Are Patients Making Good Decisions About Breast Reconstruction?

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

An outcomes article in the January 2011 issue of the Journal of Plastic and Reconstructive Surgery asks the question:  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy?

The objective of the study was to “measure women's knowledge about reconstruction and to evaluate the degree to which treatments reflected patients' goals and preferences.”

Their conclusion (bold emphasis is mine):

Women treated with mastectomy in this study were not well-informed about breast reconstruction. Treatments were associated with patients' goals and concerns, however, and patients were highly involved in their decisions. Knowledge deficits suggest that breast cancer patients would benefit from interventions to support their decision making.

Granted the study was small, but it left me wondering if we the medical community fails to educate these women.  

The study involved a cross-sectional survey of early-stage breast cancer survivors from four university medical centers.  The survey included measures of knowledge about specific reconstruction facts, personal goals and concerns, and involvement in decision making.   Only 84 patients participated (59% response rate).

Participants answered only 37.9% of knowledge questions correctly.

 

Here are the general information questions asked in the survey with the correct answers: 

1.  In general, which women are more satisfied with their breast
reconstruction --those who have reconstruction at the time of the mastectomy or who have delayed reconstruction?

They are both equally satisfied (only 33.3% of the women surveyed knew this)

2.  After which type of breast reconstruction are women more satisfied with the look and feel of the reconstructed breast—implants or flaps?

Flaps (only 15% knew this)

3.  Mark whether or not it is true for breast reconstruction with an implant -- uses fat and tissue from other parts of the body to make a breast.

Answer is false. (only 13.1% knew)

4.  Mark whether or not it is true for breast reconstruction with a flap -- usually requires more than one surgery.

Answer is true. (only 28.6% knew)

5.  Which breast reconstruction surgery is easier on the body, that is, heals faster? 

Implants are easier (only 57.1% knew this)

6.  Of every 100 women who have breast reconstruction, about how many will have a major complication, such as needing hospitalization or an unplanned procedure, within 2 years?

The answer is 25–50.  (only 3.6% knew the correct answer)

7.  How does breast reconstruction affect future screening for breast cancer?  

It has little or no effect on finding cancer  (only 35.7% knew this)

 

 

Which is right for you depends on many things. 

Are you a candidate for flap surgery and if so which is best for you – TRAM, Latissimus Dorsi, etc. 

What kind of recovery time are you willing to put up with?  Recovery from flap surgery is longer than for implant surgery

Does the thought of having a foreign body (implant) in your body bother you?  If so, then put up with the longer flap recovery time and forgo the implants.

Ask to talk with other patients who have been through the surgery, preferably with your surgeon.  They can tell you better than we can about recovery (ie the little things that can make life miserable or better).

 

 

REFERENCES

1.  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy? [Outcomes Article]; Lee, Clara N.; Belkora, Jeff; Chang, Yuchiao; Moy, Beverly; Partridge, Ann; Sepucha, Karen; Plastic & Reconstructive Surgery. 127(1):18-26, January 2011.doi: 10.1097/PRS.0b013e3181f958de

2.  Determinants of Patient Satisfaction in Postmastectomy Breast Reconstruction; Alderman, Amy K.; Wilkins, Edwin G.; Lowery, Julie C.; Kim, Myra; Davis, Jennifer A.; Plastic & Reconstructive Surgery. 106(4):769-776, September 2000.

3.  Sacramento Area Breast Cancer Epidemiology Study: Use of Postmastectomy Breast Reconstruction along the Rural-to-Urban Continuum; Tseng, Warren H.; Stevenson, Thomas R.; Canter, Robert J.; Chen, Steven L.; Khatri, Vijay P.; Bold, Richard J.; Martinez, Steve R.; Plastic & Reconstructive Surgery. 126(6):1815-1824, December 2010.; doi: 10.1097/PRS.0b013e3181f444bc

4.  Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, and Implant Techniques; Yueh, Janet H.; Slavin, Sumner A.; Adesiyun, Tolulope; Nyame, Theodore T.; Gautam, Shiva; Morris, Donald J.; Tobias, Adam M.; Lee, Bernard T.; Plastic & Reconstructive Surgery. 125(6):1585-1595, June 2010.; doi: 10.1097/PRS.0b013e3181cb6351

Pale Flowers Quilt

Recently I received this quilt from Susan as part of the ALQS5.  It is lovely!   It is 8.25 in X 10.75 in.

Here is the back before I sewed on a sleeve so I can hang it.

Here are the posts of the quilts made and received from the first three ALQS.
Made:
1st: Laced Ribbons Quilt (went to Pennsylvania, May 2008)
2nd: Flower Basket Quilt (went to Indiana, September 2008)
3rd: Fractures I (went to Australia, June 2009)
4th:  Blue Hawaii Wall Hanging (went to   Great Britain, July 2010)
5th:  Winter  (went to the Netherlands,  January 2011)

Received
1st: I Received My Quilt (from Denver, June 2008)
2nd: It's Arrived! (from Italy, November 2008)
3rd: Geverfde Quilt (from the Netherlands, August 2009)
4th:  Falling Stars  (from Great Britain, August 2010)

BC Baby Quilt

This quilt was made of a pack of Benartex Quilter’s Candy fabric squares from my stash.  I have no idea how long they have been there.  The fabric reminds me of 1930s reproduction fabric.  The center is completely made of the BC fabric and white Kona cotton .  The border strip is made of left-over BC pieces augmented with other fabrics from my stash.

The quilt is machine pieced and quilted.  It is 32 in X 38.5 in.  I have given the quilt to a fellow physician blogger who’s wife is pregnant with their first baby.

Here you can see why the fabric looks like 1930s reproduction.
Here is a photo of the back.

Breast Cancer Oncogene ZNF703

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Much of gene research is over my head, but the discovery of a new breast cancer oncogene, ZNF703, is exciting.  It appears to have been discovered by two independent research groups (references below) and published alongside one another in the same journal EMBO Molecular Medicine today this past week.

The only other breast oncogene that I am aware of is Her2 which has been very helpful in identifying which patients are most likely to respond to Herceptin.  This greatly helps in tailoring therapy to the individual.

The first group of researcher scientists used ‘microarray technology’ which allows large numbers of tissue samples to be tested simultaneously, picking up subtle differences in gene activity between normal cells and cancer cells.

The researchers had already identified a region on human chromosome eight likely to harbor genes linked to the development of a more aggressive form of estrogen positive breast cancer, because multiple copies of it are commonly found in tumors but not in healthy tissue.

Focusing on this region, they studied the patterns of gene activity in 1172 breast tumors, as well as breast cancer cells grown in the lab. This allowed them to eliminate one gene at a time until there was only one gene left within that region that was overactive in all the samples tested.

The second group specifically studied Luminal B breast cancers which represent a fraction of ER-positive tumors associated with poor recurrence-free and disease-specific survivals in all adjuvant systemic treatment categories including hormone therapy alone.

Using mass spectrometry, they identified ZNF703 as a cofactor of a nuclear complex comprising DCAF7, PHB2, and NCOR2. ZNF703 expression results in the activation of stem-cell related genes expression leading to an increase in cancer stem cells.

They were able to show that ZNF703 is implicated in the regulation of estrogen receptor and E2F1 transcription factor which points to the prominent role of ZNF703 in transcription modulation, stem cell regulation and luminal B oncogenesis.

 

REFERENCES

ZNF703 is a common Luminal B breast cancer oncogene that differentially regulates luminal and basal progenitors in human mammary epithelium;  Carroll JS, Curtis C, Aparicio S, Caldas C, et al; EMBO Molecular Medicine, Article first published online: 18 FEB 2011; DOI: 10.1002/emmm.201100122

ZNF703 gene amplification at 8p12 specifies luminal B breast cancer; Sircoulomb F, Nicolas N, et al; EMBO Molecular Medicine, Article first published online: 18 FEB 2011; DOI: 10.1002/emmm.201000121

Cancer Research UK Press Release, February 18, 2011

VIPS Guidelines for Providing Surgical Care

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

No this VIPS doesn’t stand for “very important person” or the famous (local or national) person you might care for in your practice.   I think it is best to try to treat everyone with the same standards of care.  Similar to the checklist that Atul Gawande has brought to the public eye, this keeps you from “missing” something or not providing some important aspect of care.  The Cleveland Clinic Journal of Medicine had a nice article by Dr. Jorge Guzman recently on this topic:   Caring for VIPs: Nine principles

…….

In this case, VIPS stands for “volunteers in plastic surgery.”  

The online site of the Journal of Plastic and Reconstructive surgery has an article discussing the guidelines for VIPS who provide surgical care for children in the less developed world.

The guidelines were developed by the Volunteers in Plastic Surgery (VIPS) Committee of the ASPS/PSEF  in conjunction with the Society for Pediatric Anesthesia (SPA).

This document is not intended to represent a standard that must be followed by everyone performing this work in developing countries.  Locations, circumstances, and needs may vary greatly depending on the site.  Rather it is intended to provide a framework for providers involved in the care of children in the less developed world.

The guidelines can also be found here as a pdf file:  Guidelines for the Care of Children in the Less Developed World. 

The VIPS program stresses working in conjunction with the local plastic surgeons by invitation and proper planning with a mission/purpose for the trip.  Adhere to high standards of quality of surgery, care, and teaching.  Be sensitive to host needs and customs.  Be a Good Guest!

 

 

 

 

REFERENCE

Volunteers in Plastic Surgery (VIPS) Guidelines for Providing Surgical Care for Children in the Less Developed World; Schneider, William J.; Politis, George D.; Gosain, Arun K.; Migliori, Mark R.; Cullington, James R.; Peterson, Elizabeth L.; Corlew, D. Scott; Wexler, Andrew M.; Flick, Randall; Van Beek, Allen L.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 8 February 2011; doi: 10.1097/PRS.0b013e3182131d2a

The Role of Humanitarian Missions in Modern Surgical Training; Campbell, Alex; Sherman, Randy; Magee, William P.; Plastic & Reconstructive Surgery. 126(1):295-302, July 2010; doi: 10.1097/PRS.0b013e3181dab618

Shout Outs

Updated 3/2017-- photos/videos and all links removed as many are no longer active and it was easier than checking each one.


Dr. Rich, Covert Rationing Blog, is the host for this week’s Grand Rounds! You can read this week’s edition here.

Especially since the events of last week, it would be absurd for DrRich to think that everybody is out to get him. Still, it seems plain that, of late, …...

And so, Dear Reader, while DrRich is certainly happy to be hosting Grand Rounds for the fourth time, and is particularly delighted with the quality of postings which he has the honor of featuring this week, it occurs to him that hosting an event with such high (and well-deserved) visibility might draw certain “extra attention” here.  So perhaps you had better read this quickly.………

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H/T to Dr. RW for the link to this article by Dr. Denton Cooley: Feuds -- Social and Medical

Feuds of various types can occur between individuals, families, and nations. A number of notorious feuds have occurred throughout history. For instance, two early American politicians—Aaron Burr and Alexander Hamilton …………….

The rivalry, or feud, between Dr. Michael DeBakey and me deserves some brief reflection and an attempt at explanation. …………..

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H/T to Medical Quack for the link to this article: Elderly surgeon gets three years probation in death of cosmetic surgery patient

Dr. Lawrence Hansen, an Orange County-based surgeon under investigation by the state medical board in connection with a patient’s death, has been placed on three years probation, according to court papers filed by the board last week.

An accusation against Hansen, 85, of Cypress was filed with the Medical Board in July alleging negligence, incompetence, failure to report a patient death, performing surgery in an unaccredited facility and unprofessional conduct.

DOCUMENTS: Read accusation ……….

This takes us back to the recent New York Times article by Laurie Tarkan: As Doctors Age, Worries About Their Ability Grow

and just recently to this article by Donna Cardillo, MA, RN: Can a nurse be too old to work at the bedside?

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I found this CNN article by Madison Park very interesting: Severely short Ecuadorians resistant to diabetes, cancer, study says (photo credit)

For years, Dr. Jaime Guevara-Aguirre of Quito, Ecuador, noticed that his shortest patients never seemed to get the common ailments that befell others.

These patients had a genetic mutation that would not allow them to grow more than 4 feet tall -- their heights would be fixed to that of a 7-year-old for life.

Although they aged, Guevara-Aguirre noticed that "they developed neither cancer nor diabetes." "That was fascinating," he said.

That observation launched a 22-year study. …..

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It’s that time again, St. Baldrick’s, but this year it’s different for our friend Movin Meat: The Cause of My LIfe

When my wife was diagnosed with breast cancer eight weeks ago, at the age of 36 and with four kids, the youngest of whom was 4 months old, it was what one might call a shock, the like of which you don't get too many times in a lifetime. It was a life-altering moment. As we walked out of the hospital, numb, one thing was clear, above all else:

This Changes Everything
There were so many decisions to be made. ……What was I going to do about St Baldrick's? ……….

Oh, and if you’d like to help me help Movin Meat, consider purchasing this quilt.

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Dr. Kathleen Young, Treating Trauma in Chicago, has been writing using her blog to note National Eating Disorder Awareness Week.  Check out her advice in this post: Eating Disorder Prevention (photo credit)

……….The authors of the book Real Girl/Real World created a list of 5 Easy Actions to Help Prevent Eating Disorders:

1. Don’t diet. …….
2. Forbid teasing about body shape and size. …..

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Last Thursday night I caught this local news story on a ceremony at the State Capitol to honor families of fallen troops. There were 24 families who received Gold Star Banners honoring their loved ones who died while serving our country. The Lost Heroes Art Quilt was there also.

The Lost Heroes Art Quilt is five and a half feet tall and 15 feet long. The quilt has 50 squares, one for each state in the U.S., and each square features the childhood photo of a fallen soldier dressed in an authentic G.I. Joe shirt.

It is the work of Julie Feingold.

Here is a video of the quilt.

Positive Feedback

Yes, I know it’s my job.  Yes, I know the patient paid me.  But I love receiving notes like this.  Thank you.

Heart in Hand Quilt

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

I really like how this quilt turned out.  For now it is hanging in my office.  I have decided to use it to help Movin Meat raise money for The St Baldrick's Foundation.  It is listed on Etsy if anyone is interested in buying it.

The quilt was inspired by this scarf featured on Street Anatomy. I cropped a screen shot, brushed in the heart (suggested by the arterial formation), and then printed it out on a sheet of Colorfast fabric.  The border fabric is from an old flour sack.

It is machine pieced and quilted.  The small wall hanging measures 18.5 in X 23.75 in.

I embellished the heart in the hand using yarns and thread.
The back is a simple gray print cotton calico.

1790 Eagle Quilt Finished!

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Last month I showed this quilt as a WIP (work in progress).  It is now finished after 3 weeks of hand quilting, every night for 2-3 hours.  I am pleased with how it turned out.  Forgive my photos as I am not great at taking photos of whole cloth quilts.  The quilt is white white not a cream white.

The quilt is 20 in square and hand quilted.  The front and back look like mirror images of each other.  Here is the front:

Here is the back:
Here is a photo of the eagle detail (from the back).
Here is a photo of one of the corners.

This quilt will be part of the Eagle Motif Wallhanging Decade by Decade Project and represents the decade 1790-1800.

Can You Tell Me…

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Office phone rings.

PT1992, “Can you tell me how long Dr. Bates has been at that location?”

“20 years,” I reply.

PT1992, “I think you did my surgery.  One of my saline implants has burst.”

“Let me put you on hold.  I’ll look and see if you were ever our patient.”

I am acutely aware that I don’t recognize the voice or patient name, but feel I am okay with HIPAA to verify to PT1992 that indeed we once had a patient by that name.

I then as politely as I can tell her, “I will need a signed medical records release to give you any more information as I don’t know your voice and have no other way to verify whom I am speaking with.”

She seems to accept this, but then says “Can you just tell me which company made the implants?”

I repeat the above.

PT1992, “Well can you tell me what kind of coverage I might have?”

“You should be able to get free replacement implants, but if it as it has been more than 10 years that will be all the assistance you will be able to receive.”

PT1992, “Thanks.  Since I have moved away, I’ll go to the surgeon here and have them send a release.  Will that work?”

“Yes, that will work.”

 

Related Posts: 

It’s Happened Again (June 5, 2007)

Breast Implants -- Some History (March 3, 2008)

Silicone vs Saline Breast Implants (March 4, 2008)
Silicone Implants and Health Issues  (March 5, 2008)
Saline or Silicone? (November 18, 2010)


Mentor Enhanced Advantage Warranty
INAMED (McGhan) ConfidencePlus™ & ConfidencePlus™ Platinum Breast Implant Limited Warranties

Photography in Medicine

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Fellow blogger Sterile Eye recently did a post on the historical use of mirrors in photos of wounded soldiers.  At the time I was reading an article in the journal Advances in Skin & Wound Care (full reference below) on wound photography.

Photography, not only in wound care, but in many areas of medicine/surgery (before and after photos, changes in hemangiomas, etc) is important.  As the article points out, if more than one person is to be responsible for taking these photos it is equally important that practice standards be implemented and adhered to.

The authors created a wound photography performance checklist to ensure consistency.   In addition to the patient’s name, wound evaluator’s name, and date, here are a few (not all) of the critical items on the checklist:

• Confirm patient has written consent for wound photographs on approved hospital consent form.  [This could apply to any medical photograph and any location, ie office.]
• Explain procedure to the patient and/or caregiver.
• Place camera case on hard, clean surface, avoiding floor or patient care items.
• Record patient information on customized photo label to include patient initials, medical record number, date, wound number, and location.  [Body part or hemangioma or nevus could substitute for wound.]
• Place the patient in a comfortable position to expose the wound for picture.  [Use consistency of position as suggested in pdf from ASPRS for photography in plastic surgery.]
• Apply customized photo label to the border of the wound for photograph.  [Could do this for nevi or skin lesion photos, but not for breast/abdomen photos.]
• Wash hand and remove camera from carrying case while maintaining appropriate infection control practices.  Avoid using gloves when handling camera.

The American Society of Plastic and Reconstructive Surgeons (ASPRS), along with the Plastic Surgery Educational Foundation(PSEF) and Canfield Imaging Systems have put together a really nice brochure (pdf file) as a reference.  Once again, consistency is key to having photos that can be used to assess change from growth,  healing, or surgery, etc.

The brochure show standard position when taking photos of the face, the ear, the breasts, the abdomen, the hip/thigh, the leg/foot, the hand, the forearm, and the finger.

Consistency in key.  Changes can be more reliably measured when consistency in position, distance (camera to patient), lighting, makeup (same or none when photographing the face) is maintained.

The ASPRS brochure offers these additional tips which are nice.  Sometimes photos will be taken in different locations (an ER documenting the initial injury, the office for followup) so lighting and background may be different.  Optimally:

• Use an appropriate backdrop.  Photograph patients against a solid-colored background. Light to medium blue is a good choice because it contrasts well with skin tones.  Medium gray
  may also work well.  Use a fabric drape or other non-reflective material.
• Remove distractions.  Jewelry and clothing create an unnecessary distraction in patient photos.  They should be removed from the area of interest prior to photography.For
  body photos, it is advisable to use special modesty garments (available from medical supply dealers) instead of the patient’s underwear.
• Use controlled lighting.  Patients should be photographed using a flash system or studio strobes (available room lighting is not appropriate).  Balanced cross-lighting (i.e., two strobes positioned symmetrically on either side of the camera) brings out surface texture without creating shadows that are overly harsh.
• Reduce cast shadows.  The use of balanced lighting with diffusers can soften the shadows cast by the patient.To completely eliminate cast shadows, one or two additional lights may be aimed directly at the backdrop.
• Record settings.  As much as possible, the same camera settings should be used for every patient. For settings that must be adjusted from patient to patient (such as exposure compensation), all values should be recorded, stored with the photos and referenced during post-op photography.

 

 

REFERENCES

Collaboration in Wound Photography Competency Development: A Unique Approach; Bradshaw, Leah Marie; Gergar, Margaret E.; Holko, Ginger A.; Advances in Skin & Wound Care. 24(2):85-92, February 2011; doi: 10.1097/01.ASW.0000393762.24398.e3

Photographic Standards in Plastic Surgery; ASPRS, PSEF, 2006 (pdf file)

Shout Outs

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.


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

Welcome to this weeks’ Grand Rounds, a self-selected compendium of the best of the Medical Blogosphere!

This is my 7th time to Host (first Seven Timer), and it’s always an honor. I asked everyone who submitted to send the date of their first blog post. After graphing them it’s a waste of time, nothing to see, you’re spared/welcome. Thanks everyone, anyway.

28 submissions by 27 authors, thanks to all.

First, the only post recommended by someone other than themselves (Liaka’s MedLibLog offered this, and kudos) is Dr. Wes with Social Media and The Challenge of Overcoming the Challenge of Intellectual Complacency. Tests (really, information / teaching) via Twitter. This would be cool, were I not complacent. ………

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H/T to @mtnmd for the link to this amazing story!  Chase Britton, Boy Without a Cerebellum, Baffles Doctors (go watch the video)

Chase was also born prematurely, and he was legally blind. When he was 1 year old, doctors did an MRI, expecting to find he had a mild case of cerebral palsy. Instead, they discovered he was completely missing his cerebellum -- the part of the brain that controls motor skills, balance and emotions. …..

Chase is not a vegetable, leaving doctors bewildered and experts rethinking what they thought they knew about the human brain.

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Interesting interview on NPR by Fresh Air's Dave Davies:   V.S. Ramachandran's Tales Of The 'Tell-Tale Brain'

Dr. V.S. Ramachandran is a neurologist and professor at the University of California, San Diego,….

In his latest, The Tell-Tale Brain, Ramachandran describes several neurological case studies that illustrate how people see, speak, conceive beauty and perceive themselves and their bodies in 3-D space.

Take, for example, the clinical phenomenon known as the "phantom limb." In the majority of cases where people have lost limbs, they continue to vividly feel the presence of the missing limb. Chronic phantom pain — which strikes roughly two-thirds of patients who have had a limb removed — can become so severe that patients seriously contemplate suicide.  …..

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I love these heart coasters (photo credit) featured by Street Anatomy!

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Words, phrases, titles and their meanings/origins have been on my mind as can be seen in my posts the past two days (here and here).  This continues with Future Docs’ new post:  Student Doctor or Medical Student? & Other Confusing Names

….Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic.  After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’?  Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital.   This brings us to the problems of how doctors are named in teaching hospitals.  The system could not be more confusing.  ……..

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It’s that time again, St. Baldrick’s, but this year it’s different for our friend Movin Meat:  The Cause of My LIfe

When my wife was diagnosed with breast cancer eight weeks ago, at the age of 36 and with four kids, the youngest of whom was 4 months old, it was what one might call a shock, the like of which you don't get too many times in a lifetime. It was a life-altering moment. As we walked out of the hospital, numb, one thing was clear, above all else:

This Changes Everything
There were so many decisions to be made. ……What was I going to do about St Baldrick's?  ……….

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The 2010 Medical Weblog Awards Update – the voting is closed.  The winners will be announced tomorrow.  Congratulations to all of them!  Well deserved.   (photo credit)

The 2010 Medical Weblog Awards nominees...

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H/T to  @MedicalNews for the link to this article:  Mummy remains show false toes helped ancient Egyptians walk (photo credit)

Two artificial big toes -- one found attached to the foot of an ancient Egyptian mummy -- may have been the world's earliest functional prosthetic body parts, says the scientist who tested replicas on volunteers. …….

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Check out Scanman’s recent post: A Parable Of Rigidity in which he tells of how the use of twitter allowed doctors in two different countries to help save a patient’s life.  He tend rants (justifiably) on the red tape medical journals place on writing up such a case report.

Note: This is a true incident.  ………

Some of my friends in the medical blogosphere and medical twitterverse know that I loathe the red tape associated with submitting articles / papers to big medical journals. The story above just reinforces my loathing.

I prefer posting case reports in my blog rather than go through this.  ……

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H/T to @precordialthump for the link to this very nice post over at Academic Life in Emergency Medicine:  Trick of the Trade: Conveying risk for postexposure prophylaxis

A health care worker hurried in to the ED after being poked with a needle.

'It was an old 18G needle with dried blood', she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, 'What does very low risk mean?'

Is there another way to covery risk for patients?

From the Bottom of My Heart

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Listening to NPR Saturday morning, I caught part of Scott Simon interview of brothers Stephen Amidon and Thomas Amidon, M.D. discusses their book The Sublime Engine: A Biography of the Human Heart.    The interview touched on the story of the human heart in science/medicine, history, and culture.

It turns out that the classic red heart symbol we see almost everywhere around Valentine's Day doesn't look much like a real human heart at all.

"Of all the theories about where that symbol comes from, my favorite is that it is a representation of a sixth century B.C. aphrodisiac from northern Africa," says Stephen Amidon,….. "And I kind of like that history because it sort of suggests that early on, people sort of understood the connection between love and the heart."

Words and how we use them were the focus of Dr. Pauline Chen interview by WIHI host Madge Kaplan this past Thursday, February 10th (H/T Paul Levy):  A Legible Prescription for Health 

On this edition of WIHI, Dr. Chen wants to spend some time talking about language, especially the words doctors use with one another when describing patients; the unintended barriers created the more doctors and nurses don protective, infection-protecting garb; the mounting weight of patient satisfaction surveys; and more.

Back to the NPR interview on the sublime engine: the human heart.  The authors do not feel that as our advances in surgical techniques become commonplace, that the heart will lose any of its cultural and metaphorical significance.

"One of the things that surprised me during the course of writing this book was how durable the heart's metaphorical power has been — not just in the past 50 years in the great explosion of cardiology, but in the past 500 years since the great anatomists of the Renaissance began opening up bodies and began looking at the physical heart," he says.

Even as all this was happening, the heart has retained its metaphorical power.

"So perhaps there will be a day when we no longer touch our chest and kind of nod, and people understand we're talking about qualities that can't be explained by medicine — we're talking about courage or devotion or inspiration," he says. "You can have a situation where someone receives an artificial heart, and afterward goes to their surgeon and says, 'I thank you for this from the bottom of my heart.' This will make complete sense to us."

On this Valentine’s Day, I thank you from the bottom of my heart for spending part of your day with me. 

Heart in Hand Quilt – WIP

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

This quilt won’t be done in time for Valentine’s Day as I just started it yesterday. It is inspired by this scarf featured on Street Anatomy. I cropped a screen shot, brushed in the heart (suggested by the arterial formation), and then printed it out on a sheet of Colorfast fabric.

There is a long tradition of heart in hand quilt blocks. When searching for the meaning of the symbolism I found several – charity, friendship, compassion.

These photos were taken after I finished the piecing and basting of the quilt. I now have to do the quilting. It will be approx 18 in X 23 in when finished.

Here is a close up of the center which is approx 5 in X 11 in.

Monkeying Around

I made the center block a few months ago.  I found it amusing to have the blue flannel fabric with monkeys featured in a quilt block whose name is crab claws but looks to me like a wrench. 

I made the block more difficult by cutting the wrenches out of fabric whole and not piecing them.  This also made me not want to make more of them even though I liked how it turned out.  So the block lingered on my wall waiting for inspiration. 

I finally decided to use the patience nine-patch block.  The sashing strips using the light brown fabric helped pull them all together and add to the size.  The quilt is 40 in square, machine pieced and quilted.

You can see the center block and monkey fabric better in this photo. 
This shows some of the quilting from the back.  I used a light brown thread.  I’ve given this baby quilt to a friend and his wife who are having their second boy.

How to Block and Tackle the Face

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

For medical students, residents, or anyone wanting a review, the March 1998 article by Dr. Barry Zide (first full reference below) is a great place to begin.  The article reviews the anatomy of each nerve, the areas of anesthesia obtained by each block, and gives instructions and tips for each of eight facial nerve blocks.   The article, also, has some nice photos.

1.  Infraorbital Nerve
Zide’s preferred technique is the transcutaneous nasolabial approach.

This approach has a point of injection medial to the upper nasolabial groove a few millimeters lateral to the alar groove. The injection point for the infraorbital nerve is in the center of the small triangle lateral to the alar rim and medial to the nasolabial fold. With your left index finger on the infraorbital rim, ask the patient to look straight ahead. Holding the syringe like a pen, you advance the needle to bone toward the designated point about 4 to 7 mm down from the rim. Often, the needle tip goes directly into the foramen itself. If you wish to inject the foramen, you may have to poke around for a couple of millimeters, but you will always be able to enter into the foramen this way. Then, inject 1 to 2 cc. There is a 100-percent success rate using this external block approach, and the senior author has never seen a neuritis from this or any of the three methods.

2.  Mental and Mental Plus

The mental nerve can be blocked at the mental foramen or a few centimeters after it leaves the foramen submucosally.

To block it at the foramen, locate the second lower bicuspid. Place the needle tip in the buccal sulcus near the base of the tooth and inject. The nerve itself is not covered by muscle after it leaves the foramen, just a thin layer of mucosa and perineural sheath. Often, the nerve can be palpated at the foramen or in the first few centimeters of its course. If the surgeon desires, he can inject away from the foramen by finding the upper fascicles visually or tactilely. Use the thumb of one hand to pull out the lower lip, lateral to the lower canine tooth. By squeezing the lip and sliding the thumb outward, the nerve is visible submucosally about 85 percent of the time.

Mental Plus block will also anesthetize the chin by blocking  an end branch of the mental nerve and the terminal branches of the mylohyoid.

These can be done immediately after the mental block by an anterior premandibular injection anterior to the vestibule in front of the anterior teeth.  You must change your position to behind the patient, turn the syringe more vertically, and inject in the supraperiosteal plane with at least a 1.5-inch needle. You must inject anterior to and beyond the lower border of the mandible (actually out on the lip) but not quite out of the skin. Only the mental plus block obviates the need for the inferior alveolar block (i.e., regardless of whether the mental nerve or mylohyoid nerve supplies the chin).

3.  Supraorbital/Supratrochlear/Infratrochlear
4.  Dorsal Nasal Nerve
5.  Zygomaticotemporal
6.  Zygomaticofacial
7.  Great Auricular

Have the patient flex the sternocleidomastoid muscle by pushing the head against a hand placed on the ipsilateral forehead. This maneuver will outline the sternocleidomastoid muscle against the neck skin. Mark the skin of the upper anterior and posterior sternocleidomastoid borders with two parallel lines. Then draw a third line between the first two parallel lines directly in midmuscle. Measure down 6.5 cm from the lower border of external acoustic meatus to the mid-sternocleidomastoid. A useful template is a measurement from your own hand. For example, 6.5 cm is the measurement of my baby finger tip to the webspace or my thumb metacarpophalangeal to tip. Inject a nickel to quarter sized circle of anesthetic onto the muscle fascia at this intersection

8.  V3 Block

I have included several other good references for you below.


REFERENCE

How to Block and Tackle the Face; Zide, Barry M.; Swift, Richard; Plastic & Reconstructive Surgery. 101(3):840-851, March 1998

Addendum To "How To Block and Tackle the Face"; Zide, Barry M.; Swift, Richard; Plastic & Reconstructive Surgery. 101(7):2018, June 1998.

Regional Anesthesia on the Lacrimal Nerve; Ross, Gary; Taams, Karl; Plastic & Reconstructive Surgery. 104(3):876-878, September 1999.

Nerve Block, Infraorbital; eMedicine Article, Updated: May 19, 2010;  Karen M Byrne, MD 

Regional Anesthesia for Office Procedures: Part I. Head and Neck Surgeries; Gohar Salam, MD, DO;Am Fam Physician 2004 Feb 1;69(3):585-590

Local Anesthesia Techniques in Oral and Maxillofacial Surgery; Sean M. Healy, D.D.S., Francis B. Quinn, M.D.; University of Texas Medical Branch Grand Rounds, October 2004  (pdf)

Shark Skin &

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Did you happen to catch the CBS Sunday Morning piece by David Pogue  “How Shark Skin May Help Save Lives”? 

Turns out nothing grows on a shark’s skin.  Not barnacles.  Not bacteria.  This is why biomedical engineer Tony Brennan, University of Florida, is studying shark skin.

Initially, Brennan studied shark skin as a way to help the Navy solve the huge and expensive problem of barnacle buildup on their ships.

When he studied shark denticles under the electron microscope, he discovered why.

"I said, "Wow!, That shark pattern, I'd never seen it before,'" he said. And he believes that has something to do with no bacterial growth.

Brennan wondered if he could re-create the shark skin surface on plastic sheets.

"Sharks' denticles are set up like a diamond pattern," he said, showing Pogue a clear plastic sheet he called a Sharklet, which also had a diamond pattern. Its microscopic pattern of ridges mimics the denticles of shark skin.  (photo credit)

And when you stick it on ships, sure enough - NOTHING GROWS.

Dr. Shravanthi Reddy, director of research for Sharklet, is testing Sharklet to see if it can repel bacteria the way shark skin repels algae and barnacles.

Two pieces of plastic - one smooth, one patterned with Sharklet - are subjected to bacteria and incubated for 24 hours.

The electron microscope reveals the astounding results. The plain plastic is covered with a bacteria film - "Just these big clumps of bacteria all piled up on one another," Dr. Reddy said.

And on the Sharklet surface? "You might see one or two cells, but you don't see that big clumping the way you see it on the smooth surface," said Dr. Reddy. "What's really interesting is that there are no chemical differences between the surfaces. It's the same material. No differences, other than the physical shape."

If Sharklet really works, it could be used to cover many of the ordinary surfaces in a hospital and doctors office  -- bedside tables, door panels, stethoscopes, and as Dr. Reddy notes

"Those wristbands, have you ever seen anyone clean those wristbands?" said Dr. Reddy. "Never, right? And they're on the patient the whole time they're in the hospital."

As a way to fight community based MRSA and flu, it could be used to cover gym surfaces, desks in schools, play grounds.

The topic is to be explored further in tonight in the PBS "Nova" series, "Making Stuff."

Grand Rounds Vol 7 No 20

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

It is my pleasure to bring you this week’s Grand Rounds.  As I am sick of winter and looking forward to spring, I am going to sprinkle this edition with images of some beaches near the contributors.  Enjoy!

Valentine’s Day is in less than one week.  There are several “heart” related posts.  Let’s begin with them.

This first one is from @purplesque, Sumpsimus, who gives us a glimpse of a “love affair” of the real tragi-comedy kind in her post:  Another day at work.

…..

Corinne Rieder, healthAGEnda, discusses a part of the touching journey through her mother’s battle with Alzheimer’s in her post:  Listening to My Mother.

I can’t deny it—I miss the mother I once had. Even at age 80, she was vibrant, loving, and independent. And she was strong………..

I may miss the mother I once knew, but I have also become deeply aware of how much I love and appreciate the one I have now……..

…..

Kimberly Manning, ACP Hospitalist,  in her post Life at Grady: Payback

……….Sometimes, it gets to be a lot. A whole lot.  ……

Mr. Felton smiled and shook his head. "Seem like every generation get a little more chances. Here you are a doctor, teaching me about my heart." He looked me in my glassy eyes, warm and genuine. The tears pushed out onto my lashes as I drew in a deep breath. ……….

…..

Valentine’s Day may not be a happy one when illness enters into the couple relationship, things change, often drastically.  If the demands of illness make it difficult for the partners to connect with and be supportive of each other, should they consider divorce?   Barbara, In Sickness and In Health, discusses these changes in her post:  Divorce and Chronic Illness:  One Woman's Story.

…..

Aneesa, D.O.ctor, is using  "February ~ American Heart Month" to share a personal story of her aunt’s death from heart disease and provides some educational information about heart attacks.

…..

Ves, Clinical Cases and Images:  CasesBlog, summarizes some important lab results and parameters that both patient with heart diseases and health people should know in his post:  Heart numbers to know - by Cleveland Clinic.

…..

ACP Internist (“where the staff are living and dying that the Steelers win on Sunday”) post or question of the day--- QD: News Every Day--The Super Bowl is just a game, right?  Did you know that according to researchers sports fans may literally live and die on their team's victories.  ACP Internist reviews  the research for us.

………………....

In medicine, we must use our heads to guide our hearts and vice versa.  This is true in dealing with end of life issues, with medical ethics, with healthcare cuts/budgets.

Indian Medic wants to know  who's the boss?

Often a major part of a doctors job is making decisions –….. Often it's the decision of the patient and family, but needing guidance of the attending doctor, who is expected to know the best. When all goes down well – good. But what when the parties have a difference of opinion and some problems crops up. …..?

Following is one such is incident, which made me ponder – where do you draw the line – of who takes the blame?  …….

…..

Women Neurosurgeons Blog  discusses how it’s critical to take  "The Social History" of our patients in order to provide optimal care.

…………..The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.  ……………

…..

In White Ink (formerly Intueri) gives us a good reminder NOT to use the wrong modality when communicating with patients.

…..

Elaine, Medical Lessons,  has been Considering the Significance of a Doctor's White Coat  from her perspective as a patient (pro) as a doctor (generally pro) and as a med-school teacher (it should be clean).

…..

Dr Rich, Covert Rationing Blog, gives us an iconoclastic view of advance directives and offers advice on how to establish one without giving too much ammunition to the Central Authority in his post:  “ Can Advance Directives Be Salvaged?”

…..

Julie Rosen, Bedside Manner, discusses finding common ground in the debate on advance care planning in the wake of the recent elimination of Medicare reimbursement for such services.

…..

James Baker, Mental Notes, asks and answers:   Who gets hurt when Medicaid gets cut? You do.   As he notes “Poor people don't stop getting sick just because you drop their insurance.  And doctors keep treating them.  It still gets paid for, too, and you're who pays for it.  But how?”

…..

Marshall Scott, Episcopal Chaplain at the Bedside, shares reflections in light of the ethical principles of the "Georgetown Mantra" on the recent case of two sisters imprisoned in Mississippi whose sentences would be suspended if one sister donated a kidney to the other.

………………….

Don’t forget the other parts of the body – skin, hands, back, etc.  The first one in this section should not be skipped:

From @otorhinolarydoc, Surgeon, Interrupted, writes about life in the third world in his post:  West Timor Adventures Part 3 of 10: Clinic Starts  --  Crazy clinic and huge goiters.  Really huge goiters!

…..

Dr. Romanzi  educates us on the topic Death by Clitoris: Female Circumcision circa 2011

………….And therein lies the key – the divorcement of these crucial rite-of-passage rituals from the brutal practice of female genital mutilation.   ……..

……

Glenn Laffel, MD, Pizaazz, uses his post  How the Brain Responds to Music  to review a cool study by scientists at McGill about the neurological underpinnings of musical epiphanies. It includes an amazing YouTube video of Jascha Heifetz playing a Tchaikovsky violin concerto, but admitted in his email “I’m more partial to the Grateful Dead piece mentioned in the opening sentence!”

…..

 Allergy Notes gives us  7 Tips for Allergy-free Winter.  Included is a mini map diagram of the most effective methods for control of the most common indoor allergen - the mighty dust mite.

…..

Happy, The Happy Hospitalist, discusses what his expectations are as he heads off to the physical therapist:  Physician Physical Therapy Goals:  Just Fix It.

…..

Dr Ed Pullen, DrPullen.com,  tells us that tobacco use is no longer the Leading Preventable Cause of Death in America.   Sadly, obesity has passed tobacco use. 

…..

Grunt Doc wants us to know about the trouble with observation in medical settings.

I have experience with this, from both sides. Both involve hand-washing. Still, a clean story.

Washing of hands is the right thing to do for health-care providers, between seeing patients, for infection control reasons. And, I’ve gotten ‘the letter’ from a VP charged with signing them, citing me for not washing my hands between patients.

Except, I did. This is the problem with observational medicine.

………………………….

We’ll use Grunt Doc’s post to move from the physical body to the policy/politics/economics of medicine.

David Harlow, Health Care Law Blog, discusses MA Governor Deval Patrick challenge to cities and towns to meet a cut in local aid dollars by redesigning health benefits and renegotiating with unions under a new proposed law in his post Massachusetts: Future Hotbed of Value-Based Benefit Design?  He feels value based design can turn what is perceived as a Draconian cut into a win-win situation.

…..

Paul Levy, Not Running a Hospital, shares Lessons from Cairo, using the recent events in the Middle East to make the connection between powers that be and the public’s rights.

…..

Ever wish as a physician you had taken an economics class in college.  NWS,  The Notwithstanding Blog, actually did and explains why, in spite of the flak he gets for the decision, economics is not only a good background to have before entering medical school, but the *best* thing to have studied before medical training begins:   "Undergraduate Learning of Economics for Make Benefit Glorious School of Medicine"

…..

murzee, Healthcare, etc,  has had a great series on reviewing medical literature intelligently.  In part 5 of the series, she explains inter-group differences and hypothesis testing.

…..

Louise, Colorado Health Insurance Insider, considers what happens  When The Media Recommends Over-consumption of Healthcare

It's easy to say that a few hundred dollars for a test (or a few thousand dollars if people opt to get multiple tests) is far less expensive than the cost of a heart attack.  But ……….  This exacerbates the problem of over-consumption of health care and rising health care costs.

…..

Philip Hickey,  Behaviorism and Mental Health, discusses  The Drugging of Children.   He feels children with behavioral problems are increasingly being prescribed anti-psychotic drugs.  There is nothing intrinsically wrong with these children.  They simply haven’t been adequately trained and disciplined.

…..

mdstudent31, Future of Family Medicine, asks How will COGME's 20th Report Affect Medical Students? in their review of the COGME's 20th Report, "Advancing Primary Care,"  and it’s 5 recommendations including the one which recommends an increase in "the average incomes of primary care physicians to at least 70 percent of the median income for all other physicians."

…..

Greg Vigdor, Washington Health Foundation,  gives his prescription for making the U.S. the Healthiest Nation in his post Winning the Future!  It includes: 1) Dream Big 2) Know where we are in the Journey 3) Make it about People.

…..

Henry Stern, InsureBlog, presents one reason why US cancer survival rates far outstrip Britain’s in his post:   Seeing through the MVNHS©

………………….

These last two are from a couple of people I am fond of; one is a surgeon and the other a pathologist.  Both posts are meant to leave you smiling.

The first is from bongi, other things amanzi, who tells us about a great teacher with less than stellar bedside manners:  you've got to hand it to him.

The second is from Methodical Madness who share some GI humor in her post:  tête-à-tête

……………………….

Hope you all will have a great day and even better week.  Take care and come back anytime.
………….
Next week’s Grand Rounds host will be Grunt Doc.

If you would you like to be a future host of Grand Rounds, contact:  Nick Genes (blogborygmi.com).

Advertising

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I am old school and find it difficult to advertise. I don’t begrudge others who do so ethically and in good taste.

There is a local cosmetic surgeon who is running a special via TV ads and on his website (the photo is a screensaver shot of the website cropped to remove his name) that for me is unethical.

For me the ad “entices” potential patients into surgery without giving them information about potential risk.   Hopefully that information is given in detail when the patient is seen in the office consultation.

……

This was not an issue when I was in medical school (graduated in 1982).  I trained under surgeons who had never been allowed to advertised and frankly did not think doctors should. 

Deborah Sullivan, PhD has written a nice piece on the history of advertising in medicine, specifically cosmetic surgery:

Cosmetic surgery was re-commercialized in 1982. Before then, physicians, like other members of learned professions, were exempt from the 1890 Sherman Antitrust Act. The AMA could enforce bans on advertising because the fiduciary services physicians offered were not considered a commercial trade. Opinion changed in the deregulatory climate of the Reagan years. Hoping to bring down health care costs, the Federal Trade Commission sued the AMA for restraint of trade over their prohibition of advertising. Over the strenuous objections of the AMA and the plastic surgery specialty associations, a split Supreme Court decision let a lower court ruling in favor of the Federal Trade Commission stand [8, 9]. Advertising in medicine returned, with its ethical dilemmas, and cosmetic surgery was once again on the cutting edge.

As Dr. Sullivan notes (bold emphasis is mine)

The purpose of advertising is to persuade people to do something. The most effective ads appeal to emotions—fears and desires—and associate the subject of the advertisement with highly valued attributes. It is not difficult to persuade people to do something that will give them a more youthful, sexually attractive appearance in a culture that bestows real social and economic rewards on those who possess these traits. The lure of such rewards can make us gullible and impulsive when it comes to buying the promise of beauty.

………

There are a number of physician advertising practices that are deemed inappropriate (reference 2, 3, 5).  These include

• Payment in exchange for referral of patients or media coverage
• Exaggerated claims intended to create false expectations of favorable surgical results
• Promotional inclusion of preoperative and postoperative photographs intended to misrepresent results through different lighting, expressions, or manipulated poses

I think Robert Aicher, Esq comments (reference 4)  regarding a surgeon’s web site could be extended to TV and print ads:

In this commentator’s view, ethical inferences from Web site to practitioner should be suspect. For instance, a former AMA member and Beverly Hills cosmetic surgeon, Dr. Jan Adams, surrendered his license to practice medicine on April 1, 2009, after it was suspended in 2008 for failure to pay child support, with prior alcohol-related convictions in 2003 and 2006. The November 10, 2007, death of his patient, Donda West, and his malpractice judgments of $217,337 and $250,000 in 2001 were not factors in his license surrender. Dr. Adams currently has an excellent Web site that makes no reference to any of these public records.  Accordingly, “quality” Internet advertising does not guarantee a quality practitioner, and conversely, patients routinely obtain quality results from cosmetic surgeons who do not have “quality” Web sites.

………

I’m all for educating the public.  I love the segments Dr. Anonymous does with his local TV stations for just that reason. 

REFERENCES

1.  Advertising Cosmetic Surgery: The use of advertisements for cosmetic surgery has fluctuated throughout the twentieth century; Deborah A. Sullivan, PhD; Virtual Mentor. May 2010, Volume 12, Number 5: 407-411.

2.  Are Plastic Surgery Advertisements Conforming to the Ethical Codes of the American Society of Plastic Surgeons?; Spilson, Sandra V.; Chung, Kevin C.; Greenfield, Mary Lou V. H.; Walters, Madonna; Plastic & Reconstructive Surgery. 109(3):1181-1186, March 2002.

3.  The quality of Internet advertising in aesthetic surgery: an in-depth analysis; Wong WW, Camp MC, Camp JS, Gupta SC.; Aesthet Surg J. 2010 Sep 1;30(5):735-43.

4.  Commentary on "The quality of Internet advertising in aesthetic surgery: an in-depth analysis"; Aicher RH; Aesthet Surg J. 2010 Sep 1;30(5):744.
5.  ASPS Advertising Code of Ethics and Advertising 101 (in pdf form)
6.  Advertising cosmetic surgery: are doctors complying with ethical standards?; Australian Medical Association, June 2002

Another Voyager Bag

A few weeks ago I posted about a voyager bag I made using black linen.  It was made using  the Voyager Bag (#761) pattern from Ghee’s.  Yesterday I pulled out some Alexander Henry fabric featuring horses (a light weight denim) that I’ve had for over 15 years.  I was going to make a jacket, but, well, it never happened.

This one, like the black linen one, is lined and measures 8 in X 9 in when folded over.  There are a total of 4 zippered compartments and two other pockets. 

Here is the inside.
Here is the back.

I plan on giving it to a friend for his wife who loves horses.

Kris' Bar Quilt

I made this quilt back in 1995 for my nephew.  I loved the zebra fabric and didn’t want to cut it into small pieces.  So I made a bar quilt.  I want to thank my nephew for supplying the photos, but they don’t really show the entire quilt which is really more proportional (or at least in my memory).

The quilt was machine pieced by me, but I had my friend Scottie Brooks do the hand quilting.  It measures 66 in X 82.5 in.

Here you can see the zebra fabric a little better.
The back is fabric which features an English Fox hunt.

Nutrition and Wound Healing

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Nutrition, or rather the new USDA Dietary Guidelines, have been in the news this week.  It seem apropos to take not of a recent article in the supplement to the January issue of the Plastic and Reconstructive Surgery Journal discussing nutrition and wound healing (full reference below).

The article presents an update on new developments in the field of nutrition and wound healing, not an exhaustive review of the field.

As the authors point out “most operations in well-nourished patients are successful, with uncomplicated healing responses, even if nutritional intake is absent or curtailed for 7 to 10 days.”   It’s the patient with trauma, cancer, chronic illnesses, mal-absorption issues where this is most important.

First and foremost, the nutritional assessment should begin with a complete history and physical.  The authors reference the second article below for this statistic:

This alone has been found to be 80 to 90 percent accurate in evaluating patient nutritional status, and the addition of multiple or complex biochemical, immune, or anthropometric measurements does not increase greatly the accuracy of nutritional assessment.

Malnutrition should be considered if the history reveals unintentional weight loss (20% weight loss is indicative of severe malnutrition), if the patient appears cachectic with obvious muscle wasting, or if the patient has a history of or reason for alimentary malabsorption.  It must also be remembered that Obese Patients are at High Risk for Malnutrition in the Hospitalized Setting.

If the patient is found to be malnourished prior to an elective surgery, this should be corrected.  As the authors point out:

Determining who would truly benefit from nutritional supplementation is still a matter of some debate, but there is evidence that preoperative nutritional support reduces infectious complications and anastomotic breakdown in severely malnourished patients undergoing major elective surgery.

Postoperative nutritional support should be considered in patients expected to be unable to eat for a period of at least 2 weeks.

Other key points from the article:

• Enteral feeding is superior to parenteral feeding when possible.
• Fish oil supplements (omega-3 fatty acids) adversely impacts the healing response.
• Vitamin C deficiency, in addition to impairing wound healing, has also been associated with an increased susceptibility to wound infection.  Burn victims require as much as 1 to 2 g/day to restore urine and tissue levels to normal.
• Vitamin A deficiency impairs wound healing.  Vitamin A, administered either topically or systemically, reverses the antiinflammatory effects of corticosteroids on wound healing.
• The antiinflammatory properties of vitamin E are similar to those of steroids. Vitamin A can reverse the wound-healing impairment induced by vitamin E. Vitamin E has also been shown to affect various host immune functions, often in a negative fashion.
• Zinc deficiency impairs the critical roles each of these processes play in wound healing. Zinc levels less than 100 μg/dl have been associated with decreased fibroblast proliferation and collagen synthesis.

 

Related posts:
Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know -- An Article Review (September 3, 2008)
Herbal Supplements and Surgery Reviewed (April 30, 2009)
Local Wound Care for Malignant and Palliative Wounds – an Article Review (September 13, 2010)



REFERENCE

Nutrition and Wound Healing: An Update; Kavalukas, Sandra L.; Barbul, Adrian; Plastic & Reconstructive Surgery. 127():38S-43S, January 2011; doi: 10.1097/PRS.0b013e318201256c

Assessment of nutritional status; Jeejeebhoy KN, Detsky AS, Baker JP.;  JPEN J Parenter Enteral Nutr. 1990;14:193S–196S.

Closure of Facial Mohs’ Defects

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.I

t is very likely there will never be a complete consensus on the best or correct way to close defects left by Mohs’ surgical excision of skin cancers on the face. 

Which is best?  Direct linear closure.  Local flap. Skin graft.

In my opinion, it comes down to multiple factors but perhaps the most important are:   Where on the face is the defect?  How lax is the surrounding skin? 

The authors of the recent Plastic & Reconstructive Surgery Journal article on the topic (full reference below) write in their introduction in favor of direct closure (the first step in the reconstructive ladder):

This first step on the reconstructive ladder is often overlooked in favor of more intricate local flap options. If performed properly, direct linear closure results in superior aesthetic results that are more predictable and involve less tissue dissection than local flap options. 

The article is a retrospective review of 1354 reconstructions performed post-Mohs’ facial defects by the senior author (JFT)between 2001 and 2008.  

Forehead (96/125 closed directly in this study) –-their maximum size for direct closure was 3.6 cm.  A nice tip from JFT to determine orientation of the final closure:

The senior author's (J.F.T.) preferred technique for forehead repairs is to place a single silk stitch in both directions, tailor-tack the wound closed, and orient the resultant closure based on which direction yields the least tension, with dog-ear excision following the closure. Dog-ears are meticulously excised on the forehead.

Nose (46/707 closured directly in this study) –- maximum defect size 1.2 cm on nasal dorsum, < 1 cm on tip.

The indications for direct linear closure on the nose are more limited than other anatomical areas on the face because of the relative paucity of skin laxity and the risk of alar distortion.

Lip (37/138 closed directly in this study) – maximum defect 3 cm.

Numerous textbooks have described linear closure of the lip as the preferred technique for defects of 25 percent of the upper lip and up to 30 percent of the lower lip. Our experience has shown that superior aesthetic results can be achieved with defects approaching 40 percent on the upper lip and exceeding 50 percent on the lower lip. This is particularly true in the elderly patient.

Cheek (117/186 closed directly in this study) – maximum defect 4 cm. 

The cheek, particularly in the elderly population, is an ideal area for direct linear closure of very large lateral defects. …..

The inherent laxity in the aging cheek and the ability to generously undermine this well-perfused region contribute to this result.

Chin (4/6 closed directly in this study) – maximum defect 2.2 cm.

Care must be taken with direct closure on the chin, as there is little skin laxity. Direct closure must be avoided in a horizontal plane, to prevent the inadvertent development of extrinsic lip ectropion.

Related posts:
Bilobed Flap for Repair of Nose (March 26, 2008)
Skin Grafting in Lower Third Nasal Reconstruction (April 1, 2010)
Reconstruction of the Lip -- Part I (January 29, 2008)


REFERENCE

The Rationale for Direct Linear Closure of Facial Mohs' Defects; Soliman, Sameer; Hatef, Daniel A.; Hollier, Larry H. Jr.; Thornton, James F.; Plastic & Reconstructive Surgery. 127(1):142-149, January 2011; doi: 10.1097/PRS.0b013e3181f95978

Shout Outs

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.


HL7Standards is the host for this week’s Grand Rounds! You can read this week’s edition here.

As a blog dedicated to “engaging conversations on healthcare and technology,” this week’s edition of Grand Rounds is dedicated to posts discussing the relationship between health care and technology. Technology in health care has received more than a notable amount of press over the last few years and more than a few people have something to say about it.

In response to Grand Rounds, we received a number of great submissions by health care bloggers, some positive and others negative, about the impact technology has had on how health care is perceived and understood, delivered and received. …….

…………

Next week I will host Grand Rounds.  There is no theme, but I would ask you to have them submitted by noon (CST) Monday February 7th.  To participate, please email me  [rlbatesmd AT gmail DOT com] -- include with the name of the post, the post url, the blog title, the blog url, and a short description of the post (one or two lines).  Make sure to put “Grand Rounds Submission” in the subject line of the email.

……………………………

In case you missed it, the new USDA Dietary Guidelines can be found here:   Dietary Guidelines for Americans, 2010.  Some of the key recommendations:

Increase vegetable and fruit intake.  Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans and peas.

Consume at least half of all grains as whole grains.

Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages.

Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds.

Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry.

Reduce daily sodium intake to less than 2,300 milligrams (mg) and further for …….

Reduce the intake of calories from solid fats and added sugars.

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The 2010 Medical Weblog Awards Finalists have been named! Congratulations to all of them!  Well deserved. 

This year's competition is sponsored by Epocrates® and Lenovo. (photo credit)

Voting will begin this coming Thursday, February 3, 2011 and will close 12 midnight on Sunday, February 13, 2011 (EST). We will have instructions, voting booths, and further details here at Medgadget.com on Thursday.

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The Plastic and Reconstructive Surgery Journal website has a wonderful gallery of educational videos.  Here are the titles and links to a few of them:

Facial Fractures - Video 2 – Optimizing Miniplate Fixation for Simple Mandibular Fractures

Facial Fractures - Video 7 – Frontal Sinus Repair

Blepharoplasty and Browlift - Video 1 - Blepharoplasty in the Female Patient

Skin Grafts and Local Flaps – Video 1 – The Scalp Skin Graft

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A nice news piece from BBC World Service:  A Cosmetic Surgeon's Double Life (written and video)

Top plastic surgeon Dr Enrique Steiger leads a surprising professional double life. He may make money from performing cosmetic surgery for the rich, but he also helps the less fortunate by treating casualities in African war zones.

………For several months of each year, he also lives and works in battle zones with the International Committee of the Red Cross.

He performs life-saving trauma surgery on local people who are not offered the same emergency medical treatment that is available to troops.

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Via twitter:   @ctsinclair  “Handbook for Mortals http://bit.ly/dQGPns Free book by Joanne Lynn speaking now at @FIMDM”

This online edition includes the full text of the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D., an authoritative consumer guide to end-of-life care. For more information about the book, which you may also buy online, click here.

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Via @palmd comes a link to the Discover Magazine’s post:  Celebrating female science bloggers

There’s an animated discussion in the making about female science bloggers. It started in the wake of an excellent session on women bloggers at ScienceOnline 2011, and has led to several thoughtful posts on the issues that they face, self-promotion, dealing with sexism, and more.

……... So this is a list of women bloggers who I think you should read, with specific reasons why I think you should read them, and some of my favourite posts of theirs to get you started. And note, this is not a list of top female science bloggers; it’s an all-female list of top science bloggers. ……

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For those of us love cheesecake, this was shared via twitter.  I have yet to try it, but will (photo credit). 

From @purplesque “New evenin -binge favorite- cheesecake in a mug. Replace the eggs with milled flax.  http://www.2stews.com/2009/09/cheesecake-in-mug.html”

……. This cake is great for people at work, in dorms or if you just want cheesecake...fast! My Cheesecake in a Mug, is so good and versatile that you can have a different topping each day. ……….

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From Burda Style blog:

…..For our third installment of SEWING MADE EASY™ how-to video series, one of those employees, Jamila Jordan, joins Martha to show off how to make a super cute reversible purse using the SINGER® Curvy™ sewing machine. The template and instructions for this adorable bag are available here (link removed 3/2017) so you can whip up your own version at home!