Tuesday, August 31, 2010

Shout Outs

A Blog Around the Clock  is the host for this week’s  Grand Rounds.  You can read this week’s edition here.

The summer is almost over, but we can try to remain in the summery mood just a little bit longer. Perhaps we can go to a medical conference held at a lushious tropical island resort, listen to presentations, chat in the hallways, and then have great fun at the bar in the evenings. And call is Grand Rounds. No coats and ties allowed – this meeting is supposed to be fun!….

……………………………………….

Gruntdoc has written a sobering post:  Every driver is drunk – bet your life on it

A mentor recently mentioned, in passing, that he stopped riding motorcycles when cell phones came out, as he noticed the average driver distraction level had gone way up.  He said ‘its like everybody’s drunk’.  ….

I, like C&D, would like to point out that this doesn’t make driving under the influence okay, it doesn’t.  What it does do is put into perspective the astonishing diminution of skill with divided attention between driving and texting.  …… 

……………………………..

From tweeter comes some great medical history:

EndoGoddess

Wow. RT @diabetesdaily: There's an insulin pump from 1977 on my desk! I posted a pic here: http://bit.ly/9gdXln #diabetes

……………………………

Another one from tweeter.  This one from @EvidenceMatters gives the link to an article in the Guardian by Ben Goldacre:

Costly life-[conserving] drugs: You have to draw the line somewhere. @bengoldacre on recent coverage of NICE & Avastin http://j.mp/byVdJQ

The article is well worth reading as it takes journalists and politicians to task:

…….Journalists can exploit these impossible decisions for outrage, and the pleasure of leading a popular campaign, but so can politicians………You're always going to draw the line somewhere, and if you paid £200,000 for six weeks of life there would still be more you could do.

Whoever draws that line, wherever it falls, is always going to be pilloried and despised. When you're writing about such an incredibly easy and emotive target, it might be fair to at least use a representative anecdote for illustration, instead of Barbara Moss.

And for a thorough review of the topic read David Gorsk’s (Science-Based Medicine) post:  Avastin and metastatic breast cancer: When science-based medicine collides with FDA regulation

…………………………..

Dr Charles is hosting the first annual 2010 Charles Prize for Poetry.  Have you submitted one yet? Today is the last day to enter.   The entries have been amazing!

Open to everyone (patients, doctors, nurses, students, etc.). Limit 1 or 2 entries per person.

Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter……

Contest closes August 31st.

……………………………..

KevinMD’s guest post by Shawn  Vuong  asks  Does a stereotypical surgical personality exist?

…… The stereotypical surgical personality is said to be “decisive, well organised, practical, hard working, but also cantankerous, dominant, arrogant, hostile, impersonal, egocentric, and a poor communicator.”

I think that I am decisive, organized, practical, and hard working. But am I cantankerous, arrogant, hostile, impersonal and egocentric? I hope not. I can admit that my communication probably needs work. I think I’ll give my self the benefit of the doubt, and rate my communication and ‘average’ instead of ‘poor’.

So there it is, I am half the surgical personality according to the stereotype (in my eyes — maybe everyone else thinks I am hostile and egocentric and thus fit the stereotype perfectly).  ……..

I don’t think I have the stereotypical surgeon personality, but maybe I’m delusional.  I am decisive, organized, practical, and hard working.  I can be arrogant, but mostly not.  I am usually pleasant and not cantankerous.  I try to be kind, not hostile.  I try to be a good communicator though I know I have much improvement to be done in that area.

…………………………………….

If you like jigsaw puzzles, then perhaps you’ll like this one that features a quilt from 1932:

This week's Top 100 Puzzle was created by Jennie C. Trein in 1932.  It is called Sunday School Picnic. Jennie was quite a woman.  She made her first quilt at 10 and completed over 100 in her lifetime.  Quilting wasn't her only passion, she played the piano and cornet, sang in the church choir for over 60 years, taught bible classes to children and made over 300 rugs.

………………………………….

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

     

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, August 30, 2010

Preference for Scar Location

There is a nice main article along with a discussion article in the August issue of the Journal of Plastic and Reconstructive Surgery which focuses on the preference of the scar location from the woman’s (patient’s) standpoint when the latissimus dorsi muscle flap is used in breast reconstruction.

There is always a “robbing Peter to pay Paul” when donor tissue is used in any reconstruction. Some times there is not a choice in how the donor scar will be oriented, but when there is the patient should be involved in the choice.

The surgeon needs to explain the factors which make one scar choice his/her preference. Factors such as the patient’s age, body mass index, other scars, and amount of tissue needed will all factor into the surgeon’s choice.

The patient’s preference is most likely to be made on how they view their body and on the types of clothing they like to wear (or envision wearing). Will the scar be hidden or visible with the clothing choices?

The article surveyed 250 women between the ages of 20 and 80 years, including 50 women with a history of breast cancer. The participation rate was 96% for a total sample size of 240 subjects.

The women were grouped into the following age categories: 20 to 29 years (n = 46); 30 to 39 years ( n = 32); 40 to 49 years (n = 44); 50 to 59 years (n = 70); and 60 to 79 years (n = 48).

The survey for the article study was done used photographs of a patient's back showing the variations of the latissimus dorsi donor-site locations. I scanned this photo from the first reference article.

As with the above, this one was scanned from the first reference article.

The results of the survey found:

The majority of women (66%) noted that the location of the latissimus dorsi flap donor site was important.

The lower transverse scar was the preferred scar location in 54% of the women surveyed. The second most preferred site was the middle transverse scar location.

The ability to conceal the scar in a low-back top or swimwear was noted to be important by 32%. A chance to improve the body’s contour was noted to be important by 30%.

Women younger than 50 years of age were concerned primarily with concealing the scar with clothing options, whereas women older than 50 years were concerned with both clothing options and contour of the back.

The independent factors of age, body mass index, ethnicity, body image, and clothing options were not found to show any significant correlation with scar location.

Maurice Y. Nahabedian, M.D. notes in his discussion of the article:

Personal experience with the latissimus dorsi musculocutaneous flap resonates with the conclusions of this study. The middle and lower transverse incisions have been preferred because they are better concealed. Women are able to wear certain clothing items and not reveal the location of the scar. There is usually less distortion of the posterior thorax and a better quality scar when compared with oblique or vertical incisions. …….

A final thought on this article is in reference to the evolution of breast reconstruction. ……. The posterior thorax is an equally important though less frequent donor site than the anterior abdomen. However, donor-site issues such as strength, scar, contour, and seroma need to be optimized to improve outcomes and increase patient satisfaction. This study has addressed scar and contour issues related to the latissimus dorsi flap, provided data to support the conclusions, and provided a mechanism to improve outcomes.

REFERENCES

Breast Reconstruction with the Latissimus Dorsi Flap: Women's Preference for Scar Location; Bailey, S; Saint-Cyr, M; Zhang, K; Mojallal, A; Wong, C; Ouyang, Da; Maia, M; Zhang, S; Rohrich, R J.; Plastic & Reconstr Surgery. 126(2):358-365, August 2010, doi: 10.1097/PRS.0b013e3181de1b41

Discussion: Breast Reconstruction with the Latissimus Dorsi Flap: Women's Preference for Scar Location; Nahabedian, Maurice Y; Plastic & Reconstructive Surgery. 126(2):366, August 2010; doi: 10.1097/PRS.0b013e3181de1963

Saturday, August 28, 2010

Replantation Sonnet

There lays the severed pale digit on ice

Atop the table, freshly draped in blue.

Here rests the clean hand with French nails so nice

The team calmly moves, there is much to do.

K-wires fix  jagged bone ends together.

Tiny arteries stitched, loupes magnify

Hair-fine suture, careful not to gather.

Tourniquet loosened to a rose colored high

Signal transporting cables, yes, the nerves

Repaired; not yet emitting clear signals.

Ribbons, not blue or red, but  white swerve

Into line, moving fingers into balls.

Wound edges, matching pinks, together mold

Into a ring which should have been of gold.

Friday, August 27, 2010

Thronebeary Baby Quilt

This quilt was made in early 1987 for my sister Cathy when she was pregnant with her first baby.  The name of the quilt is a play on her (then) last name – Throneberry.

When I made the quilt, she didn’t know the sex of the baby who turned out to be her son Zach.  He has grown into a very nice young man.

The quilt is machine pieced and quilted.  It features a few square of cross-stitching.  It is 45 in X 45 in.

Here you can see the cross-stitched bears better.
And another.

Thursday, August 26, 2010

Double Hand Transplant on Twitter

Louisville surgeons at The Jewish Hospital Hand Care Center recently performed the 3rd double hand transplant done in the United States.  It is the first to be live tweeted.

The procedure began around 7 p.m. on Tuesday, August 24, and finished late Wednesday afternoon, August 25.  Lead surgeon, Warren C. Breidenbach, M.D, with Kleinert Kutz & Associates, and his team of surgeons focused on the surgery while senior hand fellow Christiana Savvidou, M.D. used a laptop just outside the operating room to document the surgery as it takes place.

This bilateral transplant is the third double hand transplant to be done in the United States.  The first two double hand transplants were done at the University of Pittsburgh Medical Center, the first in May 2009 and the second in February 2010.  Louisville doctors performed the nation's first five single hand transplants.

Savvidou used the tweeter account @jewishhospital (www.twitter.com/jewishhospital) and the hashtag #handtx.

Here are some of the tweets which are a good representation of how the surgery progresses and how much time it takes.

jewishhospital

1st tweet ~ 7 pm ET, shortly before start of surgery

Want to know how a hand transplant is done? This is your chance- we are live tweeting a double hand transplant 2day starting @ 7pm! #handtx

approx 2 hrs later

The recipient’s right hand is fully prepped and awaiting the transplantation of the donor limb. #handtx

Education of terms: “prepped” = hand is being scraped & sterile dressing. “Started” = skin has been cut and surgery begun. #handtx

approx 4 hrs after start

Continuing donor and recipient dissection tendon identification and nerve identification in both recipient hands. Going smoothly. #handtx

approx 5 hrs after start

Removal of non-functioning hand tissue in preparation for donor limb attachment. #handtx

Both donor hands are on the table. Preparing for bone work - bone fixation at forearm of right recipient wrist. #handtx

@stacyluvsyah The bones are reattached with plates and screws similar to how a broken bone may be repaired. #handtx

approx 6 hrs after start

Bone fixation completed successfully in both hands. #handtx

Surgeons are now preparing the arteries. This will be the most important part of the operation. #handtx

approx 7 hrs after start

The connecting of the donor and recipient vessels (arteries and veins) is progressing very well in both hands. #handtx

approx 8 hrs after start

The hand replantation is progressing well. Surgeons are joining the tendons. #handtx

approx 10 hrs after start

Both hands are now vascularized and we are approximately 3/4 of the way complete. All is progressing well. #handtx

approx 11 hrs after start

Tendon suturing nearing completion. Nerve repair to follow. This includes suturing nerves of each finger from donor to recipient. #handtx

approx 12 hrs after start

Due to the number of nerves and tendons, this current stage could take a while…update coming when we near completion of this stage #handtx

approx 13 hrs after start

Nerve repairs on the left hand are now complete. #handtx

approx 14 hrs after start

The left hand is currently approximately 2/3 closed and final work on veins is occurring. #handtx

approx 16 hrs after start

Finishing right hand nerve repair. Due to new technique, this patient should have better feeling & motion than previous recipients #handtx

The left hand is currently being sewn shut. #handtx

approx 17 hrs after start

The left hand is now fully wrapped in surgical gauze and cotton padding. #handtx

approx 18 hrs after start

Surgeons are starting to close up the right hand #handtx

approx 19 hrs after start

Extra tissue is needed to finish closing the right hand. A skin graft is being taken from the patient's leg for this. #handtx

almost 20 hrs after start

Skin graft on right hand finished and hand is completely closed. Starting cleansing and bandaging. #handtx

(photo credit)

 

 

While we embrace the new ways to educate the public, Dr. Wes reminds us of  The Risks of Hospitals Live-Tweeting Surgeries.

For more information on hand transplant surgeon visit the teams’ website: www.handtransplant.com

Wednesday, August 25, 2010

“Women’s Health and Cancer Rights Act of 1998’’

Recently the New York signed into law requiring hospitals and doctors to discuss breast reconstruction options with the patient prior to her undergoing cancer surgery. 

It troubled me that this law was needed.  Is it not the duty of the physicians and surgeons to educate the patient on the options available? 

We need to make sure the patient and their family know of the treatment options which may vary depending on the diagnosis and stage.  Radiation.  Chemotherapy.  Surgery – lumpectomy, mastectomy, axillary dissection.  A combination of treatments.

Even if the patient and her physicians don’t chose to do immediate reconstruction, isn’t the discussion and information part of the discussion?  At least inform the patient of the option.

Do we physicians and surgeons need another law to ensure we do right by our patients?

 

Not all patient’s have health insurance so reconstruction may become unattainable due to finances.   Susan G. Komen has a nice resource page for financial assistance available for breast cancer patients.  I did not see any that would cover reconstruction.  Many will help will obtaining a prosthetic.

Patient’s that do have health insurance are afforded protection under the “Women’s Health and Cancer Rights Act of 1998.”   However, as I was reviewing and researching the WHCRC for this piece I learned that it’s not a blanket protection:

Generally, group health plans, as well as their insurance companies and HMOs, that provide coverage for medical and surgical benefits with respect to a mastectomy must comply with WHCRA.

However, if your coverage is provided by a "church plan" or "governmental plan", check with your plan administrator. Certain plans that are church plans or governmental plans may not be subject to this law.

 

 

Breast Reconstruction—Part I (October 2007)

Breast Reconstruction – Part II (October 2007)

Patient Satisfaction Following Breast Reconstruction Using Implants  (June 7, 2010)

 

 

REFERENCES

Before Breast Is Removed, a Discussion on Options; New York Times article, August 18, 2010; Anemona Hartocollis

“Women’s Health and Cancer Rights Act of 1998’’ Summary; American Society of Plastic and Reconstructive Surgeons website

Your Rights After A Mastectomy...Women's Health & Cancer Rights Act of 1998; Department of Labor

Tuesday, August 24, 2010

Shout Outs

Fizzy, A Cartoon Guide to Becoming a Doctor, is the host for this week’s  Grand Rounds.  You can read this week’s edition here (photo credit).

I am proud and honored to be hosting this week's grand rounds. As usual, I'm going to open with a cartoon:

And finally, Webster's Dictionary defines "grand rounds" as nothing, because it's not even in there. ……

……………………………………….

Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 4) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to Change of Shift – a day late, but hopefully not a dollar short!

We have some old friends and some new additions.  Our submissions cover the best of nursing and the most difficult moments. Some share successes and others could use some collegial support.

So, grab a latte, put your feet up and enjoy..

Change of Shift.  ………..

……………………………..

KevinMD has published a guest post by  Peter J Polack, MD:  Balancing a surgeon’s beliefs with the needs of the practice

Not long ago, we interviewed a physician for possible partnership in our practice. After showing him around our town, some of us partners had dinner with him to discuss business. He was a quite pleasant fellow, well trained, and seemed to be a good ‘fit’ for our practice. As dessert was being served, he said he needed to get one more thing off his chest: he prays aloud in the operating room before starting each surgical case. If we couldn’t allow him to do this, it would be a “deal-breaker.”

So, what would you have done?  …………….

……………………………

Dr Charles is hosting the first annual 2010 Charles Prize for Poetry.  Have you submitted one yet? You only have until August 31st to do so.   The entries have been amazing!

Open to everyone (patients, doctors, nurses, students, etc.). Limit 1 or 2 entries per person.

Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter……

Contest closes August 31st.

……………………………..

The flood in Pakistan has not gotten the attention on tweeter or in the medical blogs (from me or the ones I read) that the earthquake disaster in Haiti received.  So let me do a small part in passing along how you can donate to the relief effort.  This information is from the U.S. State Department:

Text "FLOOD" to 27722. Your $10 will go to the State Department Fund for Pakistan Relief…..  See Pakistan Relief Fund Page»

Text "SWAT" to 50555. Your $10 goes to UNCHR, which is also collecting Pakistan relief aid.

Additional Organizations: The most effective way people can assist relief efforts is by making cash contributions to humanitarian organizations that are conducting relief operations.  Learn More»

SAVE THE CHILDREN  Donation Phone #: 1-800-728-3843  Website: http://savethechildren.org

IRC  Donation Phone #: 1-877-REFUGEE
Website: http://www.theIRC.org

OXFAM  Donation Phone #: 1-800-77-OXFAM
Website: http://oxfamamerica.org

MERLIN  Donation Phone #: 202-449-6399
Website: http://www.merlin-usa.org

ACTED  Donation Phone #: 202-341-6365
Website: http://www.acted.org/en/support-us

AMERICAN RED CROSS   Donation Phone #: 1-800-435-7669  Website: http://www.redcross.org

…………………………………….

A tweet last week from @DrVes  led me to this CNN article by Cody McCloy:  Do-it-yourself solar power for your home  (photo credit).  I look forward to this “plug-in” technology.

Imagine outfitting your house with small, affordable solar panels that plug into a socket and pump power into your electrical system instead of taking it out.

That's the promise of a Seattle, Washington-based start-up that is working to provide renewable energy options -- solar panels and wind turbines -- for homes and small businesses. The panels cost as little as $600 and plug directly into a power outlet.

The company, Clarian Power, aims to be the first to bring a plug-in solar power system to the market, in 2011.  ……………….

………………………………………..

Another “building” story came my way via a RT from @EvidenceMatters@snowcroft  Did the ancients build to please ears as well as eyes? Claims of acoustic archaeologists: http://is.gd/evLxo (RT @bldgblog)”    The link is to an article in New Scientist by Trevor Cox:  Echoes of the past: The sites and sounds of prehistory

……….Might we be missing here something that both Hardy and our prehistoric ancestors understood? Some archaeologists have begun to think so. They argue that sound effects were an important, perhaps even decisive, factor in how early humans chose and built their dwellings and sacred places. Caves that sing, Mayan temples that chirp, burial mounds that hum: they all add up to evidence that the aural, and not just the visual, determined the building codes of the past. But is that sound science?

Assessing the claims of "acoustic archaeology" rapidly encounters a fundamental problem: sound is ephemeral.  ………….

………………………………….

I seem to be on a building this week.  Do you like tree houses?  Check out 39 Crazy Tree Houses.  Not sure which is my favorite, but I do like this one

………………………………….

Dr Anonymous’ BTR show will be a celebration of the 3rd Anniversary of the show.  Come join us.

Upcoming shows (9pm ET)

8/26: Dr. A Show 3rd Anniversary

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, August 23, 2010

More on Using Singulair Treatment for Capsular Contracture

Previously I reviewed the literature on the off-label use of zafirlukast (Accolate) and montelukast (Singulair) for the treatment of capsular contracture.  The recent issue (May/June 2010) of the Aesthetic Surgery Journal has an article (full reference below) on the use of Singulair for capsular contracture (CC).

Huang and Handel’s article reviews the literature, noting some articles I missed.  Their study is a small (17 patients, 4 with bilateral CC for a total of 21breasts treated with Baker’s Grade II or greater CC).  All of their patients were informed of possible risks associated with the off-label application of Singulair before being prescribed 10 mg of Singulair for 90 days and instructed to massage their breasts twice daily.

Unlike Accolate, the adverse event profile of Singulair is comparable to placebo, with the most common side effects being headache (18.4% vs 18.1%), influenza-like symptoms (4.2% vs 3.9%), abdominal pain (2.9% vs 2.5%), cough (2.7% vs 2.4%), and dyspepsia (2.1% vs 1.1%).

Follow-up of patient compliance and treatment results was obtained by a combination of chart review and a standardized telephone questionnaire.  Telephone interviews were used to determine the actual duration and dose of Singulair taken by the patient and whether the patient noted improvement, no change, or worsening of contracture.

The authors note that this is only a preliminary study show without a well-matched population of negative controls.  That said:

Our follow-up data showed that in two (11%) patients, the CC worsened, three (16%) patients had no change, five (26%) improved, and seven (37%) completely resolved.

As for adverse effects from Singulair:

Only one of our patients reported any side effect (fatigue). All other patients tolerated the treatment without any problems.

Their conclusions are (bold highlight is mine):

Our article presents preliminary findings on the off-label use of Singulair for CC. The drug is well tolerated with minimal side effects; therefore, we recommend its application in patients with CC. There was a greater response in breasts with mild CC, so a course of Singulair should be started early. Because it prevented recurrence in two patients with previous severe contracture, we recommend prophylactic prescription in patients with a history of recurrent contracture. In patients who already have moderately advanced CC, Singulair is unlikely to reverse symptoms to the degree that revision can be avoided.

This is a topic I will continue to follow with interest.

 

 

REFERENCE

Catherine K. Huang, Neal Handel; Effects of Singulair (Montelukast) Treatment for Capsular Contracture; Aesthetic Surgery Journal May/June 2010 30: 404-408; doi:10.1177/1090820X10374724

Sunday, August 22, 2010

Fabric Postcards

The first fabric postcard I ever made I sent to Intueri.   Since then I have made two more.  The second one I made in July and called “Toes in the Water.”  I sent it to a friend for her birthday.  It measured 5 in X 7 in.

The third one is “Happy.”  I made it for friends who were married August 20, 1960 and just celebrated their 50th wedding anniversary.  It is 5 in X 7.5 in.

Saturday, August 21, 2010

Still Grieving

Articulate bird croons

Dawning expectations.

Flowers greet hummingbirds,

Iridescent jewels.

 

Kindred longing.

My numbed optimism,

Primed quietly  --

Resisting.

 

Surplus tears,

Uncalled villains,

Whispering, ‘xploring

Yon zygoma.

 

 

 

***Still writing more poetry.  See what Dr. Charles started.

Friday, August 20, 2010

Ben's Toad Suck Daze Quilt

Conway, Arkansas has had a festival called Toad Suck Daze since 1983. For years I collected T-shirts as I loved the toad (don’t call them frogs) graphics. I finally quit collecting and wearing them, but couldn’t bring myself to just throw them away. So I asked my sisters and friends for shirts to “fill in” gaps when I decided to make a quilt of the shirts.

The quilt is machine pieced and quilted. I did the piecing, but due to the size and weight of the quilt paid a quilting friend with a heavy long-arm machine to do the quilting. It is 63 in X 80 in. I finished the quilt and gave it to my then neighbor Ben for his birthday in 2005.


Here are some close photos to show some of the individual shirts. This one is 1987.
This is Christmas 1994.
This is the first year, 1983.

Thursday, August 19, 2010

Primary Breast Abscess Risk Factors

A recent article in the July issue of the Journal of the American College of Surgeons (full reference below) looked at the risk factors for developing a breast abscess.

It is a case control study of 68 patients with a primary breast abscess. Several (36/68) developed a recurrence as defined by the need for repeated drainage within 6 months.

They found

Univariate analysis indicated that smoking (odds ratio [OR] 8.0 [95% CI 3.4 to 19.4]), obesity (OR 3.6 [95% CI 1.5 to 9.2]), diabetes mellitus (OR 5.7 [95% CI 1.1 to 54.9]), and nipple piercing (OR 10.2 [95% CI 1.3 to 454.4]) were significant risk factors for development of primary breast abscess.

Recurrent breast abscess occurred in 36 (53%) patients. Multivariate logistic regression identified significant OR for an increase in recurrence related to age (OR 1.08 [95% CI 1.01 to 1.15] per year), smoking (OR 14.73 [95% CI 3.18 to 68.22]), surgical treatment (11.94 [95% CI 1.08 to 131.72]), and a decrease in recurrence after MRSA infections (OR 0.02 [95% CI 0.00 to 0.72]).

I think perhaps this article has too small a number of individuals, but find their numbers interesting.

The eMedicine overview (second reference below) does not even address possible infections from nipple piercing, suggesting:

Mastitis is usually seen in lactating women, but the presence in a nonlactating woman should spur evaluation for an inflammatory carcinoma or new-onset diabetes.6

Causes of primary breast infections are most likely to be Staphylococcus aureus and streptococcal species. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.

The eMedicine article does recognize a correlation between breast infection and smoking:

A study by Schafer et al found a significant correlation between cigarette smoking and subareolar breast abscess.12

So while the article may have a small number of individuals, it is probably safe to say that being overweight, having diabetes mellitus, and smoking all make your risk of having a breast infection higher. By how much is more difficult to say.

REFERENCE

Risk Factors for Development and Recurrence of Primary Breast Abscesses; Vinod Gollapalli, Junlin Liao, Amela Dudakovic, Sonia L. Sugg, Carol E.H. Scott-Conner, Ronald J. Weigel; Journal of the American College of Surgeons - July 2010 (Vol. 211, Issue 1, Pages 41-48, DOI: 10.1016/j.jamcollsurg.2010.04.007)

Breast Abscess and Masses; eMedicine article, May 13, 2010; Andrew C Miller, MD, Tajinderpal S Saraon, MD, and Mark A Silverberg, MD, FACEP, MMB

Wednesday, August 18, 2010

Wish It Weren’t So

I’d love to report that doctors are always ethical and have their patient’s best interest at heart, but alas even I am not that naive. 

It is important for physicians to not mislead the public as to their training or skills.  No one expects family physicians to do liposuction surgery or eye doctors to do breast augmentations. 

Here is an article in the St. Petersburg Times by Letitia Stein from August 8, 2010:  Limited training among some cosmetic surgery doctors worries state officials

A Tampa doctor accused of allowing unlicensed assistants to perform liposuction should have his license suspended for a year and pay a $50,000 fine, the Florida Board of Medicine decided Saturday.

The board's action was a move to address the growing concern about physicians with limited cosmetic surgery training working in medical spas.   …………

The charges stemmed from a woman who came to Dr. Yves N. Jean-Baptiste for liposuction. Jean-Baptiste had trained and received board certification in family medicine. About two years ago, he began to perform cosmetic procedures at his north Tampa practice, YJB Medical and Weight Clinics, after completing a three-day "intensive, hands-on training course" in Weston, according to his attorney.

Jean-Baptiste said he performed more than 250 liposuction procedures, his attorney noted without serious complication. But the July 2009 case illuminated his safety breaches.

State health officials said Jean-Baptiste allowed two people unlicensed to practice medicine to perform liposuction on the patient, identified as D.S. Her medical records didn't show a proper exam before the procedure, how much anesthesia was used, or the amount of fat removed. And Jean-Baptiste hadn't registered his office, then on Gunn Highway, as a surgical facility as required.   …………..

 

And from Dr. Rob Oliver Jr, Plastic Surgery 101, tells us about the eye doctor who had to call 911:  Ways to (nearly) ruin your life 101 - Choosing an Atlanta eye doctor to do your breast augmentation surgery

This summer there was an awful instance of medical negligence in Georgia involving an eye-doctor (opthamologist) who had major complications while attempting to perform breast augmentation surgery in his office. You can hear a frantic 911 call from the doctor explaining that he has encountered uncontrollable bleeding he created while during her breast implant surgery and has no idea how to fix it. …….

You can view 2 video news clips on the story here & here.    ………………..

Tuesday, August 17, 2010

Shout Outs

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

Welcome to Grand Rounds Vol. 6 Number 47.  The theme this week is “In the Office.”   This is to be interpreted loosely. My office is an outpatient family medicine office, some of the author’s offices range from a South African Emergency Room to a Vancouver, WA psychology office.  Others are submitted by patient’s discussing their experience at the office or posts about some of the absurdities we face as physicians in our “office lives.”  As usual the medical writing community sent good stuff.  My choice for best in each category is listed first. The rest are in no particular order.  …...

……………………………………….

A discussion of food/nutrition, in and out of the hospital, on twitter produced this tweet by @CatchTheBaby

@DrSnit @gastromom @DrJonathan #EatOn30 for food bloggers who made healthy meals for $30/wk http://bit.ly/STKFi” 

Did you catch that?  Healthy meals for $30 per week!  I have been looking through some of the links, but wish they had easier to find shopping lists.  I also wish they had easier to find receipts for the week(s). 

Still it is interesting and there are many nice recipes to be found among the food bloggers.

……………………………

Dr Charles is hosting the first annual 2010 Charles Prize for Poetry.  Have you submitted one yet?  The entries have been amazing!

Open to everyone (patients, doctors, nurses, students, etc.). Limit 1 or 2 entries per person.

Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter……

Contest closes August 31st.

……………………………..

I love dogs and enjoy walking/running so this article by Tara Parker-Pope caught my eye:  Running With Your Dog

Runner’s World magazine this month has a great special section on running with your dog. In addition to lots of great photos, it’s filled with useful information.  Among the stories:

Five Reasons to Run With Your Dog: Number one: a wagging tails reminds us that “running should be joyful.” ……….

People Who Run With Dogs: The post includes a fun video showing a photo shoot and interviews of people who run with dogs, including one great story of a dog in Alaska who saved its owners from a mother bear with cubs.

To see all the articles on offer, go to the magazine’s Running With Dogs link.

…………………………………….

This past Friday while listening to NPR, I heard this segment “Scientists Search For Endangered Amphibians” which included a description a frog species that swallow their eggs and give birth through their mouth!  The frog is the gastric brooding frog (photo credit)

The two species of gastric brooding frog were discovered as early as 1914 in a river catchment in eastern Australia. The frogs were known for their unique mode of reproduction: females swallowed eggs and raised tadpoles in the stomach, giving birth to froglets through their mouths.

During the brooding stage, the frogs' stomachs temporarily stopped producing hydrochloric acid. This condition could have provided insight on the treatment of stomach ulcers in humans; unfortunately, both species of brooding frog are believed to be extinct. The specific causes of the frogs' decline are unknown, though the effects of timber harvesting on the local habitat were never investigated. The chytrid fungus is also suspected to have played a role in the species' disappearance.

Status: last seen in 1985 – listed as Extinct on IUCN Red List

………………………………….

Dr Anonymous’ BTR show will be 4th Year Med Student @DrJonathan.

Upcoming shows (9pm ET)

8/26: Dr. A Show 3rd Anniversary

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, August 16, 2010

Limberg Flap in Treatment of Pilonidal Sinus Disease

MDLinx has once again pointed me to an article I might never have seen.  This one is in the journal Surgery Today and deals with the treatment of pilonidal sinus disease using one of two type of Limberg flap:  the classic and the modified.

Pilonidal sinus disease (PSD) occurs in the cleavage between the buttocks.  The diagnosis of a pilonidal sinus is made by identifying the epithelialized follicle opening (the sinus).

The name pilonidal taken from the Latin, meaning literally 'nest of hairs'.

The onset of PNS is rare both before puberty and after the age of 40. Males are affected more frequently than females. It is also common in obese people and those with thick, stiff body hair.

The article does a good review of the management of PSD which remains controversial. There is currently no “gold standard” treatment. 

Conservative approaches such as weekly shaving of the involved areas may control the progression of PSD, but surgical treatment is often required since supervening infections are inevitable in
most of the cases.

Marsupialization provides a smaller wound to granulate. It is also associated with a low recurrence rate, but the healing time is as long as 4–5 weeks, and patients need to change multiple wound dressings.

The most effective treatment modality is a wide excision of the sinus tract. Excision and primary closure have both advantages and disadvantages, including rapid healing and short time off from work, and increased risk of wound dehiscence and considerable pain at the surgical site. In addition, high recurrence rates of up to 15%–25% have been reported.

Therefore, asymmetric or oblique incision and excision techniques have been introduced during last 2–3 decades to avoid the problems believed to be associated with a midline scar.  ……

The problems related to continuing natal cleft after pilonidal sinus surgeries have prompted surgeons to discover new techniques to eliminate gluteal furrow. To eliminate the natal cleft, various flap techniques such as the Limberg flap, Z-plasty, W-plasty, V-Y advancement flap, and rotating flap have been used.

In all kinds of excision plus flap procedures for PSD, recurrences rates are between 1% and 7% in the literature. cLF has been reported to have lower infection and recurrence rates. However, longer hospital stays, a high maceration rate, hypoesthesia, and an unattractive cosmetic appearance are associated with this
technique.

The authors of the study comparing the modified (mLF) to the classic Limberg flap (cLF)  found the mLF had better clinical results than the cLF group with fewer recurrences (2/205  vs 10/211).  The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in the cLF group than in the mLF group.

 

 

REFERENCE

Comparison of the classic limberg flap and modified limberg flap in the treatment of pilonidal sinus disease: A retrospective analysis of 416 patients
Surgery Today, 08/04/2010

Pilonidal Sinus Disease; World Wide Wounds article, November 2009;  David Miller, BMBS MRCS and Keith Harding, MB ChB MRCGP FRC

Pilonidal Disease; eMedicine article, August 24, 2009; James de Caestecker, DO, Barry D Mann, MD, Andres E Castellanos, MD, and Jason Straus, MD

Choosing the Correct Limberg Flap; BORGES, ALBERT F.; Plastic & Reconstructive Surgery. 62(4):542-545, October 1978.  (has nice photos)

Rhombic Flaps; eMedicine article, Feb 12, 2009; Anthony P Sclafani, MD and Michael Fozo, MD

Sunday, August 15, 2010

Eye Words Quilt Finished!

The quilt I featured a few weeks ago is finished!  I machine quilted it using a golden yellow thread in a Baptist fan quilting pattern.  The quilt is 50.5 in X 68 in.

I have become a fan of word quilts and am thinking of doing another.  Topics might  include animals (dogs, cats, horses, cows, llamas, etc) or perhaps bones (ulna, tibia, sternum, tarsal, zygoma, etc).

Here are some additional photos to show the lovely fabrics.
I love the dragonfly fabric used in the word lashes.
The backing is a spotted batik.

I was initially going to give this to a friend who is an ophthalmologist, but my husband has urged me to place it for sale on Etsy.  So it will reside there for a while and if no one buys it, then I will still give it to my friend.

Saturday, August 14, 2010

For My Mother

Acutely blocked coronary

Digitally exposed,

Finds groove

Halting.

Impeded journey

Keep limping, moving nowhere.

Obstructed, pulse?

Quick radiating

Sharp twangs

Underscore ventricular

Weeping

‘Xalting your zeal.

 

***I seem to have taken Dr. Charles poetry challenge to heart.  This is my third poem, but I won’t be submitting this one.  It is for my mother.

Friday, August 13, 2010

Amy's Nine-Patch Quilt

I made this quilt for my friend Amy who at the time was a neighbor.  I forgot to put a label on the back of this one when I gave it to her, but I think it was made in 1995.  I added a label to the back when she loaned it to me for photos.

It is a double nine-patch, machine pieced and hand quilted.  It is 51 in X 70 in.

This photo shows off my hand quilting.
This photo and the next show off some of the fabrics.

Thursday, August 12, 2010

Palpable Implant Valve

I received a call recently from a patient who is one month postop from an augmentation mammoplasty. She and her family physician had found a “lump” in her left breast on a wellness exam. The patient who loves her new implants was worried she something was wrong and she would have to have the implants removed.

I asked her to come in and allow me to do an exam. She happily agreed.

My first thought was not breast cancer. All her mammograms prior to surgery had been normal. Her breast exam prior to surgery had not revealed any abnormal lumps.

My first thought was a palpable implant valve.

Fortunately, I was right.

This patient is thin, has little breast tissue, submuscular saline implants. She did not want silicone implants. While the valve is flat and non-projecting on the surface of the implant, in women such as this patient the valve can sometimes be felt.

In reassuring the patient, she and her husband were educated. I reminded them of the muscle anatomy. The border of the pectoralis just misses covering the implant valve. I pulled out a saline implant for them to see and feel the valve.

Even though the surface is smooth, the valve is 2-3 mm thick.

She will learn through self-exam her new “normal.” She will be encouraged to come back to my office yearly for a breast exam. She has been educated to continue to get her yearly mammograms.

 

REFERENCES

Breast Implants and Breast Cancer Screening: Implants and Breast Cancer Screening; Medscape article, 11/14/2003; Stacy M. Smalley, CNM, MSN

Saline-Filled Breast Implant Surgery: Making an Informed Decision, Updated January 2004 (pdf); FDA.gov

Wednesday, August 11, 2010

Approaches for Managing Bias

This article was written more for Family Medicine physicians, but all of us can benefit from self-assessment of potential biases that might affect our judgment. It was also written with the potential bias towards the obese patient in mind, but the article could have been written with any“fill in the blank” bias as the topic.

The article points out that bias among physicians tends to “be implicit rather than explicit because of social pressure for healthcare providers to show tolerance and cultural sensitivity.”

So how do we guard against implicit bias?

Some evidence suggests that motivated individuals who are made aware of their personal implicit biases can mentally alter them.

One way of developing such awareness is to take the Implicit Association Test , a brief, online, interactive exercise that measures implicit bias by linking pictures and words (associated with such features as race, body size, or disability) to positive or negative characteristics.

Reflecting on one's own IAT results either individually or in a group can enhance understanding and acceptance of implicit bias and lead to behavior changes that actively address potential negative consequences of this bias.

In full disclosure, my results of the Implicit Association Test in regards to obesity:

Your data suggest little to no automatic preference between Thin People and Fat People.

Do you have any tips for guarding against bias, implicit or explicit?

REFERENCE

Approaches for Managing Bias Against the Obese Patient: Medscape Article, April 16, 2010; Désirée Lie, MD, MSEd

Tuesday, August 10, 2010

ISAPS Plastic Surgery Survey

The International Society of Aesthetic Plastic Surgery (ISAPS) is celebrating it’s 40th anniversary.  To commemorate the event ISAPS commissioned a global survey of plastic surgeon and procedure in the top 25 countries and regions. 

The ISAPS Biennial Global Survey involved survey participants completing a two‐page, English‐based questionnaire that focused on the number of surgical and non‐surgical procedures they performed in 2009.  Approximately 20,000 plastic surgeons were sent the survey and then reminders.  Unsure what percentage responded.

Breast augmentation has been the most popular plastic surgery procedure for the last ten years in the United State.  This study found that liposuction has gained that spot.  The study found that the top five procedures in the U.S are liposuction (18.8%), breast augmentation (17%), eyelid lifts (13.5%),  rhinoplasty (9.4%),  and abdominoplasty  ( 7.3%).

The popularity of surgical procedures varied by country.


The top 25 countries and their top two surgical procedures:

1. United States (1st -- liposuction, 2nd -- breast augmentation)

2. Brazil (liposuction, breast augmentation)

3. China (breast augmentation, liposuction)

4. India (liposuction, breast augmentation)

5. Mexico (breast augmentation, blepharoplasty)

6. Japan (liposuction, breast augmentation)

7. South Korea (breast augmentation, liposuction)

8. Germany (liposuction, blepharoplasty)

9. Italy (liposuction, breast augmentation)

10. Russia (liposuction, breast augmentation)

11. Turkey (breast augmentation, liposuction)

12. Spain (liposuction, breast augmentation)

13. Argentina (breast augmentation, liposuction)

14. France (liposuction, breast augmentation)

15. Hungary (liposuction, blepharoplasty)

16. Canada (breast augmentation, liposuction)

17.  Colombia  (liposuction, breast augmentation)

18. United Kingdom (liposuction, breast augmentation)

19. Taiwan  (breast augmentation, liposuction)

20. Venezuela (liposuction, blepharoplasty)

21. Thailand (breast augmentation, liposuction)

22. Australia (blepharoplasty, rhinoplasty)

23.  Portugal (liposuction, breast augmentation)

24.  Belgium  (liposuction, breast augmentation)

25.  Saudi Arabia (breast augmentation, liposuction)

 

The study found the number of non-surgical procedures topped the surgical procedures.  The top five non surgical procedures were found to be Botox injections (32.7%), hyaluronic acid injections (20.1%), laser hair removal (13.1%), autologous fat injections (taking a patient's fat from one location and transferring it in the same patient in another location) (5.9%) and IP Laser treatment (4.4%).

Shout Outs

Jackie, Dispatch From Second Base, is the host for this week’s  Grand Rounds.  You can read this week’s edition here.

I once worked with a psychiatrist who called listening the most underrated skill, and his words are truer now than ever. Listening is hard work; too often, we just wait for our turn to talk. And that’s if we’re being polite. We don’t talk to each other; we talk at each other or sometimes over each other in the loudest voice possible.

This trend is both sad and wrong, but there is hope, as evidenced by the thoughtful posts I received on all facets of communication. In the wonderful post The Hidden Pearls of Medicine: Stories From Our Patients, Medical Resident recalls a first patient encounter. MR calls hearing patient stories a privilege and ”has been left with a sense of wonder” after these encounters. On behalf of patients everywhere, thank you.

……………………………………….

Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 3) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

Wow – another two weeks has flown by, which means it’s time for another edition of Change of Shift!

Once again, my nurse blogging colleagues have written an interesting, thoughtful group of posts for your perusal!

So ready…set…peruse!

………………………………..

I have been following @krupali on twitter lately and following her blog, Krupali K. Tejura, MD.   She is currently on a mission trip to Uganda.   She has used twitter and her blog to help her obtain help for several of the people she has encountered there.  Here are two examples: 

Elephantitis. and Elephantitis Update

Baby needs Help--Omphalocele!

……………………………….

Another physician I have been following on twitter @GregSmithMD blogs at Shrink Rapping.  Currently, he is doing a series “Psychiatry A to Z."   All of them have been good, but the one on grief is especially so.

"Your father has collapsed."

The call comes at the worst time possible. My mother-in-law is moving into a new house, we are moving into her house, we need to pack, someone needs to watch the kids.  ……….

……………………………

Dr Charles is hosting the first annual 2010 Charles Prize for Poetry.  Have you submitted one yet?  The entries have been amazing!

Open to everyone (patients, doctors, nurses, students, etc.). Limit 1 or 2 entries per person.

Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter……

Contest closes August 31st.

……………………………..

The New York Times had this article by Roni Caryn Rabin  Feeding Dementia Patients with Dignity

First Alzheimer’s disease stole Rosemary DeFelice’s speech, mobility and independence. Then, at 75, she lost the ability to eat.

She would chew away at her food, coughing and sputtering and spitting up but swallowing very little, said her daughter, Cyndy Viveiros. And like many relatives caring for patients with advanced dementia, Ms. Viveiros had to decide whether or not to have a gastric feeding tube inserted. ….

But social workers advising Ms. Viveiros suggested another option: continuing to have her mother carefully fed by hand, giving her only as much as she wanted and stopping if she started choking or became agitated.  ………..

which promoted a wonderful post by TBTAM: We’re Feeding Dementia Patients with Feeding Tubes???

An article in this weeks NY Times entitled Feeding Demented Patients with Dignity suggests that hand feeding dementia patients may be a better option than tube feeding them.

My God, are we really putting feeding tubes in the elderly demented? When did this happen?

During college, I worked as a nurses aide in a nursing home outside Philadelphia. For 20 hours a week (40 hours in the summer) for two years, I cared for patients in all stages of dementia, from the walking confused through to the end stage, stiffened victims confined to wheelchairs or beds. But in all that time, I never, ever saw anyone with a feeding tube.  ……

…………………………………….

Via MedPage Today comes an update by Todd Neale:  Tweeting Surgery 

Have you ever wanted a play by play of a colorectal cancer operation on your mobile device of choice? Well, you're in luck.

This coming Tuesday, August 10, at 1 p.m., Southern Regional Health System in Georgia will post updates from a low anterior resection on Twitter (@srhsatlanta). …

…………………………………….

A tweet from @DrJonathan 

Mail carrier who delivered secrets recently retired,here's her blog entry about reading secrets: http://www.fromuktouswithlove.blogspot.com/

I had never heard of the PostSecret project until I followed the tweet and read Kathy’s post:  PostSecret

This is a post that I have been looking forward to writing for some time now. And it has nothing to do with the United Kingdom or the British! It is a project that I became involved in (unknowingly) a few years ago that has turned out to be a very interesting and unique experience. If you are unaware of PostSecret, let me start at the beginning...

As a mail carrier (in Germantown, MD) you get used to seeing unusual things go through the mail. …... But nothing prepared me for PostSecret!  ….

If we could be as open to each other as the people who pour out their secrets, I think it would be a more understanding world. But too often people are afraid to show their inhibitions, sufferings and well, their secrets. As long as we have PostSecret, there is an outlet for those want to share. I have no doubt that it has been a good thing.

Frank's website is one of the most visited websites in the whole world. www.postsecret.com  …….

Some of the “secrets” shared are very, very sad.  Others are equally funny.

………………………………….

Dr Anonymous’ BTR show will be Pre-Med Student (@premedhellblog).

Upcoming shows (9pm ET)

8/19: 4th Year Med Student @DrJonathan
8/26: Dr. A Show 3rd Anniversary

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, August 9, 2010

Ear Plugs -- A Form of Tissue Expansion

Recently, I followed a link from @plsurgeon on twitter to this article:  Holes for popular plug ear jewelry usually stretched open, not cut.

I have yet to be asked to repair any holes in ear lobes from plugs, but have repaired many torn ear lobes from pierced ear jewelry.  While I admit, I’m not a fan of ear lobe plugs, I appreciate the ability of our body’s tissue which allows for the expansion.  (photo credit)

 

Physicians use soft tissue expansion for reconstruction to “expand” or increase the available tissue to replace missing tissue.

The expansion or stretching technique used for ear plugs is not done to replace missing tissue, but to allow a larger plug to be used as jewelry rather than the fine wire of traditional ear piercing.

….Hoover is a do-it-yourself sort of guy. First, he pierced his ears himself with a sewing needle. He then inserted tapered rods to stretch the holes until they were large enough to hold plug jewelry. "It's a painful gain," he said.

Fitterer sells tapered rods in his piercing parlor or performs the stretching himself. He said rare parlors cut large holes.  ……