Postoperative Management of CMC Joint Fracture Dislocation of the Hand

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I haven’t seen or treated any wrist dislocation injuries since my hand surgery fellowship, but still read an article regarding their treatment every now and then. I stumbled across this one (full reference below) via MDLinx. The full article is available for free online.

The authors of the article note in their literature search that most multiple carpometacarpal (wrist) fracture/dislocation injuries are due to motor vehicle accidents. They were unable to find any large studies of multiple CMC dislocations. One of the “largest” had only 10 patients.

Multiple CMC dislocations are uncommon and occur from high-energy trauma. Treatment of these injuries require operative fixation. The reduced fractures/dislocations are stabilized using K-wires which remain in place for 6-8 weeks.

Prolonged immobilization can result in stiffness of hand joints, tendon adhesions, and muscle weakness. The authors of the CJPS article note that early controlled motion must be balanced with sufficient immobilization of the fractures/dislocations to allow healing.

The main purpose of their case presentation is to describe a novel postoperative rehabilitation regimen in their multiple CMC fracture dislocation patient (a 28 yo male).

The wrist and hand were immobilized in the neutral position for two weeks in a short arm splint and for an additional four weeks in a short arm circumferential cast.

The Kirscher wires were removed at the outpatient clinic at eight weeks. Radiographs confirmed union…

Hand therapy, consisting of protective splinting and active-assisted ROM, was initiated eight week following injury. ….

Hand therapy was then progressed to the use of a novel circumferential carpal stabilization brace that the patient wore at all times. The carpal brace extended from the metacarpal heads to the radiocarpal joint. This permitted movement of the radiocarpal and metacarpal joints, while firmly supporting the CMC articulations. Following removal of the cast, the brace was worn at all times. ……

REFERENCE

Postoperative management of carpometacarpal joint fracture dislocation of the hand: A case report; T Bell, SJ Chinchalkar, K Faber; Canadian Journal of Plastic Surgery, Autumn 2010, Volume 18 Issue 3: e 37-e 40

Carpometacarpal Fracture Dislocation; Wheeless’ Textbook of Orthopaedics (accessed Sept 16, 2010)

Hand, Metacarpal Fractures and Dislocations; eMedicine Article, August 20, 2009; James Neal Long, MD, James A Chambers, MD, MPH, Jorge I de la Torre, MD, FACS,

Comparison of Repair Incisions for Complete Unilateral Cleft Lip – an Article Review

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

For disclosure, I have not done a cleft lip repair in years.  The referrals of cleft lip patients in Arkansas funnel them to Arkansas Children’s Hospital where they get very good care.  That has not keep me from reading the articles in my journals.

This one (full reference below) with a following commentary caught my eye.  It offered a comparison of three incisions used for repair of unilateral cleft lip:  Millard incision, Pfeifer incision, and Afroze incision.

The Millard incision is based on a rotation flap on the noncleft side coupled with an advancement flap on the cleft side.   In one form or another, it is the most widely practiced method today. (photo credit)

The Pfeifer incision is a straight line repair for unilateral cleft lips.  The “straight-line” incisions on cleft and noncleft sides are made of equal lengths by incorporating a series of waves leading to a final scar that should follow the lateral line of the philtrum.

The Afroze incision is described in the article as a variant incision combining the Millard incision on the noncleft side (medial side) and the Pfeifer incision on the cleft side (lateral side).

The authors of the comparison study conducted a prospective cohort study of 1200 patients with complete unilateral cleft lip with or without cleft palate over a period of 4 years.  The first cohort of 400 patients was treated using the Millard incision between September of 2001 and October of 2002; the second cohort of 400 patients was treated using the Pfeifer incision between November of 2002 and January of 2004; and the last cohort of 400 patients was treated using the Afroze incision between February of 2004 and March of 2005.

Outcome assessments were performed 2 years postoperatively and consisted of assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, nostril symmetry, and appearance of alar dome and base.

The authors concluded that the Afroze incision was superior:

With regard to white roll, vermilion border, scar, Cupid's bow, and lip length, the Afroze incision always gave superior results compared with the Millard or Pfeifer incision.

Depending on the cut-off for treatment success, the Afroze incision also showed better results regarding nostril symmetry.

With respect to the alar base and alar dome, all three incisions showed comparable outcomes.

I wish I could show you the photos included in the article as for me and Dr. Wolfe, the photos don’t agree with the authors conclusions. 

The patient with the bull's eye on his glabella preoperatively was operated on with a rotation advancement, and I feel he has the best result of the three. There is a very nice white roll and a discrete Cupid's bow, and the scar comes close to mirroring the normal philtral column on the noncleft side. …..

The second patient, with the “1” on his glabella, repaired with the Pfeifer incision, I think has the worst result of the three. The scar runs straight up into the nostril, giving him the appearance of having a runny nose, the lip on the cleft side is a bit short, there is no Cupid's bow, and there is a slight alar slump beneath the soft triangle.

The third, with the glabellar black spot, was repaired with the Alfroze technique. He has a nice Cupid's bow, but the lip scar wanders away from the desired area of the philtral column and is distracting. There is a very significant vestibular web, and the alar base on the cleft side lacks definition, as does the footplate area of the medial crus. The commissure-to–high point distance on the cleft side also appears a bit shorter than on the noncleft side.

Perhaps if they had chosen different photos for the article it would have been better.  The ones chosen, unfortunately, don’t back up the authors conclusions.

REFERENCES

Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Reddy, Srinivas G.; Reddy, Rajgopal R.; Bronkhorst, Ewald M.; Prasad, Rajendra; Kuijpers Jagtman, Anne Marie; Bergé, Stefaan; Plastic & Reconstructive Surgery. 125(4):1208-1216, April 2010;  doi: 10.1097/PRS.0b013e3181d45143

Discussion: Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Wolfe, S. Anthony; Plastic & Reconstructive Surgery. 125(4):1217-1219, April 2010; doi: 10.1097/PRS.0b013e3181d45017

Unilateral Cleft Lip Repair; eMedicine article, June 19, 2009; Pravin K Patel, MD, Raja Ramaswamy, MS,  Mitchell F Grasseschi, MD, David E Morris, MD

Shout Outs

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

Dr. Grumpy is the host for this week’s  Grand Rounds which marks the first edition at the beginning of GR’s 7th year!  You can read this week’s edition here (photo credit).

Thank you all for coming. Coffee and bagels are in back. Sign in on the sheet. Medical students, please remember that you're allowed to sit ONLY if there are chairs left after the attendings, fellows, residents, and homeless people (here for the bagels) have been seated.

Food was provided by our drug rep Rikki, on behalf of Wirfliss Pharmaceuticals. She asks that when writing a prescription, please keep their many Wirfliss products in mind. …...

And we're off! The topic was: THINGS THAT MAKE ME GRUMPY!
To start, I present: THE PHARMACISTS!

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A beautiful post in many ways by @epi_junky , a Paramedic who blogs at Pink Warm and Dry.  The post is 89 Years and Two Days.

65 of them married to her first love.  Her only love.  The man she’d spend her entire adult life with.  The only man she ever looked at according to her daughter.

62 of those years spent taking care …...

5 years spent grieving the death of her husband and best friend.

7 months living with pancreatic cancer.  …...

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Want to know more about ADHD and adults.  Then check out these post with video interviews:

Dr. Rob, Musings of a Distractible Mind: Better Health Interviews – Fact or Fiction: Attention Deficit Disorder

Last Thursday (9/17/10) I had the pleasure of attending a conference on Attention Deficit Disorder.  The following are my two interviews.  They are both very interesting, and both apply greatly to my practice as a primary care physician.

The first is Dr. Ari Tuckman, author of the book More Attention, Less Deficit, as well as the podcast with the same name: ….

Kevin, MD:  Fact or Fiction: ADHD in America, panelist video interviews

On September 16, 2010, I attended Fact or Fiction: ADHD in America, a Capitol Hill Forum, along with Val Jones of Better Health and Rob Lamberts of Musings of a Distractible Mind.

The event, coinciding with ADD/ADHD Awareness Week, was a panel discussion discussing the impact ADHD has on our society.

It was sponsored by Shire, in partnership with the Entertainment Industries Council (EIC) and the Lab School of Washington [Disclosure: I received a stipend for covering the event.]

Below are interviews Rob and I did with some of the panelists.  …………

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Much discussion about improving our diets/nutrition.  Here are some links with cooking tips/recipes/etc.

H/T to @gastromom for two links.
The first is to a WSJ Health article, Teaching Healthy Ways To Doctors in the Kitchen, by Melanie Grayce West.  I would enjoy taking this class.

Thirteen of Lenox Hill Hospital's doctors-in-training gather for one more class at the end of another long day of lectures and rounds: How to peel onions and chop garlic. ……

The program—which organizers say is the first of its kind in the city—includes six seminars on everything from nutrition, to weight management to exercise and a cooking class at the Institute of Culinary Education in Manhattan. It is based loosely on a joint project of the Culinary Institute of America and Harvard Medical School called Healthy Kitchens, Healthy Lives. …….

The second one is a NY Times Health article, Expert Tips From the Stir-fry Chef.

Grace Young, author of the recently published “Stir-Frying to the Sky’s Edge,” from Simon and Schuster, recently joined the Consults blog to answer readers’ questions about healthful stir-fry cooking.  ……

I too hate eggplant that is greasy. I find that if you steam the eggplant first, you can dramatically reduce the amount of oil necessary for stir-frying. Cut about a pound of eggplant into bite-size pieces and place them in a heatproof bowl. Then steam the eggplant for five to eight minutes, depending on the size of your pieces, until the eggplant is just tender when pierced with a knife. Don’t overcook it, as the eggplant will be stir-fried. I find that I don’t need more than 3 tablespoons of oil and that the steamed eggplant can be stir-fried within one to two minutes with your seasonings.  ….

Here’s an inspiring story:  H/T to @bobcoffield

RT @boltyboy: Kaiser Permanente's own Jamie Oliver and the reason they have 30 farmers markets http://nyti.ms/aRfRG4

The NY Times article, Doctor’s Orders: Eat Well to Be Well, by Katrina Heron features two physicians (father and son)

DR. PRESTON MARING ……. Though Dr. Maring blithely refers to himself as “that food nut around the hospital,” he is serious about the role he believes doctors should play in creating awareness of healthy food choices. To that end, he has worked to obtain fresh local food for hospital trays and in cafeterias. He began a Web site and blog that offers recipes and advice on meal planning and budgeting. He spent the summer working on a series of three-minute Web videos to explain the basics of shopping for healthful foods and efficient preparation techniques.   ……

Dr. Maring’s Farmers’ Market and Update  -- a great source of healthy recipes.

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Here’s more on diet and health.  This comes from @JoshuaSchwimmer    who blogs at InfoSnack. 

Uremic Frost: The Kidney Diet: How to Eat in Order to Protect Your Kidneys and Avoid Dialysis http://bit.ly/byA7II

The link takes you to an eBook, The Kidney Diet:  How to Eat in Order to Protect Your Kidneys and Avoid Dialysis,  which you can read online, download, or print out.  It is full of great information.

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The Quilting Gallery has a post, Caps for Good, which tells of a project by Save the Children.

Baby caps are a simple and effective tool that can keep babies warm and ultimately contribute to reducing newborn deaths in the developing world.

In many developing countries, something as simple as a knit or crocheted cap can help the baby keep warm, which is key to helping newborns survive. ……

This is where you can help by making a cap! Your caps will be sent to Save the Children’s newborn health programs in Africa, Asia and Latin America.

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Dr Anonymous’ guest this week will be EMS Newbie Podcast.     The show begins at 9 pm EST.

Upcoming shows:       
10/7: Dana Lewis        

Teenagers Use of Self-Tanners

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

Skin cancer rates continue to rise. Exposure to UV radiation and the resulting damage to the skin is major reason. It doesn’t matter whether this exposure is from outdoor or indoor sources.

Use of self-tanners should (intuitively) decrease the exposure to UV radiation as the desired “tan” is obtained from an alternative source. Not necessarily, especially in teens.

The Archives of Dermatology article referenced below reports on a study survey done by Vilma E. Cokkinides, Ph.D., of the American Cancer Society, Atlanta, and colleagues. Their survey was telephone-based conducted, conducted from July 1 through October 30, 2004. A total of 1600 youths and 1589 primary caregiver paired interviews using nearly identical questionnaires were done with an overall response rate of 44.0%.

The Sun Survey assessed the use of sunless tanning products by the adolescents in the past year, along with details about demographics, skin type, attitudes and perceptions of sunless tanning and other sun-related behaviors.

Among the teens surveyed, 10.8% reported using sunless tanning products in the past year. Approximated 14% of their parents used them. Self-reporting teen users tended to be older and female, to perceive a tanned appearance as desirable, to have a parent or caregiver who also used these products and to hold positive beliefs or attitudes about them.

Amazing to me was the finding by the researchers that the teens who used the self-tanners had just as many sunburns the previous summer, were just as likely to use indoor tanning beds, and did not routinely use sunscreen.

The conclusion I draw from this is: Teenagers use self-tanners to augment UV exposure to get (and keep) the level of tan to their skin. Teenagers aren’t thinking about skin cancer.

How do we change this? Gentle nudges as Dr. Luks suggests with exercise. Same thing here – gentle nudges.

Sources
"Use of Sunless Tanning Products Among US Adolescents Aged 11 to 18 Years"; Vilma E. Cokkinides, PhD; Priti Bandi, MS; Martin A. Weinstock, MD, PhD; Elizabeth Ward, PhD; Arch Dermatol. 2010;146(9):987-992. doi:10.1001/archdermatol.2010.220

Hawking Surgery

“Hawking” surgery makes me grumpy.
Glossing over the risks involved with surgery to promote your product makes me grumpy.
E! Reality Show is “hawking” plastic surgery as part of the prize package for brides in their new show “Bridalplasty.” 

Woodland Paths Quilt

I made this quilt for my baby brother Glen for his 30th birthday (1998).  The pattern is called woodland paths.  I found it in Barbara Brackman’s Encyclopedia of Pieced Quilt Patterns.  It is found on p 246 and is #1962.  It is listed as a Nancy Cabot pattern from 1934.

The quilt is machine pieced and quilted.  It is 80 in X 100 in.  The photos were taken recently by my sister-in-law.  You can see that I used brown in the pattern to  create a border. 

 
Even though I pieced it, designed it, and did the binding, I paid Peg Reese (Peg’s Quality Quilting) to do the machine quilting.

Old and Unused Drug Disposal

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

I’ve written before about this topic.  It was difficult to dispose of the unused prescription drugs when my brother-in-law died.  I was not involved in my mother’s old drug disposal, but can’t imagine it was easy (if done at all). 

Old and unused drugs don’t just happen when someone dies.  They can occur because your surgeon gave you a script for more pain pills than you needed.  This is commonly done as it is difficult to gage just how much pain someone is going to have postop.  Then there are the pills unused because you didn’t tolerate the side effects or had an allergic reaction.  Other are left over when patients are placed on new /different drugs for their conditions.

We have been reminded frequently of late that prescription drugs are now the most commonly abused drugs.  These unused drugs are a major source for that abuse.

The Drug Enforcement Administration (DEA) has initiated a prescription drug “Take-Back” campaign to help remove these old and unused drugs from our medicine cabinets.   September 25th has been designated as National Take-Back Day.

More than 2,700 sites nationwide have joined to participate in the event which will collect potentially dangerous expired, unused, and unwanted prescription drugs for destruction. 

National Take-Back Day will take place on Saturday, September 25th from 10 am to 2 pm local time.  The service is free and anonymous.  No questions will be asked about how the drugs came into the person’s possession.

Prescription and over the counter solid dosage medications, i.e. tablets and capsules accepted.  Intra-venous solutions, injectables, and needles will not be accepted.  

Collection sites in every local community can be found by going to www.dea.gov . This site will be continuously updated with new take-back locations.
In Little Rock/North Little Rock region, the sites include:
If you do not find a collection site near you, please check back frequently, sites are added every day.
Arkansas Game & Fish Commission
War Memorial Stadium Parking Lot
1 Stadium Drive, Little Rock, AR
UAMS Police Department
Reynolds Institute on Aging, First Floor
629 Jack Stephens Drive, Little Rock, AR
Cammack Village Police Department
Cammack Village City Hall
2710 N McKinley, Little Rock, AR
UALR Police
University Plaza Parking Lot
2801 S. University Ave, Little Rock, AR
Pulaski County Sheriff’s Department
Pulaski County Regional Detention Center
3201 W Roosevelt Road, Little Rock, AR
Little Rock Police Department
Pulaski County Regional Detention Facility
3201 W Roosevelt Road, Little Rock, AR
North Little Rock Police Department
NLR High School
Charging Wildcat Arena
2200 Main Street, NLR, AR
Pulaski County Sheriff’s Department
Oak Grove Volunteer Fire Department
18122 Hwy 365 N, NLR, AR

Cost of Hand Transplantation?

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

The recent double hand transplant and catching up on my journal reading has prompted me to look into the cost of hand transplantation. My personal identity seems to me to be tied up in my hands. I am a surgeon. I cook for my husband. I am a quilter.

I have at times tried to imagine loosing a finger or a hand. It difficult to the point of almost being unimaginable for me. Which hand would I give up? Which digit?

I am so right handed, I find it difficult to brush my teeth using my left hand. Yes, I could learn in time. Same with using a pen. Even my limited use of my left arm when I had olecranon bursitis brings my dependency on my hands/arms into sharp focus. It was humbling.

The PRS article (first reference) in assigning utility surveyed participants asking them “to imagine as vividly as possible that they had experienced an amputation of the dominant hand or bilateral hand amputations.”

For example, our survey asks the respondent to choose between living for 40 years with a prosthetic hand and living for x years with a healthy hand. The value of x is varied until the respondent feels that the choices are equivalent. If the respondent judges that living for 40 years with a prosthetic hand is equivalent to living for 20 years with a healthy hand, the utility of living with a prosthetic hand is calculated as 20/40, or 0.50.

I have yet to decide what my answer would be. The article survey of 100 second-year, third-year, and fourth-year University of Michigan Medical School students determined utility as follows:

Transplantation with minor complications (unilateral = 0.78; bilateral = 0.73)

Transplantation with major complications (unilateral = 0.59; bilateral = 0.53)

Prosthetic device use (unilateral 0.75; bilateral 0.63)

Emotionally most would agree that hand transplantation is a worthy goal. Physically, it is possible. The outcome is not always as good as envisioned. Never is the transplanted hand as functional as a non-injured hand. Never.

The function of a transplanted hand has been found to be similar to a replanted hand.

to put it in the words of one physician from the Louisville team that performed the first U.S. hand transplant, the patient will likely “have difficulty with buttons, perhaps not be able to pick up a dime.”

Gerald Fisher, the second of the Louisville recipients, returned to work hanging gutters just two months after his operation
According to the Lyon team, the world’s first double-hand transplant recipient is able to shave and take care of other personal hygiene tasks that he was unable to do before his transplant

With much physical/occupation therapy afterwards, the transplanted hand can be functional. It’s not likely I would be able to pick up a needle to sew/hand quilt again, but I would be able to brush my hair and teeth.

The ethics of a non-life threatening diagnosis (loss of one or both hands) being treated with a procedure that requires immunosuppressive drugs for life is still being debated and should be. From the PRS article (first reference)

The toxicity of immunosuppressive medication, however, brings about an ethical dilemma. In solid organ transplantation, 40 percent of posttransplant deaths were attributed to infection; transplant recipients have a seven-fold 5-year risk over the general population of developing malignancies.

This all brings us back to the actual costs of hand transplantation which is very difficult to determine though Dr. Oda and colleagues have done a good job in attempting to do so. I think they may have underestimated the costs.

Lifetime costs for single hand transplantation average $528,293, whereas costs for double hand transplantation average $529,315.

Total costs of prosthesis adoption for unilateral and bilateral amputation are $20,653 and $41,305, respectively.

The mean surgical cost, including preoperative evaluation, hospitalization, and physician fee, are $13,796 for single hand transplantation and $14,608 for double hand transplantation.

The cost of immunosuppressive therapy for 40 years, including drugs and clinic visit, is $433,283 ($362,894-503,672).

The cost of productivity loss for hand transplantation and prosthetic adaptation are $42,265 and $9753, respectively.

Oda and colleagues doubled the traditionally cost-effectiveness threshold of $50,000/QALY (employed based on the acceptance of kidney transplantation) to $100,000 for their analysis.

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03).

Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the accepted cost-effectiveness threshold of $100,000/QALY.

As pointed out by Dr. Concannon in the discussion of Oda’s article, I and others can muse all we want but it will most likely ultimately be out of our hands.

Ultimately, while the costs and worthiness of this technique may be debated in scientific journals, it will certainly not be decided in them. There are industry and governmental agencies with far sharper pencils than we have that will look very closely at the cost-benefit ratio before deciding whether this will be an acceptably “covered” procedure for their respective constituents. Perhaps the biggest hurdle in the implementation of limb transplantation will involve mastery not of the immune system but of actuarial tables.

REFERENCES

An Economic Analysis of Hand Transplantation in the United States; Chung, Kevin C.; Oda, Takashi; Saddawi-Konefka, Daniel; Shauver, Melissa J.; Plastic & Reconstructive Surgery. 125(2):589-598, February 2010.; doi: 10.1097/PRS.0b013e3181c82eb6

Discussion: An Economic Analysis of Hand Transplantation in the United States; Concannon, Matthew J.; Plastic & Reconstructive Surgery. 125(2):599-600, February 2010.; doi: 10.1097/PRS.0b013e3181c831e5

Hand transplantation not cost-effective; AAOS Now, January 2010 Issue; Peter Pollack

Hand Transplantation; Brown University Biomed Course Info (2001); accessed September 15, 2010

Shout Outs

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

Pallimed.org is the host for this week’s  Grand Rounds.  You can read this week’s edition here.

I am not sure if Nick(@blogborygmi) realized this when he approached me about a date to host, but this is the last edition of Grand Rounds for Volume 6.  A hospice blog as final chapter to a great year of medical blogging, there are things in life that are more serendipitous than this of course.  But of course here at Pallimed (@pallimed), we do cover things beyond just the last few days of life. So feel free to take a look at our 1,000 other posts.

On to the best of the medical blogosphere!  No themes here but I did ask (like GruntDoc) to include a post of  other than your submission to help broaden our reach this week…….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 6) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

I can’t believe two weeks has passed already, but the calendar says that, indeed, it is time for the latest edition of Change of Shift!

Quite the eclectic collection of stories this week!

Before you begin, I just want to remind everyone that I still have discount codes available for BlogWorld/New Media Expo 2010. We’ll be getting together in Vegas next month! Check the button on the top bar for details.  I’d love to meet as many nurse bloggers as possible!

And now, I am proud to present……..

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Great Diane Rehm Show this past Thursday on Thalidomide and the FDA

Fifty years ago, a newly appointed medical officer at the FDA stood up to corporate pressure and refused to approve thalidomide, the drug already used for morning sickness in other parts of the world. The case transformed how Americans think about medicine and the FDA's drug-testing policy. Diane and guests explore how thalidomide is being used today and discuss how Frances Kathleen Oldham Kelsey saved thousands of babies from the perils of thalidomide.

I have posted about Thalidomide in the past.

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Orac has written a thoughtful response to the New York Time story  by Amy Harmon:    New Drugs Stir Debate on Rules of Clinical Trials.  His post is titled:  Balancing scientific rigor versus patient good in clinical trials

A critical aspect of both evidence-based medicine (EBM) and science-based medicine (SBM) is the randomized clinical trial. …..

The ethics of clinical trials, however, demand a characteristic known as clinical equipoise. Stated briefly, for purposes of clinical trials, clinical equipoise demands that there be a state of genuine scientific uncertainty in the medical community over which of the drugs or treatments being tested is more efficacious and safer……

In oncology clinical trials, as in clinical trials for treatments of any life-threatening disease, there is always a tension between wanting the "cleanest" possible results versus doing the best for each individual patient. It is a balancing act that relies on the ethics of physicians and a combination of hope and altruism in the patients who become subjects in such trials. … How to maximize the good for as many patients as possible is the goal, but, as we have seen, this is a goal that is not so easily accomplished, just as clinical equipoise is a concept that is easy stated but not so easily applied. PLX4032 teaches us that.

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This is worth reading (and listening to):  New York Times article by The Voices of Schizophrenia by Tara Parker-Pope (photo credit)

Few mental illnesses are as complex and confusing as schizophrenia, a mental disorder in which people may experience hallucinations or delusions, hear voices or have confused thinking and behavior.

Although the word “schizophrenia” means “split mind,” the disorder does not cause a split personality, as is commonly believed.

The latest Patient Voices segment by Karen Barrow, a Web producer, offers rare insights into schizophrenia and schizoaffective disorder, a related condition that combines thinking and mood problems, as seven men and women share their experiences.  ………….

To hear these and other stories of schizophrenia, click on the Patient Voices audio link. And then please join the discussion below.

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I love Jimi Hendrix’ music, so really enjoyed this piece on NPR last week:   Send My Love To Linda: An Untold Jimi Hendrix Story

January 16th, 1970.

The greatest rock guitarist to ever play the instrument, Jimi Hendrix, has eight months and two days to live. He spends part of the day at New York City's Record Plant laying down some tracks. After a few busted takes, Jimi launches into one of the most amazing instrumentals that few people have ever heard.

Hendrix called the piece "Sending My Love to Linda," and ……. Despite being a Hendrix fan, I had to go back and find out more about who this Linda was……….

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Dr Anonymous show this week will be a follow-up school name change & value of alumni.   The show begins at 9 pm EST.

Will My Opt-Out Status Affect You?

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

I opted out of Medicare several years ago.  This means I don’t see Medicare patients other than in the emergency room when I’m on unassigned call.   I don’t submit bills to Medicare or to those patients.  I just let it slide.

Last Wednesday, I received the following letter from a large radiology group in my home town:

September 2010
RE:  PECOS Enrollment
To our referring physicians and their office managers:

At __________we have begun a project to identify ordering physicians who are not enrolled in Medicare’s Provider Enrollment, Chain and Ownership System (PECOS).  Our purpose is to remind physicians of the importance of enrollment to them and to us.

Beginning in January, 2011 those providers filing Medicare claims listing an NPI number on the claim of an unenrolled provider will have their claims denied.  This would apply to any claim you send in and to any claim we submit for services provided to your patients because we are required to list your NPI number on our claims.  This applies both to patients referred to our private offices and the hospitals where we provide radiology professional interpretations or services.

So, you can see our effort is not purely altruistic.  We have a financial interest in reminding you of the importance of PECOS enrollment.  In trying to ascertain whether you are enrolled, we are using an online program you can find at www.oandp.com/pecos.  Simply enter your NPI number in the entry block and press enter.  If you enter a valid NPI number, your name will appear and beside it will be a symbol indicating where Medicare recognizes your PECOS enrollment.

Since Medicare is continually updating the files, we may have accessed the system before your enrollment was completed.  We will continue to monitor the situation in hopes you will enroll if you intend to continue seeing Medicare patients.  If you have already enrolled or have no plans to enroll, please excuse our intrusion.

Sincerely,

This bothers me.  It is not likely that I will be sending them any patients from my office, but that doesn’t mean there won’t be the occasional patient with my name on their chart in the ER.  IF I need to take a Medicare patient to the operating room from the ER, will the hospital not get paid?  Will the anesthesiologist not get paid?

Will my non-participation in Medicare affect my fellow healthcare providers receiving payment?  If so, that is just not right.  I voiced this concern to Senator Blanche Lincoln shortly after receiving this letter.  She agrees with me.

This radiology group is usually correct in their policy interpretations, but I still went searching for more information.  I found this summary:  What You Need to Know about Enrolling and Ordering/Referring in the Medicare Program.  It includes this

Physicians who have validly opted out of Medicare will not need to complete a Medicare enrollment application.

Still, I am not reassured.   The policy doesn’t seem to take into account that I may through unassigned ER call see the occasional Medicare patient.  The policy seems to “assume” that since I opted-out, I never see any Medicare patients.  If this were the case, I would never affect my fellow physicians/hospitals payment.  I’m left wondering if I will affect their payments for that occasional patient I see through the unassigned ER route.

I will tell you that I have gone to the NPI site and reviewed my information.  I have gone to the Medicare (PECOS) site and attempted to registered my information.  I will not be re-enrolling as a Medicare provider at this point in time.  

Four More Fabric Postcards

Toward the end of August and first of September, I seem to have gotten into a fabric postcard groove.

This “Iris in a Vase” is my 6th postcard.  It was made by fussy cutting the flower and leaves, then appliquéing them onto the background fabric before adding the vase.  It is 8.75 in X 6 in.

I made it for my friends Vickie and Ben who will be celebrating their 20th wedding anniversary next month. 

 

#7 Postcard is called “Primitive.”  The people were fussy cut and then appliqued onto the background fabric.  It measures 5.5 in X 7.5 in.

Here is the back

 

#8 Postcard is called “Deserted Island.”  It was also fussy cut and then appliqued onto the background fabric.  It measures 6 in X 8 in. 

This is the back

 

#9 Postcard is simply called “Parrot.”   The background fabric is two pieces sewn together.  The fussy cut parrot was then appliqued onto the background.    It measures 5.25 in X 7 in.

Here is the back

Scrappy Nine Patch

This nine-patch quilt began as a way to use up some of the leftover 2.5 in squares.  I gathered together the browns and tans.  I had enough of a unifying cream-colored fabric to use in the nine-patches and the “solid” connecting 6 in squares. 

The quilt is machine pieced and quilted.  I mailed it to a blog friend whom I think will enjoy it.

The top thread is a lovely yellow-gold color.
I used a brown in place of the cream fabric to create a border.
The back is a bone color.  Here you can see the quilting.

Hands -- Guidance and Germs

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

Some interesting items this week involving hands.  The one which has gotten much news coverage is the issue of hand washing.  Take a look at some of the headlines:

High five! Hand washing on rise (Chicago Sun-Times)

For Many, 'Washroom' Seems to Be Just a Name (New York Times)

93% of women wash their hands vs. 77% of men (USA Today)

All the above are reporting on the same study, but the difference in presentation is amazing to me.

The above study doesn’t involve hand washing in a hospital or doctor’s office setting.  The JAMA article (2nd reference below) does, but this article focuses on whether public reporting of hand washing compliance is helpful or not.  Do we inflate our numbers to make ourselves look better?

Public reporting creates an incentive to maximize performance but does not specify the manner in which this is achieved. Broadly speaking, 2 approaches are possible. Hospitals can adopt evidence-based strategies designed to improve patient outcomes that will also improve the publicly reportable indicator, or they can adopt indicator-based strategies designed to improve the reported indicator that may not improve outcomes and may even cause harm. Evidence-based improvement strategies would be favored in an environment in which organizations focus on improving patient outcomes—when such strategies exist and are easy to implement. Conversely, indicator-based improvement strategies would be favored in an environment in which the hospital focuses on protecting its reputation, when evidence-based improvement strategies are unproven or resource intensive, or when measurement of the indicator is easily manipulated to show improvement. …

I wish copyright laws would allow me to reproduce the entire essay from a recent issue of JAMA (first reference below).  The essay is written by Ariela Zenilman about her father’s hands. 

Between the scrapes from paper cuts, the finger on which a ring is worn, and the color of nail polish, the hands of the human body tell a story. They are the most mysterious reflection of character. The hands ….. Surgeons are blessed with steady hands for a reason: they reduce the trembling in the hands of worried family members, counteract pain and destruction, and alter creation for the better by fixing fault and disease within the body. A surgeon has the remarkable gift of a set of multifunctional and dexterous hands.

I have always admired my father's hands. From a very early age I could tell his grace and dedication to detail were apparent in how he moved and touched, felt and experienced the world around him. …... His hands seemed inexplicably and effortlessly linked to his every thought: as a young child I always dreamed of having hands like his.…….

When I see my father's hands ……. His hands are a mere reflection of his heart, an attribute I hope to see in my hands as I follow in his footsteps.

…. Hands reflect ability, accomplishment, and passion. …………., I have learned to trust my instincts, follow my heart, and, most of all, not to underestimate the power of my own hands.

I love hands.  I have been in love with the anatomy and mechanics of hands since medical school.  Before then I just loved to watch them work (my mother making biscuits, my teacher’s writing, basketball players shooting baskets, pianists, etc). 

For the general public, wash your hands – flu season is upon us.

For us involved in patient care, wash your hands before and after each patient.  This is one (if not the best) of the best lines of defense in preventing the spread of infection.

REFERENCE

The Hands That Guide Me; Ariela Zenilman; JAMA. 2010;304(10):1049. doi:10.1001/jama.2010.1291

Public Reporting of Hospital Hand Hygiene Compliance—Helpful or Harmful?; Matthew P. Muller; Allan S. Detsky; JAMA. 2010;304(10):1116-1117.

Finger and Wrist Exercises (April 19, 2010)

Treatment of Common Congenital Hand Conditions – an Article Review

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

This is a very nice article of five common congenital hand conditions.    The online journal includes three informative videos of surgeries with tips.

Syndactyly

Syndactyly is a common congenital hand anomaly, occurring in approximately one in every 2000 to 3000 live births.  Syndactyly can be inherited in an autosomal dominant manner, with variable expression or reduced penetrance.  It may also occur sporadically.

Syndactyly is classified as

• complete when the fingers are fused all the way to the tip, including the nail folds
• incomplete when the nail folds are not involved
• simple when the fingers are fused by a skin bridge
• complex when the bones are fused together

Syndactyly between the middle and ring fingers is most common, occurring in 57% of the cases, followed by the ring and little fingers, which occurs in 27% of the cases.

Constriction Ring Syndrome

Constriction ring syndrome is a rare condition with a reported incidence ranging from one in 1200 to one in 15,000 births.   The index, middle, and ring fingers are frequently affected, whereas the thumb is occasionally involved.  Deformities usually occur in multiple extremities and are most predominant in the distal parts.

Constriction ring syndrome is a condition in which the limbs or digits of the fetus become entangled with strands of the embryonic membrane.   This entanglement can create problems which include amputation, acrosyndactyly, and lymphedema.

The part of the finger distal to the constriction ring is often hypoplastic or absent, whereas the proximal part is intact.

• Mild constriction ring is often asymptomatic.
• Moderate constriction ring causes lymphedema distal to the ring.
• Severe constriction ring blocks circulation of the arterial and venous system and causes nerve palsy resulting from nerve compression.

Duplicated Thumb

The incidence of duplicated thumb (preaxial polydactyly) is approximately one in 3000 live births.  It is most commonly found in Asians (2.2 in 1000).   The incidence in other groups:   Native Americans (0.25 in 1000), African Americans (0.08 in 1000), and Caucasians (0.08 in 1000). 

The majority of duplicated thumb cases are sporadic and unilateral, and do not require genetic consultation.  It is possible that triphalangeal thumb is associated with an autosomal dominant inheritance pattern.

Wassel Classification--Types I to VII based on level of duplications:
I : bifid distal phalanx (DP)(bone under the finger nail)
II: duplicated DP
III: bifid proximal phalanx (PP) (digit bone nearest the palm)
IV: most common type with duplication of proximal phalanx which rest on broad metacarpal
V: bifid metacarpal (MC) (bone in palm)
VI: duplicated MC
VII: triphalangism

Hypoplastic Thumb

Hypoplastic thumb can be present in isolation or in combination with any radial deficiency.  After duplicated thumb, hypoplastic thumb is the second most frequently encountered thumb anomaly.   Bilateral thumb involvement occurs in approximately 60% of children with thumb hypoplasia.

The Blauth-Buck-Gramcko classification is widely used to describe the hypoplastic thumb and is based on web space narrowing, hypoplasia of musculoskeletal components, joint instability, and abnormalities of extrinsic tendons.

Hypoplastic thumbs are associated with systemic syndromes such as Holt-Oram syndrome; the vertebral, anal, tracheal, esophageal, phalangeal, and renal (VATER) anomalies; or Fanconi anemia in 18 to 43 percent of the patients.  The entire affected upper extremity should be examined to determine the extent of the deficiency over the radial side of the limb.

Trigger Thumb

Trigger thumb in children is characterized by flexion at the interphalangeal joint and rarely presents with snapping as in adults. In most cases, a nodule or thickening of the A1 pulley is palpable.

Controversy remains as to whether the trigger thumb found in children is a congenital disorder or acquired after birth.

A prospective investigation of 1166 neonates showed no trigger thumb at birth, but two cases were observed at a 1-year follow-up.  Several other studies have also supported the opinion that childhood trigger thumb is an acquired rather than congenital condition.  However, cases of trigger thumb associated with trisomy 13 (Patau syndrome), fraternal twins, and families with generational occurrence indicate that there may be a heritable component in certain patient populations.

This article and the companion videos are worth your time.


REFERENCES

Treatment of Common Congenital Hand Conditions; Oda, Takashi; Pushman, Allison G.; Chung, Kevin C.; Plastic & Reconstructive Surgery. 126(3):121e-133e, September 2010.

Treatment of Common Congenital Hand Conditions - Video 1 - Syndactyly release with proximal-based dorsal rectangular flap

Treatment of Common Congenital Hand Conditions Video 2 - Ablation of the radial thumb and ligament reconstruction

Treatment of Common Congenital Hand Conditions - Video 3 - Pollicization of the index finger

Shout Outs

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

The Schwartz Center is the host for this week’s  Grand Rounds.  You can read this week’s edition here (photo credit).

Welcome!

The theme of this week’s Grand Rounds is hot topics in healthcare communication. Since this is also the last issue of summer, I’m including photos from my summer vacation to Yellowstone National Park, a hotbed of geothermal activity. (Just for fun see if you can identify Yellowstone’s mascot, the American bison, hidden in one of the photos.)

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Dr Charles has announced the winner of The Charles Prize for Poetry, 2010.  There were over 125 poems entered.   I hope you will head over and read them.  Congratulations to the winners!

Winner:
Fireflies, by a medical resident
Runner Up:
Song for my Father, II, by Pal MD
Honorable Mentions:
TO SYLVIA, by Maria A. Basile, M.D.
The Harvest, by C.L. Wilson
If I Were Frida Kahlo, by Amanda Hempel

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Dr. Val, Better Health,  announced on twitter yesterday:

@drval Save the date: @kevinmd @doc_rob @drval live coverage of ADHD awareness on Ustream Thurs, (9.16.10) 12-2 ET. http://bit.ly/d4G67t

Hope you will join the group if you happen to be available.  The event is coverage of this forum:

Fact or Fiction: ADHD in America, A Capitol Hill Forum
Rayburn House Office Building Room B-338
Washington, District of Columbia
United States

To coincide with ADD/ADHD Awareness Week, join us for "Fact or Fiction: ADHD in America, a Capitol Hill Forum," a lunch and panel discussion which will dispel myths and shed light on the diagnosis, treatment and management of ADD/ADHD in people's everyday lives.

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ReachMD has a really nice audio program full of the history of prosthetic heart valves:   The 50th Anniversary of the First Prosthetic Heart Valve: 1960 to Today

On the 50th anniversary of the first successful prosthetic mitral valve replacement, how far has cardiac surgery come, and where are we headed? Tune in to hear Dr. Albert Starr, co-founder of the first artificial mitral valve,……, recounts his first foray into the field of valvular disease and the extraordinary process of inventing the first artificial mitral valve. …… What does Dr. Starr see as the "next big thing" in cardiac surgery? Dr. Janet Wright hosts.

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Perhaps I need to try designing a new hospital gown.  Not sure anyone would pay attention to my ideas as Cleveland Clinic has to Diane Von Furstenberg.  Apparently the Clinic has been working with the designer for three years and is now ready to try out the newly designed gown (photo credit)

  A possible issue I see with the gowns is the lack of snaps along the top of the sleeves.  Snaps along that shoulder seam make it easier to place the gown on patients with limited shoulder motion or large upper extremity casts/dressings.  It also makes the gown easier to remove/replace on patients in the OR.

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I love this!  It was shared by Jill of All Trades, MD in her post “Stray Cat”

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Dr Anonymous guest this week is Radio Rounds.   The show begins at 9 pm EST.

Upcoming shows:      
9/18: Saturday Nite
9/23: Follow-up school name change & value of alumni
9/30: EMS Newbie Podcast
10/7: Dana Lewis        

Local Wound Care for Malignant and Palliative Wounds – an Article Review

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

Wounds in palliative care patients may be related to their underlying malignancy or to skin breakdown (poor nutrition, advanced age, poor perfusion, etc).  Wounds and associated skin changes that develop in palliative patients are generally considered as nonhealable. 

Therefore, the goal is refocused in an attempt to reduce emotional distress to patients and their families as well as reduction of  local physical wound issues.  The article defines these issues using the mnemonic HOPES:    Hemorrhage, Odor, Pain, Exudate, and Superficial infection.

The article reminds us that malignant wounds (due to cutaneous mets) have been estimated to affect 5% to 19% of patients with metastatic disease.  The chest, breasts, and the head and neck, followed by the abdomen, are the most common sites for these metastatic malignant wounds.

Regardless of the cause, if the wound has been determined to be a non-healable wound, then the goals remain as above—reduce the patients emotional distress and address the “HOPES.”

H: Hemorrhage (or bleeding)
May be due to granulation tissue or to tumor erosion into a blood vessel. 

For minor bleeding, agents such as calcium alginates are readily available as a wound dressing. Calcium, as part of the alginate, is released into the wound in exchange for sodium, potentially triggering the coagulation cascade. The sodium alginate then converts the fiber to a hydrogel, promoting local comfort and protection. In severe cases, suturing a proximal vessel, intravascular embolization, laser treatment, cryotherapy, radiotherapy, and electrical cauterization may be necessary.

O: Odor

Unpleasant odor and putrid discharge are associated with increased bacterial burden, particularly involving anaerobic and certain Gram-negative (eg, Pseudomonas) organisms.  

Topical application of metronidazole is readily available as a gel and cream. ….. Some patients derive the greatest benefit if the metronidazole is administered orally.

Activated charcoal dressing has been used to control odor with some success. To ensure optimal performance of charcoal dressing, edges should be sealed, and the contact layer should be kept dry.

If topical treatment is not successful or practical, putting odor-absorbing agents such as kitty litter or baking soda (not charcoal; only works as a filter) beneath the bed may reduce odor.

P: Pain

Pain is frequently experienced during dressing changes. 

Careful selection of dressings with atraumatic and nonadherent interfaces, such as silicone, has been documented to limit skin damage/trauma with dressing removal and minimize pain at dressing changes.

In addition to the choices of dressing supplies, when possible the frequency of dressings can be reduced.  Gentle technique can also reduce the pain of dressing changes.

For severe pain, clinicians may need to consider oral agents combining long-acting narcotics (oral, patch), as outlined in the World Health Organization Pain Ladder, with adjunctive agents for the neuropathic component and short-acting agents for breakthrough. In resistant cases, clinicians may consider using general anaesthesia, local neural blockade, spinal analgesia, or general anesthesia or using mixed nitrous oxide and oxygen

E: Exudate

Exudation is promoted by inflammation that may be associated with infection. Excessive moisture creates an ideal wound environment for bacteria to proliferate, especially when the host defense is compromised.

Moisture is contraindicated in nonhealable wounds; hydrating gels and moisture-retentive dressings (hydrocolloids) should be avoided. 

To contain and remove excess exudate from the wound, a plethora of absorbent dressings has been developed. Major categories of dressings include foams, alginates, and hydrofibers, along with superabsorbent products based on diaper technology

S:  Superficial infection

All chronic wounds contain bacteria:  contamination or colonization.   Preventing infections is important for palliative care patients.

Debridement is a crucial step to remove devitalized tissue, such as firm eschar or sloughy material, which serves as growth media for bacteria. …….

Topical antimicrobial products are available, but no one product is indicated or suitable for all patients…….

In nonhealable wounds where bacterial burden was more of a concern than tissue toxicity, antiseptics including povidone-iodine, chlorhexidine, and their derivatives are propitious treatment options (Table 5).

Other topical antimicrobial agents are summarized in Table 6. If the infection is promulgated systemically, systemic agents must be administered. Prophylactic use of antibiotics has not been demonstrated to facilitate wound healing.

REFERENCE
Local Wound Care for Malignant and Palliative Wounds; Woo, Kevin Y., Sibbald, R.Gary; Advances in Skin & Wound Care. 23(9):417-428, September 2010

My Artful Bra

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

The Artful Bras Project was begun by a guild in South Carolina, and has been a huge success.

A quilt shop I follow on Facebook, Stitchin’ Heaven, is doing a similar project which they call Bras 'n Boots.  Both as a way to donate and as a challenge to myself (my sewing skills) I offered to make a bra for them. 

The bras will be modeled at a “Dinner & Style Show” on October 16th by male members of the Wood County community (hence the request for size 38C and larger bras).  Tickets are $20

A buffet-style dinner will be provided by The Texas Tea Room, and we're inviting our local officials and community leaders of Wood County to model the bras for us. Men, of course! Then, as they stroll the crowd, we'll stuff their bras with dollars to vote for our favorite one!

It's going to be a really fun night, and the proceeds will benefit the Susan G. Komen Foundation. Tickets are available only until October 1st at Stitchin' Heaven. Both in our shop, and online.

I began by going to Penney’s to purchase the bra:  38 D.  The sales lady looked at me and smiled “This isn’t for you.”  I smiled back and told her about the project.

The rules for the project stated

Requirements for bra entry can be any style 38+D Bra.

The bra will need to be completely covered inside and out, including straps.

You can embellish the bra in your choice of design and material, but please make it sturdy for display and “wearing”.

Your bra will need to be hung and pinned on a non-slip hanger so it won’t fall off.

At home, I drafted a pattern for the basic covering of the bra.  To reduce the amount of hand sewing I would need to do, I cut the bra in half in the front so I could pull the bra segment into the fabric bra “tube.”  The straps fortunately disconnected easily and could be threaded into a fabric tube.

The base bra I made from taffeta I had purchased at an estate sale years ago.  I had initially thought I would then cover this with a scarf (see in photo above) I had purchased that looked like confetti, using the fringe and adding beads, etc.

It didn’t seem to be coming together for me as I saw it in my head, so I shifted gears.  I pulled out lace, buttons, scraps, etc looking for inspiration.  I stumbled across some ribbon from a Godiva chocolate box that I had saved.  I found some lovely red scraps of Ultra-suede.  

I bought some glitter glue to add a little more sparkle.

I would love it if some of my Texas friends would actually attend the event.  If you do, please, take and share photos.  Thanks

Knitted Miragamo Bag

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

I finished this knitted Miragamo bag.  I found the pattern for the Miragamo Bag by Georgie Kajer on Ravelry.  I went to my local specialty yarn store to find the hemp yarn as suggested, but they didn’t carry it.  I ended up buying and using Louet Euroflax Chunky Wt. in brown. 

The bag measures 14.5 in wide, 12.5 in high, and 4 in deep.  The handles are Grayson E leather handles.

The bag is fully lined with pockets (6 in wide X 5.25 deep).
The pattern directions called for using plastic canvas to make supporting structure for the bag.  I used Pellon Peltex 70 instead.  I covered each Peltex piece with brown fabric so the white wouldn’t be an issue showing through the linen knit pattern.  Here you can see the band strip.
Here is a photo of the fabric-covered Peltex sewn together to form a “box” which then was sewn into the bag.  This “box” lays between the knitted linen and the lining.  It is indeed the skeleton of the bag.

I wanted extra pockets in the bag.  You know we have cell phone, camera, etc that you don’t want to end up lost in the bottom.
This photo shows the three parts – knitted bag, skeleton, and lining.

Rusty approves! 

Using Botox for Hyperhidrosis

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

A few months ago a friend asked me about using Botox for her axillary hyperhidrois.  I had not ventured into this use of Botox (no patients referred or ask for it), but have been intrigued by it.  

A few weeks after our discussion which included me suggesting she ask her Dermatologist about the treatment as I felt this would be easier for her to get her insurance to cover the cost, I had the opportunity to use some “leftover” Botox on her.  This meant she would only get approximately half the suggested units, but she jumped at it.

Before treatment in addition to using antiperspirant, she would wear a T-shirt under her scrub top.  Often she would add protective “pads” to prevent ruining her good clothing.  Since she has been able to forgo the “pads” and the t-shirts.   It hasn’t been long enough to know if the reduced dose will reduce the longevity of the treatment.

Botulinum toxin (Botox) treatment temporarily blocks the nerves that trigger the sweat glands. The FDA approved Botox for axillary (underarm) hyperhidrosis in 2004.

The recommended dosage of Botox solution is 50 Units per axilla per treatment.  This is divided into injects approximately 1.5 – 2 cm apart.  (photo credit)

The pain my friend experienced seemed to be minimal, but topical creams could be used.

Improvements in sweating are typically seen within two to four days. The benefit usually lasts four to six months. Then, the treatment needs to be repeated.

   

REFERENCES

Botox Website:  Severe Underarm Sweating

Medscape has a video by Marina Peredo, MD on the Treatment of Hyperhidrosis With Botox

Dr. William Hall has a nice Youtube video:  BOTOX for Excessive Sweating/Hyperhidrosis Procedure.

Hyperhidrosis: A Review of Current Management; Atkins, Joanne L.; Butler, Peter E. M.; Plastic & Reconstructive Surgery. 110(1):222-228, July 2002

Use of A Grid To Simplify Botulinum Toxin Injection for Axillary Hyperhidrosis; Lam, David G. K.; Choudhary, S.; Plastic & Reconstructive Surgery. 112(6):1741-1742, November 2003.

Use of a Grid to Simplify Botulinum Toxin Injection for Axillary Hyperhidrosis; Kavanagh, Gina M.; Plastic & Reconstructive Surgery. 117(1):317, January 2006.

Botulinum Toxin A for Axillary Hyperhidrosis (Excessive Sweating); Marc Heckmann, M.D., Andrés O. Ceballos-Baumann, M.D., and Gerd Plewig, M.D.; N Engl J Med 2001; 344:488-493

Scar Scales and Measuring Devices

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

In clinical practice, scars are most often evaluated simply by the patient and surgeon’s subjective assessments of color (redness, traumatic tattooing, faded since last assessment, etc) and physical qualities (adherent, depressed, flat, raised, texture, etc).   The patient may comment that the scar is painful or itchy. 

Some objective measurements such as length and width can easily be made and compared over time.  Thickness is a bit trickier to easily measure without specialized tools.

I recently stumbled over a review article of the scales and measuring devices used for scar assessment on Medscape (full reference below).  Most, I admit, I have never seen or used as I am not an academic plastic surgeon.  The article is a nice review.  While it may help me better understand research articles I read, I doubt it will change how I assess scars in my practice.

Scar-measuring devices used for objectively measuring certain scar traits:

Pliability

• Pneumatonometer uses pressure to objectively measure skin pliability. It is composed of a sensor, a membrane, and an air-flow system that measures the amount of pressure needed to lock the system.  Most commonly used to measure intra-ocular pressure.
• Cutometer is a noninvasive suction device that has been applied to the objective and quantitative measurement of skin elasticity.  It measures the viscoelasticity of the skin by analyzing its vertical deformation in response to negative pressure.   (photo credit)

Firmness

• Durometer measures tissue firmness by applying a vertically directed indentation load on the scar.   It was originally described for use in scleroderma.

Color

Tools developed to objectively measure scar color use spectrophotometric color analysis to calculate erythema and melanin index.  These devices include:

• Chromameter (Minolta, Tokyo, Japan)
• DermaSpectrometer (cyberDERM, Inc, Media, PA, USA)
• Mexameter (Courage-Khazaka, Cologne, Germany)
• Tristimulus colorimeter

Thickness

• Ultrasound scanners, such as the tissue ultrasound palpation system (TUPS) --   “TUPS was found to demonstrate a moderate correlation in terms of reliability.  TUPS does have drawbacks, however, in that it requires technical training and experience in image interpretation and is relatively expensive compared to other modalities.”

Three-dimensional Topography

Three-dimensional systems may be attractive for their ability to capture scar surface characteristics with high definition and reproducibility, but their expense makes them more applicable to research than in my office.

• 3-dimensional optical profiling system (Primos imaging) made by GFMesstechnik (Germany)

Scar scales are subjective measurements used to quantify scar appearance.   The article mentions 5 scar scales that are currently used and were originally designed to assess subjective parameters in an objective way.  All of these scar scales are observer-dependent.  Scales are best used to determine change within an individual rather than between individuals.

• The Vancouver Scar Scale (VSS) --  first described by Sullivan in 1990.  It assesses 4 variables: vascularity, height/thickness, pliability, and pigmentation. Patient perception of his or her respective scars is not factored in to the overall score.
• Manchester Scar Scale (MSS)  -- proposed in 1998. It assesses and rates 7 scar parameters: scar color (perfect, slight, obvious, or gross mismatch to surrounding skin), skin texture (matte or shiny), relationship to surrounding skin (range from flush to keloid), texture (range normal to hard), margins (distinct or indistinct), size (<1 cm, 1–5 cm, >5 cm), and single or multiple.  
• Patient and Observer Scar Assessment Scale (POSAS) -- includes subjective symptoms of pain and pruritus and expands on the objective data captured in the VSS.   It consists of 2 numerical numeric scales: The Patient Scar Assessment Scale and the Observer Scar Assessment Scale. It assesses vascularity, pigmentation, thickness, relief, pliability, and surface area, and it incorporates patient assessments of pain, itching, color, stiffness, thickness, and relief. The POSAS is the only scale that considers subjective symptoms of pain and pruritus, but like other scales it also lacks functional measurements as to whether the pain or pruritus interferes with quality of life.
• Visual Analog Scale (VAS) -- is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions (pigmentation, vascularity, acceptability, and observer comfort) plus contour. It sums the individual scores to get a single overall score ranging from "excellent" to "poor." It has demonstrated high observer reliability and internal consistency when compared to expert panel evaluation, but it has shown only moderate reliability when used among lay panels.
• Stony Brook Scar Evaluation Scale (SBSES)  --  was proposed in 2007.  It is a 6-item ordinal wound evaluation scale developed to measure short-term cosmetic outcome of wounds 5 to 10 days after injury up to the time of suture removal. It incorporates assessments of individual attributes with a binary response (1 or 0) for each, as well as overall appearance, to yield a score ranging from 0 (worst) to 5 (best).  It was designed to measure short-term rather than long-term wound outcomes. 

REFERENCE

A Review of Scar Scales and Scar Measuring Devices; Regina Fearmonti, MD; Jennifer Bond, PhD; Detlev Erdmann, MD, PhD; Howard Levinson, MD; Posted: 08/24/2010; ePlasty. 2010;10:e43 © 2010 Open Science Company

The Vancouver Scar Scale: An Administrative Tool and Its Interrater Reliability;  Baryza MJ, Baryza GA.; J Burn Care Rehabil 1995; 16:535-538.

A new quantitative scale for clinical scar assessment;  Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW.;  Plast Reconstr Surg, 1998; 102: 1954-61

The Patient and Observer Scar Assessment Scale: a reliable and feasible tool for scar evaluation; Draaijers LJ, Tempelman FR, Botman YA, et al.;  Plast Reconstr Surg. 2004;113:1960–65.

Visual Analogue Scale scoring and ranking: a suitable and sensitive method for assessing scar quality?; Duncan JAL, Bond JS, Mason T, et al.;   PRS. 2006;118(4):909–18.

Development and validation of a novel scar evaluation scale.;  Singer AJ, Arora B, Dagum A, et al.;  Plast Reconstr Surg. 2007;120(7):1892–7

Shout Outs

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

Dr. Dino, Musings of a Dinosaur, is the host for this week’s  Grand Rounds.  You can read this week’s edition here (photo credit).

Ah, fall. That wonderful season when the heat recedes, the leaves descend, the children go back to school…and the pennant races heat up. Once again this year my Phillies are in the thick of it, so as the host of Grand Rounds I avail myself of the privilege of dragging you all down to the ballpark with me.  ……

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 5) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to Change of Shift!
Boy, that was a fast two weeks!

For those who don’t follow me on Facebook, I’m a little slow on the computer front as I am recovering from Lasik – please excuse any typos that have made it through my blurry proof-read.

Also – I have discount codes for BlogWorld/New Media Expo 10, so if you are planning on attending the second annual Social Health track (and you should!!), shoot me an email via the “Contact” button. Details can be found up top under the “BlogWorld” button!

Time to dive in…

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A very thoughtful post by Dr. Howard Luks (@hjluks), The Orthopedic Posterous:  Can a Simple Inquiry Close the Patient-Physician Communication Gap

……Many physicians are surprised by the findings of a group of Yale researchers who were recently published in the Archives of Internal Medicine

They found a huge disconnect and a huge communication gap existed between patients and physicians.  ……

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Check out these medical postage stamps found over at Street Anatomy: 

Above is …. a series of 3 stamps for the New Zealand Post, that portrayed New Zealand Innovations. Carly Hitchcock created these medical stamps ….  Cool work!

I love that plastic surgery connection:  Harold Gillies.

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Thread’s Teach Yourself to Sew series is for beginning sewers or anyone who wants to brush up on their skills. The topics range from demonstrating basic sewing techniques, to sharing tips, and giving step-by-step instruction for beginner sewing projects.  Here are some of them:

TEACH YOURSELF TO SEW

• Project: Make a Felt Jewelry Bag
• Knit Fabrics
• Woven Fabrics
• Project: How to Sew a Bias-strip Scarf
• How to Sew a Basic Seam
• How to Sew French and Lapped Seams
• How to Mark a Dart
• How to Sew a Dart
• Project: How to Sew a Skirt
• Sleeves 101
• How to Sew a Sleeve

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Dr Anonymous doesn’t appear to have a guest scheduled for this Thursday.