Fat Grafting to the Breast and Oncologic Risks

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Fat grafting to the breast has become an acceptable practice.  It is being used to repair small defects as well as to augment.  As I noted in my post (November 22, 2010), the two articles (2nd and 3rd references below) from researchers at the University of Pittsburgh School of Medicine suggests that it is NOT safe to use adipose-derived stem cells (ADSC) that may be part of fat grafting in any patient with active tumor cells.

This new article (first reference below) discusses potential risks of current and novel approaches to autologous fat grafting to the breast within the context of both the underlying science and clinical practice.  They conclude (bold emphasis is mine):

There are theoretical reasons why fat grafting might influence breast cancer growth or metastasis. Certain laboratory studies can be interpreted as supporting their negative impact on tumor development, metastasis, or recurrence. However, careful review of these concerns suggests that they arise from factors and situations that are not present to a significant extent in the clinical setting.

A study that approximates more closely the clinical situation of fat grafting into the breast has been presented in poster form.   This study investigated an orthotopic model of breast cancer in which human breast cancer cells were implanted into the mammary fat pad of immunodeficient animals, followed by placement of a human fat graft (with or without noncultured supplemental cells) immediately adjacent to the mammary fat pad containing the nascent tumor. The study found no increase in tumor growth with either an estrogen receptor-positive or an estrogen receptor-negative human breast cancer line. This is consistent with the absence of evidence for increased cancer risk in the many reports of fat grafting for breast reconstruction and augmentation. However, at this time, the number of patients with prolonged follow-up is only approximately 1000 and appropriate caution in proceeding is indicated.

……….In the clinical setting, several studies note the importance of good communication between the surgeon and an experienced radiologist to ensure accurate interpretation of breast imaging findings. Incorporation of these steps into good clinical practice and timely reporting of outcome data, including long-term follow-up—preferably in the form of multi-center clinical studies or a robust international patient registry—will ensure that the field develops in a safe and appropriate manner.

REFERENCES

1.  Oncologic Risks of Autologous Fat Grafting to the Breast; Fraser JK,  Hedrick MH, Cohen SR;  Aesthetic Surgery Journal January 2011 31: 68-75, doi:10.1177/1090820X10390922

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

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

Florida Student Gets Hand Transplant

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

This is a difficult post for me to write.  As much as I admire the surgeons who are pushing this new advance I found myself bothered by this one.  Why?     That’s what I have been asking myself.  After all, Linda Lu, 21 year old, is a college student from Orlando, Florida is ecstatic about the new hand.

"I've already accepted it as my hand since the day I woke up," Linda Lu said during a Monday press conference at Emory University Hospital in Atlanta, where the surgery took place. "But just looking at it, sometimes I still can't believe that it's there... It kind of feels like magic."

"I'm in information technology," Lu said. "So, my primary goal is to be able to type."

Simple enough goal, isn’t it?   When playing the “what would I give up game” my hands are never given up easily.  I could probably learn to sew with only one hand, but it would be difficult and it would become mostly machine sewing.  I could still blog as I could type with one hand – not as fast, but it would get done. 

I would not be able to do surgery with one hand, but a hand transplant would not give that back to me anyway.  The dexterity would never be good enough.

Linda is reported to have lost her left hand when she was 1 year old.  The amputation was done due to complications from Kawasaki disease.

Still I’m left with this uneasy feeling.  Most people born with only one hand/arm adjust well.  For example, look at the baseball pitcher Jim Abbott. 

This healthy young woman will now be placed on anti-rejection medications for life.  It will make any pregnancies she has high-risk ones.  She will be more susceptible to infections.  Some anti-rejection medications increase the risk of cancers.

Just because we can do a procedure doesn’t mean we always should.  I hope my uneasiness regarding this one is misplaced.  After all, I am getting my information from news articles and not from a discussion with the patient.

Newsprint articles

Florida Student Receives Rare Hand Transplant Surgery, FoxNews.com, March 28, 2011

Valencia student has rare hand transplant at Emory University, LA Times, March 28, 2011 (video as well as print)

Related posts:
Double Hand Transplant on Twitter  (August 26, 2010)
Cost of Hand Transplantation?  (September 22, 2010)
Rejection  (December 1, 2010)
New Technology May Help Prevent Rejection in Hand Transplant Patients (December 13, 2010)

Shout Outs

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

Dr Mike Sevilla (formerly Dr. Anonymous), Family Medicine Rocks, is the host for this week’s of Grand Rounds! You can read this week’s edition here.

I'm honored to be hosting Grand Rounds for the fourth time. This is not the GR theme today, but I did want to mention that it's Doctor's Day tomorrow in the United States. Doctor's Day was first observed on March 30, 1933. Eudora Brown Almond, wife of Dr. Charles Almond, decided to set aside a day to honor physicians.

The red carnation is commonly used as the symbolic flower for National Doctors Day. In 1990, law was passed designating March 30 as "National Doctors Day." Big shout out to all my physician colleagues out there!  ……

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A very moving post by Richard Sheff, MD on KevinMD.com: Giving the patient and family precious minutes to say goodbye

Dorothy suffered a second heart attack, leaving more of her heart muscle damaged and causing her to slip into congestive heart failure. There was not much we could do to reverse the many blockages in her arteries. Yet she was cheerful, as were her four children.

One morning Mary came to find me. “Dorothy says she isn’t feeling well.” …………….

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HT to @hrana for the link to this HuffPost article by Robert M. Tornambe, M.D: "What Is Beauty? A Plastic Surgeon's Perspective"

Everything has beauty, but not everyone sees it. ~ Confucius

The word "beauty" is the most overused, misunderstood, poorly defined word in the English language. What makes a woman beautiful? The Holy Grail of beauty has never been completely understood. The cliché, "Beauty is in the eye of the beholder," is incorrect in my opinion. Perception is the key. It is "perception of beauty" that is in the eye of the beholder. Each of us, however, has a different perception of beauty. We all have different tastes, likes and dislikes, and this affects our definition and perception of beauty with regard to the American woman. As a plastic surgeon, it is my job to counsel people about this perception of beauty because so many misconceptions exist. ……….

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HT to @helenjaques for sharing this tweet “RT @BMAstudents Self experimenting doctors: Altruistic or self serving? http://bit.ly/fUFIMX”  (free registration required)

…. Rebecca Ghani investigates the long and sometimes bizarre tradition of self-experimenting doctors.

Self experimentation throws up problems around practicality, accuracy, reliability, and ethics. ….. And why do this when there’s an agreed medical and ethical protocol for clinical trials?

But delve a little deeper and …….

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The debate continues on whether organ donors should be paid.  The Baltimore Sun has a pro/con article:  The consequences of a donor kidney market

Should you be paid to part with a kidney?

It's an unseemly question, but it's one that medical professionals have been grappling with as the waiting list for kidneys gets longer, supply of the organs stagnates and other solutions fall short.  …….

Read on for two views on this topic. …….

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New York Times article by Paula Span:  Aging Without Children

…….How childless adults should approach their later years is a question that surfaces with some frequency among readers and commenters here. It’s true, as many attest, that being a parent doesn’t guarantee elder care. But it’s also true that the bulk of America’s old people are, in fact, cared for primarily by relatives: spouses first, then adult children.

“Children are a good insurance policy,” said Merril Silverstein, a prominent gerontologist at the University of Southern California. “In some other countries, that’s why people have children. Here, though it’s less certain, it’s still a pretty good bet.”  ……

It shouldn’t be that way, argued Debra Umberson, a sociologist at the University of Texas at Austin, who has written about childlessness and parenthood: “We shouldn’t have to have kids who work for us for free so we don’t have to go to a nursing home.” ………………

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A really nice instructional post on the Etsy Blog written by julieincharge: How-Tuesday: Make a Quilt Label

As anyone who has ever stitched, admired, or snuggled with a quilt knows, quilting has a history steeped in resourcefulness, storytelling, community, and warmth. In honor of National Quilting Month, which marks its 20th anniversary this year, Amy Milne, the director of the Alliance for American Quilts, has penned a how-to project and a call for the importance of labeling quilts (and artworks of all kinds) for the sake of staking a spot in handmade history and taking pride and authorship in your craft. Do you have a quilt that holds a special spot in your heart or family history? Be sure to share your story in the comments below. ………..

Reimbursement for Surgical Dressings

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

I opted out of Medicare many years ago, so I could skip articles like the one referenced below.  I don’t.  

Kathleen Schaum writes a very informative article on the ins & outs of reimbursement for surgical dressings.  She gives a self-test to help you and your team assess your knowledge:

….If you pass the LCD/Article self-test, congratulate yourself for a job well done. If you do not pass the self-test, you should immediately take steps to become compliant. Let's start the self-test now.

* Do you know how to find the LCD for Surgical Dressings and the Surgical Dressing Policy Article that is pertinent to the geography that you serve?

If yes, have you printed both documents, read them, and shared them with your entire wound care team? If no, the Web sites in Table 1 will connect you with each of the DME MACs' LCDs and Articles. Remember that your wound care patients are counting on you to understand and implement a process that will meet all the LCD/Article guidelines.

* Can you correctly answer these frequently asked questions?

Unfortunately, the LCD for Surgical Dressings and its attached Article have been either forgotten by or not introduced to some modern-day wound care professionals. ……...

Q: Why do medical suppliers tell my patients with skin tears that Medicare does not cover the dressings that I order?

A. Wound dressings are covered by Medicare when they are used on a surgical wound, partial-, or full-thickness skin wound, or partial- or full-thickness burn. Dressings are not covered for skin tears, abrasions, Stage I ulcers, first-degree burns, or cutaneous fistulas unrelated to a surgical procedure.

…….

The helpful web sites given in Table 1 of the article:
CIGNA Government Services (CIGNA) – http://www.cignagovernmentservices.com
National Government Services (NGS) – http://www.ngsservices.com
National Heritage Insurance company (NHIC) – http://www.medicarehic.com
Noridian Administrative Services (Noridian) – https://www.noridianmedicare.com




REFERENCES
Can You Pass the Surgical Dressing Ordering and Documentation Test?; Schaum, Kathleen D.; Advances in Skin & Wound Care. 24(3):112-117, March 2011; doi: 10.1097/01.ASW.0000395044.66516.02

Surrounded by Angels Baby Quilt

I made this baby quilt for my friends who recently celebrated their 20th wedding anniversary.  I had made a double wedding ring quilt quilt for them a year earlier.  I used the red and green fabrics from that quilt for this one.

Whole pineapple log cabin blocks make up the center.  The border is meant to mirror those blocks.  The quilt is machine pieced by me, but I had my friend Scottie Brooks do the hand quilting.  It was finished in October 1998.

My friend, Ben, took the photos for me.  The quilt is approximately 44 in square.

I named the quilt “surrounded by angels” due to the fabric I used as part of the back.
Here you can see the label and the angel fabric.

Following Instructions

“Take one to two pain pills by mouth every 4 to six hours”

To me that is clear.  I was reminded recently that it isn’t to all patients. 

A patient complained of lack of relief from her pain medicines after surgery.  Her description of the pain didn’t suggest any complications so I ask how she was taking them.  I was looking for a way to safely use NSAIDS or tylenol as a boost rather than giving her something stronger.

“I take one pain pill and then wait an hour to take another one.”
I prompted her to tell me when she took the next dose.
“I wait four hours and then take one pain pill, but I wait for six hours to take the next one.”

Ah!

I had mentioned to her and her caregiver that due to her small size she should begin with just one, then wait for 30 minutes to an hour to see if she needed the second one.  They were doing that, but the other part wasn’t clear.

“Take one to two pain pills by mouth every 4 to six hours”

1.  Take one pain pill every 4 hours.

2.  Take two pain pills every 4 hours.

3.  Take one pain pill every 6 hours.

4.  Take two pain pills every 6 hours.

….

Oh, but there are really more options aren’t there:

1.  Take one and half pain pill every 4 hours.

2.  Take one pain pill every 5 hours.

….

So she was taking the medicine in a correct way, but it wasn’t the optimal one for her.  We had a short discussion which seemed to help.

……………………..

There is much discussion about patients and compliance in taking medicine.  It starts with the physicians, nurse, and pharmacists.  I have to write good instructions.  Sometimes this is difficult to do and keep them short enough to go on the label.

With pain medicines it is nice for patients to know there is a range of effective, safe dosages. 

U.S. Pharmacopeia has proposed labeling standards which can be viewed here. Comments on the proposed standards may be submitted to 17PrescriptionContainerLabeling@usp.org through March 31, 2011.  One of the changes is:

Give explicit instructions—Instructions should clearly separate the dose itself from the timing of each dose and use numeric characters (e.g., “Take 2 tablets in the morning and 2 tablets in the evening” rather than “Take two tablets twice daily”). …

Ambiguous directions such as ‘‘take as directed’’ should be avoided unless clear and unambiguous supplemental instructions and counseling are provided (e.g., directions for use that will not fit on the prescription container label)

First Full Face Transplant in US

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

It continues to amaze me that colleagues are able to do such marvelous work to improve the lives of some.  For Dallas Wiens, 25, the benefits and hope of an improved life outweigh the risks of surgery and rejection (transplant).

He is a construction worker from Ft. Worth, TX who suffered severe burns to his head two and a half years ago when the boom lift he was operating drifted into a nearby power line. The nearly fatal accident left him in a coma for three months.

Related posts
Face Transplantation – First in the US Done (December 18, 2008)
Appearance Is A Function of the Face (December 30, 2009)
More on Facial Transplantation (March 1, 2010)
First Full Face Transplant Done!  (July 12, 2010)
Facial Prosthetics Restores Face (August 5, 2010)
First Full Face Transplant Done! (July 12, 2010)
Facing Monday  (January 24, 2011)

Shout Outs

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

Better Health is the host for this week’s “Emotional Issue”of Grand Rounds! You can read this week’s edition here.

Welcome to this week’s edition of Grand Rounds, the Cliff’s Notes of the medical blogosphere. Each week a different medblogger reads through peer submissions and summarizes/organizes them all into one blog post (using their own unique structure or theme). Instructions for participation (and hosting) are here.

When I host Grand Rounds I like to organize the posts into emotion categories – kind of the way that movies are categorized into “drama, action, comedy, etc.” …... Judging from the volume of posts in each category, it seems that the majority of you are either surprised or outraged!

I organized the submissions by emotion category, and then listed them in order of submission (the first one was submitted earliest within each category). I hope you enjoy meandering through the blog posts with this structure!   .. ……

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A beautiful post by Dr. Wes:  The Wren

It was beautiful sunny early Spring day, a Saturday as I recall. Trips were made to various stores to purchase items for school, then a last minute dash to the electronics store so I could pick up another charger for my cell phone. I ran ahead, my daughter and wife lagged behind, weary from the day's outing - at least so I thought …….

As I reflect of that experience ….., there was much to be learned from the experience of caring and offering compassion, one that mothers seem uniquely gifted at imparting to their children. Mothers are special that way. My mother showed me the importance of caring first-hand, never flinching even when the odds are stacked against you and your tiny aviary friend.   …………….

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I hope you will read these two related posts.  The first is from Bongi, other things amanzi:  The Graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, ….. unfortunately i learned what he meant.  ……

The second one was written by Movin Meat after he read Bongi’s post:  The Graveyard

Bongi is an amazing writer, and if you haven't, I strongly urge you to read his latest post, titled "The Graveyard."

I imagine that a huge number of doctors know exactly what he means. I remember being told by a surgeon, while I was in medical school, that "you're not a real doctor until you've killed someone." I thought at the time (and still think) that there was a puerile bravado behind that admonition, but there is also a grain of truth. I have my own graveyard. Curiously, not all of its inhabitants are dead. They are the cases where I screwed up, or, charitably, cases that went bad where I feel that maybe I could've/should've done things differently.  .…………..

And, yes, I have mine.  I just haven’t managed to write about it.

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Joshua Swimmer, MD puts the radiation issue in perspective in his post:  Radiation Chart  (be sure to click on the chart to view the enlarged version)

There’s a lot of discussion of radiation from the Fukushima plants, along with comparisons to Three Mile Island and Chernobyl. Radiation levels are often described as “<X> times the normal level” or “<Y>% over the legal limit,” which can be pretty confusing.

Ellen, a friend ……suggested a chart might help put different amounts of radiation into perspective, and so with her help, I put one together. She also made one of her own; it has fewer colors, but contains more information about what radiation exposure consists of and how it affects the body.

……I don’t include too much about the Fukushima reactor because the situation seems to be changing by the hour, but I hope the chart provides some helpful context.

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Two related stories from NPR: Old-Time Methods Yield Spring Greens All Winter and Cooking Up Healthy Winter Greens At Nora's  

Wilted Hardy Greens with Garlic

Note: If baby greens (with a 2- to 3-inch leaf) are not available, you may use larger greens (10- to 12-inch), but be sure to remove the tough center rib. Slice the leaves into 1/2-inch to 1-inch strips before cooking.
1 pound mixed baby greens (kale, swiss chard, mustard greens)
1 to 1 1/2 tablespoons olive or sunflower oil
1 to 2 teaspoons chopped garlic
2 tablespoons water, vegetable broth or white vermouth (optional)
Wash the greens and drain in a colander, leaving some moisture on the leaves. Heat a saute pan large enough to accommodate all of the greens over medium heat. Add oil, then the chopped garlic. Saute until softened, about 1 minute, stirring often to prevent the garlic from burning. Add the greens. Toss and saute them until they are wilted. Season with salt and pepper. If too dry, add more liquid. …………

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From Core77 Design Magazine & Resource:  Andrew Myers Screws People to Make Portraits (photo credit) by hipstomp

……….Of course, it never occurred to me that the screw heads could be painted, that the evenly-spaced pegboard holes could be the basis for pixels, and that screws driven to different depths could be used to create depth perception. And that's why Andrew Myers is an artist and I am just a blogger who writes about artists. ……….

Stopping Smoking Before Surgery

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

Physicians and surgeons all agree on the link between smoking and postoperative complications.  We don’t agree (or know) how much time is required between cessation of smoking and surgery for optimal risk reduction.

Dr.Thomas Fiala wrote a nice blog post, Smoking Cessation and surgical complications, recently  discussing the 3rd reference article below.

Smokers that quit smoking before surgery had 41% fewer complications. The researchers found that each week of cessation increases the effect by 19%.

Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).

Smokers that quit had lower rates of total complications, fewer wound healing complications, and fewer pulmonary complications.

The first two articles referenced below were evaluated in an article written by Michael Smith for MedPage Today:  Smokers Who Quit Preop Seem to Do Okay Postop.  Those two articles looked at pulmonary complications not wound healing complications.

There was also no significant benefit or harm when the analysis was restricted to the three studies with biochemical validation of quitting, the researchers reported. The relative risk was 0.57, with a 95% confidence interval from 0.16 to 2.01.

As noted by Clara and Chow (2nd reference, review of 1st reference article) (bold emphasis is mine):

While the review performed by Myers et al provides valuable information, it does not definitively answer the question raise……

Physicians should ideally try to get their patients to stop smoking several months prior to their surgery. The appropriate advice regarding the optimal timing of smoking cessation for patients seen close to their scheduled surgery awaits further research.

I tend to agree with Dr. Fiala who writes, “There is no safe minimum number of cigarettes that you can sneak before surgery. Even a couple can do you in.”

Related posts
Smoking in Facial Aesthetic Surgery Patients (December 28, 2009)


REFERENCES

1.  Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis; Katie Myers; Peter Hajek; Charles Hinds; Hayden McRobbie; Arch Intern Med. 2011;0(2011):archinternmed.2011.97.

2.  The optimal timing of smoking cessation before surgery; Clara K. Chow; P. J. Devereaux; Arch Intern Med. 2011;0(2011):archinternmed.2011.88.

3.  Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis; Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO; The American Journal of Medicine - February 2011 (Vol. 124, Issue 2, Pages 144-154.e8, DOI: 10.1016/j.amjmed.2010.09.013)

Animal Names Word Quilt – WIP

I previewed some of the word blocks for this quilt earlier.  I have now completed the piecing.  Here’s how the top looks.  Now I have to do the quilting.

Here you can see the bear and camel blocks.
Here is the elephant hiding out in the “n”
Here is the gator in the “a”

A Lasting Gift

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

Monday I read with interest the Amednews.com article by Kevin O’Reilly:  1 in 3 Surrogate Decision-makers Carries Lasting Emotional Burden: a new study finds that advance directives ease stress when making treatment choices for others.

"We had always thought about documenting your wishes and knowing what the patient wanted as a protection and a benefit for the patient," said Wendler, head of the Unit on Vulnerable Populations at the National Institutes of Health Clinical Center's Dept. of Bioethics. "This study suggests that there is an additional benefit as a protection for the family. Just leaving decisions up to the family may well be counterproductive and make it harder on the family, not easier."

I and my siblings can attest to the lasting gift our mother gave us.  There is a peace in knowing we followed her wishes when she had the massive intra-operative stroke which ended her life.

She repeatedly over the years told us what she wanted and what she didn’t want.  We are able to discuss it without feeling morbid.  My husband is not.

My dear husband finds it uncomfortable when I want to tell him what my wishes are when the time comes for tough choices.  I tell my siblings and hope they will help him (and me) when the time comes.

I don’t know what his wishes are.  So if I have to make the choices for him, I may in reality be making the choices I would want made.  Because it won’t be clear, there may be conflict between what his family (parents and siblings) would chose verse my choices.

Many of us medical bloggers promote Engage With Grace (a movement aimed at having all of us understand and communicate our end-of-life wishes) over the Thanksgiving weekend.  The Annuals of Internal Medical article (full reference below) reinforces the importance of this discussion between family members. 

I would go so far as to say the discussion should occur between friends as well. 

Having the discussion may become a lasting gift of peace you and I can give each other.

Here are my Five Wishes (pdf file):

1. I would ask my sister (CD) to help my husband (BH) make care decisions for me when I can't.

2. If there is no chance of recovery from the illness, then simple make me comfortable.  Do not do anything and everything.  If there is no chance of recovery from a major trauma, then do what needs to be done to preserve the organs for donation.  If the doctors don’t remember to ask, then tell them.  Donate everything that is usable – this includes the face, the hands, bones, heart, liver, everything.  As I wish to be cremated, it will be nice to know someone is helped.

3. I am not fond of pain, but hate the foggy headedness and nausea I get from the pain medicines I have taken.  If possible find a compromise for me so I can be aware of visitors, listen to music and books, etc.

4. I want visitors who will tell me jokes and stories, who will read books (novels, adventure stories, mysteries, newspapers, etc) to me.  If I am able, I will play cards and checkers with you.  Bring the dogs along.  Watch movies and TV with me.   Cover me with a colorful quilt.

5. I want all of you to know I love you.   Here are My Funeral Wishes.  If we (BH and I) still live at the same house when my death does occur (hopefully years from now), then spread my ashes under the oak tree in back (the one with the wind chimes) where the ashes of Columbo, Ladybug, and Girlfriend reside.

REFERENCE

Systematic review: the effect on surrogates of making treatment decisions for others; Wendler D, Rid A.; Ann Intern Med. 2011 Mar 1;154(5):336-46.

Walking a Dog

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

Earlier this week there was an article in the NY Times by Tara Parker-Pope  --Forget the Treadmill. Get a Dog.  -- which states in a more elegant way what I have been saying for years now. 

……Several studies now show that dogs can be powerful motivators to get people moving. …..

Just last week, researchers from Michigan State University reported that among dog owners who took their pets for regular walks, 60 percent met federal criteria for regular moderate or vigorous exercise. …….

A study of 41,500 California residents also looked at walking among dog and cat owners as well as those who didn’t have pets. Dog owners were about 60 percent more likely to walk for leisure than people who owned a cat or no pet at all. ……..

I have called my dog Rusty my personal trainer.  He never lets me off the hook.  We walk daily regardless of the weather (hot, cold, rain, snow).

I also use a pedometer to remind me to get up and move more.  It it a nice device to motivate me to not sit (& blog, read, knit, quilt) too much.

Here’s a replay of my tribute to Rusty, My Personal Trainer (January 2010)

“Five more minutes,” I tell him as he nimbly places his paws on my knees, brown eyes imploring.
“Okay, you win.” 
Orange ball cap on my head, gloved hands grab the leash.
We exit the gate, the January sun cold as we jog toward the neighbors woods. 
Will there be ducks on the pond today?

In Stitches: a book review

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

I was given the book In Stitches to review.  The book is a memoir written by fellow blogger and plastic surgeon Anthony Youn, MD.

Having lived through medical school and residency, I don’t tend to read memoirs of the experience, so it is not a book a would tend to gravitate towards.

Having said that, I enjoyed reading it.  Dr. Youn has an easy to read writing style.  He tells his story with a lot of humor throw in. 

His Korean father, an ObGyn in Michigan decided his son would be “A doctor. Surgeon.” when his son is only 2 days old.  Dr. Youn goes to medical school for his father, but along the way learns to love the discipline and maintain his humanity.

You can read excerpt from In Stitches  here.  If you love memoirs, if you enjoy reading about the effort it takes to become a physician, if you enjoy good books; then you will enjoy this one.

In addition to the book’s website, there is a Facebook page and a book trailer on youtube.

You can follow Dr. Youn on twitter:  @TonyYounMD

Shout Outs

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

Amy, Diabetes Mine, is the host for this week’s Grand Rounds! You can read this week’s edition here.

The Ides of March is the first day of the Roman New Year. It also marks the first day of spring in the Roman calendar.

On this day in history, Julius Caesar was warned by soothsayers to “beware of the Ides of March”. Apparently, he did not heed the warning strongly enough as he was stabbed by Marcus Brutus on the Ides of March in 44 BC.

We must begin with last week’s betrayal by the forces of nature, as Dr. Paul Auerbach, of Stanford Emergency Medicine, voices our feelings at Heathline:

“Our thoughts and prayers go out to everyone in harm’s way related to the earthquake and tsunami that just struck Japan, as they did for persons in New Zealand, Haiti, and every other country recently affected by a natural disaster.”  ……

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A wonderful post by Michelle Au, the underwear drawer :  it gets better

The lowest point in my residency was in January of my intern year.  I was a Pediatrics resident back then, doing a month-long rotation on "Team 2," which is what we called the general inpatient pediatric team, with a focus on the patients on our liver transplant service.
It was a very long month.…………..

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Via both @movinmeat and @inwhiteink:  Satellite Photos - Japan Before and After Tsunami - Interactive Feature - NYTimes.com

and to @movinmeat:  @arclight this is an excellent, if long/wonky explanation of what happened at Fukushima Daichi nuclear plant Why I am not worried about Japan’s nuclear reactors

New York Times:  100 Photos of Japan Aftermath

…..
If you are looking for ways to help Japan, consider donating to the Red Cross:  Japan Earthquake and Pacific Tsunami Relief
or if you’d rather do so by texting:  Donate to @SalvationArmyUS by texting "JAPAN" to "80888" or text "REDCROSS" to "90999"
Other good sources for information can be found in Thomas Fiala, MD’s post:  OT:  Information on Japanese earthquake & tsunami relief efforts

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Two stories from NPR:

Radiation Fears Rise At Japanese Plant by NPR Staff and Wires

Dangerous levels of radiation are leaking from the earthquake-crippled Fukushima Daiichi nuclear power plant north of Tokyo and levels are rising, Japanese Chief Cabinet Secretary Yukio Edano said Tuesday.

Japanese Prime Minister Naoto Kan ordered everyone within 20 kilometers (about 12 miles) to evacuate. He told everyone within 30 kilometers (about 19 miles) to go inside. Japan's NHK television said most residents inside the 20-kilometer radius have already evacuated.  ………….

Why Iodine Tablets Come Out When Radiation Threatens by Scott Hensley

Just in case, Japan has distributed a whole bunch of potassium iodide to evacuation centers near the troubled Fukushima Daiichi and Fukushima Daini nuclear power plants.

The International Atomic Energy Agency said in a statement that 230,000 units (the stuff comes in tablets and as a liquid) are at the ready.

Why is that important? Well, one of the substances that can be released in a nuclear accident is radioactive iodine (I-131, if you're interested in the details). And some radioactive iodine has already been detected by Japanese authorities.  ……….

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H/T to @globalsurgeon: An interview in IPS News of @ReinouGroen from @SurgeonsSOS on #globalsurgery : Needing Surgery Shouldn't Be a Death Sentence 

Surgery saves the lives of millions of people around the world, but only a tiny percentage of them live in low- and middle-income countries (LMICs), where a shortage of skills, supplies and infrastructure can turn easily treatable accidents and illnesses into lifelong disabilities and even death.

The world's poorest receive only four percent of all major surgical operations worldwide, while 75 percent of surgeries benefit the richest third of the world, according to a 2010 Harvard University School of Public Health study.  …….

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Our medical blog friend, Dr Anonymous, has officially ended his old blog:  Goodbye @doctoranonymous.   He changed his twitter name last week: @drmikesevilla and has revealed his new website/blog:  Family Medicine Rocks. 

Best wishes to you, Dr. Sevilla!

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On a lighter note, this story comes from @KnittingNephron  ---Knitted breasts created by 91-year-old pensioner

You might expect your granny to knit you a woolly jumper, but one pensioner has been defying expectations by using her needles to craft amazing knitted BREASTS.

Coral Charles-Dunne, 91, from Birmingham, has knitted dozens of the unusual educational tools as part of a project to inform expectant and new mums about breastfeeding.

She says spends about two hours creating each of the woolly boobs and makes them in a range of sizes, knitting for up to six hours per day. …………

Melanocyte-Keratinocyte Transplantation (MKTP) Surgery

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

Browsing the news I stumbled across this March 2010 article on ScienceDaily -- Skin Transplant Offers New Hope to Vitiligo Patients.  Though I know a little of vitiligo, I admit I had never heard of MKTP surgery.  Interesting.

MKTP (melanocyt-keratinocyte-transplantation) surgery  is performed in Europe, Asia and Middle East, but not commonly in the United States.  The article noted Henry Ford Hospital is the first to perform the procedure in the U.S. and are using the same technique developed by MKTP pioneer Sanjeev Mulekar, M.D., of the National Vitiligo Center in Saudi Arabia.

MKTP involves harvesting melanocyte cells from an area of healthy skin and separating them to make a skin cell mixture. This mixture is then applied to the treatment area and covered with a specially developed adhesive biologic dressing.  The procedure is done using local anesthesia.

Treated areas included the hands, arms, legs, feet, face and stomach. The average size of the treated area during each procedure covered an area of 46 sq cm, or roughly the size of a credit card.

More Information

Treatment of post-burn leucoderma with non-cultured melanocyte–keratinocyte transplantation (MKTP); Mulekar SV, Issa AA, Eisa AA;  Burns, November 2010; doi:10.1016/j.burns.2010.08.014

More Socks

Dr. Cris tells me I am no longer a novice at knitting socks.  I still feel like a newbie though I am finding them easier and therefore more fun.  I am surprised to find I have finished 7 pairs of socks.  Here are three of those done since Christmas.
This first pair I gave to my sister Jeanne.  They were done using Sunrise Chevron Socks pattern by Carol J. Sulcoski .  I really like that pattern and will use it again.  The yarn is Patons Kroy Socks FX.
This pair I gave to my mother-in-law.  They were done using the Circle Socks pattern by Anne Campbell.   They turned out pretty well. The yarn is Premier Yarns Serenity Sock Weight.
This third pair uses the same yarn as the first pair.  The pattern is Waterloose Socks by Randi Knudsen.  This pair was given to purplesque who found them “mesmerizing.”

Redwork Quilt

I made this quilt for the Alliance for American Quilts 2011 contest.  I just made the deadline which was March 7, 2011.  I almost didn’t make one this year as I was busy with the commissioned 1790 eagle quilt and then a few baby quilts.

The theme this year is:  “Alliances: People, Patterns, Passion,” a broad theme that celebrates cooperative relationships that work towards a common goal.

I knew I didn’t have time to piece and then quilt one.  I remembered this fabric with the scene involving people working together so I decided to do a “whole cloth” quilt and machine quilt it.

The quilt is 16 inches square.

These next few photos are to try to show some of the quilting detail.
I love these pigs.  Not sure why one is wearing what looks like a yoke.
I carefully worked around the fence slats and the window detail.
Here is the back after I added the 4 inch sleeve and before adding the label.

The first year I made a  crazy quilt and last year one I called “Label Me.”

The Economics of Limb Salvage in Diabetes

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

The January issue of the Plastic & Reconstructive Surgery included a supplement:  Current Concepts in Wound Healing: Update 2011.  One of the articles (first reference below) discusses the economics of limb salvage in diabetes.  An important topic.

Consensus panels have recommended that optimal preventive foot care should include education of the patient and health care workers, therapeutic shoes and insoles, and regular foot care as part of a multispecialty program.

After their initial introduction, the authors broke down their article into the following sections (bold emphasis is mine):

Cost and Impact of Prevention

…..In contrast, Ortegon et al. did not report results based on risk groups. These authors reported an improvement in quality-adjusted life-years and costs for all groups combined. The incremental cost-effectiveness ratio (1999 U.S. dollars) was $12,169 to $220,100 per quality-adjusted life-year gained, depending on the estimated effectiveness of ulcer prevention. The cost-effectiveness increased as the effectiveness of prevention increased. In the model of Ortegon et al., optimal foot care was only cost-effective if greater than 40 percent of foot ulcerations were prevented.

Cost of Diabetic Foot Ulcers

The average cost of diabetic foot ulcer treatment ranges from $3609 to $27,721.  …….

A small percentage of foot ulcers account for the majority of health care costs. For example, 9 to 20 percent of diabetic foot ulcers require hospitalization.  The major cost in treating diabetic foot ulcers is inpatient care, accounting for 74 to 84 percent of total costs.

Cost of Wound Technology

Many of the studies that compare the cost of new technologies for diabetic foot ulcers are sponsored by industry …..

There are two bioengineered tissue products that are U.S. Food and Drug Administration approved. Dermagraft (Advanced BioHealing, Westport, Conn.) is tissue-engineered human dermis, and Apligraf (Organogenesis, Inc., Canton, Mass.) is a bilayered product of dermis and epidermis. Both products are designed for multiple applications. Therefore, the expense of therapy is increased because of repeat treatments, but the cost-effectiveness is enhanced by reductions in costly complications such as infections and amputations. …..

The projected average yearly costs for Dermagraft were 15 percent higher than treatment of patients with good wound care; however, the cost per healed diabetic foot ulcer was less than with good wound care ($77,703 versus $73,380 converted from euros using historical exchange rates for 2007). …..

Negative-pressure wound therapy ……….The average direct costs of patients who were treated for at least 8 weeks was $27,270 for patients treated with negative-pressure wound therapy and $36,096 for patients treated with good wound care. The biggest differences in the cost of care were attributable to hospitalization ($7823) and treating infections ($15,749).  ……….

Cost of Peripheral Vascular Disease

…….It has been debated for years whether a primary amputation or revascularization procedure is more cost-effective. The rationale for early amputation assumes that the patients will be able to rehabilitate with a prosthetic and walk independently. For many patients, this is not true. Among unilateral amputees with vascular disease, successful rehabilitation is achieved in 47 to 66 percent of patients.   Several studies suggest that the cost of revascularization is less than or similar to amputations when the costs of rehabilitation and prosthetic limbs are included. For instance, Raviola et al. and Mackey et al. reported that the cost of amputations was $24,700 and $26,142 and the cost of revascularization was $23,500 and $27,081 in 1985 and 1984 U.S. dollar values, respectively.

Postoperative complications, revisions, and length of hospitalization are the primary expenses in revascularization. Raviola et al. reported that the average cost of uncomplicated revascularization was $20,300. The cost of graft revision was 41 percent higher ($28,700), and when bypass failed, the cost of amputation was $42,200. ……….

Interventions for Peripheral Vascular Disease

Revascularization of the lower extremity entails two areas of treatment: endovascular interventions and open surgical revascularization. The cost effectiveness of these procedures involves the cost of the initial procedure, the need for revisions, and the long-term success of the procedures. Lombardi et al. found endovascular procedures to be safe and cost-effective when performed in an outpatient setting. This creates immediate cost savings over open procedures. The length of stay for open procedures ranges from 3.9 to 7.4 days. ……..

Revascularization of the foot through a pedal artery may not always be possible with endovascular techniques; thus, the cost comparison is not appropriate for many limb salvage patients with diabetes.

Their conclusion:

More research is needed in this area, for several reasons. There are very few prospective data that evaluate the cost of limb preservation in patients with diabetes and lower extremity complications. Also, most of the data are based on models sponsored by the wound care industry, and much of this information is 10 years old or more. Finally, technological advances have changed what treatment costs and what we consider appropriate therapy. To understand the cost-effectiveness of limb salvage, the actual costs need to be evaluated as part of randomized clinical trials or prospective longitudinal studies that eliminate narrow inclusion criteria often seen in phase III clinical trials.

 

REFERENCES

The Economics of Limb Salvage in Diabetes; Hunt, N. A.; Liu, G. T.; Lavery, L. A.; Plastic & Reconstructive Surgery. 127():289S-295S, January 2011; doi: 10.1097/PRS.0b013e3181fbe2a6

Discussion: The Economics of Limb Salvage in Diabetes; Driver, Vickie R.; Yao, Min; Plastic & Reconstructive Surgery. 127():296S-297S, January 2011; doi: 10.1097/PRS.0b013e318203a47c

ALCL and Breast Implants – an article review

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

In light of the recent new regarding the FDA safety alert on the possible association of acute large cell lymphoma (ALCL) with breast implants, the authors of the recently Plastic and Reconstructive Surgery Journal article (full reference below, published online ahead of print) conducted a systematic literature search on the topic.

The search included the literature of PubMed, Embase, and Web of Science (Science Journals & Proceedings) databases.  Dates searched included references from 1966 for PubMed and Embase ; from 1980 for Web of Science; and from 1990 for Web of Science Proceedings, through July 2010 for all of them.

Research (categorized as epidemiologic studies or scientific papers) and non-research (case reports or case series) articles from peer-reviewed journals, conference abstracts, and unpublished manuscripts were retrieved from the literature search.

Only human-based topics and articles written in English were considered. Of the initial 884 titles, 83 articles discussed ALCL and breast implants. Fourteen additional articles were provided by 2 expert plastic surgeons (V.L.Y. and K.C.C.).

Their conclusions:

A form of ALCL, which clinically behaves more like the less-aggressive cutaneous form of ALK-negative ALCL rather than the more-aggressive systemic form, may be associated with breast implants. Future research on the epidemiology and biology of this rare disease is clearly needed to better understand its nature.

What is conclusive:

• ALCL is a rare disease, comprising 2% of all newly-diagnosed non-Hodgkin’s lymphomas (NHLs) worldwide2 and 0.9% of the estimated 65,540 cases of NHL diagnosed in the U.S. in 2010.
• Lymphomas of the breast are extremely rare, comprising 0.04-
  0.5% of all breast cancers and approximately 1-2% of all extranodal lymphomas.
• Despite the rarity of both ALCL and primary breast lymphomas, multiple cases of ALCL developing adjacent to breast implants have been reported, including by Brody et al., who have recently presented but not yet published a series of 34 cases.
• In 2009 alone, a reported 289,328 breast augmentation, 86,424 reconstruction, and 87,386 lift procedures were performed in the U.S.; unfortunately, the exact number of women who received implants is not known because only some breast reconstructions and lift procedures utilized implants.

The literature review noted the case presentation characteristics (bold emphasis is mine):

Fourteen (48%) of 29 ALCL cases were noted to have presented with a seroma, 1 (3%) ALCL case did not present as a seroma and data was not reported in the remaining 14 (48%) ALCL cases.

Seven (24%) of the 29 ALCL cases reported data indicating that the patient had a palpable breast mass on presentation, 5 (17%) reported absence of a mass and information was missing for the remaining 17 (59%) ALCL cases.

Less frequently cited symptoms among ALCL cases were pain [6/29 (21%], redness [4/29 (14%)], and capsule contracture [2/29
(7%)].

Other symptoms (e.g., skin lesions, fever) were reported in only 2 (7%) of 29 ALCL cases but in 5 (71%) of 7 patients with other NHLs [not reported in 27/29 (93%) ALCL and 2/7 (29%) non-
ALCL cases].

Duration of symptoms was rarely noted. In the 7 cases where it was, mean duration in years for ALCL cases was 0.8 (range 0.2-1.7). Mean symptom duration among 5 non-ALCL cases for which it was reported was 5.4 years (range 0.5-17).

…..
Remember the FDA report noted (bold emphasis is mine):

ALCL is a very rare condition; when it occurs, it has been most often identified in patients undergoing implant revision operations for late onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.

…..
Of interest is this post from Maggie Mahr:  The FDA “Has a Chat” With Plastic Surgeons

………….It is probably not a coincidence that ASPSS and ASAPS repeated the cancer-denial line first promulgated by Allergan: Both organizations have received funding from the company. ASPSS has also received funding from Allergan’s main competitor, J&J, which makes the Mentor implant line. (Mentor’s reaction to the FDA warning was more muted than Allergan’s but its statement also avoided mentioning the C-word.)

Both Allergan and J&J fund provide funds for ASPSS, as noted on its web site.

At ASAPS, Allergan’s funding is more indirect. It has supplied research grants through ASAPS’ research arm, the Aesthetic Surgery Education and Research Foundation. You can see those grant award announcements by searching for “Allergan” here.

The two groups ought to be ashamed of themselves. It is one thing to take funding from drug and device companies . .  . . But the groups ought to represent the medical expertise of the healthcare providers who are their members, not the PR agendas of two companies who are afraid they may lose money from too much blunt but accurate talk about breast cancer.

Previous related posts:
ALCL and Breast Implants (January 31, 2011)
Breast Implants and Lymphoma Risk (June 29, 2009)


REFERENCE

Anaplastic Large Cell Lymphoma and Breast Implants: A Systematic Review; Kim, Benjamin; Roth, Carol; Chung, Kevin C.; Young, V. Leroy; van Busum, Kristin; Schnyer, Christopher; Mattke, Soeren; Plastic & Reconstr Surgery., POST ACCEPTANCE, 25 February 2011; doi: 10.1097/PRS.0b013e3182172418

Shout Outs

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

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

This week for Grand Rounds I asked for submissions of the best work from blogger’s sites in the last week or two, and promised to judge them on Olympic scoring of 0-10.   I also asked readers to submit posts from blogs other than their own (these have a *** after the score), and to agreed to give these submissions extra credit in the scoring.  …….  Thanks for your submissions, and keep up the great work.

Gold Medal for Content goes to  John Goodman’s Health Policy Blog he writes The HMO in Your Future.  He takes to task the march towards ACO’s and suggests that this is far from evidence based.  We do seem to be moving quickly towards ACO’s whatever that really means.   Check out this post at least to hear Aretha Franklin sing I Say a Little Prayer.  ……

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 17 & 18)! You can find the schedule and the COS archives at Emergiblog.

Welcome to Change of Shift, the Double Edition!

Between traveling and the ENA Leadership Conference, the last edition Change of Shift was, shall we say, delayed. That’s the bad news.

The good news is I’m combining last week’s CoS edition with this week’s edition.

Be sure to read to the end for an important notice about the future of Change of Shift.

Let’s get started!
**********
Running Wildly pens a post probing the weaknesses in the Bullet Proof armor we use to protect our emotions at work.  ……………

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I am fascinated by story of Grant Achatz. He is a chef who was unfortunate enough to be diagnosed with stage 4 tongue cancer in 2007. In an effort to save his sense of taste, he chose to have chemotherapy and radiation rather than surgery. Even so, the radiation treatments burned his tongue and completely destroyed his taste buds. Go listen and read his interview with NPR --- Grant Achatz: The Chef Who Lost His Sense Of Taste

……Achatz's cancer is now in remission. After his treatment ended, his ability to taste came back — but slowly. His perception of different flavor combinations — sweet, salty, bitter — came back one flavor at a time.

"I started from zero, and the first thing back was sweet," he says. "So my palate developed just as a newborn — but I was 32 years old. So I could understand how flavors were coming back and how they synergized together. ... It was very educational for me. I don't recommend it, but I think it made me a better chef because now I really understand how flavor works." ……….

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I caught this story last week on the ABC evening news and was really impressed by the community who all joined in to help save this man: CPR Marathon: More Than Two Dozen Responders Resuscitate Neighbor for 96 Minutes

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Movin Meat has passed his donation goal of $15,000 for St. Baldrick’s, but if that doesn’t mean your donation wouldn’t be welcome.  I made a small donation, but would love to make a larger one if someone would like to help me help Movin Meat and  purchase this quilt.   Send me an email if you’d like to purchase it, but would like the tax write-off.  We’ll work out the details.

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A  team from Arkansas Children’s Hospital led by Dr. Lisa Buckmiller is on a trip to Kenya.  Their blog Change of Face – Bridging the Gap is chronically the trip. 

CO2 Laser Use

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

Over the past couple of months there have been a few good commentary articles on the use of CO2 laser us. 

The first one referenced below is a commentary by Dr. Scott J. Trimas on the treatment of facial acne scarring using CO2 laser abrasion.  He references his article from 10 years ago (2nd reference).  Full references are given to both articles below.

Over a 10 year period, Dr. Trimas, did 54 additional patients not included in his first article (the 2nd reference below) using full-face CO2 laser treatment for facial acne scarring. Their ages ranged from 16 to 74 years. Of those patients reviewed, 8 were male and 46 were female. He notes this population was similar to that of the original study. Most patients were followed for up to 2 years.

Dr. Trimas writes “notable improvement can be achieved with the use of the carbon dioxide laser, especially in the areas of the forehead, medial cheeks, and perioral region. Lesser improvement is noted in the areas of the lateral cheeks and temples. Nevertheless, substantial improvement is achieved in all areas.”

He also adds that one of the most substantial changes he has made is the addition of surgical excision of ice-pick scars prior to the laser resurfacing procedure. He performs the excision of the ice-pick scars at least 6 weeks prior to carbon dioxide laser abrasion.

The rationale for this excision technique was that some of the areas of the face did not seem to improve enough with just resurfacing, and I felt that ice-pick scars may have been the contributing factor. In fact, most ice-pick scars that were punch excised were in the lateral cheek regions.

That makes sense to me, as ice-picks scars are often too deep to be adequately treated by resurfacing procedures (laser or chemical peel) alone.

…..

The other recent article (third reference below) covers the use of CO2 laser for more than simply acne scarring.  It was published in the February 2011 issue of the Plastic Surgery Practice.  In the article, Dr. Joseph Niamtu III, discusses his use of the CO2 laser, giving practical tips – both the traditional ablative and the newer fractional lasers.

Take for example his notes on “Postlaser Wound Care—Past and Present”

If there is one drawback in employing traditional CO₂ ablative laser resurfacing, it is the area of postlaser wound care. It adds extra layers of work (and sometimes frustration) for the patient, surgeon, and staff. If the process and experience of postlaser wound care could be ultimately simplified, the promoting of traditional CO₂ treatments would be much easier.

I know several experienced laser surgeons who have abandoned the procedure because of the intensity of the wound care and the hand-holding required to get the patient through it successfully.

Inducing an intentional and controlled second-degree facial burn removes the entire epithelium and part of the dermis. This is obviously a giant insult to the normally intact integument. Patients who undergo fully ablative, high-fluence, high-density, multipass CO₂ laser resurfacing have to understand in the preop period that this treatment will be their hobby for 4 to 6 weeks. I am very blunt with my patients who are considering this type of laser treatment, and I do not sugarcoat the recovery.

Incidentally, for new practitioners, understating a recovery from laser treatment—or any procedure, for that matter—can really come back and bite you in the foot. In an era of new "miracle" treatments and surgeries emerging daily, some surgeons feel compelled to downplay the patient-recovery phase of treatment in hopes of "selling" a procedure. There is no better way to infuriate a patient then to tell them that a 2-week recovery is 1 week, etc. Not only does it upset them, it can cost them in other ways, such as missed work and other scheduled events, and disrupt family life in general.

I tell my patients that they won't like me for a week, that they will need about 2 weeks before they can get back in makeup, and that they will be pink for several more weeks. If I tell them the recovery is 14 days and it takes only 10 days, I am a hero. If I tell the inverse, I am a zero.

Understating a recovery is unethical and promotes negative marketing. I have seen too many instances in which a physician says 1 week for a 2-week recovery, then tries to squirm out of it by blaming the patient for "not healing well."

I really appreciate how he is blunt with his patients regarding the recovery.  Patients need to hear this along with the expected results and risks.

REFERENCES 

1.  Facial Acne Scarring:  Ten Years of Treatment With the Carbon Dioxide Laser (Commentary); Trimas SJ; Arch Facial Plast Surg Jan/Feb 2011 2011;13(1):62-64.

2.  Carbon Dioxide Laser Abrasion: Is It Appropriate for All Regions of the Face?; Trimas SJ, Boudreaux CE, Metz RD;  Arch Facial Plast Surg. 2000;2(2):137–140, pmid:10925440

3.  Confessions of a Master Blaster:  How to use CO2 laster in a cosmetic facial surgery practice; Niamtu III, Joseph; Plastic Surgery Practice, February 2011

Word Play Quilting

You may recall the eye words quilt I made last year and the “Hope quilt” I did for Intueri to help her raise money for Multiple Sclerosis Society.  I ventured into word quilts after finding Lazy Gal Quilting blog.

Recently I bought her book (Word Play Quilts) and decided to make a block for her bah humbug quilt.  My way of thanking her.  Here is the block I made and sent to her:

Here is a close up of the “bug” part.

The activity spurred me to begin working on my next word play quilt which I have been thinking about since the eye words quilt.  This one will be for my dog’s veterinarians (a husband and wife practice).  I meant for it to be composed of only domestic animals but lost to fabric in my stash. 
I really love the dog block.
I have been surprised by the number of animals I have found in my fabrics. 
Anyway, this quilt is a work in progress.  Not sure yet on which animals will make it in but enjoying the work/play.

Double Wedding Ring Quilt

I made this queen sized double wedding ring quilt for some good friends.  The quilt was meant to be a swap.  I was to make a quilt.  She was to make a wool rug for me.  I never got my rug as she broke her wrist and then got side-tracked by their first baby.  Oh, well, I still love them both.

I hand pieced this quilt, then had my friend Scottie Brooks do the hand quilting.  It was finished in 1997.  I am thankful to my friend for taking these photos for me.
The colors are red, green, purple, and cream.
Here is a photo of the back.

Bartering for Medical Care

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

Earlier this week there was an article in my local newspaper (subscription only for full access) on a family physician in Bono, Arkansas who takes chickens as payment:  Bartering for Care – House calls’ a trade-off.

In lieu of payment, patients at the Bono Barter Clinic can exchange a variety of things such as produce or labor for medical services on Thursdays. House devotes the other four days of the workweek to his regular family practice - the House Medical Clinic - both practices in a former church along U.S. 63 between Bono and Jonesboro.

Of note is that this is 20% or less of his workweek, as the bartering only takes place on Thursdays.  As we all know, our utilities don’t allow us to pay via bartering.  Neither do the medical supply companies we purchase syringes, needles, drugs (ie lidocaine, vaccines, etc), and bandages from.

Still I do commend Dr. John House.  He is strict about certain rules which is also important to note.  The barter clinic won’t submit a bill to your insurance if you happen to have coverage.  Nor will they prescribe narcotics.

KAIT.com has a full access story:  Medical clinic allows patients to barter for care

……

An amednews story from Jan 12, 2009 noted:  Trading for treatment: Bartering makes a comeback.  The article discusses the rules of bartering which will keep the IRS happy and makes suggestions to make bartering work for your practice.

• Have a willing business partner. 
• Find the right trade partner.
• Keep your percentage of barter patients low.
• Have an agreement in writing.
• Make sure values are equal on both sides of the trade.
• Follow Medicare rules.
• Follow IRS rules. 
• Keep good records.

Rebuilding the Face Injured by War

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

Monday I happened to catch the NPR segment by Terry Gildea:  Rebuilding The Faces Of War 

And now, a story about the effects of war and violence in a different part of the world and how specialists are learning from it. The wars in Iraq and Afghanistan have created a need for innovative treatments for severe battle wounds. Service members often suffer injuries that disfigure and even eliminate parts of their face. At a Defense Department clinic in Texas, surgeons are restoring missing facial features and in a way they're restoring the identities of the wounded.

Texas Public Radio's Terry Gildea takes us to the clinic at Lackland Air Force Base in San Antonio. …

He's now working with doctors at the Maxillofacial Prosthetic Clinic at Wilford Hall Medical Center. Today his anaplastologist, Nancy Hanson, is fitting him with a new set of ears. …………..

……

The story notes that the Department of Defense has two such clinics.  It mentions  Lackland Air Force Base in San Antonio, TX but didn’t specify the other.  It took some “googling” but I finally found an article that mentioned the other one:

The maxillofacial prosthetics program is only one of two such programs in the Defense Department, said Col. (Dr.) Alan Sutton, the program’s director. The other program is at the National Naval Medical Center in Bethesda, Md., he said.

While looking for the second clinic, I found this 2008 article on Air Force Senior Airman Justin Jones who at the time was a maxillofacial prosthetic technician with 59th Dental Squadron here.  His job was to help service members who have suffered disfiguring facial injuries.  [Face of Defense: Airman Helps Injured Warriors 'Face' World]

and this article from August 3, 2010:  Air Force dental team helps patients ‘face’ the world, also featuring the MacKown Dental Clinic, which explains the process:

………Often most important to the patient is the restoration of function – speech, chewing and swallowing — in cases where injury or cancer to the mouth or jaws has occurred.

The team’s first step frequently starts in the stereolithography lab, located at MacKown Dental Clinic, which is one of only two located in the DoD.

Stereolithography is a rapid prototyping method, which allows the fabrication of anatomically accurate, three-dimensional epoxy and acrylic resin models from various types of medical data. There are myriads of data formats that can be assimilated, some of which include those from computed tomography, magnetic resonance imaging, and optical scanners.

“I can take a CT scan of a burn patient’s head and create an exact replica so our anaplastologist can build replacement ears and noses that will fit perfectly,” said Mr. Dave Carballerya, stereolithography lab supervisor. “This technology is also used to incorporate dental and craniofacial implants to enhance the doctors’ diagnosis and treatment planning.”

The team’s anaplastologist then works to create facial prosthetics for the patient.

Anaplastology is the art and science of restoring a malformed or absent part of the human body through artificial means. Again, Lackland is unique in that MacKown Dental Clinic employs the only certified clinical anaplastologist in the DoD, Ms. Nancy Hansen.

“Our patients are going through the traumatic experience of missing anatomical features,” said Ms. Hansen. “We get to see them blossom because they are given hope.”

Ms. Hansen begins by making an impression of the area of the missing anatomy. Prosthetic noses, ears, jaws, even eyes can be made with silicone or hard resin. Many steps are taken to give the prosthesis a realistic look.   …………