Sunday, February 28, 2010

SurgeXperience 318 – Call for Submissions

SurgeXperiences 318 will make a trip Down Under to Life in the Fast Lane on March 7th.

Life in the Fast Lane was born out of an intense desire to procrastinate..

Australian emergency physicians exploring the changing world of elearning, critical care and toxicology through clinical cases, fictionalized anecdotes and medical satire.

Our team was born out of passionate (and usually unresolved) debate pertaining to the elements of eLearning; medical education; medical history; political ambiguity; information sharing; the open source era and the ethos of web 2.0.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  You are encouraged to submit your surgery related posts. 

The deadline for submissions to be included in the 318 edition is midnight on Friday, March 5th.  Be sure to submit your post via this form

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

If you would like to host afuture editions, please contact Jeffrey who runs the show here.

Saturday, February 27, 2010

A Fabric Postcard

Intueri recently posted about a book of postcards she received at Christmas.  She offered to send them to anyone who requested one.  I did so as I love postcards.

This prompted me to try to come up with a unique postcard for her (though she never asked for one in return).  I decided to make one – my first ever fabric postcard.  I have read instructions for them now for years, but had yet to do one.  Here two sites with good instructions:  How To Make a Fabric Postcard - Directions Plus... and How To Make A Fabric Postcard DebR Style.

The one I made for Intueri is 4in X 6 in.

The back

I received my postcard from her this past Monday.  I mailed hers the same day.  I hope she likes hers.

Friday, February 26, 2010

Blue Jeans Purse

My neighbor knows I love pockets, so when her son outgrew his shorts I got them.  I deconstructed the shorts in part and moved the larger pockets.  This allowed me to keep all the pockets in use.

I used a “new to me” product called InnerFuse to stiffen the purse, giving it shape and hopefully making it more durable.  The purse has a zipper opening and is lined.

The strap is a denim belt from an old dress which is why is is darker than the rest of the bag.

I gave the shorts back to my friend/neighbor.  She loves it.

Thursday, February 25, 2010

Lipedema, Lymphedema, Lipolymphedema

There is an interesting article (full reference below)on lipedema.  If you have an interest in the subject, then read the full article.  The terms are so similar that I found myself having to be careful (often deliberately speaking the terms out loud) when I read the article.  Even though the topic is “no laughing matter”  you could easily make a tongue-tying word game out of the words:  lipedema, lymphedema, lipolymphedema.

Lipedema is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement.  The diagnosis of lipedema is a clinical one, often challenging in patients who are overweight or obese, based on the examination and history. 

Distinguishing obesity from lipedema can be accomplished by noting (a) whether the fat deposits in the arms and legs spare the feet and hands, (b) whether the adiposity is predominantly in the extremities or it exists in the extremities and the trunk, and (c) by whether diet and/or physical activities reduce truncal adiposity but not extremity adiposity.   Easy bruising is often noted. Pain upon pressure is universal in patients with lipedema and is commonly described an "aching dysesthesia.

Lymphedema is a condition in which edema leads to inflammation and fibrosis as a result of reduced lymphatic return.

Lipolymphedema is the condition in which lipedema acquires a lymphedema component and is thus differentiated from pure lipedema by the presence of Stemmer's sign.

The Stemmer's sign is the inability to pinch a fold of dorsal skin at the base of the toes and will be positive in patients who have developed secondary lymphedema.   In patients with pure lipedema, the Stemmer's sign is negative. In lipedema patients, edema is minimal and relieved by elevation. In lymphedema patients, the edema is persistent.

Photo credit





Lipedema: A Frequently Misdiagnosed and Misunderstood Fatty Deposition Syndrome; Advances in Skin & Wound Care, February 2010 - Volume 23 - Issue 2 - pp 81-92; Fife, Caroline E. MD; Maus, Erik A. MD; Carter, Marissa J. PhD, MA

A Guide to Lymphedema; Medscape article, 01/23/2008; Kristiana D Gordon; Peter S Mortimer

Lipedema and Lymphedema;

Lipedema; Lymphedema Therapy Website

Wednesday, February 24, 2010

Cutaneous Metastatic Carcinoma – an Article Review

Most of us will never see skin metastases from carcinoma in our clinical practices as they are relatively uncommon.  It is estimated that 2% to 9% of patients with internal malignancy may develop cutaneous metastasis.  Often these will herald the diagnosis of the internal malignancy. 

The short article in the Advances in Skin & Wound Care Journal on this topic is a review (full reference below) of the topic.  It comes out of the University of Calabar Teaching Hospital, Calabar, Nigeria.  The authors had six patients with histological diagnosis of cutaneous metastatic carcinoma between 2000 to 2006.   These patients were part of a wider study of cutaneous malignancy. The variables analyzed were age, sex, site of cutaneous metastasis, clinical presentation, site of primary tumor, and outcome. This was compared with total cutaneous and total malignancy.

Six cutaneous metastatic carcinomas during this period of study comprised 6.5% of total cutaneous cancer and accounted for 0.6% of total malignancy. The patients included 2 men and 4 women (male-female ratio = 1:2), and their ages ranged from 37 to 55 years (mean, 45.2 years). No patients with these lesions were in the first 3 decades of life, and the 6 patients who had these lesions were between the fourth and sixth decades.

The involved anatomic areas of the skin metastasis were chest (3), neck, anterior abdominal wall, and vulva.  The primary cancers were breast (ductal) in two of the chest lesions.  One of the chest lesion patients was lost to follow up prior to diagnosis of the primary. 

The patient with the neck skin lesion’s primary turned out to be nasopharyngeal carcinoma.  The patient with the anterior abdominal skin involvement primary was suspected to be gastrointestinal but he was lost to follow up during the evaluation.  The vulval skin lesion patient’s primary turned out to be choriocarcinoma of the uterus.


The second reference below gives a much fuller review of the topic and is referenced in the first article.

The breast, stomach, lung, uterus, large intestine, and kidneys are the most frequent organs to produce cutaneous metastases. Cancers that have the highest propensity to metastasize to the skin include melanoma (45% of cutaneous metastasis cases), breast (30%), nasal sinuses (20%), larynx (16%), and oral cavity (12%). Because breast cancer is so common, cutaneous metastasis of breast cancer is the most frequently encountered type of cutaneous metastasis in most clinical practices. Although some tumors are very common, they may not necessarily eventuate in metastasis in a manner that parallels their incidence in the overall population. For example, prostate cancer is very common, but cutaneous metastasis from prostate carcinoma is relatively uncommon……..

The mortality rate is high in patients with cutaneous metastases. The appearance of cutaneous metastases signals widespread metastatic disease, resulting in a poor prognosis. Patients often survive for a short period, depending on the type of carcinoma, but this is changing. Exciting advances in chemotherapy have greatly increased survival in recent years.




Cutaneous Metastatic Carcinoma: Diagnostic and Therapeutic Values; Advances in Skin & Wound Care. 23(2):77-80, February 2010; Asuquo, Maurice E.; Umoh, Mark S.; Bassey, Ekpo E.

Metastatic carcinoma of the skin; eMedicine, August 14, 2008; Helm TN, Lee TC. (last accessed Feb 17, 2010)

Tuesday, February 23, 2010

Shout Outs

MD Whistleblower is this week's host of Grand Rounds.   You can read this week’s edition here.

It’s been a while since I’ve attended a conventional medical Grand Rounds. These were events where a medical luminary would fly in to give a medical audience a state-of-the-art presentation on a medical subject. Ideally, the speaker was a thought leader and a researcher on the issue.

These presentations were usually not a demonstration of the virtue of humility. We physicians, as a class, have generous egos. Academic physicians occupy a higher rung on the ego ladder. Medical Grand Rounders (MGRs), who are on the GR speaking circuit, often must bring their own ladders to assure they will be able to reach their desired atmospheric height.


INQRI Blog is the host of the latest edition of Change of Shift (Vol 4, No 17) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

The INQRI program is excited to partner with the Robert Wood Johnson Foundation’s Initiative on the Future of Nursing, at the IOM to present the February 18 edition of Change of Shift. In anticipation of the upcoming forum on the Future of Nursing: Education, we have selected nursing education as our theme.


Dr Val, Better Health, will be attending the HIMSS in early March in Atlanta:

This year, the Better Health team will be offering live coverage of healthcare’s largest tech conference: HIMSS in Atlanta, March 1-4. Three medical bloggers, Dr. Val Jones, Dr. Mike Sevilla, and Dr. Nick Genes will interview over 40 different exhibitors and stream their interviews live via UStream. You can ask questions of the interviewees by submitting questions to @drval during the event. Dr. Val Jones will report to ABC News, DC via Skype from the convention floor on Wednesday, March 3rd at 10:50am.


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

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

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

Thanks for your consideration.
Click here to donate.


From Medgadget comes A Preview of BeBionic Artificial Hand

RSLSteeper out of Kent, UK is planning to release a new prosthetic hand in May that brings new functionality and supposedly a more natural and personalized look to the market. The BeBionic hand is fully articulated with preprogrammed grips and a powered wrist. We contacted RSLSteeper to get more details on the new hand and here's from their reply:………….


Our fellow medblogger and medical colleague, Doc Gurley was in Haiti last week.  You can follow read her posts beginning with this one:  Haiti Journey: Hitting the ground.

Immediately after crossing from the DR into Haiti, you can see the visible downshift into a worse level of poverty. The major road around the lake is now, unbelievably after all these miles, dirt. Only an ankle-pile of rubble at the edge prevents flooding, making me wonder what will happen, in the rainy season, to the lifeline to Haiti.


Fiberart For A Cause is raising money for the American Cancer Society.  You can check out the items here (photo credit)

Bidding opens Tuesday, February 23 at 11:00 a.m. CST
Opening Bids posted at 10:50 a.m. CST
Bidding closes at 2:00 p.m. CST
Are you ready to bid? Checklist.


This National Geographic article,  Carnivorous Plants (photo credit), by Carl Zimmer  is accompanied by some absolutely beautiful photographs.


Dr Anonymous’ guests this week will be storytellERdoc, winner of the Best Literary Blog of 2009 Medical Blog Awards.    Come join us.

Upcoming Dr. A Shows (9pm ET)

3/1 : Dr. A On Location
3/4 : Dr. Rob from Musings of a Distractible Mind
3/11 : EMS Podcaster Greg Friese


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

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

Monday, February 22, 2010

Care of Pressure Ulcers in Palliative Care Patients

I’d like to recommend this article (full reference below) to anyone involved in the care of palliative care patients, as well as anyone who does wound care.  It is a thoughtful and well written consensus paper from the National Pressure Ulcer Advisory Panel.

The article begins by pointing out the difference in goals between palliative care patients and the usual patients with pressure ulcers (PrU).

Usual care of a PrU is designed to promote healing; however, healing or closing the ulcer in patients receiving palliative care is often improbable. Therefore, the focus of care is better directed to reduce or eliminate pain, odor, and infection and allow for an environment that can promote ulcer closure, as well as improve self-image to help prevent social isolation.


There is a significant risk of PrUs in terminally ill patients.   Many develop Stage III and IV PrUs.  Advanced age, malnutrition, immobility, friction and shear forces, and increased exposure to moisture (ie incontinence, diarrhea, etc) are common.

In 1 study, the majority of PrUs in a hospice sample occurred in the 2 weeks before death,  not unexpected as body systems physiologically begin to shut down 10 to 14 days prior to death.

For individuals who are actively dying, prevention and treatment of a PrU should be superseded by comfort needs.  This means that if it is too painful to be turned and repositioned, then those preventive activities are minimized in an effort to give comfort/pain relief.


Pressure ulcers are often unpleasant smelling wounds due to the bacteria that thrive on the wound exudates and  devitalized tissue.  We’ve agreed that it is not likely we will heal the PrU in pallitive care patients, so what can we do to decrease the smell?  The paper has these recommendations to control wound odor:

Cleanse the ulcer and periwound tissue, using care to remove devitalized tissue.

Assess the individual and the ulcer, with a focus on comorbid conditions, nutritional status, cause of ulcer, presence of necrotic tissue, presence and type of exudates and odor, psychosocial implications, and so on.

Assess the ulcer for signs of wound infection: increasing pain; friable, edematous, pale dusky granulation tissue; foul odor and wound breakdown; pocketing at base; or delayed healing.

Use antimicrobial agents as appropriate to control known infection and suspected critical colonization.

Consider use of properly diluted antiseptic solutions for limited periods of time to control odor.

Consider use of topical metronidazole to effectively control PrU odor associated with anaerobic bacteria and protozoal infections.

Consider use of dressings impregnated with antimicrobial agents (eg, silver, cadexomer iodine, medical-grade honey) to help control bacterial burden and odor.

Consider use of charcoal or activated charcoal dressings to help control odor.

Consider use of external odor absorbers for the room (eg, activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, potpourri).


The article list these products and dressings as odor-controlling:

Metronidazole,  an antimicrobial agent effective against anaerobic bacteria and protozoal infections such as Trichomonas. Topical metronidazole gel (0.75%-0.80%) is frequently used directly on the wound once per day for 5 to 7 days or more often as needed.  Metronidazole tablets can be crushed and placed onto the ulcer bed.

Cadexomer Iodine, an antiseptic that allows for low-concentration release of iodine over time and promotes an acid pH that enhances the antimicrobial action of the iodine.  

Charcoal -impregnated dressings have been found to minimize wound odor. Activated charcoal attracts and binds wound odor molecules.

Dakin Solution. Odor can also be controlled using Dakin solution 0.25% (sodium hypochlorite) saturated onto gauze packing and placed into the ulcer.  Dakin solution produces its own odor and can be irritating to the respiratory system, especially if the patient is in isolation or rooms with limited ventilation. Dakin solution may cause some pain in the wound when used.

Povidone Iodine. Odor can also be controlled using povidone solution.

Silver Dressings. Silver dressings are effective in countering some infections in the wounds and thereby controlling odor.

Other Odor-Control Methods. To control odor in the room, kitty litter can be placed under the bed. Vinegar, vanilla, coffee beans, or a candle in the room are also helpful in controlling odors.   External odor absorbers in the room are effective but, at times, the smells they create can be overwhelming themselves.







Pressure Ulcers in Individuals Receiving Palliative Care: A National Pressure Ulcer Advisory Panel White Paper(C); Advances in Skin & Wound Care. 23(2):59-72, February 2010; Langemo, Diane K.; Black, Joyce; and the National Pressure Ulcer Advisory Panel

SurgeXperiences 317 is Up!

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

Welcome to yet another fortnight of SurgeXperiences, where we feature several blog articles which might be of interest to surgeons, anesthesiologists, scrub nurses, nurses, students, techs, or just about anyone who is fascinated by the surgical discipline – where one has to cut to cure and heal.

The host of the next edition (318) has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline: midnight on Friday, March 5th. Be sure to submit your post via this form.

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

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

Saturday, February 20, 2010

Not What She Wanted to Hear

Her complaints:  “My back aches.  I can’t find a bra that fits. I have trouble exercising.”

Her Exam:   Moderate size, slightly ptotic breasts. No palpable masses.  No skin changes.

Her Measurements:  33 inch rib cage, 37 inch bust, 24 cm SNN (38C bra)

“Insurance won’t pay for a breast lift.”

Friday, February 19, 2010

Scrappy Houses Baby Quilt

I used my scraps to make four “houses” for this baby quilt.   The quilt has many points of interest:  color, shapes, objects to find.  It is machine pieced and quilted.  It is 35 in X 42 in.  I have given it to a nurse who works at the surgery center where I do most of my procedures.  I tried to make the quilt of interest to either a boy or girl as I didn’t know which she was having.

Here is a close up of one of the blocks.  I love the weight-lifting gator on the beach.
Here is another one of the blocks.  Notice the flowers, faces, trees.
The back of this quilt is a soft flannel with dogs.

Thursday, February 18, 2010

Better Health Headed to HIMSS

Dr. Val Jones will be leading a three “man” team from of Better Health bloggers as they provide live coverage of healthcare’s largest tech conference, HIMSS, in Atlanta, March 1-4.  She will be joined by Dr. Mike Sevilla and Dr. Nick Genes.

Here are ways you can follow the teams activities:

  •  Watch live interviews of exhibitors by the team on UStream. Tune in to Dr. Val’s UStream coverage (beginning at 9:30am each morning at HIMSS, March 1, 2, and 3rd).  UStream interviewee line up will be published on the Better Health blog on Friday, February 26th
  • Participate in real time via Twitter.  Follow @drval and tweet your questions to her during the interviews.   Follow the Twitter hashtag #HIMSS10 during the event to see tweets from UStream attendees and others.
  • Meet the bloggers at HIMSS. There will be a special panel discussion with Dr. Val and other popular health IT bloggers scheduled in the HIMSS Social Media Center.
  • Watch Dr. Val Reporting from HIMSS on ABC News (DC only): Tune in to News Channel 8 at 10:50am, Wednesday March 3rd.
  • Blog Talk Radio: HIMSS Wrap Up With Dr. Val and Dr. Anonymous. Tune in to the Dr. Anonymous show at 8pm ET, Wednesday, March 3rd to hear final impressions about the show. Call in to discuss the event with hosts, or join the chat room.

Shortened Radiation Treatment for Breast Cancer

An interesting article in the February 11 issue of of the New England Journal of Medicine (full reference below) looking at the effects of shorten regimens of radiation therapy in conjunction with breast conservation surgery in treatment of breast cancer.

Conventional radiation therapy is a 5-week regimen.  It is estimated up to 30% of women who are recommended to receive radiation therapy as part of their treatment for breast cancer may avoid it due to inconvenience and cost.

Researchers have begun to look at using shorter regimens, and are finding that the 10-year recurrence rates and cosmetic outcomes for breast cancer patients are similar.

Dr. Tim Whelan, a professor of oncology of the Michael G. DeGroote School of Medicine at McMaster University, and colleagues compared an intense three-week course of hypofractionated radiation therapy to the standard five-week regimen for women with early-stage breast cancer.

The study included 1234 women with invasive breast cancer who had undergone breast-conserving surgery, had clear resection margins,  and negative axillary lymph nodes.  The women were randomly assigned to receive whole-breast irradiation either at a standard dose of 50.0 Gy in 25 fractions over a period of 35 days (the control group) or at a dose of 42.5 Gy in 16 fractions over a period of 22 days (the hypofractionated-radiation group).

The risk of local recurrence at 10 years was found to be  similar in both groups:   6.7% among the standard irradiation group compared with 6.2% among the hypofractionated group. 

The cosmetic outcome for both groups was found to be similar at 10 years: 71.3% of the control group as compared with 69.8% of the hypofractionated-radiation group had a good or excellent cosmetic outcome.

In the study, there were no cases of grade 4 skin ulceration or soft-tissue necrosis occurred in either group. 



The most common side effect of radiation therapy for breast cancer needing attention is skin reaction. Most patients develop reddening, dryness and itching of the skin after a few weeks. Some patients develop substantial irritation.

Some patients develop a sunburn-like reaction with blistering and peeling of the skin, called "moist desquamation,"  most often in the fold under the breast or in the fold between the breast and the arm.   Most people with a limited area of moist desquamation can continue treatment without interruption.  Skin reactions usually heal completely within a few weeks of completing radiotherapy

Skin care recommendations include:

  • Keeping the skin clean and dry using warm water and gentle soap
  • Avoiding extreme temperatures while bathing
  • Avoiding trauma to the skin and sun exposure (use a sunscreen with at least SPF 30)
  • Avoiding shaving the treatment area with a razor blade (use an electric razor if necessary)
  • Avoiding use of perfumes, cosmetics, after-shave or deodorants in the treatment area (use cornstarch with or without baking soda in place of deodorants)
  • Using only recommended unscented creams or lotions after daily treatment.



Source reference:
Whelan TJ, et al "Long-term results of hypofractionated radiation therapy for breast cancer" N Engl J Med 2010; 362: 513-20.

American Cancer Society

Radiology Info

Wednesday, February 17, 2010

Symmastia After Augmentation Mammoplasty

Symmastia (also known as synmastia) is a condition that occurs when breast implants sit too close to the middle of the patient’s chest.  Extreme cases can even lead to the “uniboob” look. Fortunately, it is a rare complication of augmentation mammoplasty surgery. 

Developmental symmastia can occur without prior surgery in patients who have breast hypertrophy and an aberrant soft-tissue connection across the midline.

Dr Spear (4th reference article below) noted (bold highlight is mine):

Based on our experience with postaugmentation synmastia, a number of facts have emerged. All of the implants were subpectoral. The majority of these women had undergone more than one operation. Many of them had undergone successive operations to enlarge the size of their implants and breasts. Many of them had large implants, arbitrarily defined by us as greater than 400 cc or with a diameter of 14 cm or more. Several of the patients had associated chest wall skeletal deformities, and some had undergone simultaneous mastopexy at the time of their breast enlargement.

Prevention of symmastia is much better than having to try to fix it.   Care must be taken in dissection of the pocket, especially medially.  It is preferable to use implants that “fit the body.”  By this I mean, implants should not be wider than the available hemithorax of the individual patient.  Try to get the patient to use a smaller implant or perhaps a high profile with a smaller base width.  Avoid excessive detachment of the pectoralis muscle’s medial sternal attachments. 

Correction of symmastia requires restoration of the presternal subcutaneous integrity and medial closure of the pocket.   Techniques to achieve this include capsulorrhaphy, capsular flaps, AlloDerm or other materials, adjustable implants, explantation with delayed reimplantation, and change to a subglandular pocket.  All have drawbacks in terms of reliability, technical difficulty, and convenience.





1.  Symmastia: The Problem of Medial Confluence of the Breasts;  Plast & Reconstr Surg 73(2):261-266, February 1984; Spence, Robert J.; Feldman, Joel J.; Ryan, James J.

2.  Surgical Reconstruction of Iatrogenic Symmastia; Plas & Recontr Surg 121(3):143e-144e, March 2008; Foustanos, Andreas; Zavrides, Harris

3.   The "Neosubpectoral" Pocket for the Correction of Symmastia; Plast & Reconstr Surg 124(3):695-703, September 2009; Spear, Scott L.; Dayan, Joseph H.; Bogue, David; Clemens, Mark W.; Newman, Michael; Teitelbaum, Steven; Maxwell, G Patrick

4.   Synmastia after Breast Augmentation; Plas & Reconstr Surg 118(7S):168S-171S, December 2006; Spear, Scott L.; Bogue, David P.; Thomassen, John M.

5.   Correcting Symmastia; Steven Teitelbaum, MD, FACS Website (nice photos)

6.   Correction of Symmastia After Augmentation; Thomas M. DeWire, Sr., MD, FACS Website  (nice photos)

7.   YouTube Video of Symmastia Repair

8.    My Breast Augmentation & Chin Revision (YouTube Video)

Tuesday, February 16, 2010

Shout Outs

ACP Hospitalist is this week's host of Grand Rounds.   You can read this week’s edition here.

Good morning! You made it to our hospital's auditorium in time for Grand Rounds. I'm your attending physician. Before we visit the patients, we'll start with a few biology lectures. I hope you retain this information when we move on to teaching rounds.

For example, most of us need to know more about what chronic pain is and how to treat it. It's a very different beast than acute pain, but the subject wasn't taught enough while you were in med school. How to cope with pain is an important lesson.


GruntDoc is kept us updated on the travesty of justice involving a nurse in west Texas who reported a doctor to the state medical board:  Updated and Bumped: CBS 7 – Your Eye on West Texas covering the Winkler County Nurse Trial

If you’re new to this story, the backgrounder is here.

The trial of Anne Mitchell, RN for doing her duty (reporting bad patient care to the Texas Medical Board) started 3 days ago.  I cannot find CBS’s coverage (if there was any) of Day 1, but there is pretty good coverage of days 2 & 3.

Winkler County Nurse found Not Guilty

A case that should never have been brought is now over.

Now, about that Civil suit


GruntDoc is also one of the ER physicians quoted in Reader's Digest -- "10 More Secrets the ER Staff Won't Tell You"

“If three of your relatives are with you, only one of them needs to tell the story of your illness. I realize it’s validating for everyone to tell their version of events, but I’m not here to validate you.”


Congratulations to the winners of the 2009 Medical Blog Awards (MedGadget).   

The winners for this year's awards are:

-- Best Medical Weblog:  Gary Schwitzer's HealthNewsReview Blog

-- Best New Medical Weblog (established in 2009):   SCOPE

-- Best Literary Medical Weblog:   StorytellERdoc

-- Best Clinical Sciences Weblog:   Life in the Fast Lane

-- Best Health Policies/Ethics Weblog:   The ACP Advocate Blog

-- Best Medical Technologies/Informatics Weblog:   ScienceRoll

-- Best Patient's Blog:  Wheelchair Kamikaze


H/T to @sandnsurf who shared this article on tweeter.  The same could apply to physicians.  >>  Lawyers and suicide - warning signs to help a colleague in crisis

1. Pay attention to suicide warning signs……….

2. Consider risk factors for suicide……..

3. Be prepared to ask questions and to listen……

4. Get help and advice: If, despite your best efforts, you remain concerned about someone, don't be sworn to secrecy, and don't take on the challenge alone. Get your friend to a mental health professional or call one yourself, call 911, call the National Suicide Prevention Lifeline at (800) 273-8255 or call the State Bar of Texas Lawyers' Assistance Program at (800) 343-8527. Your job is to get your friend the professional help he or she needs.


I want to tell you about Robin’s 365 Project:  365 Days with Cushing’s Disease.  Here’s an excerpt:

Hidradenitis suppurativa....

I'm lucky.  Mine is "mild" compared to most.  Nonetheless, it's no fun.  In 1985, I saw a doctor because of it.  She told me to use white Dial soap and to lose weight. At that time, I hadn't gained very much weight.   Yes, 25 years ago.  And I'd had other symptoms of Cushing's, also, long before then. 


A nice tutorial from Susan Khalje on Threads:  Working with Embellished Fabrics, Part I (photo credit)

This fantastic material inspires a tutorial about working with extremely embellished fabric. I'll take you through the process as I create a garment.

I'm going to break this project down into two sections. Part 2 will be covered in another post. Here, in Part 1, I'm going to explain how to:

1. Check the fabric to make sure the embellishments are securely sewn on
2. Attach an underlining
3. Remove the beads from the seam allowances of the side seams
4. Deal with the darts
5. Sew and catch-stitch the side seams
6. Prepare the lining


Dr Anonymous’ guests this week will be Rhett and John from FireFighter Netcast  Come join us.

Upcoming Dr. A Shows (9pm ET)

2/25 : storytellERdoc
3/1 : Dr. A On Location
3/4 : Dr. Rob from Musings of a Distractible Mind
3/11 : EMS Podcaster Greg Friese

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

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

Monday, February 15, 2010

New Treatment for CRPS?

Complex Regional Pain Syndrome (CRPS) is a multi-symptom, multi-system syndrome that remain poorly understood. As I have mentioned previously , it was called reflex sympathetic dystrophy (RSD) when I first learned about it.  I still catch myself calling it RSD. 

For a complete review of CRPS, please refer to my previous post on the topic.  This post is to look at an article published in the February issue of the journal Annuals of Internal Medicine (full reference below).

A research team at the Pain Research Institute at the University of Liverpool note that there is some evidence for “for immune activation in the affected limb, peripheral blood, and cerebrospinal fluid.”

This lead them to conduct a randomized, placebo-controlled, double-blind, single-center, 2-period crossover trial study.  The study included13 eligible participants were randomly assigned between November 2005 and May 2008; 12 completed the trial.  Participants were selected from confirmed CRPS patients who had pain intensity greater than 4 on an 11-point (0 to 10) numerical rating scale and had CRPS for 6 to 30 months that was refractory to standard treatment.

They found that a single, low-dose infusion of intravenous immunoglobin (IVIG) provided significant pain relief in nearly 50 percent of patients treated.  IVIG is a blood product that contains immunoglobulin G extracts from the plasma of more than 1,000 blood donors. It is used to treat inflammatory and autoimmune diseases, immune deficiencies, and acute infections.  In this study, the pain relief lasted on average five weeks.

The editors of the Annuals make the point I want to stress:

Because the study is so small, it is difficult to know whether these results apply to most other patients with CRPS. Also, the small number of patients increases the possibility that chance may affect the results.

For now, the cornerstone in the treatment of RSD / CRPS remains normal use of the affected part as much as possible. This is done through education, pain control, and physical therapy. (photo credit)

For more information check this eMedicine article and this website (RSD Foundation). You will also find a nice video animation on the RSD Foundation site that shows how an injury might trigger RSD / CRPS.





Intravenous Immunoglobulin Treatment of the Complex Regional Pain Syndrome: A Randomized TrialAnn Intern Med. 2010;152:152-158; Goebel A, Baranowski A, Maurer K, Ghial A, McCabe C, Ambler G

Sunday, February 14, 2010

SurgeXperiences 317 – Call for Submissions

There is no scheduled host for SurgeXperiences 317 (February 21st), but don’t let that keep you from making your submissions. If you would like to host edition #317 or any future editions, please contact Jeffrey who runs the show here.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. You are encouraged to submit your surgery related posts.

The deadline for submissions to be included in the 317 edition is midnight on Friday, February 19th. Be sure to submit your post via this form.

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

Saturday, February 13, 2010

Care Taking

“It happened two days ago. I fell off a ladder,” she says, eyes averted.

“What’s happened since?” I ask as I exam the arm laceration, fortunately non-infected.

“Mom’s been sick. Electricity has come and gone with the ice storm.”

“And how’d you take care of this?” I begin to gather supplies.

Friday, February 12, 2010

Wash Cloth Potholder

A patient gave me the old potholder (pictured below with the replacement I recently made) years ago. I love it, but it has been used to the point of not being able to do its job of protecting my hand from hot pans any longer.

I did a Google search and found the instructions for making more. (photo credit/ original from here). The original came from "The How To Book: Do it Yourself with Stevens Utica Sheets & Towels", by J.P. Stevens & Co, 1978.

My new wash cloth was not quite square, so I first squared it up.

Then I folded it as shown and then used my serger to sew the edges together.
I should have changed out my threads, but didn’t as it’s “only a potholder.”
I then crocheted the edges using a simple scalloped stitch which really makes it look so much better.

Here is a great source for crocheted edging.

Thursday, February 11, 2010

Fretting Over My Patients

Schedule decimated this week due to snow storm.  Patients rescheduled. New ones easy, post ops not so stress-free.

“We need to get your stitches out.  It’s not optimum for them to be left in, but it’s more important that you can get in safely.”

Glad no one had drains.

Genius on the Edge – book review

I received a free copy of the book, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted by Gerald Imber, MD, a week ago.  I have enjoyed reading it.  The book is the biography of Dr Halsted, but also gives you a glimpse into the life of many other great medical figures:  William Osler, William Henry Welch, Harvey Cushing, etc.  (photo credit)

In many ways it is a history of medicine/surgery in America.  Halsted was very influential in bringing aseptic techniques to surgery and introduced the residency training system.  He used his knowledge of anatomy to improve surgical technique.  He performed the first successful hernia repair and radical mastectomy for breast cancer. 

Early in his career Halsted became addicted to cocaine while experimenting with the drug for use as a local anesthetic.  Treatment at the time, involved substituting morphine for cocaine.  Halsted spent 40 years of his life struggling with his addiction to both cocaine and morphine.

His career was almost ruined by his addiction, but with help from his friends who still believed in his brilliance he was able to resurrected his career at the new Johns Hopkins, where he became the first chief of surgery.  Here he took changed surgery to a lifesaving art rather than a horrific, dangerous practice.

You don’t need to be a surgeon to appreciate this book.  You only need to have a love of history.  Dr. Imber, a plastic surgeon in private practice in Manhattan, has written a fine book.

Wednesday, February 10, 2010

Botox Gets Bad Press

BOTOX has been getting a lot of bad press recently. First, the potential use of black market Botox in terroristic activity. Now it is the focus of a lawsuit in Orange County, California by a mother who alleges that the Botox treatments used to decrease muscle spasms weakened her daughters respiratory muscles, therefore causing her death.

Kristen Spears’ mother has sued Allergan alleging that her daughter died from a fatal reaction to the Botox treatments Kristen received for treatment for cerebral palsy. The trial began two weeks ago. I have looked for updates, but found none.  [update below]

BOTOX is most commonly known for it’s cosmetic uses in wrinkle reduction, but is approved by the FDA for treatment of cervical dystonia, strabismus, blepharospasm, primary axillary hyperhidrosis, and glabellar wrinkles. It is also used "off label" for a variety of more prevalent conditions that include migraine headache, chronic low back pain, stroke, traumatic brain injury, cerebral palsy, achalasia, and various dystonias.

The treatments in cerebral palsy are used to decrease muscle spasms. A multidisciplinary panel systematically reviewed relevant literature from 1966 to July 2008 and published their recommendations in the Journal Neurology:

For localized/segmental spasticity, botulinum toxin type A is established as an effective treatment to reduce spasticity in the upper and lower extremities. There is conflicting evidence regarding functional improvement. Botulinum toxin type A was found to be generally safe in children with cerebral palsy; however, the Food and Drug Administration is presently investigating isolated cases of generalized weakness resulting in poor outcomes.

Recommendations: For localized/segmental spasticity that warrants treatment, botulinum toxin type A should be offered as an effective and generally safe treatment (Level A).

Botox, manufactured by Allergan Inc., contains extremely minute quantities of Botulinum Toxin A, which causes temporary muscle paralysis. A Botox “black box” warning was ordered by the FDA in May 2009 due to reports that the effects of the toxin may spread from the area of injection to other areas of the body causing serious adverse problems. This label requirement is required on Botox and Botox Cosmetic (botulinum toxin type A); Myobloc (botulinum toxin type B); and a new FDA-approved product, Dysport (abobotulinumtoxinA).

When the botulinum toxin spreads beyond the area injected the toxin can cause symptoms similar to those of botulism. These symptoms include unexpected loss of strength or muscle weakness, hoarseness or trouble talking, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing, double vision, blurred vision and drooping eyelids

According to Allergan Inc. currently faces at least 15 Botox lawsuits that claim that the company hid the risks associated with the drug.



LA Times

Practice Parameter: Pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review); NEUROLOGY 2010;74:336-343

By a 10-2 vote, jurors decided Tuesday that Botox-maker Allergan was not responsible for the death of a young cerebral palsy patient who died in 2007 after Botox injections.

Tuesday, February 9, 2010

Shout Outs

Edwin Leap is this week's host of Grand Rounds.   You can read this week’s edition here.

Welcome to Grand Rounds for February 9th.  How are you?  Sitting here, finalizing the posts, I am stricken by my utter inability to say anything nearly as entertaining as Dr. Rob did last week.  I mean, I don’t have a single llama picture to offer you!  I’m very disappointed in myself.

So, I’ll try to intro this Grand Rounds with a reminder.  Let’s set the stage.  This morning, as I write this, my two cats are staring out the window at song-birds; happy not to be out in the frosty grass like their dog friends, but deep in their cat souls wondering ‘why am I here, what’s it all about?’  Later, of course, they’ll forget and bite each other, walk on the stove, cough up fur-balls and sleep blissfully.  But somewhere beneath the fur and collars, their tame nature will still wish for something to stalk……….


RehabRN is the host of the latest edition of Change of Shift (Vol 4, No 16) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Howdy all! I'm just back from a major cross-country road trip in the land of Dead Man's Wash and Bloody Basin. Only slightly saddle, or seat-sore from all the switchbacks, so I'm recuperating from beautiful but dusty environs, cactus pollen and the quirks of roadside hotel beds.

Sit on down at the bar, have a beverage of your choice, and enjoy the official, genuine authentic February 4, 2010 edition of change of shift.


H/T to Dr Ves Dimov, Clinical Cases and Images Blog,  for the head’s up on  Faces of America - PBS Series

Faces of America premieres nationally Wednesdays, February 10 - March 3, 2010 on PBS: "What made America? What makes us? These two questions are at the heart of the new PBS series Faces of America with Henry Louis Gates, Jr. who turns to the latest tools of genealogy and genetics to explore the family histories of 12 renowned Americans."


Voting continues at MedGadget for the medical blog awards. Polls will close 12 midnight on Sunday, February 14, 2010 (EST).  Vote here

The categories for this year's awards are:

-- Best Medical Weblog

-- Best New Medical Weblog (established in 2009)

-- Best Literary Medical Weblog

-- Best Clinical Sciences Weblog

-- Best Health Policies/Ethics Weblog

-- Best Medical Technologies/Informatics Weblog

-- Best Patient's Blog


Check out these blogs from medical teams in Haiti:


If you are a physician and would like to do volunteer work in Haiti, then check this out:  Help Haiti: AMA registers physician volunteers

The registry -- launched Jan. 26 -- is open to all licensed doctors and requests information such as specialty, language skills, availability and previous disaster medicine experience.

The registry is available online (

An in-depth Webinar on how medical responders can prepare for working in Haiti is available, along with other resources, at the AMA Web site (


I’m not ready for podcasting, but thought this tutorial by Scientific Quilter might be helpful to anyone who is:  4.2 How to add audio to a podcast using Mevio and Audacity

Recently a fledgling quilting podcaster was asking about how to create music files for her podcast, and I took the time to do some screen shots and sent them to her.

I realized in the process of writing the e-mail that this could be a helpful blog post to dispel some of the confusion in using music in a future quilting podcast (if that’s what’s stopping you from doing a podcast). Okay it’s not all that confusing, but if you’ve never done it before, this could be a good way to start.

This is the way I have done the music portion of my podcast.  This tutorial uses Mevio’s Music Alley and Audacity because that’s what I use.  Both are free to use, and be sure to read the guidlines they have for each site – particularly Mevio’s Music Alley…….


Dr Anonymous’ guest this week will be Drew Griffin from Wound Care Education Institute.  Come join us.

Upcoming Dr. A Shows (9pm ET)

2/13 : Sat Nite with Dr. A
2/18 : Rhett and John from FireFighter Netcast
2/25 : storytellERdoc
3/1 : Dr. A On Location
3/4 : Dr. Rob from Musings of a Distractible Mind
3/11 : EMS Podcaster Greg Friese

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

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

Monday, February 8, 2010

Liposuction – Shaping not Weight-loss

H/T to Jeff Frentzen, PSP Blog, for the link to this article “Large Volume Liposuction - Nip/Tuck Gets It Very Wrong” by Natalie Kita (December 22, 2009)

I am not so silly as to miss seeing FX Network's plastic surgery-based drama Nip / Tuck for what it truly is: entertainment. I don't expect pinpoint scientific accuracy. However, when doing any sort of medical-based drama, doing it well requires that you must at least attempt to be somewhere in the realm of reality where the medical facts are concerned.

Last week's episode broke that rule ten times over when it portrayed a large volume liposuction case in which 150 lbs of the patient's body weight were removed during a lipo/tummy tuck combo surgery. We won't even get into the ethical considerations of sucking the fat out of a prisoner so he can be legally slim enough to receive his scheduled lethal injection. That's a blog for another day.

I have not been a fan of Nip/Tuck for several years now.  This just adds to my disdain for the show.  Be that as it may, lets look at liposuction.

Liposuction is a surgical procedure done for shaping, not weight loss.  It is considered to be one of the most frequently performed plastic surgery procedures in the United States.  Large-volume liposuction is defined as the removal of 5000 cc or greater of total aspirate during a single procedure.

A recent Aesthetic Surgery Journal article (full reference below) looked at 25 years of liposuction experience.  Their experience mirrors the history of liposuction during their study period:  July 1983 to January 2008. The liposuction techniques studied included dry liposuction, tumescent liposuction, tumescent UAL, and tumescent LAL.  Note how the technique and safety issues evolved over time.

1983-1985  Dry liposuction with 10-, 12-, and 15–mm diameter cannulas.

1985-1987  Dry liposuction with cannula diameters reduced to 5, 6, and 8 mm.  The submental area was at all times treated with a 3–mm cannula.

Liposuction was always performed in the deep plane; aspiration ceased once mostly blood was being obtained. For the first six months in which liposuction was performed, there were no parameters defining when to stop the aspiration and volumes as high as 8000 mL were obtained.

After those six months, in collaboration with the anesthesiologists, a calculation of volume reposition was made according to the aspiration obtained. For every 1000 mL extracted, there was a reposition of 1000 mL of isotonic saline solution and 1000 mL of polygeline solution (Haemaccel 3.5% colloidal intravenous infusion; Aventis, Strasbourg, France).

All patients had blood tests before surgery and 24 hours after surgery to measure hemoglobin and hematocrit values. Aspiration volumes were reduced after six months, ranging from 2000 to 4000 mL. Patients with hemoglobin values less than 8 and who experienced the symptoms of anemia (ie, increased heartbeat, low blood pressure, constant headache, dizziness, and weakness) were transfused.

1987 – present   Tumescent liposuction was performed in all patients, technique evolved over time.

At first, only isotonic saline solution was administered before aspirations.

Beginning in 1989, the infiltration solution was prepared using two adrenaline ampoules (1 mg of adrenaline per each 1 mL ampoule) per 1 L isotonic saline solution. No lidocaine was added. The solution was administered in a 1:1 ratio (the amount of solution being infiltrated was approximately the same as the aspiration obtained).

Cannula diameters were reduced to 3, 4, and 5 mm. The amount of fat extraction was limited to 5000 mL.

1998 – 1999   Ultrasound-assisted liposuction (UAL) (16000 Hz) was performed.

2007 – 2008  Laser-assisted liposuction (LAL) was performed with an internal diode laser (wavelength, 660 nm; power, 130 mW).

There were no changes in infiltration solution, volume extraction, or operating time when using either tumescent solution alone versus suction-assisted-liposuction (SAL) or LAL. Both of the latter techniques were performed using an internal cannula after the tumescent solution was applied, followed by performance of SAL.

The authors state that time frame was the main criteria for which technique was used. 

Most significantly, the use of tumescent liposuction reduced the incidence of anemia, but increased the incidence of seroma. The incidence of postoperative pain and fibrosis in our patients was similar regardless of the technique used. Aesthetic results using assisted liposuction devices in UAL and LAL procedures were similar to those achieved in tumescent liposuction.



The second reference article is from the ASPS Patient Safety Committee.  It is a great review of liposuction and it’s risks/safety.  Here is their assessment of liposuction for obesity:

Large-volume liposuction has become a technique for addressing contour irregularities, but preliminary studies also suggest improvement in cardiovascular risks, blood pressure reduction, and reduced levels of fasting insulin after liposuction.   Although liposuction may provide some physiologic benefit to the obese patient, there are inherent risks in these patients that must be considered, such as poor wound healing, increased risk of infection, deep vein thrombosis, and sleep apnea.  ……..  Liposuction is not considered a standard treatment for obesity.

Also from the same Safety Committee Advisory:

When referring to liposuction volume, total aspirate should be the volume recorded. Some states have imposed restrictions pertaining to the aspirate volume and surgical facility; these limits range from 1000 to 5000 cc (e.g., California, Florida, Kentucky, New York, Ohio, and Tennessee). Surgeons should consult their individual state regulations; however, it is the position of American Society of Plastic Surgeons that, regardless of the anesthetic method, large-volume liposuction (>5000 cc of total aspirate) should be performed in an acute-care hospital or in a facility that is either accredited or licensed. Postoperative vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff members who are familiar with the perioperative care of the liposuction.


It must be remembered that liposuction is surgery.  As with all surgeries, complications can occur.  Minor complications that resolve on their own or with little additional treatment include small hematomas, seromas, and minor contour irregularities.  More severe complications are rare, but  include skin perforation, major contour defects, skin necrosis, thermal injury, vital organ injury, adverse anesthesia reaction, major hemorrhage, ischemic optic neuropathy, deep vein thrombosis, pulmonary embolism, and fat embolism. 




Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices; Aesthetic Surgery Journal, Vol 29 (6), pp 509-512; Lina Triana, Carlos Triana, Carlos Barbato, Marco Zambrano

Evidence-Based Patient Safety Advisory: Liposuction; Plastic and Reconstructive Surgery. 124(4S):28S-44S, October 2009; Haeck, Phillip C.; Swanson, Jennifer A.; Gutowski, Karol A.; Basu, C Bob; Wandel, Amy G.; Damitz, Lynn A.; Reisman, Neal R.; Baker, Stephen B.; the ASPS Patient Safety Committee

Sunday, February 7, 2010

SurgeXperiences 316 is Up

Dr DJ  is the host of this edition of SurgeXperiences. Here is the beginning of this edition which you can read here.  (photo credit)

Welcome to the 316 Edition of SurgeXperiences - The Surgical blog carnival. I was overwhelmed with the number of submissions I got and it was nothing short of a party for me to read all the posts.

The host of the next edition (317) has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline:  midnight on Friday,February 19th. Be sure to submit your post via this form.

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

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

Saturday, February 6, 2010


“Mrs. C**, how are you doing?”

She left the wheel chair in the waiting room, smiling “I’ll show you.”

She dances nimbly down the hallway to the exam room, having lost her forty pound apron a week ago. Her laughter is infectious.

“Let’s get rid of these drains.”




**Not her real name.

Friday, February 5, 2010

My Heart

This is a small wall hanging I recently made using five different red fabrics in the heart. The quilt is 28 in X 26.5 in. It is framed by a border print with mitered corners. It is machine pieced and quilted. I have listed it for sale on Etsy.

The photos is meant to show the red fabrics better and the “hearts” used in the quilting.
The background was cross-hatched quilted. The border was quilted with a string-of-hearts.
The back is a lovely floral print. There is a 4 in sleeve for hanging.

Thursday, February 4, 2010

FDA Approves Xiaflex

Xiaflex (collagenase clostridium histolyticum) has received approval from the U.S. Food and Drug Administration (FDA) for use in the treatment of Dupuytren’s disease.

The FDA's approval of the Xiaflex which is produced by Auxilium Pharmaceuticals Inc follows the September recommendation of a panel of outside medical experts. The panel unanimously voted to support Xiaflex.

Dupuytren's contracture is an abnormal thickening of tough tissue (fibrous layer) underneath the skin of the palm and fingers. It is the thickening of this tissue that can cause the fingers to curl. When severe, Dupuytren’s can be disabling. Until now there has been no treatment other than surgery. Xiaflex is an injection which will be done in the office. (photo credit)

The cause of Dupuytren’s disease is unknown but is more common in men over age 40 and in people of northern European descent. It is estimated that 7 million to 14 million Americans have Dupuytren's disease.

Xiaflex is a biologic drug made from the protein product of a living organism. It works by breaking down the excessive buildup of collagen when injected directly into the collagen cord of the hand. It should be administered only by a health care professional experienced with injections of the hand.

A study published in the New England Journal of Medicine looked at 308 patients with joint contractures of 20 degrees or more in a prospective, randomized, double-blind, placebo-controlled, multicenter trial showed significant improvement. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees).

The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome.

Auxilium intends to market the drug for use not only by hand, orthopedic and other surgeons but also to rheumatologists, non-surgeons who specialize in arthritis and other joint issues. Physicians would be trained with a video and a training manual, Auxilium said.


FDA Press Release

Auxilium Pharmaceuticals Inc Press Release

Injectable collagenase clostridium histolyticum for Dupuytren's contracture. ; N Engl J Med 361:968 (2009); Lawrence C Hurst et al.