Four Friends

Updated 3/2017--all links removed as many no longer active.

I wish I had @zdoggmd talent, perhaps I ‘d have a better title with a play on say “3 men and a baby.”  Three of these friends are women with breast cancer, the other is a man with pre-Alzheimer's.   All have/are facing their diagnosis and life with amazing grace and strength.  All are raising money for their causes.  I want to share their links.

Two are local friends who are doing the local Race for the Cure and  raising money for Susan G. Komen.

Noor Kabani, MD works for Baptist Medical Center in their eICU.  Baptist put together Team Kabani for her.  Here is the link to join her team or donate in her name.

Heather Owens is the daughter of two friends, one a local ED physician.  I went to her wedding a few years back.  She is just 29 yr old.  She is writing about her journey with breast cancer at Fighting Fancy.  She is featured in the October 2012 issue Soiree magazine.  Her Race for the Cure team is Fighting Fancy (click on link to join her team or donate in her name).

The third woman is the wife of one of our medical bloggers.  I have not meet her in person, but have made quilts for two of her children and given her one.  She is doing “Making Strides for More Birthdays” and raising money for American Cancer Society.  Click here to join her team or donate in her name.

My fourth friend, DeWayne Nash, is a friend from medical school.  He lives near Austin, TX and is a retired Family Medicine physician.  His blog is Organic Green Doctor.  He is doing Walk to End Alzheimers (click on the link to join his team or donate in his name).  Here is a  link to the video   which features he and his wife, showing their involvement at the Alzheimer's Disease Center.

One Pink Heart Quilt

This quilt was made for a young friend recently diagnosed with breast cancer.  When I asked what color she would like her quilt to be, she said white.  Then she suggested a single pale pink heart in the center.  I honored her color choices but the heart is place slightly off center.  The quilt is not a true whole cloth quilt but has that look.  The center is a 30 in X 42 in piece of plain white fabric quilted as if it where made of 6 in blocks.The border is of white-on-white striped fabric with mitered corners.

The quilt is machine pieced and quilted.  The heart is hand appliqued.  The quilt measures 46 in X 57 in.

This next photo shows the pink heart and quilting a litter better.

This photo shows the border quilting.

Shout Outs

Updated 3/2017--photos and all links removed as many no longer active. 

Paul Ware, Life with Huntington's, is (suppose to be) the host for this week’s Grand Rounds. You can read this week’s edition here.

Next week’s host is Dr. Rob (@doc_rob): What’s Grand and Round and Comes in an RSS Feed?

……To submit your GR post for next week’s GR, fill out the attached submission form. I must have submissions in before Sunday, March 4th at 6 PM EST……

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H/T to @jilltomlinson who asks.

Was this 27yo man's life lost in ill-conceived race to perform "World 1st" surgery? bit.ly/x2bGEJ #retrospectoscope

The link is to this Mai lOnline article: Man, 27, who had world's first quadruple limb transplant dies days after operation.

A 27-year-old Turkish man who underwent the world's first would-be quadruple limb transplant died yesterday, hours after the limbs were removed due to metabolic failure, the hospital said…….

I thought it was too risky when I first heard about the transplant prior to them having to later remove the limbs. We are certainly pushing the limits with transplants these days with double hand, face, multiple organ, etc.

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From Letters of Notes a letter that gives a glimpse of breast Cancer in 1855. This woman had surgery with no pain meds: 'Deep Sickness Seized Me"

In September of 1855, Lucy Thurston — a 60-year-old missionary who had been living in Hawaii with her husband since 1820 — underwent a mastectomy after being diagnosed with breast cancer. Incredibly, she somehow endured the operation wide-awake, without any form of anaesthetic. She wrote the following letter to her daughter a month later and described the unimaginably harrowing experience.

The procedure was a success. Lucy Thurston lived for another 21 years………………

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From @Skepticscalpel comes a post with his take on the survey in the Archives of Surgery: Surgeons and alcohol abuse.

“Prevalence of alcohol use disorders among American surgeons” appeared in the February, 2012 issue of Archives of Surgery.

A survey of 7197 surgeons, all members of the American College of Surgeons [ACS], had a 28.7% response rate and revealed that 15.4% had scores on an alcohol use assessment test that indicated abuse of or dependence on alcohol. This is consistent with the rate of such alcohol problems in the general public…………….

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VIDEO: Kyle Dyer, 9NEWS anchor, interviews with the Denver Post

Channel 9 news morning anchor Kyle Dyer talked to the Denver Post on Wednesday, February 23, 2012, about the injuries she sustained from a dog bite and her road to recovery.……. Video by Mahala Gaylord

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H/T to @impactednurse ‏for this tweet:  “Very cool. Federico Carbajal's anatomical sculptures made with galvanized wire: bit.ly/yRSvFk”

Shout Outs

Updated 3/2017--photos and all links (except to my own posts) removed as many no longer active. 

Dr. Jen Dyer, Endogoddess, is hosting this week’s Grand Rounds.   You can read this week’s edition here.

I am a total news junkie and always have been (which is probably why I started out college as a journalism major before deciding that I wanted to be a doctor). So, this week's edition of Grand Rounds features the news themes of the prior week and their relationship to health: politics, football fever, the power of facebook, red heart disease awareness, and the impact of pink. ...….

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Head’s up:  @drjohnm is asking for posts for next week’s edition of Grand Rounds which he will be hosting.  Here’s his tweet:

Dear Med Bloggers: Please send me your posts for the Valentine's day version of @grandrounds http://ow.ly/8Xmze

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Updated 3/2017--photos and all links removed as many no longer active. 

Thank you @tbtam  for the information in your post:  Alternatives to Komen for Channeling Your Dollars & Energy to Fight Breast Cancer:

One option, of course, is to give to Planned Parenthood, The other option is to donate to one of the other charities on the front lines in the battle against breast cancer. Komen, after all, is not the only game in town.

Here are a few other places where your dollars will be put to good use fighting breast cancer. All of the following groups get high ratings from the American Institute of Philanthroy and/or Charity Navigator-……..

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White Coat is attempting to shine light on the issue of Amanda Trujillo: 

I finally took the time to read some other blogs today. One of the issues that I found disturbing was the case of Amanda Trujillo…………….

I’ve tweeted to Amanda to contact me …..

I’ll request the patient’s permission for release of the patient’s medical records from the hospital. ….

And I’ll get the name of the surgeon who allegedly does not take the legal doctrine of informed consent too seriously and who allegedly uses temper tantrums as a means to bully people into submission. Maybe we can look into his background a little. If he did have a “tantrum” in a patient care area, has the hospital investigated him for his conduct?

Everything will be published here.

And if ends up that Amanda was wrong for what she did I’ll publish that as well.

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A New York Times article by Melissa Greene:  Wonder Dog

In May 1999, Donnie Kanter Winokur, 43, a writer and multimedia producer, and her husband, Rabbi Harvey Winokur, 49, beheld the son of their dreams, the child infertility denied them.  ……………..“Sometime after their 3rd birthdays, our wonderful fairy tale of adopting two Russian babies began to show cracks,” said Donnie Winokur,……….

For children with autism or behavior disorders, dogs were trained in “behavior disruption.” For children with seizure disorder or diabetes or respiratory issues, dogs were trained to alert the parents at the onset of an episode, and there have been a few able to predict the medical incidents 6 to 24 hours in advance. (How they do this is something of a mystery.)…………..

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Dogs are so cool! in my humble opinion.  There’s the above story and then there’s this one I heard tonight on ABC Evening News which made me think of my three dogs who died of cancer.  I actually called a drug company way back when to see if she qualified for a drug trial.  There was no registry then.  Oh well.  Here’s the story:  Canine Cancer Studies Yield Human Insights

Some of the most promising insights into cancer are coming from pet dogs thanks to emerging studies exploring remarkable biological similarities between man and his best friend.

Cancer is the leading cause of death in dogs. Every year, millions of dogs develop lymphomas and malignancies of the bones, blood vessels, skin and breast……………….

Jack Sevey Jr. created the website MyCancerPet.com in January 2011 after his 5-year-old boxer Bull died from T-cell lymphoma. Sevey wanted to create an online community for fellow owners of cancer-stricken pets and also steer them to helpful resources. Those include lists of clinical trials compiled by several organizations: the AKC Canine Health Foundation, Animal Clinical Investigation, the National Cancer Institute's Center for Cancer Research, the Morris Animal Foundation and the Veterinary Cancer Society……………..

Prophylactic Mastectomy in BRCA Carriers: Can the Nipple Be Preserved? (an article review)

Updated 3/2017 -- photos and all links removed as many no longer active.

The entire article is available via open access (full reference below).  Women with the BRCA gene (both 1 and 2) often elect to have prophylactic mastectomy to reduce their risks of developing breast carcinoma.  This is even more so for the contralateral breast when a primary is found.  Skin-sparing mastectomies (SSM) and nipple-sparing mastectomies (NSM) greatly improve the cosmetic results for women undergoing reconstruction.  Traditionally, the NAC has been removed due to concerns of possible tumor recurrence or development of a new primary in the remaining breast tissue of the NAC. 

The article notes "numerous retrospective studies have shown a wide range(0-58%) of nipple involvement by tumor in mastectomy specimens." 

This retrospective study involves a small cohort of 33 patients (25 BRCA1, 8 BRCA2) who underwent mastectomy between March 1987 and June 2009 treated at Mayo Clinic.  The entire nipple-areolar complex (NAC) was excised and evaluated histologically.  There was a total of 62 NACs available for evaluation. [TDLS = terminal duct lobular units]

Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct..

They conclude the probability of premalignant or malignant lesions in the NAC of BRCA carriers is low overall.  It must be remembered that it is higher (10%) in the subgroup of women undergoing therapeutic mastectomy.  It may be safe for select women with BRCA mutations to have a nipple sparing procedure, but she and her physicians (oncologist and surgeon) should have a frank discussion about her individual case.

REFERENCE

Prophylactic and Therapeutic Mastectomy in BRCA Mutation Carriers: Can the Nipple Be Preserved?; Carol Reynolds, Jennifer A. Davidson, Noralane M. Lindor, Katrina N. Glazebrook, James W. Jakub, Amy C. Degnim, Nicole P. Sandhu, Molly F. Walsh, Lynn C. Hartmann and Judy C. Boughey; Annals of Surgical Oncology Volume 18, Number 11, 3102-3109, DOI: 10.1245/s10434-011-1908-8

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Laika,  Laika's MedLibLog, is the host for this week’s Grand Rounds. You can read this week’s edition here.

Welcome to the Grand Rounds, the weekly summary of the best health blog posts on the Internet. I am pleased to host the Grand Rounds for the second time. The first time, 2 years ago, was theme-less, but during the round we took a trip around the library. Because, for those who don’t know me, after years of biomedical research I became a medical librarian. This also explains my choice for the current theme:. ………….

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Margaret Polaneczky, MD, TBTAB, explains Emergency Contraception is NOT an Abortifacent

When patients ask me how emergency contraception prevents pregnancy, I tell them that it’s primary mechanism is to delay ovulation (release of an unfertilized egg from the ovary).  There is no evidence that the EC aborts or prevents implantation of an already fertilized egg.

The efficacy of EC depends on where you are in your menstrual cycle when you have unprotected sex. …..

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H/T to @MtnMD for the link to the NY Times visual guide to the euro debt crisis:  It’s All Connected: An Overview of the Euro Crisis (interactive visual guide).

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H/T to @MedicalNews for the link to CNN article by Elizabeth Landau: When your cancer nurse has cancer, too

When new patients worry they don't know how they'll get through breast cancer, Cindy Davis puts her hand on theirs and says, "I know, but I want to tell you, I truly know, because I went through this two years ago."

"Their eyes light up and they go, 'Whoa. Really?'" says Davis, 54. "Suddenly, I'm a human being. I'm not just the nurse." ……….

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Check out this NY Times piece by Jane Rosett, an artist and a brain injury patient at Spaulding Rehabilitation Hospital:  Starting Again After a Brain Injury

“WANT a piece of gum, Jane?” asked my friend Andrée.
“What?” I asked her.
“Gum!”
I didn’t know what she was talking about.
“It’s Trident.”
It was delicious.
That evening, I told my friend David about my day’s big discovery. “It’s called gum and you chew it and it’s fun and there’s this one kind that will let me blow bubbles!”
“Yes, it’s called bubble gum, Jane,” he told me, patiently. …………..

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H/T to @ctsinclair for the LifeHacker piece:  Carve and Preserve the Ultimate Pumpkin

Halloween is just around the corner; it's the perfect time to brush up on your pumpkin carving skills and learn how to make sure your masterpiece looks as good for the trick-or-treaters as it did the day you carved it……...

Here’s mine from last year post on Safe Pumpkin Carving

My Review of Lifetime’s Movie: Five

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active.

I caught this movie last week flipping though channels looking for something to watch while I knitted. 

"Five" stars Patricia Clarkson, Rosario Dawson, Lyndsy Fonseca, Ginnifer Goodwin, Josh Holloway, Tony Shalhoub, Jeffrey Tambor, and Jeanne Tripplehorn.  It is an anthology of five short films exploring the impact of breast cancer on people's lives.

The first one, the story of Charlotte (Ginnifer Goodwin), is set in 1969.  Charlotte lays dying in her bedroom while the family mills around the house and the TV showing the mans first step on the moon.   Her story for me was taken over by the affect of her cancer on her young daughter Pearl who only wants to see her mom.   Finally she manages to sneak into the room.

The second one is Mia’s story.  Mia (Patricia Clarkson) is the tale of someone who beats the odds.  She was expected to die and even held her own mock funeral.  Her segment begins with her second wedding and flashes back through the chemo, the hair-loss, her first husband walking out on her, her “mock” funeral, etc.

The third one is Cheyanne’s story.  Cheyanne (Lyndsy Fonseca) is a 24 year old exotic dancer.  This one also focuses on how the diagnosis affects the husband Tommy (Taylor Kinney).  Very emotional.

The fourth is Lili’s story.  Lily (Rosario Dawson) is a successful career woman who recruits her sister to help tell their hard-nosed mother that she has breast cancer. They struggle through past family issues to stand by and support Lili.  This segment also introduces male breast cancer through a male patient the three women meet in the hospital waiting room.

The fifth story is Pearl’s.  Pearl grew up to be an oncologist.  She ties all the stories together as she is the oncologist of the middle three.  Pearl (Jeanne Tripplehorn) finds herself in her parents’ position of needing to tell her own daughter of her diagnosis. 

The stories are very emotional.  Within the short stories, the writers and directors did a decent job of keeping too much sentimentality out of them, but remember these are Lifetime movies so expect some.

You can watch the full length movie online here.
Five Movie Cast & Characters


Related posts:
Risk Factors for Breast Cancer (October 2, 2007)
New Breast Cancer Screening Guidelines (November 17, 2009)
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision (December 15, 2010)

Shout Outs

Updated 3/2017-- photos and all links removed (except to my own posts) removed as many no longer active.

Jason Shafrin, PhD, Healthcare Economist, is the host for this week’s Grand Rounds. You can read this week’s edition here.

This is a great time to be the Healthcare Economist. Not only am I hosting Grand Rounds for the first time, but Wisconsin sports are enjoying a renaissance. The Milwaukee Brewers are in the NLCS, the Green Bay Packers are Super Bowl Champs and undefeated, and the Wisconsin Badgers also have not lost.

How does this relate to this week’s edition of Grand Rounds? I have no idea. But I know if you’ve made it this far, you might as well take a few more minutes to review the best medical posts on the blog-o-sphere during the past week. Enjoy! ………….

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The 2011 Charles Prize for Poetry Contest deadline for entries has passed. Now while we await the announcement of the winners I hope you will enjoy reading the many wonderful entries.

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TBTAM (@tbtam) has another nice blog post on mammograms: Mammograms – Reality Check

A well-written and balanced article on mammography from USA Today may help move the conversation about this screening test away from hype and a bit closer to reality. The title – “Mammogram is ‘terribly imperfect’, though recommended.” ...

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H/T to @DrMarkham and @doctorblogs for this BMJ article by Prof Joseph Ana on this horrifying practice: Breast flattening, ironing, straightening, and pounding: a new form of violence against girls and women

Until a few weeks ago, I had never heard about the cultural barbarism of breast flattening, a native attempt to delay the development of a girl’s breasts so that they are not “attractive” to men and boys before they are ready for marriage.

Just before a girl reaches puberty her mother will (sorry but please get yourself ready to soldier on with reading this sordid topic) pass a hot instrument, usually a hot wire into the victim’s breasts or pound the victim’s breast with a pestle without any form of anaesthesia or analgesic. …..

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Runawaydoc (@runawaydoc) is a “newbie blog / pediatrician in training” who recent blog post introduces us to “the man with the golden heart.”

……As a doctor, I regret to accept that our medical system is also hijacked into this dark world. Every doctor, every lab, every pharmacist wants to extract an extra rupee. The feel of the notes satisfy more than the contentment of the patient. …….

However, in one of those social networking portals I came across a man called “Morpheus”. I was jarred with his conviction to clean the dirty waters of medicine where doctors happily waddle in. He told me that healing profession has to be cleaned, somebody has to make a move, and somebody has to start it. At the end of the day the patient should not suffer. …..

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Did you catch Radio Rounds interview of ZDoggMD? If not, you can listen to it here: Slightly Funnier Than Placebo

This week features the hottest hip hop hospitalist in the nation, ZDoggMD. When not making videos, ZDogg is a hospital physician working at a Bay Area academic hospital. Along with some of his fellow physicians he moonlights in medical satire writing and producing his own videos and songs, claiming to be slightly funnier than placebo. This episode is about the man behind the name as we delve deeper into the mind of ZDoggMD.

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My friend Methodical Madness uses her recent Mothers in Medicine post to encourage donation of blood products: Blood Bank Halloween.

The Blood Bank always has some pretty interesting Halloween decorations. Last year they had gel blood dripping from the top of the main door. This year I was excited to see a bloody hand at the Blood Bank blood product distribution window. The window is kind of like a fast food restaurant window - only it opens bottom to top instead of sliding sideways. I imagine it was designed in the 1960's. This morning when I went to take a photo of it for this blog that was marinating in my head, I was upset to find it missing. I wandered into the blood bank.

"Where is that bloody hand decoration that was in the window?" …………

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H/T to @scanman for this tweet: Superb collection/selection >> RT @mankuthirai: The 50 Best Short Stories of All Time

The short story is sometimes an under-appreciated art form. Within the space of a few pages, an author must weave a story that’s compelling, create characters readers care about and drive the story to its ultimate conclusion — a feat that can be difficult to accomplish even with a great degree of savvy……….

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Thanks to @glevin1 who noticed this website on Google+ and know I’d appreciate it: LUKE Quilts. Luke’s website has three main sections – about, projects, and blog. His quilts are amazing! Check them out.

"Save All" Signature Quilt

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Clearing out my office I found photos (not great ones) of this quilt I made in 1995 to help raise money for breast cancer research.  The quilt used fabric (between the dark green strips) which say “yes, mam” as in “say yes to a mammogram”.  The main body of the quilt uses a pattern called “save all” and the pillow area has the pink ribbons associated with breast cancer.

I solicited signatures from past presidents of the ASPRS and PSEF and members on the boards/committees.  I received 31 signatures.  I photocopied each signature onto fabric using freezer paper backed fabric which I ran through a laser printer.

The quilt is machine pieced by me, but I recall having it hand quilted by Scottie Brooks.  I’m not sure of it’s size (that’s a full size bed in the photo) so my guess would be 90+ in X 110+ in.
The quilt was donated to ASPRS’s Executive Office museum.  The signatures are from Frederick J. McCoy, MD, Peter Randall, MD, H. William Porterfield, MD, Mark Gorney, MD, George Reading, MD, James G. Hoehn, MD, Elvin G. Zook, MD, William Riley, MD, H. Bruce Williams, MD, Simon Fredricks, MD, Hale Tolleth, MD, Ronal B. Berggren, MD, Stephen H. Miller, MD, R. Barrett Noone, MD, William D. Morain, MD, Malcolm A. Lesavoy, MD, Bruce Achauer, MD, Gregory Borah, MD, B. R. Burkhardt, MD, David T. W. Chiu, MD, Loren Eskenazi, MD, Robert Goldwyn, MD, Frederick Heckler, MD, Ronald E. Iverson, MD, J. Michael Kelly, MD, Susan MacKinnon, MD, Paul Manson, MD, Karen Montero, MD, Rod Rohrich, MD, S. Larry Schlesinger, MD, and Brooke Seckel, MD.

Skyes’ Preventive Double Mastectomy

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

When Wanda Skyes, 47, had a bilateral breast reduction in February, the pathology returned with DCIS present in the left breast specimen.  Recently the comedian appeared on  "The Ellen DeGeneres Show" and during the interview revealed her breast cancer diagnosis and her decision to have a double mastectomy.

Sykes continued, "It wasn't until after the reduction that in the lab work, the pathology, that they found that I had DCIS [ductal carcinoma in situ] in my left breast. I was very, very lucky because DCIS is basically stage-zero cancer. So I was very lucky."

But, she added, "Cancer is still cancer. I had the choice of, 'You can go back every three months and get it checked. Have a mammogram, MRI every three months just to see what it's doing.' But, I'm not good at keeping on top of stuff. I'm sure I'm overdue for an oil change and a teeth cleaning already."

Because she has a history of breast cancer on her mother's side of the family, Sykes explained she opted to have a bilateral mastectomy.

"I had both breasts removed, because now I have zero chance of having breast cancer," she said. "It sounds scary up front, but what do you want? Do you want to wait and not be as fortunate when it comes back and it's too late?"

The American Cancer Society has a nice article which reviews the risk factors for breast cancer.  The risks factors for Sykes (which can be garnered from the news article) include a family history of breast cancer (don’t know which relative on mother’s side), a personal history of breast cancer, African-American, and age.

I don’t think I would have advised her to have a bilateral prophylactic mastectomy on this information, but perhaps with more info I would have.  Though an effort is made to remove all breast tissue with a prophylactic mastectomy, it is wrong for us doctors/surgeons to ever suggest that we actually DO get it all.  More truthful to say we have removed most (90% plus).

While we are on the topic of breast cancer, please, take a look at Elaine Schattner, M.D., Medical Lessons, post from Monday:  NEJM Publishes New Review on Breast Cancer Screening.

Related posts:

Risk Factors for Breast Cancer (October 2, 2007)

Prophylactic Mastectomy (January 28, 2009)

Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Is Prophylactic Mastectomy Worth It? (August 2, 2011)

Media Sources

Wanda Sykes' double mastectomy is aggressive treatment for DCIS; Karen Kaplan; Los Angeles Times/For the Booster Shots blog, September 23, 2011

Wanda Sykes has double mastectomy;  Ann Oldenburg; USA Today, Sep 23, 2011

Wanda Sykes: I had a double mastectomy; Jessica Derschowitz; CBS News, Sep 23, 2011

For more information on DCIS

Breast Cancer; PubMed Health, last updated December 2010

DCIS - Ductal Carcinoma In Situ; BreastCancer.org, last updated August 12, 2011

Ductal carcinoma in situ (DCIS); Mayo Clinic, last update June 23, 2011

Genetic Breast Cancers Show Up Earlier in Next Generation

 Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active.

Somewhere along the line I learned to encourage women with a family history of breast cancer to begin getting mammograms at an age 10 years prior to when their mother was diagnosed and to encourage their daughters to begin getting mammograms at an age 10 years prior to when they themselves were ever diagnosed. 

I learned this prior to the discovery of BRCA genes.  It was a trend that had been noted among women with strong family histories.  The new study (see full reference below) in the journal Cancer verifies that genetic breast cancers show up earlier in the next generation – on average by 8 years.

The study from MD Anderson looked 2 generations of families with the BRCA gene to assess the age at diagnosis.  Using the pool of 132 BRCA-positive women with breast cancer who participated in the high-risk protocol at The University of Texas MD Anderson Cancer Center (Gen 2), 106 women could be paired with a family member in the previous generation (Gen 1) who was diagnosed with a BRCA-related cancer (either breast cancer or ovarian cancer).

The median age of cancer diagnosis was 42 years (range, 28-55 years) in Gen 1 and 48 years (range, 30-72 years) in Gen 2 (P < .001). In the parametric model, the estimated change in the expected age at onset for the entire cohort was 7.9 years (P < .0001). Statistically significant earlier ages at diagnosis also were observed within subgroups of BRCA1 and BRCA2 mutations, maternal inheritance, paternal inheritance, breast cancer only, and breast cancer-identified and ovarian cancer-identified families.

It is reasonable to encourage these women with significant family history of breast cancer to begin surveillance at an earlier age than the general population. 

REFERENCE

Earlier age of onset of BRCA mutation-related cancers in subsequent generations; Litton JK, et al;  Cancer 2011; DOI: 10.1002/cncr.26284.

Breast Cancer Patients With BRCA Gene Diagnosed Almost Eight Years Earlier Than Generation Before; Science Daily, September 12, 2011

Mom's Cancer Shows Up Earlier in Daughters; Michael Smith, Dori F. Zaleznik, MD; MedPage Today, September 12, 2011

Timing of Radiotherapy in Implant-Based Breast Reconstruction

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

As Jackie Fox, Dispatch From Second Base, writes the choices after getting diagnosed with breast cancer can be overwhelming.  These choices (dependent on type and stage of breast cancer, desire for reconstruction, treatment needed, etc) can make the timing tricky when it comes to radiotherapy and reconstruction choices. 

The current issue of Plastic and Reconstructive Surgery Journal (first reference below) seeks to shed some light on the question of timing in implant-based breast reconstruction.

The authors looked at three populations  who received implant-based reconstruction from October of 2003 to October of 2007, a total of 257 patients (mean age, 49 years) were prospectively involved in this study.  All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders (ST 133; Allergan, Inc., Irvine, Calif.) and permanent implants (ST 410-510; Allergan).  Median followed up was 50 months.

• The first population (group 1, n = 109 patients) was made up of women affected by early-stage breast cancer with extensive nodal involvement that required postmastectomy radiotherapy and adjuvant chemotherapy.  This group received radiation on permanent implants (radiotherapy plus permanent implants).
• The second population (group 2, n = 50 patients) was made up of patients with locally advanced breast cancer who preoperatively were candidates for radiotherapy and who received chemotherapy before surgery.  This group  received radiation during the expansion phase of STE (radiotherapy plus tissue expanders).
• A third population (n = 98 patients) who did not receive radiotherapy was included as a control group.

The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints.

Highlights of the study:

The totally failed reconstruction rate was significantly higher in group 2, with 40% (20/50) of unsuccessful reconstructions, compared with 6.4% (7/109) in group 1 and 2.3% (2/98)  in the control group (p < 0.0001).

Half (10/20) the failed reconstructions in group 2 involved those stopped at the first stage with removal of temporary expander for extrusion (5 cases) or infection (5 cases).

The other half of the failed reconstructions in group 2 occurred during the second stage and were converted to flap surgery --  2 due to extrusion, 3 due to infection, and 5 due to poor results (e.g., asymmetry, Baker grade IV capsular contracture).

The 7 failures in group 1 were due to severe capsular contracture (5), wound dehiscence (1), and an infection that required implant removal (1).

The incidence of Baker grade IV capsular contracture rate was significantly higher for group 1 (10.1%) and group 2 (13.3%) compared with the control group which did not receive any radiation (0%),  p = 0.0001).

The shape assessment performed by the surgeons demonstrated a higher incidence of good results in group 1, although the highest value was still reported in the control group (group 1, 58.7 %; group 2, 30.8 %; control group, 74.2 %; p = 0.0009).

The estimate of patients' opinions demonstrated a higher prevalence of good results in group 1 in comparison with group 2, although as with the surgeons assessment it was highest in the control group (good opinion: group 1, 52.2%; group 2, 46.2%; and control group, 68.1%; p = 0.04)

The study authors conclusions:

This study demonstrated that a higher total failure rate affects breast reconstructions that undergo irradiation during tissue expansion. For this reason, we suggest that if tissue expansion can be performed during postoperative chemotherapy, chest wall irradiation should be delivered on permanent implants. The second surgical step can be scheduled 3 weeks after the end of chemotherapy, and the irradiation should not begin more than 3 weeks later. Patients whose need for radiotherapy is not known preoperatively can, in this way, improve their surgical outcome.

REFERENCES

Outcome of Different Timings of Radiotherapy in Implant-Based Breast Reconstructions; Nava, Maurizio B.; Pennati, Angela E.; Lozza, Laura; Spano, Andrea; Zambetti, Milvia; Catanuto, Giuseppe; Plastic & Reconstructive Surgery. 128(2):353-359, August 2011; doi: 10.1097/PRS.0b013e31821e6c10

BreastCancer.org:  When Is Radiation Appropriate?, last updated August 6, 2008

Is Prophylactic Mastectomy Worth It?

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

There is a recent article which asks this question (full reference below).  I think it is a question which must be answered on an individual basis.  

For someone like me, the answer would be no.  I have no family history or personal history of breast cancer.  I have small, more dense than fatty breast, but have always had normal mammograms.  I have never had any lesions which needed biopsy.

For an individual woman with a strong family history of breast cancer (especially genetically proven, BRCA1 and BRCA2) and a person history of breast cancer (ie right mastectomy for lobular carcinoma), then it is easy to say “Yes, a prophylactic left mastectomy would be worth it for you.”

In between these two examples is the gray area, and this article doesn’t necessarily make the gray area any clearer.

There is plenty of evidence that prophylactic mastectomy lowers the risk of breast cancer in the high–risk population in at least 95%.

The authors of the June 2011 Aesthetic Plastic Surgery Journal article performed a retrospective study by reviewing the records of all their patients (n=52) who underwent prophylactic mastectomy within a 25-year period to look at the aesthetic and long-term oncologic outcomes, complications, and patient satisfaction.

Of the 52 patients, 40 had the surgery on one side only (contralateral prophylactic mastectomy) and 12 had bilateral (bilateral prophylactic mastectomy), giving a total of 64 prophylactic mastectomies.

Of the 52 patients/ 64 mastectomies, there was 1 (1.56%) case of unexpected breast cancer in the mastectomy specimens.

Two thirds (42/64) were subcutaneous prophylactic mastectomies and the other third (22/64) were simple total prophylactic mastectomies.

Most of their patients chose to have reconstruction with implants (58/64 = 90.62%) while the other 6 (9.37)  chose to use autologous tissue --  5 (7.81%) received latissimus dorsi flaps with implants and 1 (1.56%) had a TRAM flap.

The complications included 4 (6.25%) breasts that developed capsular contracture, 2 (3.12%) cases of hematoma, and 1 (1.56%) infection.

More than 90% of the patients reported being either highly (39/52) or partially satisfied  (10/52).  Only 3/52 reported being unsatisfied. The authors report an overall aesthetic index of 8.8.

There were no deaths among their patients, nor any new development of breast cancer during the time period.

Related posts
Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Prophylactic Mastectomy (January 28, 2009)

Advances in Nipple-Sparing Mastectomy – an article review (April 27, 2011)

Are Patients Making Good Decisions About Breast Reconstruction? (February 28, 2011)

REFERENCE

Prophylactic Mastectomy: Is It Worth It?; Jose Abel de la Peña-Salcedo, Miguel Angel Soto-Miranda, Jose Fernando Lopez-Salguero; Aesthetic Plastic Surgery, Volume 35 (3), June 2011;  DOI: 10.1007/s00266-011-9769-x

American Cancer Society:  What are the risk factors for breast cancer?

More on Implant-Related ALCL of the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

Last week @prsjournal tweeted

Pre-print Article: Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the B... http://bit.ly/o9lQ1f

The title definitely caught my eye.  I have finally read it and re-read it.
Here’s the abstract:

Implant-related primary anaplastic large cell lymphoma (ALCL) of the breast is a rare clinical entity. With increasing attention being paid to this disease, most cases reported to date in the literature have demonstrated indolent clinical courses responsive to explantation, capsulectomy, chemotherapy and/or radiotherapy.

We describe a case of bilateral implant-related primary ALCL of the breast that proved refractory to both standard and aggressive interventions, ultimately resulting in patient death secondary to disease progression. We situate this case in the context of the current state of knowledge regarding implant-related primary ALCL of the breast and suggest that this entity is generally, but not universally, indolent in nature.

The story of implant-related ALCL is far from being completely written.  This article notes (as did the recent FDA report) most investigations performed to date suggest an association between breast implants and primary ALCL of the breast.  The specifics regarding this relationship remain poorly defined.

A review of all reported cases of implant-related primary ALCL of the breast demonstrates no obvious correlation with implant fill type (silicone vs. saline), surface morphology (smooth vs. textured), implant position (subpectoral vs. subglandular), or indication for implant placement (cosmetic vs. reconstructive).

The FDA notes (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.

……..

The FDA is requesting health care professionals report all confirmed cases of ALCL in women with breast implants to Medwatch, the FDA’s safety information and adverse event reporting program. Report online or by calling 800-332-1088.

Related posts:

More on Link Between Breast Implants and ALCL (April 25, 2011)

ALCL and Breast Implants – an article review (March 9, 2011)
ALCL and Breast Implants (January 31, 2011)
Breast Implants and Lymphoma Risk (June 29, 2009)


REFERENCE

Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the Breast: A Case Report and Review of the Literature; Carty, Matthew J.; Pribaz, Julian J.; Antin, Joseph H.; Volpicelli, Elgida R.; Toomey, Christiana E.; Farkash, Evan A.; Hochberg, Ephraim P.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 19 July 2011; doi: 10.1097/PRS.0b013e318221db96

Arkansas Jurors Find Cancer Therapy a Fraud

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

I hope @oracknows, Respectful Insolence, will write more about this. He is much better than I at sussing out fraudulent medical treatments.

I have lived and practiced in Little Rock, AR for over twenty years and I did not know this was in my backyard until my local paper (Arkansas Democrat-Gazette) reported on the outcome of the trial last week. The article title caught my eye as I was skimming the news: Jurors: Cancer therapy a fraud, Award in suit is $2.5 million (subscription only unfortunately).

A federal jury awarded $2.5 million in damages Tuesday to a California woman who paid $6,250 to undergo alternative treatments from a Jacksonville woman who promised a “100 percent success rate” in destroying cancerous breast tumors.

Antonella Carpenter, the former Jacksonville woman who has since moved to Broken Arrow, Okla., and continues to proclaim on her website that she has found a simple, painless way to kill cancerous tumors, wasn’t present for the verdict against her and her company, Lase Med Inc. …….

I don’t recall every hearing of Lase Med Inc: LIESH Therapy.

The plaintiff in the lawsuit is Therese Westphal, 54,

a mother of three sons, said she read about the treatment in a flier she found in a health-food store in California where she went to research nontraditional cancer treatments shortly after being diagnosed in September 2007 with a 2 1/4-inch tumor in the upper right corner of her left breast.

A local oncologist, Bill Tranum, MD, testified Westphal had a 75% to 90% chance of beating the cancer immediately after being diagnosed, the delay dropped her chances to 20%.

The Arkansas Democrat-Gazette article notes Carpenter refers to herself on the website as a “doctor.”

Bond (Will Bond of the McMath Woods law firm in Little Rock) says she’s not a medical doctor, but claims to have a doctorate in physics, possibly from an online university.

A local television station, KTHV, has a segment (open access) on the trial: Company defends laser treatments, despite loss in court

….."I am a physicist. I never claim to be a medical doctor, that's why the patients come to me because those are the ones who want alternative," Carpenter said.

It's an alternative using lasers to kill cancerous tumors. Carpenter says the heat activated in the process does the job.

"Elevated temperature, the tumor reached 134 degrees Fahrenheit, and that is the temperature sufficient to kill the tumors. I have the science that backs it," Carpenter said. ….

Transaxillary Breast Augmentation and Sentinel Lymph Node Integrity

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

I’m not a huge fan of transaxillary breast augmentation (TABA).  One of the major selling points for the transaxillary approach is the lack of scars on the breasts.  As a woman living in the south, my arm pits are much more likely to be seen in public than my breasts. 

As a surgeon, I also know that when revisions need to be done (capsule issues, etc) most recommend using an inframammary approach so why not just start there.  In my opinion, all women with implants will have a repeat surgery at some point in the future – implant failure (deflation, rupture) being a given.

I admit I had not thought about how the incision might interfere with future sentinel lymph node assessment prior to this article (full reference below).

Dr. Ana Claudia Weck Roxo, Rio de Janeiro State University, Brazil and colleagues conducted a small study to evaluate changes in axillary lymphatic drainage in patients who underwent TABA.

The authors share this information as to why this is important (bold emphasis is mine):

The sentinel lymph node is the first node in the lymphatic chain and the first to receive tumor cells via lymphatic drainage. Therefore, sentinel lymph node analysis allows physicians to predict the status of the lymphatic chain. The recent validation of the capacity of the sentinel lymph node to stage breast cancer patients and to help identify those who require axillary dissection has dramatically improved surgical treatment and reduced morbidity. Thus, sentinel lymph node biopsy has become an alternative to axillary dissection in patients with T1 and T2 breast cancer and is a gold standard for axillary staging because of its high sensitivity (84%-98%) and low false-negative rates (2%-8.8%).  Nevertheless, it is contraindicated in patients with palpable axillary metastatic lesions, multicentric breast disease, previous mammary or axillary radiotherapy, and/or previous axillary or mammary procedures.

The prospective study enrolled 27 patients who underwent preoperative mammary lymphoscintigraphy, a subsequent TABA (using a subglandular placement of round, textured, high-profile silicone implants through a 4-cm incision at the anterior axillary fold), and postoperative lymphoscintigraphy at 21 days and six months after the procedure.  

The postoperative imaging results examining the axillary lymphatic chain and the first axillary lymph node were analyzed and compared to the preoperative images.

None of the patients showed any changes between the preoperative and postoperative images at six months.  Only one of the 27 patients (4.5%) demonstrated a lower rate of lymphatic drainage at 21 days postoperatively compared to preoperative values.

The sentinel lymph node remained visible in all patients at all time points, and all breasts showed drainage primarily to the axillary lymphatic chain.

Their data showed preservation of lymphatic drainage and visible sentinel lymph nodes even after transaxillary breast augmentation.  I would love a larger study to confirm, but am pleased they looked at this.

REFERENCE

Evaluation of the Effects of Transaxillary Breast Augmentation on Sentinel Lymph Node Integrity; Ana C Weck Roxo, Jose H Aboudib, Claudio C De Castro, Maria L De Abreu, and Margarida M Camões Orlando; Aesthetic Surgery Journal May 2011 31: 392-400, doi:10.1177/1090820X11404399

Women Don’t Regret Prophylactic Mastectomy

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

I was alerted to the presentation at the American Society of Breast Surgeons meeting (first reference below) by Judy Boughey, MD by @MedicalNews’ tweet:

ASBS: Prophylactic Mastectomy Good Even Years Later (CME/CE) http://bit.ly/kMCsdr

Boughey and colleagues note that previous researchers using cross-sectional surveys have found that the majority of women are satisfied with their decision to have contralateral prophylactic mastectomy (CPM) one to several years after the procedure.

Their study chose to look at the consistency of satisfaction and changes in adverse effects in the same women with longer term follow-up.

To do this, they surveyed a previously established cohort of women with unilateral breast cancer who had contralateral prophylactic mastectomy at the Mayo Clinic between 1960 to 1993. All of the women had a positive family history.  All were surveyed at two time points and the results compared.

The initial survey was done at a mean of 10.3 years after prophylactic mastectomy (second and third references below).  This survey involved 583 women.

Of the 583 women who responded to the initial survey, 523 were alive and resurveyed 10 years later. Data from both surveys are available for analysis on 269 women.

The researchers found the majority of women continued to be satisfied with their decision to have contralateral prophylactic mastectomy (86% initial survey; 90% follow-up survey, p=0.06).

Similar numbers to that of the initial survey reported neutral feelings or dissatisfaction with their CPM decision on follow-up survey (8% and 6%, respectively, initial survey; 4% and 6% follow-up survey).

There was no significant change in the proportion indicating they would choose CPM again, but as with satisfaction, the proportion was slightly higher on the follow-up survey (95% initial survey; 97% follow-up survey, p=0.27).

The most frequently cited adverse effects were similar at both time points and included body appearance (29% vs 31%, initial vs follow-up survey, p=0.61), sense of femininity (21% vs 24%, p=0.25) and sexual relationships (24% vs 23%, p=0.68).

From the MedPage News article:  "This information is useful in the education of patients and physicians," said Boughey. "Patients should consider their choice carefully and be made aware of adverse events. However, those that decide for contralateral prophylactic mastectomy are likely to remain satisfied with the decision in the long term."

A related post of interest is one from Dr. Dialogue:  Is Watchful Waiting too Difficult? (originally posted there on March  13, 2010 and on Better Health on May 1st, 2011:  Why Double Mastectomies Are Popular: Watchful Waiting Is Too Difficult?)

REFERENCE

1.  Contralateral prophylactic mastectomy: Consistency of satisfaction and psychosocial consequences over time;  Boughey JC, et al; ASBS 2011; Abstract 1693 (pdf file)

2.  Satisfaction After Contralateral Prophylactic Mastectomy: The Significance of Mastectomy Type, Reconstructive Complications, and Body Appearance; Frost MH, Slezak JM, Tran NV, Williams CI, Johnson JL, Woods JE, Petty PM, Donohue JH, Grant CS, Sloan JA, Sellers TA, Hartmann LC;  JCO Nov 1, 2005:7849-7856; DOI 10.1200/JCO.2005.09.233.

3.  Contralateral Prophylactic Mastectomy: Efficacy, Satisfaction, and Regret (Editorial); Marc D. Schwartz; J Clin Oncol 2005, 23: 7777-7779; DOI: 10.1200/JCO.2005.08.903

Advances in Nipple-Sparing Mastectomy – an article review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

There is a very nice review article of the advances in nipple-sparing mastectomy surgery in the March 2011 issue of the Aesthetic Surgery Journal (full reference below).

Dr. Patrick Maxwell and colleagues includes some history of nipple-sparing mastectomy (NSM):

NSM was attempted in the 1980s but never gained popularity owing to the controversies surrounding oncological safety. Now, better technologies for preoperative staging and assessment of lesion distance from the NAC, along with an increased understanding of the anatomy of the breast ducts with relation to the nipple, are encouraging a return to the concept. One of the key publications that renewed and increased enthusiasm for this technique was the multicenter publication of 192 patients undergoing NSM with only four recurrences, all of which occurred distant from the NAC. Recurrences were seen in the upper outer quadrant, where nearly all recurrences are found with simple mastectomies, at the junction of the tail of the breast and axillary tissue.

In recent years, there has been a sudden increase in reports of NSM for prophylaxis and cancer treatment. Of the approximately 1868 NSM procedures performed for breast cancer treatment and published in recent literature, only three local recurrences within the NAC have been reported, representing 0.16% of local events attributed to patients with NAC preservation. Note, however, that most of these studies have short follow-up periods, thus rendering definitive conclusions premature.

While NSM is not an option in all cases, it is an option that when available is worth using.  No surgeon can create a nipple as lovely as the one that would be removed by the mastectomy, so if it can be used it greatly adds to the finished results.

Exclusion criteria included tumors larger than 3 cm, clinical invasion of the NAC, tumors within 2 cm from the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, and nodal disease, excluding isolated immunohistochemistry positivity.

The article does a quick review of some of the techniques for NSM (photo credit, 1st reference article):


The article is worth your time to read.



REFERENCES

1.  Advances in Nipple-Sparing Mastectomy: Oncological Safety and Incision Selection;  Maxwell G.P., Storm-Dickerson T, P Whitworth P, Rubano C, and Gabriel A; Aesthetic Surgery Journal March 2011 31: 310-319, doi:10.1177/1090820X11398111

2.  Nipple-Sparing Mastectomy for Breast Cancer and Risk Reduction:  Oncologic or Technical Problem?; Sacchini V, Pinotti JA, Barros AC, et al; J Am Coll Surg 2006;203:704-714

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

iMedicalApps is the host for this week’s Doctor Watson issue of Grand Rounds! You can read this week’s edition here (photo credit).

This is the first time iMedicalApps is hosting Grand Rounds, and to those not familiar, Grand Rounds is weekly collection of medical blog posts with different themes — hosted by various blogs.

To be perfectly honest, I had no idea what Grand Rounds was until very recently. When I started iMedicalApps in November 2009, we were a rag tag team of physicians and medical students, and I had no experience with the “medical blogosphere” — I didn’t even know it existed, I just wanted to review medical apps and provide a quality resource for medical professionals.  ………..

……………………………

These two are both breast cancer survivor related.  Powerful!

HT @medicallessons who tweeted “Make Them Hear You: Voices of Metastatic Breast Cancer - http://t.co/4Jmkzrh”

Last weekend, the Metastatic Breast Cancer Network (MBCN) launched an e-newsletter called “Voices.”

The name reminded me of a video MBC and LBBC  helped with last year: “Faces of Metastatic Breast Cancer.”

The low-key video shows a variety of women doing every day things with their families and commenting on MBC. It’s not a public service awareness message–it’s not preachy. Some people are serious, but many are laughing, playing with their kids and so on. It’s well worth a look!

Here are some other women who have inspired me: 

Molly Ivins:

“Having breast cancer is massive amounts of no fun. First they mutilate you;
then they poison you; then they burn you. I have been on blind dates better
than that.”
–Molly Ivins 1944 – 2007, columnist, political commentator and humorist

Plastic surgeon @mchrysopoulo tweeted about a video his group put together and posted on their Facebook page: Tattoos that tell Breast Cancer stories. Go watch the video!

…………………………….

Recently @seattlemamadoc shared her “Ultimate Disaster Kit” segment and interview she did.  Great advice!

Where can people find out more about emergency preparedness?
· On my Seattle Mama Doc blog, I recently wrote a post about emergency preparedness.
· I’d also recommend checking out the American Red Cross’ Website and 3 Days 3 Ways for more information.

……………….………….

H/T to @crzegrl15 who tweeted:  Nursing hero: Evacuation of war-wounded in Libya: first-person account by MSF nurse http://bit.ly/gaiZS6

Editor's note: Alison Criado-Perez, a nurse with Doctors Without Borders (Medecins Sans Frontieres, or MSF) shares this first-person account of evacuating war-wounded people out of Misrata. Ali is a nurse working for MSF in Libya and Tunisia. She has previously worked in Nigeria, Colombia, Uganda and Central African Republic. The video embedded in this blog post shows Ali actually treating a patient on the boat described in the account shared below. ………

……………………………….

H/T to @Allergy who shared this on twitter:  Lost in translation: the warning "I am deathly allergic to nuts" accidentally became "I am absolutely dying for nuts" http://goo.gl/h8Myp

Ted Leonsis, founder of the company that owns the Capitals, Wizards, and Mystics sports teams, along with Verizon Center in Washington D.C., ……

He's also had to deal with his allergy in a foreign country. He recently visited Paris, and before leaving, asked the stewardess to translate into French the following message: "I am deathly allergic to nuts. Please do not serve me any nuts or nut products." He then passed the note to a server at a French restaurant. The message was lost in translation, accidentally becoming "I am absolutely dying for nuts. I must have nuts." The error was discovered when the waiter brought ten plates of nuts out for Leonsis. ……….

…………………………………….

H/T to @grahamwalker who shared this tweet:  Awesome. NEJM Clinical Practice review on "Care of Transsexual Persons." Very progressive of them. nejm.org/doi/full/10.10…

It truly is a very nice article which I would encourage all physicians to read.

………………………………………..

Threads has a wonderful article on the recreation of this jacket created for Plimoth Plantation in Massachusetts: Threads seamstress contributed to jacket on display at Winterthur Museum

The jacket is currently on loan to the Textiles Gallery at Winterthur Museum, Library and Garden in Wilmington, Delaware: The Plimoth Jacket: A Paradise in Silk and Gold (photo credit)

On loan to Winterthur from Plimoth Plantation, the Plimoth Jacket is not an exact reproduction. Rather, it was re-created from two examples in the Victoria & Albert Museum in London. One was chosen for the cut and construction of the jacket and the other for the design of the embroidery. Both originals date to the 1620s. ……

The sewing, embroidery, and lace were all entirely done by hand. The lace spangles (the tear-drop shaped sequins hanging from the lace) were created using tools made specifically for the project. The tools and techniques replicate those from the 1600s. Even the lining was hand-woven and dyed with natural indigo.

Learn More
View a PDF presentation about the creation of the jacket.

Breast Self Exam Poster

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

HT to Street Anatomy for the link to this great poster (photo credit)  by iHeartGuts!

Related posts:
Breast Self-Exam (October 8, 2009)
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms (October 13, 2008)
Breast Cancer Screen in Childhood Cancer Survivors – An Article Review (February 2009)
Indications for Breast MRI – an Article Review (March 2009)