Between the Lines is a Must Read

I am one of the physicians Dr. Zilberberg  (@murzee) mentions repeatedly in her book “Between the Lines” who don’t understand statistics.  I know it is one of my weaknesses.  Her book has done much to aid my understanding.  I will re-read it and pass it on to my niece who has mentioned she might want to go to medical school.  I had already told her to make sure she took a statistics class.

The book is easy to read and @murzee makes the concepts easier to understand than anyone I have ever heard/read.  If you want to gain a better understandings of the different types of scientific studies, biases, and statistical analysis, then“Between the Lines” is a must read.  

Leadership and Goal Play

Paul Levy’s (@paulflevy) book “Goal Play” is out!  If you read his blog you will recognize many of the vignettes as I did.   He teaches us lessons of leadership (not management) he has learned from coaching soccer. 

Easy to read.  Engaging stories as examples.  You can read from the beginning to end or flip through and read at random.  Either way you will gain valuable insights.

The book is available both at Amazon and at Createspace. 

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Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active.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

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

Blog Review of 2009

This year seems to have gone by so quickly.  It was great fun meeting so many of you at the Blog World Expo which stands out as a great highlight of the year.  It was also a year of losses for my family – a brother-in-law, my mother, a cousin.

 

Here are a few posts that stand out for me:

• CAMRSA: Dx and Tx Update for Plastic Surgeons – an Article Review (January 8, 2009)
• Integrating Radiation Therapy & Breast Reconstruction – an article review (February 9, 2009)
• Propranolol for Hemagiomas?  (March 4, 2009)
• Requirement of Perioperative Stress Doses of Corticosteroids -- an Article Review (March 16, 2009)
• Complications After Autologous Fat Injections to the Breast – an Article Review  (April 2, 2009)
• Torn Earlobe Repair  (May 4, 2009)
• Stroke During Coronary Bypass Surgery – an Article Review  (May 28, 2009)
• Cell Phone Elbow?  (June 8, 2009)
• How Poland’s Syndrome Was Named (June 25, 2009)
• Macrodactyly (July 8, 2009)
• Raynaud’s Phenomenon of the Nipple (July 30, 2009)
• Nipple Sharing &/or Sparing Breast Surgery (August 20, 2009)
• Historical Surgical Dressings  (September 16, 2009)
• Ingrown Toenail Care in 1908 and Now  (October 22, 2009)
• Tongue-tied  (November 5, 2009)
• Finger Nail Bed Injuries (November 18, 2009)
• Case Report of a Cystosarcoma Phyllodes – an Article Review (December 3, 2009)
• Chest Wall Contouring in Female-to-Male Transsexuals (December 17, 2009)

   

  Here’s hoping 2010 will be a good year for us all!

i-Surgery Notebook App Review

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

Thanks to Vijay for suggesting I do a review of this rare iPhone app for surgeons:  i-Surgery Notebook. 

@scanman RT @rilescat: A rare find! An iPhone app for Surgeons http://bit.ly/58MtJR - Maybe @rlbates will review it?

The app was developed by Justin Steullet.  It has been available at iTunes since October 28, 2009.  There are six reviews on iTunes as of this writing which range from “don’t buy this app it’s fatally buggy” to “nice app” to “good, not great yet.  would like to be able to add categories:  ie tourniquet time, implants used, and coding (ICD-9/CPT)”  The app costs $$4.99 but is currently on sale for $2.99.  I paid for mine.

I added the app this past week and have played around with it enough to decide on several good and weak points from my standpoint.   All the screenshots come from here.

After signing into the app, it is fairly simple to add a case.  It has crashed on me twice.

I like that as I have added the names of my hospitals/surgery centers they become a menu choice rather than needing to enter the name each time.

I like that the same happens with procedure choices, but wish that it did for the diagnosis.  It would be nice to have the ICD-9/CPT codes available.

I wish that you could add more than one diagnosis and assign the corresponding diagnosis to the correct procedure when more than one thing is done for a patient on the same day.  For example, a patient with breast ptosis who has a mastopexy but during the same encounter she has two moles removed from her face.  The only way I see to do this is to enter the patient twice with the correct diagnosis for each single procedure.

I wish the default for Emergency was no rather than yes.  There is a notes section which I used for implant type used and implant volume  (RT/LT).  I, also, used this for Tumescent volume used in liposuction along with fat aspirated.  It’s good enough for me that there is a note section for those, but if I wanted that info to be a searchable database then it wouldn’t be.

I wish there was a way to edit information once you have “saved” it for that patient.  For instance, I didn’t add anything under “service” as it’s just me in my solo practice.  That turns out to be one of the options in exporting cases, so I went back to add one like “plastics” and was unable to do so.

Because there is no way to edit the information, I would suggest you make sure you have time to get it all entered without interruption or the information will be incomplete and you won’t be able to correct it.  Editing should be allowed.  After all this is notebook to aid in dictation or billing, not a medical record.

Exporting is not completely intuitive, but turned out to be easy once I played around a little.  To export all the cases rather than just one procedure type for the day or week, you need to select the date and then hit export.  Don’t bother with filling in all the options, just the date >>export.  The information will be sent via email.  It would be nice if it was sent in the form of an Excel spreadsheet.  Still it would be useful to get information to your billing person. 

I did not try the photo section, but have feedback from a twitter acquaintance @gastromom who did:

@rlbates Review of #Isurgeon notebook. Needs a lot of work. Photo did not show up. I see potential though. Love to help customize for GI.

A previous tweet from her:

@rlbates Just downloaded the Isurgery app for the iPhone. So far,crashed twice. If it works it will be perfect for GI... Update tomorrow:)

Overall, I think it is a useful app with potential.  Good, not great.

Treatment of Nasal Fxs – an Article Review

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

Nasal fractures are extremely common.  Deciding which technique to use for a given nasal fracture can be challenging.  The recent article (full reference below) in the Arch Facial Plastic  Surgery does a very nice job of condensing down the treatment of nasal fractures into a logical approach.

They start with the classification of nasal fractures (photo credit)

• Type I, “simple straight” --  unilateral or bilateral displaced fracture without resulting midline deviation.
• Type II, “simple deviated” – unilateral or bilateral displaced fracture with resulting midline deviation.
• Type III, “comminution of nasal bones”  -- bilateral nasal bone comminution and crooked septum with preservation of midline septal support; septum does not interfere with bony reduction
• Type IV, “severely deviated nasal and septal fractures”  -- unilateral or bilateral nasal fractures with severe deviation or disruption of nasal midline, secondary to either severe septal fracture of septal dislocation.  May be associated with comminution of the nasal bones and septum, which interfere with reduction of fractures.
• Type V, “complex nasal and septal fracture” – severe injuries including lacerations and soft tissue trauma, acute saddling of nose, open compound injuries, and avulsion of tissue.

The treatment of nasal fractures has classically been divided into open reduction (OR) and closed reduction (CR). 

Closed reduction involves manipulation of the nasal bones without incisions and has been the time-honored method of fracture reduction for thousands of years. It generally produces acceptable cosmetic and functional results, but its detractors point out that 14% to 50% of patients have deformities after CR.

Open reduction techniques for nasal fractures may include a range of techniques including septoplasty, osteotomies, and full septorhinoplasty.
Interesting, the study authors state,

There was no statistical difference between the results of an open repair and closed repair in terms of revision rate, patient satisfaction scores, or surgeon evaluation scores. Furthermore, our expert raters failed to find a difference in outcome based on the type of repair. Based on this data, it would seem that our patients did not perceive any difference in outcome, ie, patients were just as likely to be happy with the results of a closed repair as they were with open repair. These results contrast with those of many studies in which the surgeon's assessment shows a clear bias toward one technique or another.

The authors supplied this wonderful algorithm for treatment of nasal fractures (photo credit)



REFERENCE
The Treatment of Nasal Fractures: A Changing Paradigm; Arch Facial Plast Surg. 2009;11(5):296-302; Michael P. Ondik; Lindsay Lipinski; Seper Dezfoli; Fred G. Fedok

Radiation Therapy and Breast Reconstruction—an Article Review

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

Postmastectomy radiation therapy is important for many women.  It can improve survival and locoregional control in patients with invasive breast cancer.  When considering the optimal time and technique of breast reconstruction in patients who require postmastectomy radiation therapy, it can often be a difficult decision.  This topic of timing and best technique remain controversial.   There is no general agreement among plastic surgeons.

This article attempted to review the most recent literature on breast reconstruction in patients receiving postmastectomy radiation therapy.  They did a nice job.

To find articles for review, we performed a search of the MEDLINE database for studies of radiation therapy and breast reconstruction. We then read the reference lists of the identified articles to find additional articles for review. Studies were included if most patients were treated after 1985 and the mean follow-up period was more than 1 year. Forty-nine articles were reviewed.

Just from the headings in the article you can get a sense of the complexities of this topic:

• Indications for Postmastectomy Radiation Therapy: Consensus and Controversies
• Design of Postmastectomy Radiation Therapy: Consensus, Controversies, and the Potential for Lower Dose Regimens
• Implant-Based Breast Reconstruction in Patients Receiving Postmastectomy Radiation Therapy
• Outcomes of Implant-Based Reconstruction with Modern Radiation Delivery Techniques
• Impact of Performing the Tissue Expander-Permanent Implant Exchange before Rather than after Radiation Therapy
• Current Role of Reconstruction with a Latissimus Dorsi Flap Plus a Breast Implant in Breast Cancer Patients Who Receive Postmastectomy Radiation Therapy
• Immediate Implant-Based Breast Reconstruction Can Compromise the Design of the Radiation Treatment Fields
• Autologous Tissue Breast Reconstruction in Patients Receiving Postmastectomy Radiation Therapy
• Timing of Flap Transfer in Relation to Postmastectomy Radiation Therapy
• Immediate Autologous Tissue Breast Reconstruction Compromises the Design of the Radiation Treatment Fields
• Delayed-Immediate Breast Reconstruction

Looking at the how “immediate implant-based breast reconstruction can compromise the design of the radiation treatment fields” the authors note the growing evidence that

Not only can postmastectomy radiation therapy adversely affect the aesthetic outcome of immediate implant-based breast reconstruction, there is also increasing evidence that such reconstructions can interfere with the delivery of postmastectomy radiation therapy.

This can be from the slope of  the reconstructed breast vs the flat un-reconstructed chest changing the geometry of the medial and lateral radiation fields.  This can lead to under-dosing of the chest wall, especially centrally underneath the breast prosthesis and near the internal mammary nodes. 

On the good news (for reconstruction) side, studies have found no significant radiation scatter from the metallic port within the tissue expander used for breast reconstruction.

Kronowitz and colleagues highlight a 2005 study from M. D. Anderson Cancer Center which noted that immediate breast reconstructions may limit treatment planning for postmastectomy radiation therapy.  Bold highlighting is mine.

They retrospectively reviewed the records of 152 patients treated with postmastectomy radiation therapy, 17 of whom underwent immediate breast reconstruction and had expanders, flaps, and/or implants in place at the time of postmastectomy radiation therapy. The authors evaluated the impact of various reconstructive techniques on the ability to treat the breadth of the chest wall, treat the internal mammary nodes within the first three interspaces, avoid the lung, and avoid the heart. They found that completely deflated expanders resulted in no compromise; a partially deflated expander prevented treatment of the internal mammary nodes; and fully inflated expanders moderately or severely compromised treatment of the internal mammary nodes and chest wall.

Timing of reconstruction can be difficult as you don’t always know who is going to require postmastectomy radiation therapy.

…. recommendations regarding postmastectomy radiation therapy are often based on pathologic analysis of the mastectomy specimen, the need for postmastectomy radiation therapy is not always known at the time of mastectomy.

So perhaps “delayed-immediate breast reconstruction” might become the standard of care.  Here are their key points regarding this heading:

Until we can reliably predict the need for postmastectomy radiation therapy, decrease its adverse effects through more targeted therapy, and ensure optimal radiation delivery after immediate breast reconstruction, delayed-immediate reconstruction may be the best option with which to maintain the balance between optimal aesthetic outcomes and effective radiation delivery.

In this approach, a tissue expander is placed at the time of mastectomy to preserve the initial shape and thickness of the breast skin flaps and the dimensions of the breast skin envelope until the final results of pathologic analysis are available. 

In patients found not to require postmastectomy radiation therapy, preservation of the breast skin envelope enables the plastic surgeon to achieve aesthetic outcomes similar to those obtainable with immediate breast reconstruction.

In patients who do require postmastectomy radiation therapy, the tissue expander can be deflated before the start of postmastectomy radiation therapy to create a flat chest wall surface and permit modern, three-beam radiation delivery, and the expander can be reinflated after postmastectomy radiation therapy to permit skin-preserving delayed reconstruction.

Placement of the fully inflated expander allows for more precise positioning of the expander on the chest wall. Placement of an inflated expander also avoids the need for skin expansion and stretching of already thin mastectomy skin flaps, which can adversely affect the safety (expander exposure) and aesthetic outcome (telangiectasia formation) of breast reconstruction.

Expanded breast skin also tends not to tolerate postmastectomy radiation therapy; however, maintenance of the initial thickness of breast flaps after mastectomy, as in delayed-immediate reconstruction, results in better tolerance of the inflammatory effects of postmastectomy radiation therapy because the normal architecture of the dermis is preserved.

MAIN ARTICLE REFERENCE
Radiation Therapy and Breast Reconstruction: A Critical Review of the Literature; Plastic and Reconstructive Surgery. 124(2):395-408, August 2009; Kronowitz, Steven J.; Robb, Geoffrey L. [doi: 10.1097/PRS.0b013e3181aee987]
Articles Reference within Main Article for delayed-immed reconstruction:
Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation therapy: Current issues. Plast Reconstr Surg. 2004;114:950-960.
Kronowitz SJ. Immediate versus delayed reconstruction. Clin Plast Surg. 2007;96:39-50.
Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast reconstruction. Cancer 2006;107:893-907.
Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004;113:1617-1628.

ASPS Task Force Updates Position on Fat Grafting

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

I have written about fat grafting to the breast previously here and here. 

The Fat Graft Task Force of the American Society of Plastic Surgeons (ASPS) convened to try to answer the question of whether fat grafting compromises breast cancer detection and/or results in potentially catastrophic sequelae in patients?  Their conclusion:  there is no indication that fat grafting is an unsafe procedure with qualifications that more research is needed.

Sydney R Coleman, MD is quoted in the Cosmetic Surgery Times article, "In review of the multitude of evidence-based results of clinical trials, case series and reports, the Task Force found that there is no evidence that indicates that fat grafting is an unsafe procedure.  Nevertheless, the report did say that in order for the Task Force to make concrete recommendations for or against fat grafting for specific applications, high-quality randomized controlled trials would be needed to further evaluate safety and efficacy."

The following conclusions are from the February 2009 Task Force Report:

CONCLUSIONS
Clinical Applications
Based on a review of the current literature and a lack of strong data, the Task Force cannot make specific recommendations for the clinical use of fat grafts. Although fat grafts may be considered for use in the breast and other sites, the specific techniques of graft harvesting, preparation, and injection are not standardized. The results therefore may vary depending on the surgeon’s technique and experience with the procedure. Although there are little data to provide evidence for long-term safety and efficacy of fat grafting, the reported complications suggest that there are associated risks. Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting. There is a potential risk of fat grafts interfering with breast physical examination or breast cancer detection; however, the limited data available suggests that fat grafts may not interfere with radiologic imaging in detecting breast cancer.

Future Research
The Task Force believes autologous fat grafting is a promising and clinically relevant research topic. The current fat grafting literature is limited primarily to case studies, leaving a tremendous need for high-quality clinical studies. While this evidence-based review resulted in few, if any, new data that would prompt a substantial change in the current state of fat grafting, the lack of new information poses two important questions: (1) are current methods of fat grafting still the "gold standard," or (2) is more research needed and should funding be directed toward new studies? For many aspects of fat grafting, the Task Force found the latter to be true and has
suggested the following areas for future research:

• Randomized controlled trials to assess safety and efficacy of fat grafting for different indications
• Randomized controlled trials to assess safety and efficacy of specific fat grafting techniques
• Studies to further assess the effect of fat grafting on breast cancer detection and treatment.
• Studies to identify risk factors and improve patient selection for procedures involving fat grafting.
• Studies to investigate aspects of cell/tissue viability and graft survival, as well as long term storage and banking of fat grafts.
    

REFERENCES
ASPS' Fat Graft Task Force updates position on safety of autologous fat grafting; Cosmetic Surgery Times, Aug 1, 2009; Ilya Petrou, MD
Current Applications and Safety of Autologous Fat Grafts: A Report (pdf); American Society of Plastic Surgeons; Feb 2009
Fat Transfer/Fat Graft and Fat Injection:  ASPS Guiding Principles (pdf); January 2009


Related Posts

Fat Injections for Breast Augmentation (November 6, 2008)
Complications After Autologous Fat Injections to the Breast – an Article Review (April 2, 2009)
Recent NPR Stories on Plastic Surgery (June 3, 2009)

Internal US Technique Treats Hyperhidrosis—an Article Review

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

This was suppose to simply be an article review. I was intrigued by the potential of using ultrasound (US) to damage the sweat glands when I read this article in the August issue of Cosmetic Surgery Times. I even went back and read the Aesthetic Plastic Surgery Journal article referenced, but I have gotten sidetracked by this photo. It troubles me.

See how it is labeled an intra-operative photo? Notice the surgeon is wearing what appears to be a large jeweled ring under her sterile glove. Who wears jewelry in the OR??? That’s not proper sterile technique!

Intra-operative photo shows application of internal ultrasound therapy to damage the sweat glands. (Photo credit: Sharon Giese, M.D., F.A.C.S.)

In the article Dr. Giese states the procedure uses the heat energy of the ultrasound liposuction to “presumably kills the sebaceous glands. Permanently." No biopsies done to know for sure. No starch– iodine testing to quantify the decrease in sweat.

Dr Giese reports good results with her patients, but doesn’t quantify the number of patients. She reports that all the women no longer need deodorant. She reports that one male has had 65% reduction in sweating which can now be controlled by deodorant.

In looking further into the technique I found two more recent articles (the 3rd and 4th below).

In the 4th article, the researchers had 13 patients (3 males, 10 females) with significant axillary hyperhidrosis which they treated with the VASER ultrasound and followed for 6 months. Eleven of 13 patients had significant reduction in sweat/odor with no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree they desired. No significant complications were noted. They report the complete procedure takes less than 1 h to treat two axillae using local anesthetic.   Once again, no objective measures of sweating.

I remain intrigued with this procedure, but would love more scientific measures and studies.  Still, I suppose the patients only care about the subjective measures when it comes to sweating.

REFERENCES
Internal ultrasound technique treats hyperhidrosis; Cosmetic Surgery Times, Aug 1, 2009; Donley-Hayes, Karen

Very Superficial Ultrasound-assisted Lipoplasty for the Treatment of Axillary Osmidrosis; Aesthetic Plast Surg. 2000 Jul-Aug;24:275-279; Park S

Characteristics of Refractory Sweating Areas Following Minimally Invasive Surgery for Axillary Hyperhidrosis; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; Falk Georges Bechara, Michael Sand and Peter Altmeyer

Treatment of Axillary Hyperhidrosis/Bromidrosis Using VASER Ultrasound; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; George W. Commons and Angeline F. Lim

How Poland’s Syndrome Was Named

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

Poland's syndrome is a congenital disorder. The classic ipsilateral features of Poland syndrome include the following: absence of sternal head of the pectoralis major, hypoplasia and/or aplasia of breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of rib cage, and upper extremity anomalies. These upper extremity anomalies include short upper arm, forearm, or fingers (brachysymphalangism). (photo credit)

Additional features of Poland syndrome include the following: hypoplasia or aplasia of serratus, external oblique, pectoralis minor, latissimus dorsi, infraspinatus, and supraspinatus muscles; total absence of anterolateral ribs and herniation of lung; and symphalangism with syndactyly and hypoplasia or aplasia of the middle phalanges. (photo credit)

The name of this condition pays homage to Dr. Alfred Poland of Guy's Hospital, who in 1841 described a case of these two deformities during the autopsy of a 27-year-old convict, but as this article points out he wasn’t the first to recognize the syndrome.

If you enjoy medical history, then you will enjoy this article. It explores the historical literature to reveal the progression of knowledge about this syndrome. Here is a quick summary of different investigators who contributed to the understanding of Poland's syndrome. The article goes into more detail of each.

1826	Lallemand is first to describe the absence of the pectoralis.
1835	Bell is the first to record the absence of the pectoralis
1839	Forlep is first to describe the paired absence of the pectoralis and ipsilateral syndactyly
1841	Poland is the second to describe the paired absence of the pectoralis and ipsilateral syndactyly
1895	Thomson is the first to document an understanding that the deformities accompanied one another
1900	Furst is the first to propose that the anomalies constituted a syndrome
1902	Bing is the first to present a case series of patients with the syndrome
1940	Brown and McDowell are the first to document a thorough review of the syndrome
1962	Clarkson is the first to propose the name “Poland’s Syndactyly” for the syndrome

As the authors conclude:

Honoring physicians for notable achievements in the form of eponyms can be viewed as a harmless way to bring a little bit of warmth to an otherwise cold world of facts. The least we can do, though, is to recognize the contributions of those who endeavored to shape our current understanding of disease.

Perhaps if history took another course, Poland's syndrome would instead be called Frolep's syndrome or Furst's syndrome. Or perhaps it might simply have been called pectoral-aplasia-dysdactylia syndrome

REFERENCES

Poland's Syndrome: Current Thoughts in the Setting of a Controversy; Plastic & Reconstructive Surgery. 123(3):949-953, March 2009; Ram, Ashwin N. B.S.; Chung, Kevin C. M.D., M.S. (subscription required)

CAMRSA: Dx and Tx Update for Plastic Surgeons – an Article Review

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

Beginning the year trying to catch up on some of my journals.  Reading my Plastic and Reconstructive Journals, I noticed this very nice review article on community acquired methicillin resistant Staph aureus (first article referenced below).  It seems even more timely as HHS has just issued it’s “Action Plan to Prevent Health Care-Associated Infections”.

It begins by noting that MRSA was first discovered in the 1960’s and until “recently” was considered a hospital-acquired infection.  Looking at the genes of the S. aureus bacteria has given a clearer picture of the two (hospital acquired vs community acquired) diseases.

There are five types of SCCmec. Hospital-acquired methicillin-resistant S. aureus strains contain SCCmec types I, II, III, and V4, and community-acquired methicillin-resistant S. aureus strains contain a smaller version of SCCmec type IV. The smaller size of the SCCmec type IV is responsible for the wider susceptibility of the community-acquired methicillin-resistant S. aureus to antimicrobials, as it does not carry the genes for other drug resistance. This genetic package gives community-acquired methicillin-resistant S. aureus resistance always to methicillin and almost always to erythromycin, in addition to other drugs that may be used to treat an infection……

Of clinical importance is that almost 100 percent of community-acquired methicillin-resistant S. aureus strains contain the Panton-Valentine leukocidin (PVL) gene allowing for production of a necrotizing, cell membrane pore-forming cytotoxin that targets leukocytes and erythrocytes.  Panton-Valentine leukocidin is responsible for the localized invasiveness in community-acquired methicillin-resistant S. aureus soft-tissue infections. In contrast, only 5 percent of methicillin-sensitive S. aureus and hospital-acquired methicillin-resistant S. aureus isolates contain the PVL gene.

The article compares the two HA-MRSA and CA-MRSA

	HA-MRSA	CA-MRSA
Health-care contact	yes	no
Mean age at infection	older	younger
Skin and soft-tissue infection	25%	75%
Antibiotic resistance	many agents	some agents
PVL toxin gene	5%	100%

The article reviews who is more likely (risk factors) to acquire CA-MRSA

• History of MRSA infection or colonization in patient or close contact
• High prevalence of CA MRSA in local community or patient population
• Recurrent skin disease
• Crowded living conditions (e.g. homeless shelters, military barracks)
• History of incarceration
• Participation in contact sports
• Skin or soft tissue infection with poor response to B-lactam antibiotics
• Recent and/or frequent antibiotic use
• Injection drug use
• Member of Native American, Pacific Island, Alaskan Native populations
• Child under 2 years of age
• Male with history of having sex with men
• Shaving of body hair

It is important to be more suspicious of CA-MRSA if the patient is one of those with the risk factors listed above, but also if their clinical presentation includes the following

• looks like spider bite
• folliculitis, pustular lesions
• furuncle, carbuncle (boils)
• abscess (esp. with tissue necrosis)
• cellulites
• impetigo
• infected wound

The article covers treatment  of CA-MRSA skin infections.  They make a point that not all need to be treated with antibiotics.

Abscesses should be incised and drained with material sent for aerobic culture. Abscess drainage alone suffices in patients with a soft-tissue abscess less than 5 cm in diameter and who are not systemically ill. There is no benefit in using antibiotics for cutaneous abscesses if adequate drainage is performed; however, this does not apply to patients with cellulitis.

They then go on to point out the ones who do need antibiotics.

In a patient with comorbidities, moderate illness, or a soft-tissue infection larger than 5 cm in diameter, antibiotic therapy should be started after incision and drainage.

If community-acquired methicillin-resistant S. aureus is suspected but there is not a definite abscess, antibiotic treatment should be started. If this course is chosen, the patient should follow up 48 to 72 hours after treatment has begun, as the aggressiveness of the community-acquired methicillin-resistant S. aureus may lead to development of an abscess.

The article notes that, currently, CA-MRSA is frequently sensitive to clindamycin, gentamicin, rifampin, and trimethoprim / sulfamethoxazole, as well as vancomycin.  Linezolid is also effective but very expensive.

Currently, 90-95% of CA-MRSA strains are currently susceptible to trimethoprim/sulfamethoxazole at double strength and doxycycline.

In CA-MRSA,  there is minimal evidence at this time to support decolonization protocols in the community.    There may be some benefit in decolonization of patients with recurrent methicillin-resistant S. aureus soft-tissue infections or high-risk contacts of patients with methicillin-resistant S. aureus soft tissue infections.   Topical mupirocin in the nares has been shown to eradicate methicillin resistant S. aureus colonization in health care workers and patients for a short time.   This effect may be lost over time as individuals become recolonized, and prolonged use of mupirocin has been associated with resistance.

Preventive Measures Include

Personal hygiene

• Shower daily
• Wash hands frequently
• Keep wounds covered
• Avoid contact with wound drainage

Environmental control

• Clean shared equipment (e.g., athletic equipment)
• Clean contaminated surfaces
• Use a barrier to bare skin when in contact with shared
  equipment

Health care–associated control

• Use antimicrobials judiciously
• Diagnose and treat methicillin-resistant S. aureus lesions
  early
• Educate patients about wound care
• Consider decolonization
• Consult with an infectious disease specialist when
  appropriate

REFERENCES

Community-Acquired Methicillin-Resistant Staphylococcus aureus: Diagnosis and Treatment Update for Plastic Surgeons; Plastic & Reconstructive Surgery. 122(4):120e-127e, October 2008; Stacey, D Heath M.D.; Fox, Barry C. M.D.; Poore, Samuel O. M.D., Ph.D.; Bentz, Michael L. M.D.; Gutowski, Karol A. M.D.

Community Associated Methicillin Resistant Staphylococcus Aureus (CA MRSA); Guidelines for Clinical Management and Control of Transmission; PPH 42160, October, 2005 (pdf file)

Community-associated MRSA (CA-MRSA) Information for Clinicians; CDC,February, 2005

Blog Review of 2008

I thought I would look back over my year of blog posts and find ones  stood out for me.  Here they are in chronological order:
1.   My Facial Fracture Series (January)

Zygomatic Fractures
Nasoethmoid Orbital Fractures
Mandible Fractures
Le Forte Fractures
Eye Exam in Facial Trauma
Orbital Blowout Fractures

2.   Amputations, Prosthetics, and War (February)
3.   Tips for Surgery Patients (March)
4.   Bilobed Flap for Repair of Nose  (March)
5.   Medical Leech Use (March)
6.   The Anophthalmic Syndrome (April)
7.   Guidelines for von-Willebrand Disease (May)
8.  Abdominal Wall Reconstruction (May)
9.  Ring Finger Avulsion (June)
10.  Callipygian (July)
11.  Maggot Therapy Revisited (August)
12.  Surgical Loupes (September)
13.  Complex Regional Pain Syndrome (September)
14.  Soft Tissue Injuries of the Finger Tips (October)
15.  Medical Methods Patents (November)
Many thanks to all of you who drop in.  I hope you will return.

I hope you have a great 2009!