't it the case that all social workers are nice? Perhaps it is this niceness, combined with their knowledge and skills that makes them so indispensable. …….

Geriatrics practice would be impossible without social workers.

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Pallimed comments on Palliative Care: (Un?)-Necessary Specialty

One of the web's more popular doctor bloggers, the anonymous* Dr. Lucy Hornstein (aka #1 Dinosaur - her blogging pseudonym), recently posted an entry titled: Palliative Care: An Unnecessary Specialty.

Now before you get too mad or defensive (like I first did), go read the post and the comments. She is a family medicine doctor and the main thrust of the article (despite the provocative title) is that all doctors and especially primary care doctors should be skilled in palliative care. …….

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David Harlow, Health Care Law Blog, interviewed Peter Neumann, Director, Tufts Center for the Evaluation of Value and Risk in Health, about the role of cost-effectiveness research in health care policy.

The national debate on health care reform is currently focused on health insurance reform -- coverage, one of the proverbial three legs of the health care reform stool: coverage, cost and quality.

In order to bend the cost curve -- no matter what the approach to health care reform: be it federal legislation, state initiatives, federal pilots and demonstration projects, and/or private sector initiatives -- most would agree that we need a rational approach to cost-effectiveness research, or comparative effectiveness research that we can all rely upon……….

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Kim, Emergiblog, has some thoughts regarding health care reform legislation which she addresses in her post: between the lines of fear and blame

…..Our system has issues, no question.

*****

So, will the new health care legislation make for healthier communities by providing jobs, parks, grocery stores, education opportunities and health care clinics to poverty-stricken neighborhoods?……

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Dr. Mary Johnson, Dr J’s HouseCalls, tells us about the horrific ordeal of being sued for “libel” even though the suit was unsuccessful in her post: On Oprah Winfrey And Nomvuyo Mzamane And A Defamation Lawsuit In Philly.

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Bongi, other things amanzi, tells us of an exemplary fellow South African surgeon

part of the job is to treat some unsavoury people. sometimes you know what it is they have done. mostly you don't. sometimes you even may make a difference. but mostly you just do your job. after all it is not our part to play judge and jury (and, in our case, executioner)……..

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Chris, Life in the Fast Lane, tells us about doctors in the emergency department Wrestling with Risk

….It’s true I am fascinated by the concept of risk, and decision-making in environments that are time-pressured and information-limited. Nevertheless, Dr. David Schriger raised more than a few points in his talk that even the most ‘risk averse’ person would find interesting, some of which I’ll discuss below…….

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Paul Auerbaur, Medicine for the Outdoors, tells us about a man who helped his dog (man’s and woman’s best friend) who got bitten by a rattlesnake in his post he did what?

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Allergy Notes, tells us how Basophil expression levels of CD203c might be used to monitor asthma.

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Beka, Medscape Blogs, wants to hear from fellow nurses regarding input about Charge experiences.. has it changed over time...? Do You Recall Your First Shift Charge Nurse Experience? (free registration required).

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Amy, Diabetes Mine, wants to educate us on the FDA Hearings on Blood Glucose Meters – A Patient Advocate’she Perspective

Experts are always split on these issues it seems, so I’m sure you are as curious as I am as to what came out of this great debate. I was fortunate to spend some time on the phone with Ellen Ullman, a patient advocate and research associate at Close Concerns — who was the ONE AND ONLY PATIENT REPRESENTATIVE invited to speak at these FDA hearings.

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Next week Grand Rounds will be hosted by Evan Falchuk, See First Blog. Thanks to Dr. Val Jones and Dr. Nick Genes for the work they do to ensure the continued success of Grand Rounds. If you would like to be a future host, please contact Nick.

When and How to Perform a Biopsy on a Chronic Wound – an Article Review

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

Super nice article on in the March 2010 issue of Advances in Skin & Wound Care (full reference below) on a very important topic. Most of us may know when a biopsy should be done of a chronic wound, but most of us are not trained in how to do one. Different areas of the chronic wound are best biopsied depending on the suspected diagnosis.

The article clearly lists the indications and contraindications for a wound biopsy.

This is probably the most important question for healthcare professionals dealing with wound care. Benefits of biopsy in a wound can be divided into 3 groups that reflect the 3 main causes of wounds in general:
1. to diagnose the etiology of a wound (wound edge),
2. to rule out malignancy (wound edge), and
3. to obtain tissue for bacterial quantitative culture or to identify an infecting organism.

The next question to consider is: Are there any contraindications to wound biopsy?
There are 2 relative contraindications to wound biopsy11:
1. blood dyscrasia with the risk of uncontrollable bleeding
2. venous congestion and extremely vascular wounds (arterial insufficiency) in a setting that access to care is limited or the biopsy wound is unlikely to heal.

There is an extensive table listing the preferred biopsy site for different suspected pathologies. Some of those listed include:

• Basal cell carcinoma (superficial) -- It is best to do a shave or curette biopsy of the rolled margin.
• Basal cell carcinoma (other variants) – It is best to do a deep punch or excisional biopsy of the base or wound edge.
• Squamous cell carcinoma -- It is best to do a punch or excisional biopsy of the deep wound base.
• Pyoderma gangrenosum -- It is best to do a punch or deep wedge biopsy of the wound ulcer border and center. The biopsy should include cultures to rule out infection.
• Vasculitis (large vessel) – It is best to do a deep incisional wedge biopsy of the center of the lesion. DIF (direct immunofluorescence) should be considered.

The article gives clear instructions on how to perform three different types of wound biopsies: shave, punch, and elliptical deep excisional.

I recommend this article to anyone (family physicians, dermatologists, plastic surgeons, etc) who take care of chronic wounds.

REFERENCE

When and How to Perform a Biopsy on a Chronic Wound; Advances in Skin & Wound Care 23(3):132-140, March 2010; Alavi, Afsaneh; Niakosari, Firouzeh; Sibbald, R. Gary; doi: 10.1097/01.ASW.0000363515.09394.66

SurgeXperiences 319 is Up!

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

Vijay, Scan Man’s Notes, is the host of this edition of SurgeXperiences. Here is the beginning of this edition which you can read here. (photo credit)

You know, I am hearing a lot about March Madness from my American friends on twitter and facebook. I am not knowing what that really means, but I am thinking it must have something to do with their healthcare reform bill which I am growing sick of hearing about. So I was thinking I will use this March Madness thing as a theme for this edition of SurgeXperiences. Since I am already telling you that I am not knowing anything about what this March Madness is about, I am going to let you guess how I am using it as my theme. *

The host of the next edition (320) has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline: midnight on Friday, April 1st.   Be sure to submit your post via this form.

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

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

Counting Skin Lesions

One, two,  why’s this nevus blue
Three, four, doc there’s many more
Five, six, this one looks like a dog tick
Seven, eight, let’s keep them all straight

Nine, ten, I say the end.

Bunny in My Garden Quilt

I made this quilt using some of the left over autograph blocks from the Blog World Expo quilt. It is a baby quilt for a niece who is due in June (my husband’s youngest brother and his wife). The quilt is machine pieced and quilted. It is 34 in square.

The center block has a bunny, hence the quilt’s name. I did some in-the-ditch quilting, the daisies, and some cross-hatch quilting.
The back is a soft pink flannel.

Standing Stools in the OR

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

When I was in medical school (1978-1982) and the first few years of residency, it was common to find coke cases used in the operating room. Being only 5 ft 3 in tall, I almost always needed at least one, and often two of these cases to stand on.

Checking online, the most common measurements for wooden coke cases were: 18" X 12" X 4-5" This made for a safe standing area. They were sturdy, even when stacked. These cases were used commonly in the 70’ when sodas were bottled in glass not cans.

When I became the “surgeon,” I got to chose the OR table height. No longer do I need to stand on a step stool. When I am working with someone much taller than I am, I will raise the table to a comfortable height for them and stand on a step stool. Doesn’t happen often these days.

This is what you will find used as a surgical step stool now (photo credit). They are washable. The standing area measures 16-1/2"L x 12-1/2"W. They are 5” tall.

Botox for Upper Extremity Spasticity

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

Until recently, the therapeutic use of non-cosmetic BOTOX (onabotulinumtoxinA) for adult upper extremity spasticity was considered off-label use. Last week, the U.S. Food and Drug Administration (FDA) approved Botox to treat spasticity in the upper extremity flexor muscles in adults.

Spasticity is common after stroke, traumatic brain injury, or the progression of multiple sclerosis. Spasticity is defined as

“a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex as one component of the upper motor neuron syndrome.”

Spasticity often creates problems with mobility, self-care, and function. The spastic muscles can become stiff. Associated joints can be affected by lack decreased range-of-motion with contractures forming.

Botox works by temporarily blocking the connections between nerves and muscles, resulting in a temporary paralysis of the spastic muscle. Advantages of using Botox to treat muscle spasm include the ability to target specific muscles which when successful allows reduction of other systemic medications (ie Zanaflex, Baclofen, Dantrium).

Botox does not take the place of conservative measures, such as positioning, stretching and exercise in spasticity management. These measures remain essential.

Botox can decrease the dosage or use of oral antispastic medications which often provide only limited effects with short duration and frequent unwanted systemic side effects, such as weakness, sedation and dry mouth.

Botox has a Black Box Warning that states the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism. Those symptoms include swallowing and breathing difficulties that can be life-threatening.

The most common adverse reactions to Botox reported by patients with upper limb spasticity were nausea, fatigue, bronchitis, muscle weakness, and pain in the arms.

Botox has not been shown to be safe and effective treatment for other upper limb muscles, spasticity in the legs, or for treatment of fixed contracture – a condition that affects range of motion. Treatment with Botox is not intended to substitute for physical therapy or other rehabilitative care.

REFERENCES
FDA News Release

Botulinum toxin type A in the treatment of upper extremity spasticity: A randomized, double-blind, placebo-controlled trial; NEUROLOGY 1996;46:1306; D. M. Simpson, MD, D. N. Alexander, MD, C. F. O'Brien, MD, M. Tagliati, MD, A. S. Aswad, MS, J. M. Leon, PhD, J. Gibson, MD, J. M. Mordaunt, MS and E. P. Monaghan, PhD

Botulinum Toxin in Poststroke Spasticity; Clin Med Res. 2007 June; 5(2): 132–138; Suheda Ozcakir, MD and Koncuy Sivrioglu, MD

Grand Rounds – Here Next Week!

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

I am honored to be the host of Grand Rounds next week.  Please, send your posts to rlbatesmd@gmail.com with “Grand Rounds” in the subject line.  Include the title of the post and a correct link.   You may also include a “line or two” of post description if you like.  I will accept post up until noon CST Monday, March 22nd. 

I have hosted Grand Rounds twice before and never ask for a theme.  I started to do the same this time, but realized it is Women’s History Month here in the United States.  Earlier this month was International Women’s Day. 

So I would like to encourage you to submit posts that have to do with women in medicine as patients, as providers, as scientists, etc. 

Thank you.  I’m looking forward to your submissions.

Shout Outs

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

Medicine and Technology is this week's host of Grand Rounds.   You can read this week’s edition here.

Welcome to Grand Rounds Vol 6 No 25. Grand Rounds is a weekly summary of the best health blog posts on the Internet. I wish to also extend a special thanks to those medical bloggers who are participating in Grand Rounds for the first time. This week, we had many submissions, so let's get started.

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St. Baldrick's is a fundraising foundation dedicated to raising funds for pediatric cancer research.  Shadowfax went Going Bald Once More.  Here are some photos of the shaving.  Yesterday he tweeted

Heading down for the shaving. Zippy didn't make it, alas. Pics to follow soon. Donations total $10,500 as of this moment. Yay!

Also, taking a moment to remember Nathan Gentry and Henry Scheck, the reasons we go through with this whole affair.

Had a very productive day. Fixed the kitchen faucet AND shaved my head for kids' cancer! http://bit.ly/bWfyGi Guess which one was harder...

The razor left about 1/8-1/4 inch of stubble behind. Gotta go shave clean now. Wouldn't be giving my donors their money's worth otherwise.

It's not too late to donate.

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Shadowfax does the above to try to decrease the number of grieving parents.  Christian Sinclair re-tweeted this from @GrievingDads:   Please don't forget often overlooked dads mourning loss of children www.GrievingDads.com 

Grieving Dads website was started by Kelly Farley

As a bereaved father of two children, my mission is to leave a legacy in honor of my daughter Katie and my son Noah who left this world all to soon.

Based on my own realization and first hand knowledge of the lack of support services and information available to fathers suffering the loss of a child, I have chosen to reach out to all men that are traveling this lonely and what appears to be a never ending road known as unspeakable loss.  

The goal of this site is to ultimately create a social documentary focused on a cross-section of bereaved fathers and tragic circumstances related to child loss.  Men of all ages, locations, ethnicity, socio economic status and religious beliefs are welcomed at this site, regardless of the circumstances of your loss…..

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H/T to @JoshuaSchwimmer for his tweet directing me to this New York Times article by on malignant hypertension by Lisa Sanders, MD:   High Altitude

The middle-aged woman lay in the intensive-care unit, observing the tumult around her. …….

In the afternoon she had taken her teenage daughter shopping. As her daughter disappeared down an aisle, the woman struggled to keep up. Her breath was rapid and ragged. She could hear her blood pounding with each heartbeat. Suddenly the whole right side of the world seemed to go out of focus, color and shapes blending together. She didn’t want to frighten her daughter, so she said nothing. “Please just let me get home,” she prayed silently. She drove with her bad eye shut, and when she got home she promptly lay down. ……

When the patient arrived at the emergency room, her blood pressure was 225/115 — terrifyingly high…….

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Via a tweet from @ePatientDave comes the recommendation of a new blogger into the med-blogger community.  Welcome!

A new patient blog, VERY good writer: Gastrically Changed. (Gastric bypass pt, labor & delivery RN) http://is.gd/a9T3e

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KevinMD notes Mammogram screening divides doctors and patients.

Mammogram screening for breast cancer continues to simmer in the news.

The recent USPSTF guidelines, no longer recommending a routine mammogram for women between the ages of 40 and 49, continue to stir controversy between physicians and their patients.

In a recent survey from the Annals of Internal Medicine, it looks like the debate between doctors and patients will continue for the foreseeable future…….

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Allergy Notes has a nice post Teamwork helps fire ants - National Geographic video

Since South American fire ants arrived in Mobile, Alabama, in the 1940s, they have spread to become one of the most reviled pests in the Sunbelt. There have been several failed, and heavily politically influenced, eradication campaigns. The fire ants (red or black) are very aggressive and build nests in mounds of fresh soil.

You may also wish to check out my 2007 post on Fire Ant Bites.

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Interesting story on NPR’s All Things Considered:   Picking The Poison: The Story Of Forensic Medicine (photo credit)

Say you live in jazz-age New York and want to get rid of someone — but you don't want to get caught. What would be your poison of choice?

Author Deborah Blum recommends arsenic — otherwise known as "inheritance powder" — which was pretty much untraceable until the 1920s.

"Arsenic, as it turns out, is fairly tasteless, and if you give it at just the right dose ... you can actually make it mimic a gastrointestinal illness," Blum tells NPR's Guy Raz. …….

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Great story on NPR by Susan Stamberg:  Female WWII Pilots: The Original Fly Girls (photo credit)

In 1942, the United States was faced with a severe shortage of pilots, and leaders gambled on an experimental program to help fill the void: Train women to fly military aircraft so male pilots could be released for combat duty overseas.

The group of female pilots was called the Women Airforce Service Pilots — WASP for short. In 1944, during the graduation ceremony for the last WASP training class, the commanding general of the U.S. Army Air Forces, Henry "Hap" Arnold, said that when the program started, he wasn't sure "whether a slip of a girl could fight the controls of a B-17 in heavy weather."

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Dr Anonymous’ guests this week will be Dr. Lucy Hornstein from Musings Of A Dinosaur.  Come join us.

Upcoming Dr. A Shows (9pm ET)

3/25 : Gerry Tolbert

Double-Bubble Breast Deformity

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

Recently a Staten Island woman was awarded $3.5 million after developing a double-bubble breast deformity after a breast augmentation/mastopexy surgery.

I don’t know if the award was warranted, but I do know that the deformity is a known risk of breast augmentation surgery. I try very hard to tell patients about possible risks of surgery, but none of us go into surgery thinking we will be the half or one or two percent.

As the surgeon, I take pride in my work and give the best I can. It is never my intention for a patient to have a poor result. It is not good for them or for me.

So let’s talk a minute about double-bubble deformities. What is it? In a double bubble deformity the implants are usually positioned too superiorly under the muscle (first bubble) with an overhang of skin/breast tissue drooping lower (second bubble). (photo credit)

Patients with significant postpartum atrophy, glandular ptosis, and significant native tissue volume are at a higher risk for developing a double-bubble deformity.

In patients with the above, it is best to consider placing the implant in the subglandular position rather than the submuscular. It is also important to consider doing the mastopexy first and the implantation procedure at a different surgery in the future.

Another important consideration is doing the proper lift procedure so that enough skin is removed. This may mean the patient has to accept more scars (ie an anchor scar rather than inferior vertical scar, or an inferior vertical scar rather than a periareolar scar).

Once the deformity has developed, then correction may require capsule work, repositioning the implant, revising the mastopexy (or adding one).

REFERENCES

Breast Augmentation; Plastic and Reconstructive Surgery. 114(5):73e-81e, October 2004; Spear, Scott L.; Bulan, Erwin J.; Venturi, Mark L.

Breast Augmentation: Choosing the Optimal Incision, Implant, and Pocket Plane; Plastic and Reconstructive Surgery. 105(6):2202-2216, May 2000; Hidalgo, David A.

Shaping the Breast in Aesthetic and Reconstructive Breast Surgery: An Easy Three-Step Principle. Part IV-Aesthetic Breast Surgery; Plastic and Reconstructive Surgery. 124(2):372-382, August 2009; Blondeel, Phillip N.; Hijjawi, John; Depypere, Herman; Roche, Nathalie; Van Landuyt, Koenraad

Breast Asymmetry; Aesthetic Surgery Journal, Nov 2003 (Vol. 23, Issue 6, Pages 472-479); Daniel C Morello, Marie Christensen, David A Hidalgo, Scott L Spear

Treatment of Breast Ptosis; Aesthetic Surgery Journal, July 2003 (Vol. 23, Issue 4, Pages 279-285); Stephen R Colen, Sharon Y Giese, Ruth Graf, Dennis C Hammond

SurgeXperience 319 – Call for Submissions

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

Vijay, Scan Man’s Notes, will be the host There is no scheduled host for SurgeXperiences 319 (March 21st), but don’t let that keep you from making your submissions. So be sure you make your submissions to him.  If you would like to host edition #319 or any future editions, 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. You are encouraged to submit your surgery related posts.

The deadline for submissions to be included in the 319 edition is midnight on Friday, March 19th.   Be sure to submit your post via this form.

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

Laughter Shared

“Doc, after surgery will I be able to play the piano?”

I smiled, having fallen for that joke  often as a young surgeon. 

Older now, I answer “How good are you at it now?  You should be just as good.”

We both laugh.

"Label Me" Quilt

I have been saving labels from clothing for years now.   They are from shirts, jeans, dresses, and ties.  I have often thought they would make a nice quilt, using them like the old cigar silks were used.  It took the announcement of this quilt contest to finally push me to make the quilt.  Their theme is “New from Old” and the inspiration statement spoke of my use of the labels as the cigar silks had been used:

Imagine antique quilt blocks, trims, color palettes, and stitches translated and transformed by state-of-the-art sewing machines, vibrant modern fabrics, and new techniques by the innovative quiltmakers of today.

I used a fusible stabilizer to arrange the labels, hold them in place for stitching, and to align the vertical strips.  The labels are used in form the  “coins” while I used silk ribbons from bow ties for the vertical black strips.  The quilt is machine pieced and quilted.  It is 16 in square.

Here is a closer photo to show some of the labels in better detail.

It is a quilt I’m not sure I want to give up, so as a trial run I have put it up for sale on Etsy. If it doesn’t sale by the contest’s entry date, then I will enter it in the contest.

Hymn of Skin

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


In the March 3, 2010 issue of JAMA, there is a poem by Sarah Wells called “Hymn of Skin.”  While I enjoyed the whole poem, my favorite part is:

Plastic surgeon of the heavens, how I delight
in a furrowed brow, crow's feet, age spots—
wrinkle me up a dozen times to show I lived
hard, good, funny—after all beauty, being what it is,
is only skin deep—may my soul seep through
dry scales of later hands, resting tranquil in my lap.
O omniscient dermatologist, what ingenuity,
past hurts evident in scrapes and scars—
a clumsy stumble down uneven concrete stairs,
knees and ankle raw and dripping; pockmarked cheeks
from teenage zits—all healed, in the end, but not forgotten.
How often we need reminders of where we’ve been.

Preventing Peripheral Neuropathy in Gastric Bypass Patients

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

This article comes from my medical school (UAMS).  The full reference is given below.  This topic is important to me because it relates to nutritional status of these patients who may present to my office for excess skin excision procedures, etc.

You may wish to read my related post from September 2008: Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know -- An Article Review

Here is part of the opinion statement from Dr. Rudnicki  published online:

Given the ever-increasing problem of obesity, it is not surprising that the number of patients who undergo bariatric surgery continues to rise. ………….

Ideally, one would like to prevent these neuropathies, but there is no consensus of opinion as to what vitamins and micronutrients need to be taken following bariatric surgery. In addition, many patients who take supplements early on fail to maintain the regimen even though some of the neuropathies can occur fairly late. Supplements frequently recommended include a multivitamin, iron, vitamin D, folic acid, calcium citrate, and vitamin B12. Although thiamine is typically included in a multivitamin, the amount is fairly small, so I recommend adding 100 mg daily for at least the first year. Some have suggested zinc supplementation, but this is potentially problematic because exogenous zinc may interfere with copper absorption. Obtaining blood work every 6 months after surgery will help to identify and treat nutritional deficiencies early.

For those patients who have had a bariatric procedure and then develop a neuropathy, evaluating levels of thiamine, copper, vitamin B12, methylmalonic acid, and homocystine is indicated. In addition, since one deficiency is frequently associated with others, obtaining levels of vitamin A, C, D, K, and E, as well as iron, zinc, selenium, and magnesium is worthwhile. Checking total protein, albumin, and cholesterol also gives a sense of general nutritional status. Occasionally, no clear-cut deficiency of a vitamin, mineral, or trace element can be identified in patients with various peripheral nervous system manifestations. Nevertheless, these patients may have at least some recovery with improving nutritional intake and vitamin supplementation, suggesting that we still do not fully understand how nutritional status affects the peripheral nervous system.

REFERENCE

Prevention and Treatment of Peripheral Neuropathy after Bariatric Surgery; Current Treatment Options in Neurology Vol 12, No 1, January 2010; Stacy A. Rudnicki, MD

DOI 10.1007/s11940-009-0052-2

Shout Outs

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


David E. Williams' Health Business Blog is this week's host of Grand Rounds.   You can read this week’s edition here.

Welcome to Grand Rounds 6:24. Regular readers know I provide a mix of health care wonkery, cheerleading of entrepreneurs, and light-hearted, humorous Grand Rounds. But this week’s batch of submissions is mostly in the pain and suffering category.

If you think I’m joking, read on.

Pain and suffering

Other Things Amanzi is profoundly affected by the death of a kidney transplant patient. The fellow walked into the hospital with the realistic hope of life without dialysis and departed on a cold morgue slate. Can’t win ‘em all, but that’s not much comfort in this case.

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Check out Dr Val's (Better Health) videos of the interviews done last week at the   HIMSS conference in Atlanta at the Better Health YouTube Channel:  BetterHealthLLC

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MamaTrauma is the host of the latest edition of Change of Shift (Vol 4, No 18) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

A year ago I was still in nursing school and in total awe of all the nurse bloggers I was reading when I should have been studying. Now not only am I working my dream job, I am hosting Change of Shift! It is such an honor to be counted among the ranks of all those nurse bloggers I am still so in awe of.  I hope you all enjoy reading this edition.

We’re starting off with Mother Jones and her commentary on Change of Shift: The Art of Giving Report.  It really is an art……

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St. Baldrick's is a fundraising foundation dedicated to raising funds for pediatric cancer research.  Shadowfax is Going Bald Once More

Yup, St Patrick's day is soon approaching, and that means that St Baldrick's day is also approaching…. 

This is my third year doing this, and I do it in memory of my friend Nathan Gentry, who lost his battle with Neuroblastoma at age seven, and in memory of Henry Scheck, who passed away from Medulloblastoma.

Thanks for your consideration.
Click here to donate.

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Allyson Beatrice, Cocktail Party Physics, writes about science and children’s books in her post:  food for juicy, young brains

…If you adore Science Verse, the same author and illustrator have given us Math Curse, Scieszka and Lane, Viking, 1995.

A young student with math anxiety discovers that his whole life is comprised of various math problems, but fortunately, math also offers him a solid solution. The illustrations are just as epic in silliness as Science Verse, as are the problems he encounters. From the moment he gets out of bed, he's presented with math problems as he tried to get dressed for school:

I have 1 white shirt,
3 blue shirts,
3 striped shirts,
and that 1 ugly plaid shirt my Uncle Zeno sent me.
How many shirts is that all together?
How many shirts would I have if I threw away that awful plaid shirt?
When will Uncle Zeno stop sending me such ugly shirts?
Everything seems to be a problem.

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I am a big fan of Medical Moments in 55 Words, but had no idea who the doctor behind the blog was until recently when fellow blogger Denver Doc and friend tweeted (@DocofAges)

Check out nice article on my blog: http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2010/03/05/health_and_care/

Here is the beginning of the Boston Globe article:

PRIMARY CARE medicine may be on the decline in prestige and pay, but the fancy surgical specialties can’t offer the same daily dose of satisfaction, heartbreak, and connection. Judy Paley, a primary care doctor with a two-person practice and a load of bills in Denver, has started a blog brimming with what she calls “close encounters of the life-saving kind.’’ Reading it is good for what ails you.

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I hope you will read Dr David’s recent post: The Irony of Patient Autonomy

One of the cornerstones of medical ethics is the concept of patient autonomy. MedicineNet.com provides a succinct definition: “The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.”……..

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Learned about this local charity group via  Arkansas Blog’s post:  Plant a tree

It's Tree Streets, an urban forestry project that is no more complicated than planting trees along public right of ways in the center city. It is about to plant its 1,000th tree. Think of the canopy of shade this work will provide for years after all the hole diggers, planters and waterers are gone.

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Dr Anonymous’ guests this week will be EMS Podcaster Greg Friese.  Come join us.

Upcoming Dr. A Shows (9pm ET)

3/18 : Dr. Lucy Hornstein from Musings Of A Dinosaur

Possible Implant Rupture: Is MRI Useful? – an Article Review

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

Currently, magnetic resonance imaging (MRI)  is considered the accepted standard to evaluate silicone breast implant integrity.  This article (full reference below) reports a retrospective review study devised to “evaluate its utility in diagnosing ruptured silicone implants in the setting of capsular contracture and to correlate the preoperative assessment of implant integrity with or without magnetic resonance imaging with operative findings.”

The study involved 171 patients with capsular contractures with a total of 319 capsulectomies.  Preoperative MRIs was done on 160 implants, whereas the remaining 159 were evaluated using only physical examination and/or mammography. The authors then analyzed postoperative results  to determine the sensitivity, specificity, and accuracy of preoperative MRI in comparison with clinical and/or mammography evaluation alone.

They found that while the MRI was occasionally valuable, overall it was no more accurate than clinical evaluation in predicting implant status (intact or ruptured):   magnetic resonance imaging 124 of 160 (78 percent) and clinical 121 of 159 (76 percent; p = 0.77).
Their conclusions:

In the setting of capsular contracture, physical examination with or without mammogram is as accurate as magnetic resonance imaging in determining implant integrity. Although magnetic resonance imaging is a sensitive diagnostic tool, in symptomatic patients with capsular contracture, it cannot be viewed as infallible

It is nice to know that I am not slighting my patient by not always getting that MRI.  If she has a hard capsule, if my clinical exam suggests a rupture, then I strongly encourage her to have a capsulectomy with implant removal or exchange.  The MRI will not change that plan, so I don’t tend to order one.

REFERENCES

Capsular Contracture and Possible Implant Rupture: Is Magnetic Resonance Imaging Useful?; Plast Reconstr Surg 125(3):830-835, March 2010; Paetau, Alyssa A.; McLaughlin, Sarah A.; McNeil, Rebecca B.; Sternberg, Erez; TerKonda, Sarvam P.; Waldorf, James C.; Perdikis, Galen [doi: 10.1097/PRS.0b013e3181cb6066]