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Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Colorado Health Insurance Insider is the host for this week’s Grand Rounds! You can read this week’s edition here.

Welcome to Grand Rounds.  As we get back into the work week routine after the Thanksgiving weekend, we have a great collection of health care articles for you to browse through.  Enjoy! ……..

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MedGadget is hosting a new contest: Imagine Medicine: The Photography / Photoshop Contest

…………Welcome to the Imagine Medicine contest!

We are looking for fascinating medical photography that... imagines medicine.

Nothing is off the table: portraits, group shots, happy shots, tragic shots, clinical shots, photoshop illustrations, macro, micro, and anything in between. Can you imagine medicine, showcase it as art, and make us wonder?

Here's the lowdown. The contest is open to all. Upload your photograph(s) to Flickr, and tag them with "imaginemedicine" and "medgadget" keywords. Make sure you add at least one sentence describing your work. The deadline for submissions is 11:59pm ET on December 5, 2010. The winner will be announced on December 10th and the prize is a brand new 16GB iPad with Wi-Fi. ………

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Information is Beautiful has some wonderful grafts on Vitamin D (photo credit) which includes this one:

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The above is very timely as NPR presented a story by Richard Knox on vitamin D this morning:  Medical Panel: Don't Go Overboard On Vitamin D.

The Institute of Medicine is throwing cold water on the latest dietary supplement fad: big doses of vitamin D.

Humans make vitamin D when they are exposed to the sun. But many worry that clothing, indoor living and sunscreen are depriving most people from enough of the sunshine vitamin. It's also hard to get enough vitamin D from the diet, proponents say, despite fortification of milk and orange juice.

But the Institute's Food and Nutrition Board, which makes official recommendations on dietary intake, says advocates of high-dose vitamin D are going overboard.

After two years of study and debate, the panel says children and most adults need 600 international units of vitamin D a day. People over 70 need 800.  ……

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Via twitter from @doctorwes:  Barbara Walters discussed her aortic valve replacement candidly: 4 'second-opinions' and a change of cardiologist http://bit.ly/g6Jtom

………. Here’s the great news. You are not allowed to go to the dentist for at least three months after the surgery, because bacteria from your teeth can travel to your heart and cause an infection. No dentist. Also, no vigorous exercise for weeks. You experience great fatigue. No one raises an eyebrow if you take a nap every day. Finally, open-heart surgery sounds so awful that everyone worries about you, and what with the phone calls, the notes, and the flowers—all extolling your virtues and letting you know how wonderful you are — you feel as if you were reading your obituary. That’s the good news. The bad news is that, even though the operation is relatively routine, there is still a 1-to-2-percent chance that you won’t make it. Someone actually could wind up reading your obituary.  ………….

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Another via twitter comes from @drdavidballard: How early psychologists looked to magicians to turn illusions into reality .... http://bit.ly/emGQ3D

It is a link to an article in the December issue of Psychologist by Peter Lamont:  The misdirected quest

At the end of the 19th century, Hermann and Kellar were the two greatest conjurors in the world, though who was greatest depended upon whose publicity one believed. In the United States they competed over audiences and advertising space, and each considered the other his arch-rival. When Hermann died in 1896, Kellar was free to establish his reign and, aside from his notable achievements in the world of magic, he was almost certainly the inspiration for the Wizard of Oz. But before Kellar became the grand wizard, and shortly before Hermann’s death, the two great rivals agreed to compete in a quite different environment – the psychological laboratory. ………

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This quilt was shared with me by two people on twitter (@KnittingNephron and @jdcmlewis).  It was posted on “The Daily What” yesterday.  (photo credit)

iPhone Baby Quilt of the Day: By Harriet Rosin for her grandson, Gabriel.  Benjamin Stein adds: “There’s a Nap for That!” (Obligatory.)

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I’m hoping to attend with a couple of friends -- Arkansas Women Bloggers Meetup Scheduled! (photo credit)

When: December 11, 2010 11am-1pm

Where: Museum of Discovery @ 500 President Clinton Avenue

Why: Meet other bloggers and help decide future activities/goals for AWB

We will keep you updated with event details as we pull them together.

To RSVP, you can leave a comment on this post. If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at arkansasbloggers@gmail.com.

Suture Material and Skin Irritation

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 have written about Suture Allergy vs Suture Reactivity so was very interested in this new article accepted for publication in the journal of Plastic and Reconstructive Surgery (online ahead of publication). 

The article comes from researchers in Greece who chose to use digital image analysis to evaluate the erythema  associated with tissue reaction to suture material. 

The sutures evaluated were polydioxanone (PDS II(R), Ethicon, Sint-Stevens-Woluwe, Belgium), polypropylene blue (Polypropylene(R), Assut Sutures, Ascheberg-Herbern, Germany), polyamide 6 (Ethilon(R), Ethicon, Neuchatel, Switzerland), metallic clips (APPOSETM, ULC Tyco, Hampshire, UK), and polyglactin (Vicryl Rapid(R), Ethicon, Norderstedt, Germany).

Digital photos of 100 patients(70 females, 30 males; all Caucasian) were compared by software, evaluating red color superiority (mean value of red color) in the region surrounding the wound.  Most of the patients were Fitzpatrick skin type II and III (46 and 47 respectfully).  Mean age was 42 years old, ranging from 15 to 86 years. Each underwent the excision of cutaneous and subcutaneous lesions.

Surgical wounds included those after excision of skin or subcutaneous lesions on the face (68%), neck (14%), abdominal wall (12%), axilla (1%) and back (5%). All other anatomical areas were excluded from this study in order to produce sample homogeny as concerns the healing of skin wounds in different body areas.

The researchers excluded wounds which could not be primarily closed without tension or were located over a bony prominence to minimize other confounding factors as were wounds with any kind of post-operative complications, e.g. hematoma, dehiscence or infection for the same reason.

The researchers used two different suture materials in each patient to improve comparison between suture material and skin type.  This was done by dividing each surgical wound into two halves.  Each half was sutured with two different suture materials for each wound. The same number of sutures were used on each half of the wound.  The patients were randomly assigned a pair of suture materials by the means of a sealed envelope method.

The pairing of five different kinds of suture material yielded ten pairs (PDS II- Polypropylene, PDS II - Ethilon, PDS II -metallic clips, PDS II – Vicryl Rapid, Polypropylene - Ethilon,  Polypropylene-metallic clips, Polypropylene-Vicryl Rapid, Ethilon - metallic clips, Ethilon – Vicryl Rapid, metallic clips-Vicryl Rapid).

Each pair was tested on ten patients.  Sutures were removed on the 10th post-operative day.

According to the aforementioned comparisons polydioxanone was found to have the best performance, followed by polyglactin, polyamide, polypropylene and metallic clips. All the above mentioned differences between suture materials were statistically significant (p<0.05).

Their conclusions:

The absorbable sutures used for skin closure in our study were removed after the period of time which is indicated for non-absorbable suture material and respective to the site of the wound. Less skin erythema was observed after the use of absorbable materials (polydioxanone and polyglactin) than with the three nonabsorbable materials (polypropylene, polyamide and metallic clips).

This leads to the conclusion that, when used in skin closure and removed after 10 days, absorbable materials produce less tissue reaction in the form of erythema than non-absorbable sutures do.

So their small study would indicate that PDS II created the least skin redness at 10 days, followed by Vicryl Rapid, Polypropylene, Ethilon, and metallic clips.

REFERENCE

Significant differences in skin irritation of common suture materials assessed by a comparative computerized objective method; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 17 November 2010; doi: 10.1097/PRS.0b013e3182043aa6; Original Article: PDF Only

Ethan's Baby Quilt

Our nephew Ethan was born on Thanksgiving Day 2004.  He was a month early, but is healthy and very smart!   This is another of my “crazy” scrappy quilts.  It is machine pieced and quilted.  It is 35 in X 46 in .

Here you can find a pink rabbit, sunflowers, butterflies, flags, a witch, and a bear.
Here you can find a frog, birds, a parrot, pumpkins, and planets.
Here you can find faces, a tiger, a car, planets, and more.

Engaging with Grace Blog Rally

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

The past couple of years during Thanksgiving weekend, many of us bloggers have participated in a “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

The original mission – to get more and more people talking about their end of life wishes – hasn’t changed.  At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Think about them, document them, share them. 

Wishing you and yours a holiday that’s fulfilling in all the right ways.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. If you want to reproduce this post on your blog (or anywhere) you can download a ready-made html version here

While you are engaging your family in a health care discussion, perhaps, you could engage your family into creating a medical family tree. 

Map out your family medical history
Here’s how to create your medical family tree.

1. Find out your ancestry. Include the country or countries where you ancestors came from originally. Some ancestries, like Jews of Ashkenazi (Eastern European) descent, have a higher risk for certain cancers.

2. List blood relatives. Include your first- (parents, siblings, children) and second- (nieces, nephews, aunts, uncles, grandparents) degree relatives. Add the current age of each or the age when they died.

3. Add cancer diagnoses, if any. Include the age when they were diagnosed with cancer, if you can find that out. List details, such as the part of the body where the cancer started and how the cancer was treated (chemotherapy, radiation therapy, surgery).

4. Include any birth defects or genetic disorders that you learn about.
Use the Surgeon General’s Office Family Health Portrait. This online tool helps track all family-related diseases, not just cancer………….

L-Brachioplasty – 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.

With the increase number of patients receiving weight-loss surgery, there is has been an increase in those asking for procedures to remove the remaining excess skin such as panniculectomy, abdominoplasty, lower body lift, brachioplasty (arm lifts), and thigh lifts.

The scars involved in brachioplasty surgery are not a good trade-off if there is minimal skin excess or looseness.  These individuals are better served by upper arm exercises to increase the muscle mass.

Brachioplasty (arm lift) is defined as the removal of excess skin and subcutaneous tissue to reshape the upper arm (axilla to elbow). (photo credit)

The L-brachioplasty described in the Hurwitz article from the July/August 2010 issue of the Aesthetic Surgery Journal addresses significant excess upper arm skin and the excess which often extends to the chest wall lateral to the breasts (photo credit).

The article very clearly described the procedure from the beginning to middle to end to postoperatively.  If you do brachioplasty surgeries, it is an article worth reading.

The operative time for each arm is approximately 40 minutes. The incisions are covered with sponge dressing and then wrapped in ACE bandages (BD, Franklin Lakes, New Jersey) with the hands elevated. The sponges and bandages are removed and replaced with tightly fitting elastic sleeves five days postoperatively.

Hurwitz mentions 13 women and two men were treated over the past four years using this procedure.  Complications included one seroma (treated by aspirated on one occasion) and incision dehiscence limited to less than 1 cm in five patients.  No patients had contractures across the axilla. 

Most insurance companies (as with Aetna and Cigna) consider brachioplasty surgery a cosmetic procedure.


REFERENCES

L-Brachioplasty: An Adaptable Technique for Moderate to Severe Excess Skin and Fat of the Arms; Hurwitz, Dennis J., Jerrod, Keith; Aesthetic Surgery Journal, July/August 2010 30: 620-629;  doi:10.1177/1090820X10380857

Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. Sep 1995;96(4):912-20.

Arm Lift Photo Gallery from Sean Younai, MD, FACS

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.

Amanda Brown, DVM is the host for this week’s Grand Rounds! You can read this week’s edition here (photo credit).

I'd like to welcome you all to the Thanksgiving 2010 edition of Grand Rounds (ok, actually this is Grand Rounds Vol. 7, No. 9 - but who's counting?) - it is VERY gratifying to me that so many of you have contributed, offered support, and generally welcomed me into this traditionally human-only medical blog carnival. At this time of year, I always stop and think about what I'm thankful for, and this year I'd say the medical blogging community is definitely on my list. And the office call drinking game! That, and Starbucks, of course. Triple grande nonfat latte FTW! Oh. Um. Sorry, I got a little carried away. I'm also incredibly grateful that my clinic microscope got tuned up today - I may actually have let the Nikon tech see me do the happy dance, in fact. So...anyway... Here we go!

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MedGadget is hosting a new contest:   Imagine Medicine: The Photography / Photoshop Contest

…………Welcome to the Imagine Medicine contest!

We are looking for fascinating medical photography that... imagines medicine.

Nothing is off the table: portraits, group shots, happy shots, tragic shots, clinical shots, photoshop illustrations, macro, micro, and anything in between. Can you imagine medicine, showcase it as art, and make us wonder?

Here's the lowdown. The contest is open to all. Upload your photograph(s) to Flickr, and tag them with "imaginemedicine" and "medgadget" keywords. Make sure you add at least one sentence describing your work. The deadline for submissions is 11:59pm ET on December 5, 2010. The winner will be announced on December 10th and the prize is a brand new 16GB iPad with Wi-Fi. ………

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I wish I could go see this exhibit of work from Street Anatomy at the International Museum of Surgical Science in Chicago, IL.  Initially, the exhibit was to run from September 3 through November 19, 2010, but has been extended to December 19th!  Congratulations, Vanessa! (photo/info credit)

  ………This exhibition, the latest in the Museum's ongoing "Anatomy in the Gallery" program, is guest curated by Vanessa Ruiz, the author of a popular niche blog, www.streetanatomy.com, that has covered the intersections between medicine, art, and design for the past two and a half years……

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Via tweeter: RT @blogborygmi RT @poisonreview: Did astronomer Tycho Brahe die of mercury poisoning or voluntary urinary retention? http://bbc.in/cfoRxU

BBC News article: Danish astronomer Tycho Brahe exhumed to solve mystery

Tycho Brahe was a Danish nobleman who served as royal mathematician to the Bohemian Emperor Rudolf II.

He was thought to have died of a bladder infection, but a previous exhumation found traces of mercury in his hair.

A team of Danish and Czech scientists hope to solve the mystery by analysing bone, hair and clothing samples. ……

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My siblings and I are very different.  I have always been fascinated and sometimes befuddled by this.  It’s probably why I enjoyed this piece on NPR by Alix Spiegel:  Siblings Share Genes, But Rarely Personalities

…………In fact, in terms of personality, we are similar to our siblings only about 20 percent of the time. Given the fact that we share genes, homes, routines and parents, this makes no sense. What makes children in the same family so different?…………

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I’m hoping to attend with a couple of friends --  Arkansas Women Bloggers Meetup Scheduled! (photo credit)

When: December 11, 2010 11am-1pm

Where: Museum of Discovery @ 500 President Clinton Avenue

Why: Meet other bloggers and help decide future activities/goals for AWB

We will keep you updated with event details as we pull them together.  

To RSVP, you can leave a comment on this post.  If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at arkansasbloggers@gmail.com.

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me” and is included in this weeks quilts being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern.

All proceeds will support the AAQ and its projects.

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There does not seem to be any Dr Anonymous’ show scheduled for this week. 

You may want to listen to the shows in his Archives. Here are some to get you started:

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

Risks of Fat Grafting in Breast Cancer Patients

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.

Fat grafting as a means of either (cosmetically) enlarging breasts or (reconstructively) correcting defects / asymmetries after breast cancer surgery/radiation therapy has been gaining ground as an acceptable method in the past few years.  True, much debate is still occurring but research is being encouraged to answer questions regarding safety (short and long-term) and efficacy.

The two articles (full references below) from researchers at the University of Pittsburgh School of Medicine suggests that it is NOT safe to use adipose-derived stem cells (ADSC) that may be part of fat grafting in any patient with active tumor cells. 

From the first article’s abstract (bold emphasis is mine):

Adipose-derived stem cells (ASCs) have been proposed to stabilize autologous fat grafts for regenerative therapy, but their safety is unknown in the setting of reconstructive surgery after mastectomy. ….

Here, we ask whether ASC promote the in vitro growth and in vivo tumorigenesis of metastatic breast cancer clinical isolates. Metastatic pleural effusion (MPE) cells were used for coculture experiments. ASC enhanced the proliferation of MPE cells in vitro (5.1-fold). ……… The secretome profile of ASC resembled that reported for MSC, but included adipose-associated adipsin and the hormone leptin, shown to promote breast cancer growth. Our data indicate that ASC enhance the growth of active, but not resting tumor cells. Thus, reconstructive therapy utilizing ASC-augmented whole fat should be postponed until there is no evidence of active disease.

From the second article’s abstract (bold emphasis is mine):

There is often a pressing need for reconstruction after cancer surgery. Regenerative therapy holds the promise of more natural and esthetic functional tissue. In the case of breast reconstruction postmastectomy, volume retention problems associated with autologous fat transfer could be ameliorated by augmentation with cells capable mediating rapid vascularization of the graft. …..

. Available evidence from case reports, cell lines, and clinical isolates favors the interpretation that regenerating tissue promotes the growth of active, high-grade tumor. In contrast, dormant cancer cells do not appear to be activated by the complex signals accompanying wound healing and tissue regeneration, suggesting that engineered tissue reconstruction should be deferred until cancer remission has been firmly established.

The early research suggest that fat grafting as a reconstructive tool in breast cancer survivors is safe (non-tumor causing) as long as care is taken to be sure any remaining tumor cells are dormant and non-active.

It must be remembered that fat grafting is a surgical procedure and as such is not risk free.  All surgical procedures carry the risks of infection, bleeding, etc.  The fifth reference below reminds us that fat grafting is not always a simple, benign procedure.

Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting. ………. 

Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.

REFERENCES

Regenerative Therapy and Cancer: In Vitro and In Vivo Studies of the Interaction Between Adipose-Derived Stem Cells and Breast Cancer Cells from Clinical Isolates; Ludovic Zimmerlin, Albert D. Donnenberg, J. Peter Rubin, Per Basse, Rodney J. Landreneau, Vera S. Donnenberg; Tissue Engineering Part A. September 2010, ahead of print.

Regenerative Therapy After Cancer: What Are the Risks?; Vera S. Donnenberg, Ludovic Zimmerlin, Joseph Peter Rubin, Albert D. Donnenberg; Tissue Engineering Part B: Reviews. November 2010, ahead of print.

Fat Grafting to the Breast Revisited: Safety and Efficacy; Coleman, Sydney R.; Saboeiro, Alesia P.; Plastic & Reconstructive Surgery. 119(3):775-785, March 2007; doi: 10.1097/01.prs.0000252001.59162.c9
Autologous Fat Grafting to the Reconstructed Breast: The Management of Acquired Contour Deformities; Kanchwala, Suhail K.; Glatt, Brian S.; Conant, Emily F.; Bucky, Louis P.; Plastic & Reconstructive Surgery. 124(2):409-418, August 2009; doi: 10.1097/PRS.0b013e3181aeeadd
Sepsis With Multiple Abscesses After Massive Autologous Fat Grafting for Augmentation Mammoplasty: A Case Report; Keu Sung Lee, Seung Jo Seo, Myong Chul Park, Dong Ha Park, Chee Sun Kim, Young Moon Yoo and ll Jae Lee; Aesthetic Plastic Surgery, November 2010; DOI: 10.1007/s00266-010-9605-8

Scrappy Log Cabin Baby Quilt

This quilt is made from fabric in my scrap bags.  I didn’t hold the “logs” to any set width, but cut each block to a finished 10.5 in (including seam allowances) when each was finished.  The quilt is machine pieced and quilted.  It is 40 in X 40 in.

I have given it to my niece who is pregnant with her first baby due this spring.

Here you can see some of the fabrics used.  It has some wonderful “I spy” effects:  find the rabbit, the frog, the carolers.
Here you will find a tiger, a snail, a road sign, stars.
Here you can find people, horses, race cars, colors (green, yellow, red, white, black), stars, strips, bees.
Here you can find a parrot, a weasel, a lady bug.

Saline or Silicone?

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.

There really is no simple answer to saline or silicone whether the choice is for a reconstructive or cosmetic patient.  For me it comes down to discussing the pros and cons of each with the patient and trying to help them decide which is best for them.

A recent article in the journal Cancer suggests that reconstructive patients are more satisfied with silicone implants over saline.  Upon looking at the information closer, it is an ever so slight increase in satisfaction as to be laughable.

Colleen M. McCarthy, MD, MS, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues conducted a multicenter, cross-sectional survey of 482 postmastectomy, implant-based reconstruction patients.  A total of 672 women were asked to complete the BREAST-Q (Reconstruction Module), but only 482 completed them (176 women had silicone implants and 306 chose saline).

BREAST-Q Reconstruction Module scores satisfaction in 15-items including  breast shape, feel to the touch, appearance, feelings of "normalcy," and integration into self.  The score averaged 58.0 for silicone implants versus 52.5 with saline implants on a 100-point scale in a univariate analysis.

Why are the scores so low (58.0 and 52.5)?   This study wasn’t planned to discern those answers though it did note that the addition of radiation to the mix lowered the satisfaction scores.

The article by Scott Spear, MD is a wonderful review of the pros and cons of each.  It is well worth reading.  He summarizes at the end of his article:

As implant choices have evolved, certain concepts have proven useful. When the main determinant for patient satisfaction is the shape and feel of the implant (and in cases where the implant might be especially visible), a silicone gel implant is the better choice. In cases where the primary concerns are safety (real or perceived), minimal access incisions, and ease of monitoring, saline may prove to be a better choice.

Related posts
Patient Satisfaction Following Breast Reconstruction Using Implants (June 7, 2010)
Silicone vs Saline Breast Implants (March 4, 2008)



REFERENCES
Patient Satisfaction with Postmastectomy Breast Reconstruction: A Comparison of Saline and Silicone Implants; McCarthy CM, et al; Cancer 2010; DOI: 10.1002/cncr.25552.

Breast Implants: Saline or Silicone?; Spear, Scott L., Jespersen, M. Renee; Aesthetic Surgery Journal July/August 2010 30: 557-570, doi:10.1177/1090820X10380401

Rationing

 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.

Do you recall the severe rationing of food and water the Chilean miners had to endure to survive?   The rationing was done to stretch their limited resources.

I would argue the state of Arizona’s new policy to not cover organ transplants for patients on Arizona Health Care Cost Containment System (AHCCCS) or their version of Medicaid is a similar form of rationing.

AHCCCS, as many Medicaid programs, is underfunded.  They are trying to operate on a limited budget.  Something has to give.

Sadly in this case, many (NPR reports 98) had already been granted approval for organ transplants which they may not receive.  Francisco Felix, 32, who due to Hepatitis C needs a liver transplant, is reported to have made it to the operating room, prepped and ready for his life-saving liver transplant when doctors told him the state's Medicaid plan wouldn't cover the procedure.  The liver he was to receive went to someone else.

In this prolonged economic downturn, I wonder how many parents have had to tell their children who were accepted into their dream college they will not be able to go, the family income has changed and it is no longer affordable?

In a perfect world, everyone would have health insurance.  Health insurance companies (private, state, and federal) would have unlimited resources so that all “evidence-based” medically necessary care/procedures/medications would be covered.

Hell, in a perfect world, we wouldn’t need health care.

It isn’t a perfect world.  There are limited resources.  Tough decisions must be made in doing the most with the available resources.

Is this the sort of rationing of medical care we will be seeing more of in the future?

P.O.U.R.

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.

A patient with postoperative urinary retention forced me to review the topic, conducting my private M&M conference.

Without giving away too much on my patient – female, less than 50 yo, general anesthesia used, length of surgery 4 hrs, ambulatory/outpatient, foley used intraoperatively, fluids used judicially (though I do not know the exact amount given by anesthesia), pain meds (Toradol, fentanyl, and sent home with script for Percocet).

From the first reference article below

I made my usual call to the patient the evening of surgery, asked how she was, “how’s the pain?”, “any concerns?”, “any nausea?”, “are you eating and drinking?”. I don’t recall specifically asking about whether she had peed or not, but I do recall her saying she needed to end the call so she could go to the bathroom.

I received a call from her the next afternoon. “Dr. Bates, I can’t pee. I keep trying and all I can do is dribble.”

The surgery center graciously agreed to catheterize her. I received a call from them immediately afterwards, “Dr. Bates, her residual volume is 1000+ cc.”

The patient graciously agreed to have the foley left in place for the next 24 hrs. I called her later the same evening and we agreed on a time for her to come into my office for the removal of the foley the next day (and yes, I gave thought into leaving it for a second day).

The surgery center’s action kept my patient from having to check in through the emergency department, incurring a wait time and additional cost.

The patient’s agreement allowed me to treat her as an outpatient, helped me reduce the need for a second catheterization, and keep her from incurring more expense.

It was fortunate that the patient had weaned herself from the pain medicine by this time and was mostly taking only Tylenol. Her P.O.U.R quickly resolved.

I did not see this complication coming for this patient. Perhaps the foley could have been left in and removed in recovery. Perhaps anesthesia could have restricted fluids more (though they were careful).

I can think of no reason she might need a urology follow up. Am I missing anything? Where is KeaGirl when you need her?

REFERENCES

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit; Anesthesia & Analgesia, August 2005 Vol. 101 No. 2 592-596; doi: 10.1213/​01.ANE.0000159165.90094.40

Postoperative Urinary Retention; Anesthesiology Clinics, Volume 27, Issue 3, Pages 465-484 (September 2009)

Patient Safety in the Office-Based Setting; Horton, J Bauer; Reece, Edward M.; Broughton, George II; Janis, Jeffrey E.; Thornton, James F.; Rohrich, Rod J.; Plastic & Reconstructive Surgery. 117(4):61e-80e, April 1, 2006; doi: 10.1097/01.prs.0000204796.65812.68

Urinary Retention in Adults: Diagnosis and Initial Management; Brian A. Selius, DO, Rajesh Subedi, MD; Am Fam Physician, 2008 Mar 1;77(5):643-650.

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.

Kim, Emergiblog,  is the host for this week’s Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to the Doctor Who edition of Grand Rounds!

We’ll travel through the medical blogosphere of 21st century Earth, where we will find that Grand Rounds can be found on Twitter (@grandrounds) and on a website known as Facebook (Grand Rounds).

Our spaceship/time-machine, the TARDIS (Time And Relative Dimensions in Space), is standing by.

“All of time and space; everywhere and anywhere; every star that ever was. Where do you want to start?” – the Eleventh Doctor

The adventure begins…….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 10)! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to the latest edition of Change of Shift!
Good stuff this week, so let’s get to it!
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A warm Change of Shift welcome to Erin, a school nurse who blogs at Tales of a School Zoned Nurse. Every single one of Erin’s posts would make a wonderful addition to CoS, but I was taken by One.  …..

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The New York Times has an article by Gardiner Harris on new cigarette labels:  F.D.A. Unveils Graphic Warning Labels for Cigarettes.  I approve this message!

Federal drug regulators unveiled 36 proposed warning labels for cigarette packages on Wednesday, including some that are striking pictures of smoking’s effects.

Designed to cover half of a pack’s surface area, the new labels are intended to spur smokers to quit by providing graphic reminders of tobacco’s dangers. .….

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Dr. Rich makes a great argument on How the Obesity Crisis Is Like the Mortgage Crisis

………..So, while few people actually stuck to a strict low-fat diet, many, many people became addicted to refined carbohydrates, and as a result became fat.
……….  We now hear somewhat more reasonable advice about good fats and bad fats, and good carbs and bad carbs. But much of the damage has been done, and at least partially because of the major push for low-fat diets, we Americans are fatter and less healthy than we used to be.
By the way, to this day it has never been shown that low-fat diets applied across the population would reduce the incidence of heart disease.  ……………..

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Fellow bloggers do you remember Wellsphere?  Well, the latest “thief” of our information using our reputations and twitter feeds in a similar way is Organized Wisdom.  Check out @laikas recent blog post on the topic:  Expert Curators, WisdomCards & The True Wisdom of @organizedwisdom

 Organized Wisdom (http://organizedwisdom.com and @organizedwisdom on Twitter) is a 3-4 year old company that uses a similar approach to filter useful health information out of the daily junk.  ……

Part of the problem may be that Organized Wisdom doesn’t only share links from “Health Centers”, but also from Wellness Centers (Aging, Diet, Exercise & Fitness etc) and Living Centers (Beauty, Cooking, Environment). Apparently one card can have information for 2 or 3 centers (diabetes and multivitamins for example)

I feel used.

Organized Wisdom uses the credibility of me and other curators, including so-called “top expert curators” as Dr Pho (Kevin MD – blog), to cover up the incredibility of others, with the intention to lure users in.  ……..

Just as with Wellsphere, I have asked Organized Wisdom to remove me from their expert curator list.  I hope you will do the same.

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From twitter: @ksboulden: I just RSVP to attended the meetup of Arkansas Women Bloggers. Can't wait!

Arkansas Women Bloggers Meetup Scheduled! (photo credit)

When: December 11, 2010 11am-1pm

Where: Museum of Discovery @ 500 President Clinton Avenue

Why: Meet other bloggers and help decide future activities/goals for AWB

We will keep you updated with event details as we pull them together.  

To RSVP, you can leave a comment on this post.  If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at arkansasbloggers@gmail.com.

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me” and is included in this weeks quilts being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week Three: Monday,Nov. 15-Monday, Nov. 22

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern.

All proceeds will support the AAQ and its projects.

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There does not seem to be any Dr Anonymous’ show scheduled for this week. 

You may want to listen to the shows in his Archives. Here are some to get you started:

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

Families and Plastic Surgery

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 read this article by Colin Stewart , Spouses often are jerks about plastic surgery (link removed 3/2017), a few weeks ago.  Since then I have been thinking about not just the husbands but families in general I see in my practice.  Remember I practice in Little Rock, Arkansas not Hollywood but I still find this to be true and not just of husbands.

Husbands of plastic surgery fans have a sensitive role to play.

It’s a challenge that most of them fail. Instead of communicating effectively and caringly with their wives about plastic surgery, husbands tend to act like jerks or wimps.

I think often the patient may also fail in communicating effectively to her spouse, significant other, family, and friends why she feels the need to have cosmetic/plastic surgery.  In defense of the spouse and others, it can be a mind-field.  After all, you don’t want to suggest your loved one is less than perfect with her small breasts or her saddle bags or the bat wings or her father’s nose or …..

It is easier for me to ask the question “why do you want to have ____?” in my office.  There’s less judging, not the same emotional baggage.  The individual is less likely to feel rejection from me if I suggest she re-examine her reasons or discuss them more fully with me.

I want the individual to be the one who initiated the visit to my office.  I certainly don’t want a pageant mom to bring in her daughter for liposuction or breast augmentation anymore than I want a husband to push his wife into having larger breasts.

The article mentions

The wimpy approach.

“You look wonderful, dear,” they say. “You don’t need any work done, but if it makes you happy, go ahead.”

The in-control approach.

Many other husbands go to the other extreme and become dictators. They demand their own way, whether it’s pro- or anti-plastic surgery.

It’s much nicer for all involve when the patient and her/his family discuss the options with respect for each other.  Some family members are anti-surgery because of fear of losing the person when they change themselves.  Some are anti-surgery because of the fear of losing the loved one to a complication of anesthesia or the surgery itself.

When those fears are voiced, the individuals can address the emotions.  Marriage counseling is often a better solution than surgery.  Bigger breasts won’t necessarily keep the husband from leaving for the younger woman.  And, yes, some women pre-plan their cosmetic surgery before the divorce.

Certainly a family member’s fear of losing the loved one to a death related to potential risks of surgery/anesthesia need to be addressed.  Complications happen.  Deaths happen, fortunately rarely, but they do happen.

The desired improvements must be weighed against those risks.  The patient (and her family) must be realistic regarding expectations. 

The article describes a successful discussion between a patient and husband.  She gave voice to specific reasons for desiring the surgery.  He voiced his concern.  They both listened to each other.  She won him over.

When Rinna began considering lip-reduction surgery to remove the scar tissue, she expected Hamlin to object, and she was right.

Plastic surgery is “never a good thing, in my opinion,” he told People magazine. “Plastic surgery is just an extension of that whole ‘let’s stay fresh and young’ vibe.”

She said, “I knew Harry would say, ‘Don’t touch it, don’t mess with it.’ He was like, ‘Maybe you should just leave it alone.’ He loves me the way I am.”

But she told him how important the operation was to her and what it was like to be the butt of never-ending snarky comments about her lips.

Family discussions can help the patient to be honest with herself regarding her reasons and expectations.

Bart and Amy's Quilt

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 made this quilt for my brother-in-law and sister-in-law.  He was in seminary school then, now is a chaplain in the Army recently returned to the United States from his second tour of duty in Iraq. 

Amy took these photos for me (thank you), but I’m not sure you can tell how lovely the fabrics are.  The dark fabrics are jewel tone in nature (ruby, sapphire, emerald, and brown topaz).  I think I pieced the quilt around 1994 (Amy thinks 2000 or 2001, but I think I pieced it much earlier and it just took that long to get it quilted).  It is machine pieced, 71 in X 97 in.  I don’t believe I did the quilting, unsure who did.

The setting is a play on the Jacob’s Ladder block to form a cross with the center block, God’s Eye (Ojo).

Upper two:   Crown of Thorns (Wedding Ring)/Robbing Peter to Pay Paul (Arizona)

The lower four – left (facing quilt) and right
Christmas Star  …………………..  unsure, maybe King David’s Crown
?Joseph’s Coat variation ……….David and Goliath (from The New Quilting & Patchwork Dictionary which is different from the link)

The fact that I can’t recall all the quilt block names is a great example of why we quilters should document our ideas, inspiration, and sources as we make our quilts.  If anyone can correct me, I’d be grateful.

Physician Threatened by Libel Action

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 was alerted to this issue by a couple of tweets:

@mariawolters: @rlbates please blog this if you can RT @DrEvanHarris: Libel threat to Doc w/ concerns abt  "Boob job" cream! http://bit.ly/a4bM5U

@baapsmedia: @beachbumbeauty @cosmetic_candy @rlbates Pls RT 2help defend medical scrutiny on unsubstantiated claims: http://tinyurl.com/37u6wal

Shouldn’t it be possible to voice a concern about a medical treatment, procedure, or claim without the fear of retaliation?  If the claims are backed by science, then simply addressing my concerns would be enough.

Fear of retaliation silences discussion.  Fear of retaliation makes it difficult to do the “right thing” when the public or an individual patient is at risk.

This incidence involves a British plastic surgeon threatened with libel action by the ‘Boob Job’ cream’s manufacturer after she voiced concerns/doubts of its effectiveness.

Sense About Science has a great summary of the entire affair:  Plastic surgeon threatened for comment on ‘Boob Job’ cream.

Dr Dalia Nield of The London Clinic was quoted in an article in the Daily Mail on 1st October 2010 saying that it was 'highly unlikely' the 'Boob Job' cream would increase a woman's breast size. The manufacturer, Rodial Limited had claimed that the cream, reported to be a favourite of Scarlett Johansson, can increase breast size by 2.5 cm. Dr Nield said the company had not provided a full analysis of tests on the cream and that if its claims that fat cells moved around the body were true it could be potentially dangerous. Rodial Limited has threatened Dr Nield with libel action. Dr Nield stands by her comments………..

Dr Dalia Nield said: "As a surgeon I am well aware of the necessity for claims on medical products to be based upon rigorous scientific testing, as well as the possible dangers which can result from treatments. It is my duty to speak out when products making these claims are not backed up by evidence. The safety and health of people could be at risk if I cannot do this."

Good for you Dr. Nield!  I agree with you and love this comment:

i want scientific proof, apply only to one boob the a side by side comparison after 56 days
- steve, usa, 1/10/2010 0:36

Injectables Roundup

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 have come across some interesting articles recently regarding injectables.  Let’s begin the non-controversial one: Behind the Lines by Linda W. Lewis, Nov/Dec 2010 MedEsthetics (pp 32-.  This one notes several filler discontinuations:

Johnson & Johnson (jnj.com) withdrew porcine collagen-based Evolence in November 2009; Allergan (allergan.com) discontinued its human and bovine collagen fillers, CosmoDerm, CosmoPlast, Zyderm and Zyplast, late last year and will stop distribution by the end of 2010.

The article mentions the latest filler introductions:

Juvederm XC from Allergan and Restylane-L and Perlane-L from Medicis (medicis.com).  These products differ from their predecessors only in the addition of lidocaine to the formulations.

Much greater changes are on the horizon, however, as manufacturers seek approval for exciting new products like Novabel (Merz Aesthetic, merzaesthetics.com) and Aquamid (Contura, aquamid.com).

The article also mentions that some physicians are using Restylane SubQ in buttock and breast enlargements.  This leads me to the next article (full reference below):   Macrolane(TM) for breast enhancement: 12-month follow-up.  The Swedish study used a new formulation of a stabilized hyaluronic acid-based gel of non-animal origin (NASHA(TM)-based gel) called Macrolane(TM) VRF30) in their open-label, multicentre, non-comparative study.

The aim of this study was to develop a reproducible technique for injecting NASHA-based gel posterior to the mammary gland (subglandular injection), and to assess treatment safety and efficacy. The feasibility of dual-plane submuscular injection was also explored.

Twenty-four non-pregnant, non-breastfeeding women (mean age 37 years) with small breasts were recruited, 20 of whom underwent subglandular injection.   Patients were treated in groups of four to enable step-wise revision of the injection technique. Safety and efficacy assessments (12-month follow-up) included adverse event (AE) reporting and the Global Esthetic Improvement Scale, respectively.

It’s a small study with the authors reporting 83% satisfaction in the post-procedure breast appearance at 6 months, 69% at 12 months.  I find it interesting that the most commonly reported adverse event was capsular contracture.   Obviously,  larger studies are needed before this can be routinely recommended to patients.

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Dentist are “pushing” their scope of practice beyond the teeth/dentition to include Botox and fillers.   While dentists may know how to do injections well and should know facial nerve/muscle anatomy well, I personally feel this is beyond the definition of dental practice.  I suppose it will be up to state dental and medical boards to work this out.

 The Evolving Role of Dentist in the Injectables Business by Jeff Frentzen, PSP Blog  leads you to the full article: The next revolution in dentistry: facial injectables by Bruce G. Freund, DDS, Oct 25, 2010.

REFERENCE

Macrolane(TM) for breast enhancement: 12-month follow-up; Per Hedén; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 14 October 2010; doi: 10.1097/PRS.0b013e318200ae57; Original Article: PDF Only

Longevity of SMAS Face Lift

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 think it is safe to say that all plastic surgeons have been asked, “How long will my face lift last?”  As pointed out, by Dr. Sundine and colleagues (first reference article) this question is difficult to answer using our current literature.  They tried to answer the question focusing specifically on the two-layer superficial musculoaponeurotic system (SMAS) face lift.

To do this, Sundine and colleagues conducted a retrospective chart review of 42 patients who underwent secondary face lifts performed by the senior author from January of 2001 to December of 2008. Patients who had their primary face lift performed by another surgeon were excluded.  The charts were reviewed for the dates of the initial surgery and subsequent operations, patient data, procedures performed, and complications. The patient photographs were also reviewed.

The average age at the time of the primary face lift was 50.7 years (range, 34.9 to 69.9 years), and the average age at the time of the secondary face lift was 61.9 years (range, 43.6 to 77.2 years).

The average length of time from the primary to secondary face lift was 11.9 years (range, 1.0 to 34.5 years). ….

One glaring shortcoming of the study is the failure of the authors to contact every patient the senior author performed a primary face lift (there were 299 during the time frame) to determine whether any patients received a secondary face lift with another surgeon.

So while the over-simplified answer may be “approximately 10 years,” there really is no simple answer.  Patients give many reasons for desiring a second facelift.  (second reference)

Readers of this article will already know that people have a universe of reasons for having a face lift. In practice, one commonly notes not only unhappiness with the mirror but also the loss of a spouse or the anticipation of finding one: the patient's social milieu and group dynamics (face lifts as a rite of passage). Some people perceive an advantage in finding or maintaining employment, all reasons that may have little to do with the face itself but with life conditions of the person requesting the procedure. In other words, subjectivity and life forces are major factors, and the decision to have such a procedure may have little relationship to how the patient actually appears.

Biological factors such as skin quality, facial weight, and the age at which the initial procedure is performed significantly affect both the quality of the initial result and its duration, and the same cultural and personal forces remain. There is no distinct tissue endpoint for undergoing a secondary lift, just as there is no distinct biological point at which a primary lift becomes “necessary.” With so many factors to be considered, the longevity of any type of face lift remains a difficult question to answer with any certainty.

In addition, to the above there are the constraints of life that may prevent a patient from returning for a desired facelift – poor health, financial concerns, family reasons, and perhaps even a poor experience the first time.

REFERENCE

Longevity of SMAS Facial Rejuvenation and Support; Sundine, Michael J.; Kretsis, Vasileios; Connell, Bruce F.; Plastic & Reconstructive Surgery. 126(1):229-237, July 2010.; doi: 10.1097/PRS.0b013e3181ce1806

Discussion: Longevity of SMAS Facial Rejuvenation and Support; Lambros, V.; Stuzin, J. M.; Plastic & Reconstructive Surgery. 126(1):238-239, July 2010; doi: 10.1097/PRS.0b013e3181dab6f3

The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Friel, M.T.; Shaw, R. E.; Trovato, M. J.; Owsley, J. Q.; Plastic & Reconstructive Surgery. 126(1):245-257, July 2010; doi: 10.1097/PRS.0b013e3181dbc2f0

Discussion: The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Pusic, A.L.; Klassen, A. F.; Scott, A. M.; Cano, Stefan J.; Plastic & Reconstructive Surgery. 126(1):258-260, July 2010; doi: 10.1097/PRS.0b013e3181dbba19

Shout Outs

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.

Mother Jones RN, Nurse Ratched's Place,  is the host for this week’s Grand Rounds! You can read this week’s Veteran’s Day edition here (photo credit).

Welcome to the Veterans Day edition of Grand Rounds. Elvis and I are delighted that you dropped by. The King is very excited today because we are saluting celebrities that have served in the Armed Forces. Elvis said that his days in the army were memorable. I imagine having Life Magazine take your picture while you’re sitting in your underwear would be a memorable experience. My co-host and I want to thank everyone for their submissions, and we especially want to thank Dr. Nick Genes for allowing us to hold Grand Rounds at Nurse Ratched’s Place. ….

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Really patient-centered! via Paul Levy (Running a Hospital):  Here comes the bride - at Anne Arundel Medical Center by Wendi Winters (Capital Gazette)

The bride wore an elegant strapless gown and a radiant smile. The nervous groom was impeccable in his spotless Air Force dress uniform and a TV-sized heart monitor.  …….

"The wedding must go on," senior nursing director Ann Marie Pessagno said as she arranged the chairs for the ceremony that almost wasn't.  ………

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Dr Margaret Polaneczky updates us on HRT and breast cancer in her post:  HRT and Breast Cancer Deaths – Just in Case You Weren’t Listening the First Time…

…………….While the breast cancer risks associated with HRT use appear to be quite real, for a individual woman, they are not that large. Here’s how I explain the risks to my patients ……………..

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From tweeter  @IVLINE “For all your fracture naming needs http://bit.ly/98agy2 with pictures included.”  The link is to LITFL’s Eponymous Fractures.  Here’s an example of the great information you will see there:

Barton’s fracture
John Rhea Barton
1794-1871, American surgeon
Description/ Mechanism of injury:
Fall on outstretched hand

Intra-articular fracture of the distal radius with dislocation of the radiocarpal joint. Fractures may be displaced volar or dorsal direction

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From twitter: @docgrumpy: “The iPhone/iPod app "Nerve Whiz" is awesome for peripheral nerve help- and it's free (I wasn't paid for this, FYI)”

Nerve Whiz is an app designed by a neuromuscular neurologist at the University of Michigan.

Nerve Whiz is a free application for medical professionals interested in learning the complex anatomy of nerve roots, plexuses, and peripheral nerves. Select which muscles are weak, or point to areas of sensory loss, and the application can provide you with distinguishing features and detailed information, complete with relevant pictures and detailed information, complete with relevant pictures and diagrams.

NOTE: Nerve Whiz is intended to be an educational tool only. Nerve distributions vary between patients, and central or multifocal processes can mimic focal peripheral lesions. As such, this application should not be relied upon to make clinical decisions.

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me.” The quilts are now being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week One: Monday, Oct. 25-Monday, Nov. 1

Week Two: Monday, Nov.8-Monday, Nov. 15

Week Three: Monday,Nov. 15-Monday, Nov. 22

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern. No Daylight Savings Time changes this year to contend with--DST changes on November 7.

All proceeds will support the AAQ and its projects.

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There does not seem to be any Dr Anonymous’ show scheduled for this week. 

You may want to listen to the shows in his Archives. Here are some to get you started:

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

Stem Cells

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 October issue of the Plastic and Reconstructive Surgery Journal has a nice review article of stem cells (bold emphasis is mine).  The article gives an overview of current advancements in the field of stem cell research, as well as perspectives for future clinical applications.

Stem cells are defined by their capacity to both self-renew and differentiate into multiple cell lines. Traditionally, they have been divided into two main groups based on their potential to differentiate. Pluripotent stem cells (embryonic) can differentiate into every cell of the body, whereas multipotent stem cells (adult) can differentiate into multiple, but not all, cell lineages.

In addition to the traditional stem cell classification, a new class of stem cells has recently been described—induced pluripotent stem cells—which are derived from genetically reprogrammed adult cells. These diverse cell populations will provide researchers and clinicians with an expanded armamentarium to treat diseased and dysfunctional organs.

Embryonic stem cells

• are derived from the inner cell mass of the blastocyst and have the capacity to differentiate into all tissues of the body.
• at least 225 human embryonic stem cell lines have been generated by researchers
• the pluripotentiality and unlimited ability for self-renewal that make embryonic stem cells attractive for cell replacement therapy also simultaneously translates into unregulated differentiation and formation of teratomas and teratocarcinomas, especially in undifferentiated states
• significant political and ethical hurdles that hinder further investigations of human embryonic stem cells

Adult stem cells

1. avoid the ethical concerns regarding fetal tissue harvest
2. well-studied adult stem cell population includes mesenchymal stem cells
3. Mesenchymal stem cells have been isolated from bone marrow, umbilical cord blood, and adipose tissue.
4. Adipose tissue–derived stem cells can be readily harvested during a minor liposuction procedure under local anesthesia.

Induced pluripotent stem cells

1. Takahashi and Yamanaka published a landmark article in 2006 that defined a specific set of transcription factors capable of reverting differentiated cells back into a pluripotent state, thus creating “induced” pluripotent stem cells.
2. It is widely accepted that mouse and human induced pluripotent stem cells closely resemble molecular and developmental features of blastocyst-derived embryonic stem cells

While the clinical potential for stem cell use is huge as noted in the article

Stem cell–based clinical trials are still in the early stages of development. In a preliminary case study, three patients were treated with autologous bone marrow stem cells seeded onto porous ceramic scaffolds for limb cortical defects ranging from 4 to 7 cm.  ………

In another case report, a 7-year-old girl with a critical-sized calvarial defect was successfully treated with cancellous iliac bone grafts in combination with autologous adipose tissue–derived stem cells.

In a case series, 20 patients with severe symptoms or irreversible functional skin damage due to radiotherapy were treated with autologous adipose tissue–derived stem cells delivered by computer-assisted injections.  …….

Interestingly, the first clinical phase I trial for utilizing adipose tissue–derived stem cells was carried out in patients with Crohn's disease. …..
In another phase I clinical trial, eight patients with Duchenne disease were treated with myogenic (muscle-derived CD133⁺) stem cells. ….

there is abuse of the term stem cell.  Stem cells facelifts are a marketing scheme (IMHO) which are promising results that haven’t been studied.

Stem Cell Face-Lifts?
Stem Cell Facelift: Fact or fiction?
The Newest Untested Fad:  Stem-Cell Facelifts
and from Dr. Thomas Fiala’s this blog post The "Stem Cell" facelift

But so far, we have no evidence - zip, zilch, nada - that there is any actual regenerative effect on skin when the turbo-charged fat is added to the face. We know you get more volume in the treated areas, so the treatment could be useful for those with a volume-depleted area, or those who want fuller cheeks - but that's about it.

Furthermore, under FDA rules, when stem cells get involved with fat transfers, the procedure falls under a whole new set of regulations. The fat and stem cell combo is now seen as a "biologic agent" by the FDA, and regulated as a drug. In the eyes of the FDA, stem cells and fat represent a non-approved drug. Investigational, yes - approved, no.

Interestingly, one of the spin-offs of this change to drug status is a change in whether physicians can advertise this process. They are no longer just advertising a procedure (the stem cell facelift), but they are doing direct-to-consumer marketing for a drug (the fat and stem-cell mixture) which has not yet been cleared by the FDA. And it's illegal to promote non-approved drugs.

Dr. Barry Eppley disagrees with the above stance in his post:  Stem Cell Facelifts - Science or Science Fiction?

Conversely, the hopeful part of a Stem Cell Facelift is that it is a perfectly natural procedure that has no harmful effects, an almost organic procedure if you will. It is all the patient’s own tissues and may exemplify the appealing concept of ‘heal thyself’. Because one’s own cells are being used (recycled?), it is not a procedure that requires FDA approval or that of any governing medical organization. (so don’t be misled that it is an FDA-approved procedure or technique) At the worst, one gets the benefit of fat grafting whether the stem cells really become alive or not. And the use of fat grafts to the face with our current appreciation of what happens as our face ages is a proven benefit.

However, in checking the FDA’s own website, I find that I would disagree with Dr. Eppley and agree with Dr. Fiala:  What are stem cells? How are they regulated?

Stem cells, like other medical products that are intended to treat, cure or prevent disease, generally require FDA approval before they can be marketed. At this time, there are no licensed stem cell treatments.

REFERENCES

Stem Cells; Behr, Björn; Ko, Sae Hee; Wong, Victor W.; Gurtner, Geoffrey C.; Longaker, Michael T.; Plastic & Reconstructive Surgery 126(4):1163-1171, October 2010; doi: 10.1097/PRS.0b013e3181ea42bb

Cathy's Scarf Quilt

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.

Today would have been my mother’s 76th birthday, so it seems appropriate to share a quilt made for my sister of  old scarves embroidered both by our mother and us girls.  Back in June I shared the quilt I made for my sister Susan from some of the old scarves.

I machine pieced this small wall hanging, 34 in X 34 in, somewhere around 2000.  Cathy hand quilted.

Here you can see some of the embroidered areas better.

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This post has been added to the Blogger’s Quilt Festival Fall 2010.  There are many lovely quilts.  Go check them out.

I Need to Reschedule You

Over the past 20 years, there have been very few times I have asked patients to reschedule.  Even though I tell patients they have nothing to apologize for when they then to cancel, I always apologize.   This is especially true when it comes to asking them to reschedule surgery.

Yes, I know you have asked for time of work.  Yes, I know you have arranged for someone to help care for you, for your children, etc.  Yes, I realize you may have airline tickets to come into town to stay with family here while recovering.

Yes, I keep all that in mind, so if I ask you to reschedule it truly will be a handful of good reasons:

I am sick or need surgery myself.  I had to ask a patient to reschedule her breast reduction early in my solo career.  I had an acute herniated disc (C6-C7) which left me with numbness in my left  index and long fingers and loss of triceps function, not to mention the pain.  I had to explain to her that it was not safe for me to do her surgery until after my own.  [She did reschedule.]

A family member is sick or dying.   I had to ask a patient last May to reschedule after my mother had her stroke during her CABA.  After we made the decision to AND (allow natural death), we did not know how long it would be.  I did not want to be in surgery when it happened.  I thought it was reasonable.  [She never rescheduled.]

I have a funeral to attend.  I have not canceled or rescheduled a surgery for this (yet), but have rescheduled a few office visits.  As I and my friends get older, I can see this happening more frequently in the future.  I will try to be considerate of both my friend/family and my patients.

Usually, when I ask a patient to reschedule it will be a last minute thing.  I regret this, but as you can see from the reasons I allow myself to make this request it will always be last minute.  Some things are tough to plan.

Believe me when I say I am sorry to have to ask you to reschedule.  I truly mean it.

Know Your Surgeon

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 would caution anyone who elects to have cosmetic or plastic surgery to go to a surgeon’s office.  Meet your surgeon.  Along with learning about the procedure, ask about their training.  If your procedure is to take place outside of a hospital (for example, in a surgery center), ask if your surgeon has privileges to do the procedure in a major hospital (the hospital should have checked their training when doing the credentialing).

Treat cosmetic/plastic surgery as surgery with all the benefits AND risks of non-elective surgery.

I stumbled across this article Owner of Cosmetic Surgery Clinic Sentenced in New York for Health Care Fraud.

Arthur Kissel,a/k/a "Arthur Froom," was sentenced October 25th in Manhattan federal court to 10 years in prison for healthcare fraud offenses.  Neither Kissel nor his wife Sonia LaFontaine are doctors, but they engaged in a series of fraudulent practices out of their Manhattan cosmetic surgery clinic.  (pdf file of press release from United States Attorney Southern District of New York)

LaFONTAINE and KISSEL, along with several coconspirators including doctors who worked at LRMA, engaged in four different types of fraud at the clinic:
•  LaFONTAINE performed procedures which were billed as if they had been performed by licensed physicians.
•  LRMA billed cosmetic procedures as medically necessary procedures so that health insurance companies would be duped into paying for them.
•  KISSEL and LaFONTAINE submitted claims to health insurance companies for procedures that were never performed.
•  KISSEL and LaFONTAINE exaggerated insurance claims by increasing the number and complexity of procedures.
KISSEL and LaFONTAINE were indicted in March 1998 with conspiracy to commit health care fraud. KISSEL was extradited from Canada in 2008 and pled guilty on September 4, 2009.

Kissel and LaFontaine’s practices actually led to the death of one patient:

In imposing the maximum sentence permitted by law,Judge CHIN rejected KISSEL's claims of "ignorance and dumbness"and found that he "acted out of greed." He also stated that his crimes "led directly to the death" of JOEL CUNNINGHAM, who died on January 8, 1998, while undergoing an outpatient abdominal liposuction procedure at LRMA. CUNNINGHAM had wanted to become a NYPD police officer, but was too heavy to meet the entrance standards. He decided to have a liposuction procedure at LRMA,which used extensive advertising claiming that it was operated and supervised by a "world renowned surgeon," when in fact it was operated and supervised by KISSEL and LaFONTAINE. Evidence presented at a subsequent wrongful death suit in state court indicated that Cunningham had died of complications from anesthesia, which had been administered by an LRMA anesthesiologist who was at the time on professional probation due to drug and alcohol abuse.

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

Welcome to this week's mid-term edition of the medical blog-o-sphere's Grand Rounds! Before we begin, be SURE to get to the polls to VOTE!
This week submissions were classified by state or country of origin. Politically incorrect posts by state were colored RED whereas politically correct posts by state were colored BLUE. (States with both extremes are represented in PURPLE.)
Now what would any political post be without a POLITICAL MAP of the states represented in this week's Grand Rounds?  …………….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 9)! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to Change of Shift!
After a Vegas-induced vacation, our nursing blog carnival is back!
There has been lots of activity in the blogosphere over the last four weeks, so let’s get right to the heart of it! ………..

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Check out Dr. Rob’s recent House Call Doctor podcast: When Should You Worry About a Nosebleed?

……….Doctors call nosebleeds epistaxis. I’ve mentioned before that doctors like fancy names for things; it just sounds smarter to use a Latin or Greek word. It’s especially good at parties. ……….

As someone who has had many nosebleeds within my life, you may also want to check out my old post from two years ago: Nose Bleeds. Either way, Dr. Rob and I have you covered.

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An ethical question comes up regarding the use of social media as noted by @dreamingspires

A Tweeting Hospital and Kidney Patient: The Case of the tweeting Kidney Patient has caused a small whirlpool of a ... http://bit.ly/dfsREG

The original nhssm's posterous blog post: 2nd Case Study - St George's Healthcare NHS Trust and the Tweeting Kidney Patient

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From twitter: RT @MargaretAtwood @DrSnit @kidney_boy: Hey, you're famous! http://ow.ly/30LR1. The link is to a Guardian.co.uk article by Esther Addley: Margaret Atwood creates superhero outfits for Twitter avatars

With more than a dozen novels, 17 poetry collections and countless literary awards including the 2000 Man Booker prize to her name, Margaret Atwood's credentials as one of the world's greatest living writers are not in question. ……..

in a remarkable exchange over Twitter, which saw the Canadian writer contacting two readers who had expressed admiration for her work, and offering to design "superhero comix costumes" for their avatar alter-egos, @kidney_boy and @DrSnit.

"[They] both have excellent Twitter names – suitable for superheroes – and were comix fans, and were discussing Comic.con, as I recall," she told the Guardian. ………..

This tweet links to a companion article:

@steve_lieber Some of the @PeriscopeStudio artists (incl. me) have drawn @margaretatwood's Kidney Boy and Dr. Snit. http://periscopestudio.com/?p=3638

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me.” The quilts are now being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week One: Monday, Oct. 25-Monday, Nov. 1

Week Two: Monday, Nov.8-Monday, Nov. 15

Week Three: Monday,Nov. 15-Monday, Nov. 22

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern. No Daylight Savings Time changes this year to contend with--DST changes on November 7.

All proceeds will support the AAQ and its projects.

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Dr Anonymous’ show will be follow-up to FMEC Mtg. The show begins at 9 pm EST.