Fireworks Safety

 Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

Time for a reminder of safe firework use.  This Daily News article by Lauren Johnston -- Doctors replace woman's missing thumb with big toe transplant – shows and tells you why.

A Long Island woman's big toe will adapt to function as a thumb after doctors performed a rare transplant operation to replace the vital missing digit.

Shannon Elliott, 25, lost the thumb and two fingers from her left hand in November when a firework exploded in her palm. …….

I hope you will all have a safe and happy July 4th.  Be safe and stay out of the ER.
Please use the following tips:

• Never allow children to play with or ignite fireworks.
• Read and follow all warnings and instructions.
• Fireworks should be unpacked from any paper packing out-of-doors and away from any open flames.
• Be sure other people are out-of-range before lighting fireworks. Small children should be kept a safe distance from the fireworks; older children that use fireworks need to be carefully supervised.
• Do not smoke when handling any type of "live" firecracker, rocket, or aerial display.
• Keep all fireworks away from any flammable liquids, dry grassy areas, or open bonfires.
• Keep a bucket of water or working garden hose nearby in case of a malfunction or fire.
• Take note of any sudden wind change that could cause sparks or debris to fall on a car, house, or person.
• Never attempt to pick up and relight a "fizzled" firework device that has failed to light or "go off"
• Do not use any aluminum or metal soda/beer can or glass bottle to stage or hold fireworks before lighting.
• Do not use any tightly closed container for these lighted devices to add to the exploding effect or to increase noise.
• Never attempt to make your own exploding device from raw gunpowder or similar flammable substance. The results are too unpredictable.
• Never use mail-order fireworks kits. These do-it-yourself kits are simply unsafe.

If you need more information on the injuries that can occur, check out these sites:
Fireworks Related Injuries by the CDC
Prevent Blindness America

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Dr. Elaine Schattner of Medical Lessons is the host for this week’s Grand Rounds. It’s the “customer service in healthcare” edition. You can read this week’s edition here.

Learning about medicine is a lifelong endeavor whether you’re a patient, a doctor, a caregiver, a hospital administrator or, perhaps, even an insurance company executive. In today’s Grand Rounds, we’ve an array of eleven perspectives that, directly or indirectly, bear on the suggested theme of education.

If there’s a motif that emerged unsolicited this week, it’s empathy, a term highlighted in the titles of two submitted posts:

In Glass Hospital, Dr. John Schumann considers what motivates health care workers in a thoughtful post, Finding Empathy. Schumann, an internist and medical educator at the University of Chicago, suggests that doctors and nurses need to re-encounter and re-engage with empathy to continually find meaning in their work………

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Keith, Digital Doorway, is the host of the latest edition of Change of Shift (Vol 4, No 26) !   You can find the schedule and the COS archives at Emergiblog. (photo credit)

Well, after a long hiatus, I'm finally hosting Change of Shift once again, and I'm happy to do so from the comfort of our new home here in Santa Fe, New Mexico! (For those of you unfamiliar with Change of Shift, it is a nursing blog carnival wherein nurses from around the blogosphere are featured in an "online magazine" that is hosted on a different nursing blog every two weeks.)

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A truly heartwarming story from CNN:  Soprano serenades doctors after lung transplant by Ashley Fantz.

Charity Tillemann-Dick,  27, had a bilateral lung transplant done at Cleveland Clinic in September 2009.  She had been diagnosed with Idiopathic Pulmonary Hypertension in 2004.  What a beautiful voice!

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Jill of All Trades, MD has written a  wonderful post -- 5 “Bueno” Tips on How to Learn Medical Spanish.  She shares how she did so:

…….Thankfully, and perhaps somewhat miraculously, I now very rarely need an interpreter. Seriously, I think the last time I used one was “meses” (months) ago. I cannot even remember when.

So “como” (how) did I do it? Here’s my advice:
1. Find a good medical Spanish book: There are not that many. Buy the best one. And read the entire thing, word-for-word. Underline as you go. Then, re-read the underlined items from the first round. ……….

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Jeffrey Parks, MD, otherwise known as Buckeye Surgeon, has written a warning post which you should all read:  What Does Dave Weigel have to do with Sermo?

…….Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post………

What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases……….

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I read about Dawn Warmbold recycling plastic bags into sleeping mats for the homeless in my local paper, but their online access is by subscription only.  Fortunately, I found a similar article in the Log Cabin Democrat:  ‘Sleeping mat-ters’ to local group

……..Warmbold has personally created 40 mats and instructed several church groups and organizations on how to create the mats. “The word is spreading like wildfire,” Warmbold said. “The homeless have asked us not to stop making them. There are more homeless than mats to hand out. That’s how much in demand they are.”

Warmbold, also called “the bag lady” has been teaching others how to carry the torch and encouraging them to create circles of their own to produce mats. She created an instructional Youtube video, which has received more than 2,500 views.

The video can be viewed by going to Warmbold’s channel at www.youtube.com/user/dawnw4848.

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Dr Anonymous’ BTR show will be on summer break until late August.

Upcoming shows (9pm ET)

Jul-Aug: Summer Break
8/26: Dr. A Show 3rd Anniversary

Pre-Hospital Surgical Prep

 Updated 3/2017 --  all links (except to my own posts) removed as many no longer active.

The June 2010 issue of the Surgical Products magazine has an article by Amanda McGowan focusing on the prep in preventing surgical site infections – Preventing SSI: It Starts in the Prep.

What really caught my attention was the pre-hospital prep described for one hospital.  Currently, (as most of my patients exhibit good hygiene) I haven’t begun anything more than taking a shower (with basic soap), washing their hair, and brushing their teeth pre-op.  My SSI rate is less than 0.5% over 20 years.  The bold is my emphasis.

As Beth Beck, director of infection prevention and control/employee health at Springhill Medical Center in Mobile, AL, explains, her facility follows specific steps in the prep process to help reduce infection risk.

“We ask the surgeons to have the patients bathe with chlorhexidine the night before,” she says.

“Then, once they arrive to the hospital, we wipe them down with a CHG-impregnated cloth and we instruct patients to brush their teeth twice. We have them rinse with a CHG oral rinse. Then, we give them skin and nasal antiseptic.”

Now remember this is a surgical products magazine, so the focus on the article may be to sell me the skin and nasal antiseptic product which the article mentions is marketed by 3M and is meant to reduce Staphylococcus aureus (Staph aureus) colonization, a leading cause of SSI.

The article quotes Joe Gillis, marketing manager for the skin and nasal antiseptic product at 3M:

According to Gillis, approximately thirty percent of surgical patients today are colonized with Staph aureus in the nares. In turn, a study published in The Lancet in 2004 revealed that eighty percent of Staph aureus infections are caused by the patient’s own nasal flora. Additionally, one percent of the surgical population carries methicillan-resistant Staphylococcus aureus (MRSA).

The article goes on to explain that Beck’s facility is in the trial phase of using the skin and nasal antiseptic product on orthopedic patients who are undergoing an operation involving implants.  The hospital added the nasal antiseptic part of the routine after seeing an increase in surgical site infections in orthopedic patients.

What is your or your hospital’s routine “prep before the prep?”

Recommended:
How-to Guide: Prevent Surgical Site Infection
How-to Guide: Reduce Surgical Complications

My Dog Hair Shawl

 Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

Early in my blogging life I wrote a post called: Hair of the Dog (May 28, 2007). Here it is followed by more of the story and photos of my dog hair shawl.

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It will have been 4 years on May 30th since Ladybug was euthanized. She had osteosarcoma of the left maxilla. And no that isn't a cigar in her mouth. It's a rolled up rawhide treat. Ladybug was half-Rottweiler and half-Pyrenees. She was nearly 8 years old when she died. She was a charmer! She would sit with her hunches on the sofa and her front legs on the floor. She is missed.

The origins of the phrase "hair of the dog" seem to go back to "the Romans and many ancient peoples before them believed that like cures like. They would bind the hairs of a dog that had bitten someone to that very person's wound to make it heal better EVEN of the dog was rabid." It then morphed into referring to handover cures (no "hair" included in these).

Another use for the hair of your dog is to make something from it. Depending on your own dogs breed (and the Pyrenees is perfect), your dog may have wonderfully full, soft hair. Years ago while walking through 'Books-a-Million', a book caught my eye. The book was "Knitting with Dog Hair" by Kendall Crolius. It described the steps needed (comb and keep the hair in a dry paper bag until you have enough, spin into yard, and then knit). VIP Fibers provides the service of preparing the hair after you collect it. I saved the hair from Ladybug and my two Labradors, Girlfriend and Columbo (who died in November 2003 from an abdominal cancer at age 11). I have a lace shawl from their hair. It feels like mohair.

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A short time ago, Dr. Smak uploaded a photo of the front of the "Knitting with Dog Hair" on Facebook which sparked two conversations. One on her post and another on the photo of my shawl I uploaded to show to her. So here is more of the story of my dog hair shawl.

Ladybug followed Columbo, Girlfriend, and I home one winter day in 1996 after finding us on our walk in the woods. We tracked down her owner who didn’t want her back. Ladybug was about 6 months old at the time and was still growing. She had outgrown her “cuteness” as a really small puppy. She ended up being a large 80-90 lb dog, but just as sweet as could be and a leaner (I loved that).

In the spring she would “spit” clumps of her undercoat as the weather got warmer. Girlfriend, a long haired Labrador, did the same to a much less extent. These clumps were very soft. I happened upon the book around the same time. I was a very basic knitter, had never processed wool, and knew nothing about spinning. Undeterred, I began to collect their hair. I saved only the hair brushed from them in the recent days after bathing them.

Once I collected half of a large paper bag full, I began a search for wool to mix it with as instructed in the book. I found a small yarn shop in Conway, Arkansas – Fiberworks. I bought some raw black wool (do not remember the type). This was in the spring of 2000.

I then searched the internet for someone to process the wool. I sent it to Ohio Valley Natural Fibers. I bought a drop spindle and took a spinning class to learn how to spin my wool. It did not work out. I wanted lace weight so I could have a shawl. Mine was more worsted weight and I was SLOW.

A nurse friend who circulated in the operating room said she would spin it for me. I offered to pay her which she refused. It turned out, she didn’t have the time to do it. So a couple of years after Ladybug and Columbo had died (they both died in 2003), I go up the nerve to ask for my dog hair/wool back.

I then searched the internet and found VIP Fibers . My old check as payment to them is dated April 2006. I got back --------- skeins with these wonderful labels.

During the intervening years, I had purchased a book titled "Shawls and Scarves" edited by Nancy Thomas. I made three shawls to learn how to do lace knitting, preparing for the time I had my dog hair yarn to use.

For my dog hair shawl I used the “lace dream” pattern by Eugen Beugler in the book. Here is a photo after re-blocking it.  It also shows the true color better than the one above.

Here is a close shot to try to show some of the detail.

Confetti for C Quilt

This quilt was made for J’s sister C.  It is made of bright colors to reflect her personality.  The block is “puss-in-the-corner.”  I began with some left-over blocks from Bud’s quilt and added greens, blues, and purples to the reds, oranges, and yellows.  It is machine pieced and quilted.  It measures 42 in X 54 in.

This photo shows some of the quilting and fabrics.
The back is a white muslin.  I wish the quilting showed better as the back is lovely.

Tips for Using Self-Tanners

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

Your doctor has told you not to use tanning beds any more.  Your skin is beginning to show more aging than your age should have.  You have a family history of skin cancer and want to avoid it.  Whatever your reason, you have decided to look at self-tanners as an alternative.

I applaud that decision, but remember to use safe sun practices and/or sunscreens as self-tanners offer no protection to your skin from UVA or UVB rays.

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According to About.com:Chemistry, self-tanners have been around in some form since 1960. 

In 1960, Coppertone introduced its first sunless tanning product - QT® or Quick Tanning Lotion. This lotion produced an overall orange effect. Today's sunless tanning products produce much more realistic results.

Bronzers

• Cosmetic bronzers produce immediate effects that can be easily removed with soap and water. Bronzers are available as powders, creams, and lotions.  Only lasts until it is washed off.

Sunless Tanning Lotions and Sprays

• Most sunless tanning products are lotions and sprays containing dihydroxyacetone (DHA) as the active ingredient. DHA is a colorless sugar that interacts with the dead cells located in the upper layer of the epidermis. This interaction is why exfoliation of “clumps” of dead skin cells is so important in getting an even color. This change usually lasts about five to seven days from the initial application.

The magazine Elle has a nice article which offers this advise for choosing the product to use:

Locke says choosing the right formula also determines how your tan will appear. “Go with a reputable brand, one that uses a lower percentage of DHA so that you can build your color accordingly,” she says.

Bronze-seekers should also go for products infused with erythrulose, a sugar sourced from raspberries. The combination of DHA and erythrulose in a sunless tanning product is believed to yield longer-lasting, cosmetically pleasing color.

Some self-tanners, like those found in the St. Tropez collection, also contain green pigment to help counteract any orange.

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Give yourself plenty of time, this is not something that should be rushed or can be done in 15 minutes:  “it will be around two hours before you can put on "street clothes" and go somewhere.” 

What will you need to have handy?

You will need a place to take a shower or bath, a cotton washcloth to exfoliate your skin, soap, skin lotion, self tanner, facilities to wash your hands frequently, a band or tie to keep hair off of your face, and a fingernail scrub brush.

If you are going to apply self tanner to your back, make sure you have a sponge paintbrush (the three inch size is good) with a handle of three inches or more. You may also want a loose outfit, such as a robe, to wear while the self tanner is drying. It's also good to have a watch or clock around.

Before applying the self-tanning product, it is import to do proper skin-prep.  Your skin needs to be clean and freshly exfoliated.

Go for a scrub that is gentle (think spherical, man-made beads over granular ones with uneven edges) to avoid irritating the skin prior to tanning. The ideal scrub should also be oil-free (“an oil-based polish can act as a barrier between the self-tanner and top layer of the skin,” says Locke). When in a bind, using a loofah or muslin cloth with water will do the trick too.

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using the cotton washcloth to remove dead and dry skin by rubbing your skin gently in a circular motion. Pay particular attention to the lower half of your legs, knees, ankles, tops of feet, and elbows. …
Important: Do not shave your legs if your skin is at all sensitive.

Next, apply a light layer of moisturizer to your skin, especially the areas like the elbows, hands, feet, ankles, and knees.

Time to apply to self tanner

• Take a look at the clock and note the time.
• Start with your legs and work your way upwards doing the face and neck last.
• Apply quickly but thoroughly, spreading in a circular motion to avoid streaking, being careful not to miss any areas.
• In most areas apply the self tanner a little more heavily than you would apply ordinary lotion.  Exceptions: Do not apply it directly to your toes, your heels, or the sides of your feet.  The face and neck areas take the self tanner well, so apply sparingly. Don't forget to apply it behind your ears.
• Wash both of your hands thoroughly every 5 minutes to avoid getting color in your palm and between the fingers.  Don’t forget to use the nail scrub brush.
• Next comes your torso and arms.  Use the sponge paint brush to apply self tanner to your back. Don't forget under your arms and the sides of your torso.
• Wash your hands again being careful not to splash water on any of the areas you wish to be tanned.
• Now you have entered the drying zone.  After 15 minutes (preferably 30 minutes), you can put on a loose nightgown or Mumu to wear while you continue to dry. 
• Avoid exercise or anything that will make you sweat for one hour.

To maintaining your tan, you will need to reapply self tanner every three days.

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From the WebMD article come these suggested self-tanners:

Banana Boat Summer Color Self-Tanning Lotion ($6.99)
L'Oréal Sublime Glow Daily Moisturizer ($11).
Neutrogena MicroMist Airbrush Sunless Tan spray ($11.99).
Clarins Liquid Bronze Self Tanning ($32.50)
Sally Hansen Airbrush Sun ($9.95)
Estée Lauder Bronze Goddess Golden Perfection Self-Tanning Lotion for Face ($22.50)
California Tan Tinted Self Tanner Lotion ($27)

Sources

Summer Glow: Best Self-Tanner Tips (May 2010); Elle

Sunless.com (source for tips on application, products, feedback)

You Asked! Expert A's to Your Beauty Q's About Self Tanners; WebMD Magazine, June 2010

Acute Hematoma Seven Years Postop – an Article Review

 Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

There is a unique case presented in the Canadian Journal of Plastic Surgery of an acute, symptomatic hematoma occurring 7 years postoperatively.  Most unique is the well defined mechanism of injury which caused the hematoma.

For background, the article reminds us that hematoma formation is a complication of augmentation mammoplasty whether for cosmetic or reconstructive purposes.  Most of these will occur in the immediate postoperative period.  The incidence is reported to range from 2-10.3% in this immediate postoperative period.

In their review of the literature, the authors found only 20 cases reported to have occurred in the late postoperative period.  Most of these cases did not have a definitive mechanism of injury or develop symptoms immediately after the triggering event.

In contrast, their patient presented with both a known and traceable cause of her bleed and with symptoms that developed immediately after the initial event.

The patient was a 53 year old female who had undergone a right mastectomy with reconstruction using a saline implant seven years previous to this injury. 

The patient reported having right breast soreness after performing vigorous stretching exercises.  The following morning, she noted increased pain and bruising over the medial aspect of the breast.  She underwent right breast ultrasound in the clinic that demonstrated a small fluid collection between the anterior surface of the implant and the overlying tissue, which was of unclear consistency…..A magnetic resonance imaging scan confirmed both intracapsular and extracapsular hemorrhage.

The patient was taken to the operating room; on entering the capsule, a pool of dark red blood was visualized and 200 ml of clot was removed…..

Interesting case review.


REFERENCE
Acute symptomatic hematoma with defined etiology seven years after breast reconstruction: A case report and literature review;
Canadian Journal of Plastic Surgery, Summer 2010, Volume 18 Issue 2: e 27-e 29; AK Seth, JY Kim

Late Hematoma after Augmentation Mammaplasty Apparently Due to Myoelectrostimulation; Cagli, Barbara; Vulcano, Ettore; Marangi, Giovanni Francesco; Cogliandro, Annalisa; Persichetti, Paolo; Plastic and Reconstructive Surgery. 119(1):439-440, January 2007; doi: 10.1097/01.prs.0000233618.94269.d4

Local Complications after Cosmetic Breast Augmentation: Results from the Danish Registry for Plastic Surgery of the Breast; Hvilsom, Gitte B.; Hölmich, Lisbet R.; Henriksen, Trine F.; Lipworth, Loren; McLaughlin, Joseph K.; Friis, Søren; Plastic and Reconstructive Surgery. 124(3):919-925, September 2009; doi: 10.1097/PRS.0b013e3181b0389e

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Debra Gordon, A Medical Writer’s Musings, is the host for this week’s Grand Rounds. It’s the “customer service in healthcare” edition. You can read this week’s edition here.

I want to start this week's Grand Rounds' blog with my own blog post. I asked for postings on customer service and I have one to share. My 17-year-old son has been having some issues with depression and social anxiety. We got him in to see a therapist and his family practitioner prescribed a low dose of Prozac, both of which seemed to be helping until he hit a crisis when his girlfriend broke up with him. He literally fell apart and scared us to death.

His therapist called me back the night of the crisis within 5 minutes of my leaving a message with the answering service. He was only in town for a week before leaving for vacation, but he saw our son twice and called our son's primary care doctor to suggest upping the antidepressant dose. The doctor called me one evening to say she totally concurred and, since our son's therapist would be out of town the following week, wanted to see our son herself.

I was so touched…………….

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A nice CBC News article featuring @globalsurgeon on maternal health:  Africa and the surgical imbalance by Nick Czernkovich.

I met Adam in the Democratic Republic of Congo. He was born by cesarean section and then, a few months later, he was back at hospital for emergency stomach surgery. At the age of 23, he again found himself under the knife for an appendectomy.

Adam is one of the lucky ones. Born and raised in the U.S., he had access to these relatively basic but life-saving surgeries without which he — and his mother — would probably not have survived.

Now 44, Dr. Adam Kushner is a certified general surgeon, but the small miracles of his early surgical encounters have not been lost on him.

Dr. Adam Kushner in Masisi, DRC, in April 2010. (Nick Czernkovich/CBC)

When I met him he was working for Doctors Without Borders in a rural hospital in the town of Masisi in North Kivu province, one of the most troubled in the eastern Congo…………….

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OncRN, an oncology nurse, has written a lovely post on saying good-bye to our patients:

you care for a patient for months, maybe years.
eventually the end comes…….
this line of work is littered with or decorated by (depending on your state of mind) many, many good-byes
this variety is uniquely emotional and complicated because our language and/or culture is sorely lacking in words appropriate for such a send off.
i'm sorry? godspeed? farewell? stay in touch? - nothing quite works.
anything, though, to avoid the ubiquitous 'take care'.…
you wish you could turn it over to your son……….

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Dr. Rob set up a blog for Zippy a few years ago to raise money for research for childhood brain cancer. It was/is a tribute to Dr. Smak’s son who was diagnosed with brain cancer and lost his fight. Initially, there was much giving. I even made a quilt which we auctioned off for the cause.

Zippy has recently been in New York with Intueri who is a wonderful writer. I hope you will check out her reports of Zippy’s adventures and consider making a donation.

Introducing Zippy.

Zippy Goes to Times Square.

Zippy Goes to Wall Street.

Zippy Goes to Bryant Park.

Zippy Looks at the New York City Skyline.

Zippy Goes to Central Park.

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Discovered a “new to me” dermatology blog:  Only the Best Skin Care Advice Blog via a comment on my blog post yesterday by the author, Dr. Cynthia Bailey.   Check out her recent post:   Cracked, Dry, Brittle and Splitting Fingernails; Dermatologist’s Tips

THE PROBLEM:

Your nails dry out as you age, losing their natural oils which act as a glue to hold the nail layers together. If you have thin fingernails and dry skin to begin with you can expect this to happen to you ‘sooner rather than later’. 

Exposing your hands to harsh soaps, cleaning products, solvents and rough work makes things worse. At first your nails begin to ‘fray’ on the edges, becoming brittle. Eventually the layers split. 

Nail hardeners make this worse because the alcohols, formaldehyde and other chemicals in the nail hardeners really dry out your natural oils. (Crazy fact: Nail hardeners actually contain more of these chemicals than nail polishes!  It’s these chemicals that make the nails feel harder at first, but- whammo- after a few weeks the splitting is worse than ever.)

THE FIX:……………….

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This past weekend I made another messenger bag. This one using old cargo pants, making good use of two of the great pockets.

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Dr Anonymous’ BTR show guest this week will be Dr. Bryan Vartabedian, 33 Charts. The show begins at 9 pm ET.

Upcoming shows (9pm ET)

Cowden Syndrome and Breast Cancer

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

I was unaware of Cowden Syndrome prior to seeing the article (full reference below) mentioned in my MDLinx Plastic/Reconstructive Surgery weekly update.  I went looking for more information.

According to Genetics Home Reference website:

Cowden syndrome is a rare disorder characterized by multiple noncancerous, tumor-like growths called hamartomas and an increased risk of developing certain cancers.

Almost everyone with Cowden syndrome develops hamartomas. These growths are most commonly found on the skin and mucous membranes (such as the lining of the mouth and nose), but can also occur in the intestinal tract and other parts of the body. Abnormal growths on the skin and mucous membranes typically appear by a person's late twenties.

People with Cowden syndrome have an increased risk of developing several types of cancer, including cancers of the breast, thyroid, and the lining of the uterus (the endometrium). Noncancerous breast and thyroid diseases are also common. Other signs and symptoms of Cowden syndrome can include an enlarged head (macrocephaly); a rare, noncancerous brain tumor called Lhermitte-Duclos disease; and intellectual disability.

How common is Cowden syndrome?

Researchers estimate that Cowden syndrome affects about 1 in 200,000 people; however, the exact prevalence of this condition is unknown because it can be difficult to diagnose.

It’s the increased risk of cancers in the breast that was the focus of the Journal of Plastic, Reconstructive & Aesthetic Surgery article.  It was for this reason that their 3 case report patients had prophylactic mastectomies with reconstruction. 

According to the eMedicine article:

Carcinoma of the breast occurs in 20-36% of female patients and is one of the most serious consequences of Cowden disease (multiple hamartoma syndrome). Carcinoma of the breast also has been reported in 2 men with Cowden disease (multiple hamartoma syndrome).  Fibrocystic disease and fibroadenomas are present in approximately 75% of patients.

And from the University of Iowa patient guide:

Of all the women diagnosed with CS, 30 to 50 percent of patients will develop breast cancer and 50 to 70 percent of patients will not develop breast cancer. The average age of breast cancer in women with CS is 38 years; however, cancer has been reported in patients ranging from 14 to 65 years of age. Women are also at increased risk for other benign breast conditions, such as ductal hyperplasia, intraductal papillomatosis, lobular hypertrophy, fibrocystic breast disease, or fibroadenomas.

Although the risks are lower, men with CS also have an increased risk for developing breast cancer. However, the degree of risk for breast cancer in men is unknown.

REFERENCES

Cowden syndrome and reconstructive breast surgery: Case reports and review of the literature; E. Ali, P.G. Athanasopoulos, P. Forouhi, C.M. Malata; Journal of Plastic, Reconstructive & Aesthetic Surgery - 07 June 2010 (10.1016/j.bjps.2010.04.047)

Cowen Syndrome – Genetics Home Reference, A service of the U.S. National Library of Medicine®

Cowden Disease (Multiple Hamartoma Syndrome); eMedicine article, April 26, 2010; Kendall Adkisson, MD, Katherine H Fiala, MD

Cowden Syndrome: A Guide for patients and their families; April 2002; University of Iowa Hospitals and Clinics

Happy Father’s Day!

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

On this Father’s Day, I thought I’d list some men who have been influential in medicine and surgery.

Hippocrates (ca. 460 BC – ca. 370 BC)has been named the Father of Medicine.

In surgery, there are three different men who are often given the title of the Father of Surgery:

Sushruta (600 B.C., from India)

Sushruta, one of the earliest surgeons of the recorded history (600 B.C.) is believed to be the first individual to describe plastic surgery. Sushruta who lived nearly 150 years before Hippocrates vividly described the basic principles of plastic surgery in his famous ancient treatise 'Sushruta Samhita' 1,2 in 600 B.C. 'Sushruta Samhita'(Sushruta's compendium) which is one of the oldest treatise dealing with surgery in the world indicates that he was probably the first surgeon to perform plastic surgical operations.

Alzahrawi:  Father of Surgery (A.D. 936 - 1013)

Al-Zahrawi is known in the West as Albucasis. He wrote Kitab Al Tasrif, a 30-volume medical textbook which included sections on surgery, medicine, orthopedics, ophthalmology, pharmacology, nutrition, etc. The thirtieth treatise, On Surgery and Instruments, is considered the first rational, complete, and illustrated treatment of its subject.

Ambroise Paré (c. 1510 – 20 December 1590)

Ambroise Paré (c. 1510 – 20 December 1590) was a French surgeon. He was the great official royal surgeon for the kings Henry II, Francis II, Charles IX and Henry III and is considered as one of the fathers of surgery. He was a leader in surgical techniques and battlefield medicine, especially the treatment of wounds. He was also an anatomist and the inventor of several surgical instruments.

Gizabeth, Methodical Madness, may correct me, but the Father of (modern) Pathology is considered to be Rudolf Ludwig Karl Virchow (13 October 1821 – 5 September 1902).

was a German doctor, anthropologist, pathologist, prehistorian, biologist and politician, known for his advancement of public health. Referred to as "the father of modern pathology," he is considered one of the founders of social medicine.

Vijay, Scan Man’s Notes, may correct me, but the Father of (diagnostic) Radiology is considered to be Wilhelm Conrad Roentgen (March 27, 1845 – February 10, 1923).

was a German physicist of the University of Würzburg. On November 8, 1895, he produced and detected electromagnetic radiation in a wavelength range today known as X-rays or Röntgen Rays, an achievement that earned him the first Nobel Prize in Physics in 1901. He is also considered the father of Diagnostic Radiology, the medical field in which radiation is used to produce images to diagnose injury and disease.

Happy Father’s Day to fathers everywhere!

Scolded by Wii

I finished a post-abdominoplasty check, drains and sutures removed.  I then began to tell her how to slowly increase her activities and exercise.

She smiled,  “I have to tell you.  I got back on the Wii just to walk yesterday.  It told me I had lost weight too quickly.  I needed to slow down.”

"H" Rail Fence Quilt

Here is another quilt I made years ago. I made it for my husband’s dad and step-mother. The family name begins with an “H.” No, I didn’t take my husband’s last name. I have kept my own father’s name.

Anyway, I decided to make us of the rail fence layout which forms a repeating “H” in the design. I made it using Christmas fabrics/colors. The quilt is machine pieced by me, but hand quilted by Cobblestone Cupboard. It measures 88 in X 98 in. The quilt was finished October 1994.

Here is a close view of the quilt/fabrics.

Happy Father's Day!

An Unusual Case of Itching in a Surgery Patient

Patients who are in the early postoperative period (first 2 days) will sometimes complain of itching. I hear this either during the call I make the evening of surgery or when the patient calls the next day. I follow up this complaint up with a few questions:
How severe is it?
Where do you itch?
Is there any rash?
When did it start?
Most often the itching is a minor irritation. Often they or a family member will immediately think they have to be allergic to one of the medications they are taking. Most often this is not the case.

If the itching is localized to the area of the surgery, then most often it is due to the surgical scrubs not being cleaned off well enough (almost impossible to fully do). This itching goes away quickly when the patient takes their shower and can fully cleanse the soaps away.

I worry more about an allergic reaction if the itching is generalized, includes a rash, and has gotten worse after the second or third dose of some medication. When told this I review medications they are taking and stop the most likely offending one.

Regardless of the cause, if it bothers the patient enough I will tell them to try taking Benadryl to ease the irritation of the itch.

…………………

There was an unusual case of itching I encountered once in a postoperative patient. The patient was a 27 yo nurse who developed an elevated temperature (no increased pain, no redness or added tenderness in the surgical area, no pain on urination) and flu like symptoms on the second day after surgery. The rash broke out on the third day after surgery.

Her rash consisted of vesicles located initially on the chest, neck, and later her face and arms.

My initial thought was chicken pox. She initially insisted there was no way it could be, but agreed to see her internist. Turned out I was right.

She was miserable while she recovered, having to deal with the surgery issues AND the chicken pox.

Should Female Cosmetic Genital Surgery Be Done?

Updated 3/2017 --  all links (except to my own posts) removed as many no longer active. 

I seem to be asked more often these days if I do vulva reduction surgery. I’ve even been asked if I “refresh” vaginas (refer them to their gynecologist). I am happy it is a extremely small part of my practice.

I’m actually happy to see that the current issue of the journal Reproductive Health Matters are taking a close look at cosmetic surgery, especially female cosmetic genital surgery.

Marge Berer (full reference below) says the following in her editorial:

The papers and Round Up summaries in this journal issue and their sources use the following terms for a mind-boggling list of procedures: labia reduction, labiaplasty (also called nynfoplastia in Brazil), genitoplasty, pulling the labia to make them longer, filling or replenishing of the labia majora, female genital reshaping, intimate surgery (translated from the Brazilian cirurgia intima), vaginal narrowing or tightening (e.g. after vaginal delivery or for increased pleasure for men), vaginal rejuvenation, hymen reconstruction, hymen repair (for restoration of virginity), clitoral lift, clitoral hood reduction, clitoral repositioning, breast reduction, breast augmentation, breast lifting, liposuction, and abdominoplasty (tummy tuck). And how about G-spot augmentation?

Then there is the terminology surrounding female genital mutilation – or cutting or circumcision or excision – and the reconstructive surgery that has developed to address the physiological problems it creates. This includes, according to Elena Jirovsky’s research in Burkina Faso, surgery to the vaginal opening if it has become too small due to adhesions, or the removal of perturbing scar tissue and keloids. More recently, she reports, a surgical procedure to reconstruct the excised clitoris has emerged, developed by a French surgeon. ……..

Too big, too small, too narrow, too wide, too high, too low, too flabby, too wrinkled. The permutations are endless. What a great way of making money!

In his 2008 article in the Journal of Plastic and Reconstructive Surgery, Dr Gary Alter, who is also featured on the E! Network series, "Dr. 90210," stated:

The most common female genital aesthetic procedure is a labia minora reduction (labioplasty).

Women have become more aware of differences in genital appearance as a result of explicit photographs and movies and the wide acceptance of genital hair removal. Most consider an aesthetic ideal as labia minora and clitoral hood that do not protrude past the labia majora, but individual aesthetic judgment varies.

If a woman considers her labia enlarged or deformed, she may have diminished self-esteem and be sexually inhibited. In addition, the vast majority of women with enlargement of the labia minora also complain of a variable amount of discomfort with clothes, exercise, and/or sexual activity. The large size can interfere with hygiene and can cause constant irritation. Demand for labia minora reduction has increased because of recent media coverage of this operation.

Are we plastic surgeons driving this or are the women? Is the media coverage? Is this truly a physical issue or do these women perhaps need to be seen and evaluated by a therapist first?

I don’t have the answers to my own questions, but I do feel strongly that we surgeons need to remember “First, do no harm.” Are the benefits of the surgery enough to outweigh any potential complications?

I do not think these are procedures we should be promoting or advertising.

REFERENCES

Cosmetic Surgery, Body Image and Sexuality; Reproductive Health Matters, Volume 18, Issue 35, Pages 4-10 (May 2010); Marge Berer

A poor prognosis for autonomy: self-regulated cosmetic surgery in the United Kingdom; Reproductive Health Matters, Volume 18, Issue 35, Pages 47-55 (May 2010); Melanie Latham

Activism on the medicalization of sex and female genital cosmetic surgery by the New View Campaign in the United States; Reproductive Health Matters, Volume 18, Issue 35, Pages 56-63 (May 2010); Leonore Tiefer

Aesthetic Labia Minora and Clitoral Hood Reduction Using Extended Central Wedge Resection; Alter, Gary J.; Plastic and Reconstructive Surgery. 122(6):1780-1789, December 2008; doi: 10.1097/PRS.0b013e31818a9b25

My Tweeterview by Diario Medico

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

I was contacted by @alainochoa who works with Diario Medico a month ago.  He wanted to interview me using twitter – a tweeterview.  We went back and forth on dates.  It happened this morning.  Amazing how nervous I got just before the interview.

You can read the interview here.

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Steve, Adventures of a Funky Heart, is the host for this week’s Grand Rounds.   It’s the “heart edition” edition.  You can read this week’s edition here.

Welcome to the Funky Heart edition of Grand Rounds, featuring the latest and greatest medical writing! For those of you visiting for the first time, Adventures of a Funky Heart! is written by Steve, a 43-year-old living with a Congenital Heart Defect (CHD). (My specific defect is Tricuspid Atresia) In the United States, an average of 1 person out of every 125 is born with a heart defect – almost 2 million of us at last count! Once considered just a childhood disease, thanks to medical advances and better surgical procedures over 90% of CHD patients can now live to adulthood! For the first time in history, over half of all CHD Survivors are adults!

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Katie, NursesNetwork.com, is the host of the latest edition of Change of Shift (Vol 4, No 25) !   You can find the schedule and the COS archives at Emergiblog. (photo credit)

I joined a book club several years ago.  I have read books I normally wouldn’t choose and always enjoy them.  At a local restaurant I frequent I always order the daily special.  It has forced me to try different and tasty fare. I also have teenagers.  I never make a big decision without talking to them.  They bring a unique and fresh perspective that would not occur to me.

I am thrilled to be hosting Change of Shift.  While I do not always share the opinion of my colleagues, I learn so much and am challenged to view my profession in a new and different light………….

……………………………………

I’m a huge fan of NPR and for different reasons found these stories from last week of great interest:

Add It Up: Pricing Out A Visit To TV's 'Dr. House'  (interest due to my being in the medical community)

Gregory House (Hugh Laurie) is rude, inconsiderate and doesn't like playing by the rules — but, man, is he a good doctor. ……..How much money would it cost to diagnose the patient in the "Ignorance Is Bliss" episode of House?………

That leaves our poor patient with a total medical bill of at least $298,200………….

Dealing with a Parent's Early Death  (interest is due to having lost my dad when I was eight)

The death of a parent can leave emotional scars on a child that last for decades. One in nine American's have been through this type of loss before the age of 20. Helping children cope with the loss of a parent and dealing with childhood bereavement as an adult………

There was also an interesting WSJ article by Jeffrey Zaslow relating to early loss of a parent:  Families With a Missing Piece

For adults who were children when their parents died, the question is hypothetical but heartbreaking: 
"Would you give up a year of your life to have one more day with your late mother or father?"
One in nine Americans lost a parent before they were 20 years old, and for many of them, this sort of question has been in their heads ever since. …….

…………………………………….

On a lighter note, these two companion tweets from Geek2Nurse of a patient’s rap made me smile:

(Actual) psych patient rap, verse 1: "I'm not manic, I'm not psychotic. I'm not schizophrenic, And I'm not neurotic..." (cont. next tweet)

(Cont.) Psych patient rap, verse 2: "It ain't the hip-hop, It ain't rock & roll; I just gotta get myself some weed, To neutralize my soul."

……………………………………….

The Alliance for American Quilts received 115 quilts for it’s “New from Old Quilt Contest Contest.”  You can see all the quilts here.  My entry is “Label Me.”

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Dr Anonymous’ BTR show guest this week will be Family Physician Dr. Kim Yu. The show begins at 9 pm ET.

Upcoming shows (9pm ET)

6/24: Dr. Bryan Vartabedian, 33 Charts
Jul-Aug: Summer Break
8/26: Dr. A Show 3rd Anniversary

Safety of Sunscreens

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

I “preach” sunscreen use to my family, friends, and patients.  I do this because sunscreen helps prevent skin cancers, but in light of the recent  President’s Cancer Panel report on Cancers from Environment 'Grossly Underestimated'  and concerns by the group Friends of the Environment I thought perhaps I should look at the safety of the active chemicals/nanoparticles in sunscreens.

You need both UVA and UVB protection. It is the UVA rays that are most responsible for wrinkling and aging the skin. It is the UVB rays that are the most responsible for the sunburn and skin cancer formation.

According to the American Academy of Dermatology (AAD), sunscreens should ideally be water-resistant, so they cannot be easily removed by sweating or swimming, and should have an SPF of 30 or higher that provides broad-spectrum coverage against both UVA and UVB light.  I think it is not worthwhile to purchase any sunscreen with an SPF higher than 55.

Remember the SPF rating only reflects the product's ability to screen or block UVB rays only. SPF 15 blocks approximately 93%of all incoming UVB rays. SPF 30 blocks 97%; and SPF 50 blocks 99%.

Active ingredients used in sunscreens:

• Avobenzone (Parsol, Eusolex, Escalol)  (chemical block, UVA blocker)
• Bemotrizinol (Tinosorb S)  (chemical block, UVA + UVB blocker) 
• Bisoctrizole (Tinosorb M)  (hybrid; UVA + UVB blocker)
• Cinoxate (chemical block)
• Ecamsule (chemical block, UVA blocker) – L’Oreal’s patented Meroxyl SX
• Octyl methoxycinnamate (octinoxate) (chemical block, UVB blocker) – potential photosensitizer
• Octyl salicylate (octisalate) (chemical block, UVB blocker)
• Oxybenzone (chemical block, UVB blocker) --  potential photosensitizer
• Sulisobenzone (chemical block, UVB blocker) – potential photosensitizer
• Titanium dioxide (physical block, UAV + UVB blocker)
•  Zinc oxide  (physical block, UAV + UVB blocker)

I am beginning to see physical block sunscreens called organic.  I find this disingenuous as most rely on nanoparticles of Zinc Oxide (ZnO) or Titanium Dioxide (TiO2) rather than naturally found particle size.   I think this is simply a marketing ploy even if “technically” true as they are both minerals.

Physical sunblockers block UV radiation mainly by reflecting/scattering the rays. They are generally insoluble and do not penetrate the skin.  Zinc oxide (ZnO) and titanium dioxide (TiO2) nanoparticles used in sunscreens range in the 20 – 30 nm size.  Their use has become popular as the nanoparticles appear transparent when applied to the skin rather than as a thick opaque white cover.  This transparency makes the sunscreen much more cosmetically acceptable than the larger-particle ZnO and TiO2 use.

The physical and chemical properties of nanoscale materials, such as reactivity, persistence, or bioavailability, can differ significantly from their larger scale counterparts.  This is the concern of the group Friends of the Earth who feel that sunscreens with nanoparticles are a risk to your health and urge you not to use them.

While the FOTE quote a recent Australian study by Macquarie University's Professor Brian Gulson as evidence that sunscreens using nano-ZnO are potentially hazardous due to absorption into the blood stream through the skin, Gulson in an interview notes that his study doesn't shed any light on the question of whether the nano-particles themselves played a part in the zinc absorption. “That was the most critical thing. This isotope technique cannot tell whether or not it's a zinc oxide nano-particle that got through skin or whether it's just zinc that was dissolved up in contact with the skin and then forms zinc ions or so-called soluble ions. So that's one major deficiency of our study.”

Other studies not mentioned by FOTE suggest the case for safe, non-penetrating, transparent, topical ZnO sunscreen formulations appears to be strengthening as the one by Sheree Cross and colleagues.

Chemical sunblocks work mainly by absorbing UV light.  Most are synthetic chemicals that are soluble in oil and/or water. Many can penetrate the skin at least to some degree.

The useful ability of chemical sunblocks to absorb UV light is also a potential source of harmful effects as some can actually be responsible for photosensitization leading to sun damage rather than protection.  Often this is what is happening when someone says “I’m allergic to sunscreen.”

Not all chemical sunblocks are created equal. For example, ecamsule (Mexoryl SX), homosalate and a few others appear to have a relatively good safety profile. On the other hand, such agents as octocrylene, octinoxate, oxybenzone and sulisobenzone appear to be more damaging. If choosing a chemical sunscreen formula, examine the list of ingredients and look up the information (on this site and elsewhere) on the specific blockers used in the formula.

The chemicals used in sunscreens as with many skin care ingredients have not been researched to the possibility of low-level topical or systemic toxicity with long-term use.

A concern in the use of nanoparticles and chemicals in sunscreens is the exposure of the body due to oral and nasal uptake due to application to the lips and mouth area, around the nose, and via contact with sunscreened hands themselves or with handling food. 

Philip Moos and colleagues looked at the effects of nanomaterials in the colon.  Their experiments used cell cultures of colon cells to compare the effects of zinc oxide nanoparticles to zinc oxide sold as a conventional powder. They found that the nanoparticles were twice as toxic to the cells as the larger particles.   This is a study of cell cultures which now needs to be looked at again in living gut before getting too concerned.  The scientist also not that the concentration of nanoparticles that was toxic to the colon cells was equivalent to eating 2 grams of sunscreen — about 0.1 ounce.

While the final word may not be out on the safety of nanoparticles and chemical in sunscreens at this point I feel safe in using them and recommending their use to family, friends, and patients.  No sunscreen is recommended for oral consumption, so care should always be used in washing your hands prior to eating. 

Lips are an area commonly involved in skin cancer formation, so it is important to protect them.  When using sunscreen lip balm, don’t lick your lips.  This will reduce the accidental ingestion of any potentially harmful chemicals, nanoparticle or not.

If you are worried about chemicals or nanoparticles in sunscreens, then use other sun safe practices:

• Staying in the shade, especially between the sun’s peak hours (10 a.m. - 4 p.m.).
• Covering up with clothing, a brimmed hat and UV-blocking sunglasses.
• Avoiding tanning and UV tanning booths.

Sunscreens should not be used in babies under 6 months old.  It is recommended by the American Academy of Pediatrics for this group to use other sun safe practices such as the ones just mentioned.

When you do use sunscreens, use at least an SPF 15 and preferably one with a sunblock component also.  To protect against the UVA rays, the product needs to have avobenzone (Parsol 1789), ecamsule (Mexoryl), titanium dioxide, or micro-zinc oxide.

• Apply the sunscreen 20-30 minutes before going outside.  Reapply every two hours when outside at a beach, etc. for adequate protection.
• Use enough. To ensure that you get the full SPF of a sunscreen, you need to apply 1 oz – about a shot glass full.
• Reapply after getting out of the water or toweling off. Even "water-proof" sunscreens are not usually "towel-proof".
• Use even on a cloudy day, up to 80% of the sun's ultraviolet rays can pass through the clouds. In addition, sand reflects 25% of the sun's rays and snow reflects 80% of the sun's rays.
• Don't forget to apply lip balm with SPF 15 or higher.

Don’t forget you can check out the Environmental Working Group’s list of the best and worst sunscreens can be found on their  searchable database.  A few of the best rated include:  Al Terrain Aquasport Performance SPF 30, Badger Sunscreen for Body and Face SPF 30, California Baby Sunscreen SPF 30, and Vanicream Sunscreen Sport SPF 35.

REFERENCES
Facts About Sunscreens; American Academy of Dermatology
SmartSkincare.com
Food and Drug Administration:  Sun Protection; Rulemaking History for OTC Sunscreen Drug Products
American Academy of Pediatrics
Friends of the Earth:  Nanosunscreens Threaten Your Health

Human Skin Penetration of Sunscreen Nanoparticles: In-vitro Assessment of a Novel Micronized Zinc Oxide Formulation; Sheree E. Cross, Brian Innes, Michael S. Roberts, Takuya Tsuzuki, Terry A. Robertson, Paul McCormick; Skin Pharmacol Physiol 2007;20:148–154; DOI: 10.1159/000098701

ZnO Particulate Matter Requires Cell Contact for Toxicity in Human Colon Cancer Cells; Philip J. Moos, Kevin Chung, David Woessner, Matthew Honeggar, N. Shane Cutler and John M. Veranth; Chem. Res. Toxicol., 2010, 23 (4), pp 733–739; DOI: 10.1021/tx900203v

The Dermatology Blog:  Sunscreens Cause Skin Cancer? What?!  (June 1, 2010)

Egg on My Face

Yesterday, Gizabeth, my husband, and I took a road trip to see the medical history exhibit at the Old Jail Museum in Greenwood, Arkansas. We had decided to make the museum for our daytrip after Google (yes, they share some of the egg – smile) maps put Greenwood just 8 miles from Altus and the Arkansas wineries.

We had a lovely day planned – leave Little Rock around 8:30 am, drive through McDonald’s for coffee (I love their coffee!), head to the museum which opened at 11 am (est time of first leg a little over 2 hr), have lunch at one of the winery restaurants, and then visit the flea market/farmer’s market in the Altus town square.

First error of the day: Greenwood, AR is NOT next to Altus, but there is a Greenwood Community located there. Notice the Greenwood, AR not marked by Google over to the west near Fort Smith and the Oklahoma- Arkansas border. That’s where we needed to be.

After stopping to ask directions in “Greenwood”, we got back on the road and headed west. We finally got to the museum which is located in an old jail, hence the name – Old Jailhouse Museum.

My second mistake – the medical history exhibit was in 2009, not this year. We enjoyed the visit anyway.

The museum grounds also has this wonderful dog-trot log cabin! At one time my grandmother on my father’s side lived in one of these. I loved the place. It is always cool in that center (dog-trot) area in the summer. Always has a nice breeze.

I did notice a couple of items with a medical bend. Here’s an old wooden wheelchair. Can you imagine having to use this?

This old wringer washing machine was the source of some horrible injuries to arms. I grew up using a wringer washing machine (a “newer” model than this). Mother got a non-wringer machine after I went to college.

This photo shows the damage tornados can do.

We ate a late lunch at a local diner, the Bulldog, then headed back to Little Rock. Glizabeth needed to be back by 5 pm (we were back by 5:20 pm) as she had a wedding to attend.

Even with the “egg on my face” stuff (or maybe because of it), we had a great day full of conversation, laughter, and music.

Efficiency

“I see you remembered to bring the office forms I mailed you.”

“Yes, but I need to fill them out,”  he replies.

I hand him a pen and clipboard, thinking “you had over a week to fill them out at home.”

Fifteen minutes later, I smile as he hands me the filled-in forms.

J's Snakes Quilt

My friend Gizabeth blogs at Methodical Madness. Her son just turned 5 years old. He has a pet snake.

Years ago (early to mid 1990’s I think) I printed out Cheri Strole’s Snake Paint quilt pattern (pdf). Fortunately, I didn’t lose it and actually was able to find it when I decided I needed to make J a quilt. I’m sorry that I couldn’t find a link for the pattern for anyone who might like this quilt.

I machine pieced an quilted this quilt. It is 43.5 in X 55 in. I used ultra-suede scrapes for the eyes and tongues, but quilting cottons for the rest of the quilt.

I am not a big fan of snakes, but I do love these.
The next several photos just show the snake faces. You can also see the quilting.



The back of the quilt was pieced to use some leftover fabrics.

I’ll be giving the quilt to Gizabeth tomorrow when she, my husband, and I take off for a road trip to visit a couple of the medical museums in Arkansas. I sure hope he likes it.

Melanoma of the Nail Matrix

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Two recent articles in the Archives of Dermatology serve as a reminder that melanoma may occur under the finger nail in the nail matrix.

The first one (full references for both below) used slides and prepared information from 12 cases to “test” dermatologist. Here is one of the examples given in the paper:

Nevus. A, Clinical features; B, nail plate dermoscopy; C, intraoperative dermoscopy. ABCDEF rule information: A (age, 35 years), C (change in band at 2 years; it became enlarged or darker), D (digit, third finger, right hand), and F (no family or personal history of melanoma)

Only 46-55% made the correct diagnosis of nail matrix melanoma in situ in this study. The level of expertise did not statistically influence the correct diagnosis.

Early diagnosis of melanoma of the nail unit is challenging. The tumor most often presents with a longitudinal nail pigmentation (longitudinal melanonychia), but this is not a specific sign for melanoma.

Longitudinal melanonychia can also be caused by numerous nonmalignant conditions that include nevi of the nail matrix, benign melanocytic hyperplasia (nail matrix lentigo), and a number of inflammatory, traumatic, or iatrogenic nail disorders that induce the activation of the nail matrix melanocytes.

Features on clinical examination that are suggestive but not pathognomonic of melanoma include inhomogeneous pigmentation with bands or lines of different colors, presence of nail plate fissuring or splitting, rapid enlargement of the band, a proximal part of the band that is broader than the distal (triangular shape), blurred lateral borders, and pigmentation of the periungueal skin.

These features have been summarized in the ABCDEF rule for diagnosis of nail melanoma and may help clinicians in distinguishing "nonalarming" from "alarming" bands. Each letter indicates features that are associated with an increased risk of melanoma:

• A (age as peak incidence of nail melanoma is between 50 and 70 years. A also reminds us of most commonly affected races: African Americans, Asians, and Native Americans).
• B (band: black to brown, breadth > than 3 mm, blurred borders)
• C (change: enlarging or darkening)
• D (digit: most fingernail melanomas affect the dominant hand)
• E (extension of the pigmentation to the surrounding tissues)
• F (family or personal history of melanoma)

The second one reminds us that melanoma in the nail matrix location (nail apparatus melanoma or NAM) is associated with a poor prognosis, mainly because of a delay in diagnosis. Too often diagnosed at an invasive stage. The authors note this is particularly true in cases involving amelanotic melanoma. They report 3 cases of in situ amelanotic melanoma with clinical lichenoid features, concluding that chronic unexplained monodactylic nail dystrophy should be investigated histologically.

All three of their patients (ages 39 to 60 yrs) presented with nail alterations characterized by lichenoid changes with longitudinal striation, distal splitting, and nail plate atrophy. Histologic examination revealed in situ amelanotic melanoma extending from the proximal matrix up to the distal part of the nail bed. (photo from article)

The authors give us the background on amelanotic NAM:

Amelanotic NAM represents 20% to 30% of ungual melanoma cases compared with less than 7% of the other cutaneous melanomas.

It usually presents as a chronic paronychia, a torpid granulomatous ulceration, a wartlike keratotic tumor, or a pyogenic granuloma.

It is usually located in the periungual folds or in the nail bed.

Clinical misdiagnosis, which is particularly frequent in amelanotic melanoma, is responsible for a delay in diagnosis as well as a poor prognosis.

REFERENCES
Dermatologists' Accuracy in Early Diagnosis of Melanoma of the Nail Matrix; Nilton Di Chiacchio; Sergio Henrique Hirata; Mauro Yoshiaki Enokihara; Nilceo S. Michalany; Gabriella Fabbrocini; Antonella Tosti; Arch Dermatol. 2010;146(4):382-387.
In Situ Amelanotic Melanoma of the Nail Unit Mimicking Lichen Planus: Report of 3 Cases; Josette André; Isabelle Moulonguet; Sophie Goettmann-Bonvallot; Arch Dermatol. 2010;146(4):418-421.

The Vanishing Oath

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

I received a copy of the documentary, The Vanishing Oath, from the the films producer Nancy Pando.   I’m not sure I can best Dr Wes’ review, but would like to add my impressions.  The documentary film  was directed by a young emergency room physician, Ryan Flesher, MD and produced by a former clinical social worker, Nancy Pando, LICSW.   Dr. Flesher’s own dissatisfaction/disillusionment with medicine led to the films production.

Physician burnout is an important topic and as with most job dissatisfaction is not due to just one thing.  The film addresses many with interviews of physicians, the public, and one lawyer – long hours, need to see more patients in less time, threat of malpractice lawsuits, increasing paperwork, increasing pressures from outside sources (government, insurance companies, etc).

Being a surgeon, I was particularly struck by the young aspiring hand surgeon who left (video clip) medicine after all of his years of training because of the toll it took on himself and his family.  I would love to know what he is doing now.  What job replaced medicine and surgery for him, because no job is without it’s own problems and exasperations.  Time management or life balance is always a “juggling” act which some are better at than others.

I will admit here and now that I have experienced some of this, so I was hoping (as I think Dr. Flesher was) that the film would show me better ways to guard against all those forces that take my joy of practicing medicine away.  Sadly, it didn’t, but there were two physicians interviewed who seem to always (or almost always) love their job.  I “soaked” these two up, especially the segment of Dr. Peter Rosen who advises “the most important thing is to revive your ideas, why did you want to be a doctor?”  I love his story of his first patient when he was 8 yrs old.  He has retained that enthusiasm. 

I am now working to get this shown in my community as Dr. Wes managed to in his.  No dates set as of today.

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

MDiTV is the host for this week’s Grand Rounds.   It’s the “best edition ever, maybe” edition.  You can read this week’s edition here.

Thanks to everyone who submitted to this week’s edition of Grand Rounds.  After following the weekly blog carnival for  months, submitting a few times and now playing the role as host has been immensely gratifying. The submissions covered a wide-range of topics; from surgical procedures to how the progression of 80’s music mirrors the evolution of birth control (seriously). ….. Thanks again to everyone that participated and I hope you all enjoy this week’s picks of the best medical blog reads as much as I did!

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Medical schools across the country have been holding their graduation ceremonies and white coat burning ceremonies.  JAMA has include a wonderful essay by Sunita Puri, MD MS on her coat:  Worn

I never thought this day would come.

The meaning of the day struck me at the oddest of moments. I was rushing around my apartment, picking up bedsheets, pillowcases, towels, jeans, gym clothes, all badly in need of a whirl in the washing machine. Oddly, it was always an afterthought to add my short white coat to my pile of laundry. And today, as I placed it at the top of the pile, I suddenly remembered that I never needed to wash it again. I had just returned from my last day of my last clinical rotation as a medical student. The last day I ever had to wear this short, awkward coat.

I began my usual prelaundry ritual of examining my white coat. I emptied its pockets,…….. Yet in surveying the coat now, I was moved by the memories that each imperfection indexed. …..

Mrs J gave me the pen that later leaked, bruising my right lower pocket with a black splotch. …….

Ms A's mother gave me the turquoise necklace that I kept in my lower left coat pocket. …...

I had to retire the coat with the spray of coffee on its entire left side. Mr D was my patient only briefly, in his shuffle between the surgery, medicine, and ICU services, but I had been the one to call and tell his wife that she should drive to the hospital soon. …….

Over the course of this two-year introduction to clinical medicine, my white coats served as time capsules and canvases. Their physical appearance changed as an intoxicated patient's blood splattered during my first attempt at an arterial blood draw …….

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Dinah, Shrink Rap, asked readers for Shrinky Book recommendations and has compiled the full list of recommendations:  Our Readers' List of Best Shrinky Books.  Here are just a few of the suggested books.  Check out the post for the full list.

Existential Psychotherapy, by Irvin Yalom

Shoot the Damn Dog by Sally Brampton

Darkness Visible by William Styron

An Unquiet Mind by Kay Redfield Jamieson

Man's Search for Meaning by Viktor Frankl

In Session by Deborah A. Lott
The Dance of Anger by Harriet Lerner
In a House of Dreams and Glass By Robert Klitzman, MD
I had a black dog - Matthew Johnstone

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Another list of books.  This one is summer reading suggestions from the New Yorker: If You Liked My Book, You'll Love These.  The list includes suggestions from six writers, genre by genre.

In the science section:

The Immortal Life of Henrietta Lacks (Crown),  by Rebecca Skloot, has spent fifteen weeks (and counting) on the Times best-sellers list.
The Man Who Mistook His Wife for a Hat: And Other Clinical Tales (1985)  by Oliver Sacks
Confessions of a Knife (1979) by Richard Selzer
Love at Goon Park (2002) by Deborah Blum
A wonderful character study of Harry Harlow, the dark, eccentric scientist whose amazing, often disturbing research on primates led to much of our understanding of child-rearing.
His Brother’s Keeper: A Story From the Edge of Medicine (2004) by Jonathan Weiner
The tale of a mechanical engineer who turned himself into a geneticist with hopes of saving his brother’s life.

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LockupDoc has written a nice post:  How doctors can use their own feelings to provide better care

……..But, wait. There’s an invaluable clinical pearl that physicians can borrow from the world of psychotherapy to help them to better hone this “sixth sense.”

I’ll explain.

Have you ever been around a negative, depressed person for too long? Or too many negative, depressed people in a short period of time?……………..

And that’s the “secret”–it’s actually quite simple: The feelings that others elicit in you are often reflections of their own internal mood states. So, how you feel in the presence of someone very well might be similar to what they are feeling……

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 Threads has a nice tutorial by Kenneth King on Ribbon Braid. 

This little braid is one I learned a few years ago while flying to a teaching gig. It’s what is called a “two element” braid, which means there are two strands that go into the making of it. For the demonstration, I’m choosing to use white and black ribbon for clarity, but you can use either the same colors for both elements, or a different color……………

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Dr Anonymous’ BTR show guest this week will be Ray Saputelli, NJ Academy of Family Physician. The show begins at 9 pm ET.

Upcoming shows (9pm ET)

6/10: Ray Saputelli, NJ Academy of Family Physicians
6/17: Family Physician Dr. Kim Yu
6/24: Dr. Bryan Vartabedian, 33 Charts
Jul-Aug: Summer Break
8/26: Dr. A Show 3rd Anniversary