SurgeXperiences 203 is Up!

 Updated 3/2017 -- links removed as many no longer active.
Bongi, other things amanzi, is the host for this edition of SurgeXperiences.  He has done a great job!  I hope you will head over and take the time to read it. 
And after you finish this edition, you may wish to check out the past ones.  Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Book Review -- Critical Conditions

I enjoy reading novels by Stephen White. He is a clinical psychologist who lives in Colorado. This one, Critical Conditions, involves his main character, Dr Alan Gregory, in some twists and turns of human behavior dealing with a family deals with one of their own who needs care that their HMO won't approve. It's a good read, classified as a psychological thriller.

Some of it will make you think about the discussions ongoing in medical care/insurance coverage. His first page made me think of Dr Edwin Leap's request for last week's Grand Rounds -- "Why we do it".

Here's that first page:

I hold the hands of people I never touch.
I provide comfort to people I never embrace.

I watch people walk into brick walls, the same ones over and over again, and I coax them to turn around and try to walk in a different direction.

People rarely see me gladly. As a rule, I catch the residue of their despair. I see people who are broken, and people who only think they are broken. I see people who have had their faces rubbed in their failures. I see weak people wanting anesthesia and strong people who wonder what they have done to make such an enemy of fate. I am often the final pit stop people take before they crawl across the finish line that is marked: I give up.

Some people beg me to help.
Some people dare me to help.

Sometimes the beggars and dare-ers look the same. Absolutely the same. I'm suppose to know how to tell them apart.

Some people who visit me need scar tissue to cover their wounds. Some people who visit me need their wounds opened further, explored for signs of infection and contamination. I make those calls, too.

Some days I'm invigorated by it all. Some days I'm numbed.
Always, I'm humbled by the role of helper.
And, occasionally, I'm ambushed.

This first page also made me think about my post Suitability.

Pink

This quilt is one I made for Vijay's daughter. She wanted it to be pink and it is. It is very, very pink! I went through the fabric my neighbor had given me and found several pinks in the fat quarter, some of which were not "whole" fat quarters. The concentric courthouse steps pattern seemed to be a good way to show off the pink fabrics and make use of the small amounts I had of each. Here is the result

The quilt is 43 in X 43 in. It is machine pieced and quilted. I wish the quilting showed better. I used a heart pattern (four hearts looped together) in the center. Then used a "daisy and leaf" pattern around the outer part of each. The border is then a woven rope pattern.

 

Gynecomastia -- a repost

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

This is a repost from last August with a few additions.

Gynecomastia is defined as benign, excess breast tissue development in male individuals. Recent studies have reported an overall incidence of 32 - 36 %, and up to 64.6 % in adolescent boys. The incidence of bilateral involvement also varies in the literature from 25 -75 percent of patients. The underlying cause seems to be an increase in the ratio of estrogen to androgen activity. 

In general physiologic gynecomastia can be observed in three peaks during life.

1. The neonatal period: 60-90% of infants have transient gynecomastia due to transplacental transfer of maternal estrogens.
2. Puberty: 48-64% of boys at puberty have gynecomastia. Usually peak age of onset is between 13 and 14 years, followed by a decline in late teenage years.
3. Late in life: The highest prevalence of gynecomastia is seen among men aged 50-80 years.

Pathologic gynecomastia occurs as a result of various metabolic disorders (alcoholic cirrhosis), endocrine disorders (hyperthyroidism, adrenal cortical hyperplasia), acquired hypogonadal states (orchitis, testicular trauma), congenital hypogonadal states (Klinefelter syndrome, congenital anorchia), and increased estrogen states (bronchogenic carcinoma, testicular tumors). (Table 1--MedScape article)

Pharmacologic gynecomastia occurs by several mechanisms, including increased direct estrogenic activity, increased secretion of estrogen, decreased testosterone synthesis, and decreased androgen sensitivity. There are also many drugs with poorly understood mechanisms that are associated with gynecomastia. (Table 2--MedScape article)

Clinical evaluation of patients with gynecomastia is very important. However, further work-up is rarely indicated.

History should include age, duration and onset of breast enlargement, symptoms of pain or tenderness, medications and recreational drug use, and psychological and social effects. A review of systems that covers all the above mentioned causes should be obtained.

Physical examination of the breasts should involve assessment for glandular or fat predominance (by the pinch test), degree of glandular ptosis, skin excess, nodules/masses, and nipple abnormalities or discharge. Glandular or parenchymal tissue is characterized by rubbery breast tissue that is mobile and extends from a subareolar, centric position. Breast cancer accounts for 0.2% of all malignancies in men and generally presents as a unilateral firm mass, often eccentric in location rather than centered beneath the areola. This should be remembered if any suspicious nodules or masses are found. These may have abnormal firmness, overlying skin ulceration, eccentric location, or abnormal nipple discharge.

The normal male breast is typically flat with some fullness around the nipple-areola complex. The nipple-areola complex is normally 2 - 4 cm in diameter (average, 2.8 cm) and located over the fourth intercostal space. Nipple to sternal notch distance is, on average, 20 cm. A muscular male chest may exhibit superior fullness with a transition to a flat inferior chest near the inframammary fold. Completion of the physical examination should in particular assess for testicular enlargement/atrophy and asymmetry, thyromegaly, hepatomegaly, pulmonary abnormalities, and abdominal masses. Additional diagnostic testing should be individualized to address abnormalities identified in the history or physical examination.

The majority of patients with gynecomastia require no treatment other than removal of the precipitating cause. If it is drug-induced, it may regress if the offending medication is stopped. Treatment of hyperthyroidism, correction of hypogonadism and surgical removal of testicular, adrenal or other causative tumors can also lead to regression.

Treatment for gynecomastia is indicated in cases where it produces significant pain, embarrassment or emotional discomfort and therefore interfering with the patient's life. A patient should consider proceeding with surgical management once diagnosis of gynecomastia is established of nonphysiologic causes or of duration greater than approximately 12 months, because hypertrophic breast tissue beyond this stage usually becomes irreversibly fibrotic.

Classification of gynecomastia as defined by Rod Rohrich, MD & others is based on the amount and character of breast hypertrophy and the degree of ptosis.

Grade I patients --minimal hypertrophy (less than 250 gm of breast tissue).

• Grade IA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
• Grade IB--primarily fibrous breast tissue

Grade II patients -- moderate hypertrophy (between 250 and 500 gm of breast tissue).

• Grade IIA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
• Grade IIB--primarily fibrous breast tissue

Grade III --severe hypertrophy (more than 500 gm of breast tissue), grade 1 ptosis
Grade IV --severe hypertrophy (more than 500 gm of breast
tissue), grade 2 or 3 ptosis

Ultrasound-assisted liposuction is effective in all grades of gynecomastia. Usually, no further treatment is needed in grade I or II gynecomastia. Often, single ultrasound-assisted liposuction treatment is all that is necessary for grades III and IV, especially in those with mild ptosis and good skin quality. Often the glandular tissue will need direct excision which can be done through a small peri-areolar incision. If removal of redundant skin and/or resistant lipodystrophy is still required after ultrasound-assisted liposuction, a staged excision is delayed for 6 to 9 months to allow for maximal skin retraction and healing, thus potentially allowing down staging of the magnitude of the excisional technique (and therefore minimizing scarring)

REFERENCES

Classification and Management of Gynecomastia: Defining the Role of Ultrasound-Assisted Liposuction.; Plastic & Reconstructive Surgery. 111(2):909-923, February 2003; Rohrich, Rod J. M.D.; Ha, Richard Y. M.D.; Kenkel, Jeffrey M. M.D.; Adams, William P. Jr., M.D.

Breast Cancer in a Patient with Gynecomastia; Plastic & Reconstructive Surgery. 84(6):976-979, December 1989; Fodor, Peter Bela M.D.

Management of Gynaecomastia: An Update ; Int J Clin Pract. 2007; 61(7):1209-1215.; P. Gikas, MD; Kefah Mokbel, MS, FRCS (also a MedScape article)
Gynecomastia--eMedicine article, June 9, 2006; Ali Fawzi, MD

Additional References & Info

Gynecomastia, eMedicine Article, Nov 15, 2006; Mark R Allee MD and Mary Zoe Baker MD

This is a very nice youtube video (some of it is graphic)

Callipygian

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

I learned a new word recently.
callipygian

PRONUNCIATION:
(kal-uh-PIJ-ee-uhn)
MEANING:
adjective: Having well-shaped buttocks.
ETYMOLOGY:
From Greek calli- (beautiful) + pyge (buttocks). Two related words are dasypygal and steatopygia.
USAGE:

"And it hasn't been lost on modern film directors that a nice set of tights can showcase the callipygian assets of a well-formed leading man."

Heroes in Hosiery; South China Morning Post (Hong Kong); Jul 20, 2006

I am being asked by more and more patients about buttock shaping, lifting, and even implants. The entire idea of defining a nice buttock is interesting to me. Difficult to put into words, but something "you know when you see" one. And yes, I do check out men's butts. The girls in the OR and I have been know to whisper about how nice Dr ___'s butt looks in his scrubs.

Okay, back to the topic. What defines a well-shaped buttock?
Characteristics
The features that are common to attractive youthful, female buttocks in all ethnic groups include:

• A smooth inward sweep of the lumbosacral area and waist.
• A very feminine cleavage as the buttocks separate superiorly and inferiorly.
• Maximum prominence in the mid to upper buttocks.
• There should be minimal infragluteal crease, with no droop above this line.

Sacral dimples or depressions may be present or absent in attractive youthful buttocks, but are not considered a determinant of their beauty.
Even with the difference in cultural ideas of the "ideal" buttock, the above features hold. Some ethnic differences include (some good photos can be found here):
Caucasian patients

• will generally want buttocks that are full but not really large.
• fullness of the lateral thigh is considered objectionable.
• Some prefer a full rounded lateral buttocks.
• Others prefer a flat or hollow lateral buttock (considered a more "trim" or athletic look).

Hispanic or of recent Hispanic descent

• prefer buttocks that are very full.
• lateral buttocks that are very full
• a slight fullness in the lateral thigh.

Asian patients

• prefer buttocks that are shapely but small to moderate in size
• little or no fullness in the lateral buttocks or lateral thigh.

African-Americans and Caribbean's of African descent

• have a strong and consistent cultural ideal of very large buttocks
• often will request a "shelf" (extreme prominence of the upper buttocks)
• prefer very full lateral buttocks
• a very full, prominent trochanteric area of the lateral thighs is considered attractive by both men and women in this culture

There are multiple procedures that can be used to get to or closer to the "ideal" (must in keep in mind the patient's ideal) buttock. These include:
Micro-fat grafting
Buttock Reduction/Contouring
Gluteal Implants
Buttock Lifts
Combination of the Above
And don't forget these exercises that help tone and bulk up the glutes. You can find them here or a video here or this youtube video (the one below) or this one,

REFERENCES
Dr Thomas L Roberts, III, MD, FACS Website: BetterButtocks.com (nice photos and patient information)
Body Contouring, Buttocks Surgery; eMedicine Article, Dec 19, 2006; Robert F Centeno MD and Neal R Reisman MD, JD
Body Contouring, Flankoplasty, and Thigh Lift; eMedicine Article, Feb 25, 2008; Keith M Robertson MD and Bruce G Freeman MD
Beautiful Buttocks: Characteristics and Surgical Techniques. Clin Plast Surg, July 2006;33(3):321-32; Cuenca-Guerra R, Lugo-Beltran I (abstract available here)
Buttocks Lifting: How and When to Use Medial, Lateral, Lower, and Upper Lifting Techniques; Clin Plast Surg. July 2006;33(3):467-78; Gonzalez R. (abstract available here)
Gluteoplasty; Aesthetic Surgery Journal, Vol 23, No 6, pp 441-455; Constantio G Mendieta MD (abstract available here)
Gluteal Aesthetic Unit Classification: A tool to Improve Outcomes in Body Contouring; Aesthetic Surgery Journal, Vol 26, No 2, pp 200-208; Robert F. Centeno MD (abstract available here)
Gluteal Reshaping; Aesthetic Surgery Journal, Vol 27, No 6, pp 641-655; Constantino G Mendieta MD (abstract available here)

Shout Outs

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

Grand Rounds is up over at Dr Edwin Leap's place. His theme was "Why we do it". Nicely done and some very nice posts. Read this week's grand rounds here.

Welcome to Grand Rounds! This is my first time hosting, so thanks for your patience as I stumble through. And thanks to everyone who submitted! There are some extremely insightful folks out there, and I’m grateful to showcase their thoughts.

Change of Shift is up over at Emergiblog. This is the start of a new year (and with a new logo):

Welcome to Volume 3, Number 2 of Change of Shift!
New year, new logo!
I tried, I really tried, to make a logo that wasn’t blue but I just could not do it.
I just love blue on blogs!
Many thanks to all who have contributed this week, and to those who contributed but don’t realize it yet!

Dr Wes and Dr Rob are working together to help "pinch childhood brain cancer".

with Zippy, the lovable red lobster, to raise awareness and funds to support childhood brain cancer research over at FunWithZippy.com. He asked if we'd help support the effort and host the official "Fun With Zippy" t-shirt on our medical t-shirt site MedTees.com, for which we were only too happy to help out.

All proceeds from the sales of these shirts, button, aprons, mouse-pads, stickers and the like with Zippy's logo will support childhood brain cancer research.

Dr Anonymous' Blog Talk Radio show will be back on air this Thursday night! His guest this week will be Dr Theresa Chan whose blog is Rural Doctoring. It is a wonderful addition to the blogosphere. The show starts at 8 pm CST (or 1 am GMT). I hope you will join us.

Tips for first time Blog Talk Radio listeners (from Dr A):

A nice post by Dr Val yesterday (though aren't they all nice)

I attended a lecture entitled, "Limb Labs: Getting Amputee Soldiers Back to Work After World War I." The lecture was held at the National Museum of Health and Medicine on the Walter Reed campus in Washington, DC. Both lecturers (Beth Linker and Jeffrey Reznick) did a wonderful job of transporting the audience back in time, outlining the cultural beliefs and historical context of the day. This is what I gleaned from their lectures:

Dr Wes will be doing a live on-line chat for an hour on August 6th, 2008 at 7PM CST. He recently did an hour-long radio show on atrial fibrillation (afib) with his colleague Dr. Jose Nazari, MD. The podcast is now up and can be listened to or download it here.

Methylene Blue and Skin Necrosis -- Repost

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

I "conversed" with a young woman this weekend via e-mail who has this complication. So I thought I would repost my review of it from December 2, 2007.

Sentinel lymph node (SLN) dissection has increased in use for the management of high-risk melanoma and other cancers, such as breast cancer. The procedure identifies an SLN by intradermal or intraparenchymal injection of a blue dye (either isosulfan blue or methylene blue), a radiocolloid, or both around the primary malignancy.

When isosulfan blue is used there is a 2% incidence of allergic reactions. These include "blue hives" and anaphylaxis. Because of these reactions, the use of methylene blue is becoming more wide spread as no toxicity has been attributed to it.

The use of methylene blue requires an intraparenchymal injection of 5 mL of 1% methylene blue dye. While methylene blue has had no systemic toxicity attributed to it, it has been associated with a local inflammatory reaction which may lead to skin necrosis at the site of injection. Stradling et al. reported skin lesions in 5 of 24 patients who received intradermal injection of methylene blue dye for lymphatic mapping in breast cancer. The skin lesions included a variety of local inflammatory presentations, including erythematous macular lesions, superficial ulcers, necrotic ulcerations, and abscess formation. After injections were restricted to the deep parenchyma, no further skin lesions were noted. This local toxicity of methylene blue with superficial injection concerns surgeons who perform subareolar injection because of its potential effect on the nipple/areolar complex.

Prevention

Methylene Blue should not be given by subcutaneous, so try to inject into the deep dermis or subcutaneous layer. This should help prevent the skin complications.

"Some individuals have found that dilution of methylene blue (2 mL of methylene blue and 3 mL of saline) allows successful mapping while avoiding this local toxicity (Pat Whitworth, MD, personal communication, May 2004" -- from second reference article.

Treatment
Treatment consists of basic wound care.
1) Keep the wound clean.
2) Keep the wound moist.
3) Keep the wound well nourished, which implies reducing or eliminating edema and keeping pressure off the wound.
4) Debride only as necessary, be conservative.

References
Methylene Blue Solution for Injection Data Sheet--MedSafe

Is Blue Dye Indicated for Sentinel Lymph Node Biopsy in Breast Cancer Patients With a Positive Lymphoscintigram?; Amy C. Degnim, MD, Kevin Oh, MD, Vincent M. Cimmino, MD, Kathleen M. Diehl, MD, Alfred E. Chang, MD, Lisa A. Newman, MD, MPH and Michael S. Sabel, MD; Annals of Surgical Oncology 12:712-717 (2005)

Adverse skin lesions after methylene blue injections for sentinel lymph node localization; Stradling B, Aranha G, Gabram S; Am J Surg 2002;184:350–2.

Allergic reactions to isosulfan blue during sentinel node biopsy – a common event; Cimmino VM, Brown AC, Szocik JF, Pass HA; Surgery. 2001;130:439–42. doi:10.1067/msy.2001.116407.

Dye Rashes; Raimer SS, Quevedo EM, Johnston RV; Cutis. 1999;63:103–106

The Role of Subareolar Blue Dye in Identifying the Sentinel Node in Patients with Invasive Breast Cancer by K. Mokbel and A. Mostafa-- MedScape Article

The Big Read

I saw this on Purplesque's blog (thanks Vijay for the introduction). It seems to be a meme going around the blogosphere rather than a list coming from the come from National Endowment for the Arts (NEA). The NEA does have a program called "The Big Read".

The Big Read is an initiative of the National Endowment for the Arts designed to restore reading to the center of American culture. The NEA presents The Big Read in partnership with the Institute of Museum and Library Services and in cooperation with Arts Midwest.

Still it is interesting to read the "meme list" and see which ones you have read. So here it is:

“The Big Read reckons that the average adult has only read 6 of the top 100 books they’ve printed.”

1) Bold: I have read.
2) Underline: Books I love.

3) Reprint this list in your own blog so we can try and track down these people who’ve read 6 and force books upon them ;-)

1. Pride and Prejudice - Jane Austen
2. The Lord of the Rings - JRR Tolkien
3. Jane Eyre - Charlotte Bronte
4. The Harry Potter Series - JK Rowling
5. To Kill a Mockingbird - Harper Lee
6. The Bible
7 . Wuthering Heights - Emily Bronte
8. Nineteen Eighty Four - George Orwell
9. His Dark Materials – Phillip Pullman
10. Great Expectations – Charles Dickens
11. Little Women - Louisa M Alcott
12. Tess of the D’Urbervilles - Thomas Hardy
13. Catch 22 - Joseph Heller
14 . The Complete works of Shakespeare (Like Purplesque I've tried, and failed. Have seen many of them performed.)
15. Rebecca - Daphne Du Maurier
16. The Hobbit --J.R.R. Tolkien
17. Birdsong – Sebastian Faulks
18. Catcher in the Rye - JD Salinger
19. The Time Traveler's Wife
20. Middlemarch - George Eliot
21. Gone With The Wind - Margaret Mitchell
22. The Great Gatsby - F Scott Fitzgerald
23. Bleak House - Charles Dickens
24. War and Peace - Leo Tolstoy
25. The Hitch Hiker’s Guide to the Galaxy - Douglas Adams
26. Brideshead Revisited – Evelyn Waugh
27. Crime and Punishment - Fyodor Dostoyevsky
28. Grapes of Wrath - John Steinbeck (one of the few Steinbeck's I haven't read)
29. Alice in Wonderland - Lewis Carroll
30 . The Wind in the Willows - Kenneth Grahame
31. Anna Karenina - Leo Tolstoy
32. David Copperfield – Charles Dickens
33. Chronicles of Narnia - CS Lewis
34 . Emma - Jane Austen
35. Persuasion - Jane Austen
36. The Lion, The Witch and The Wardrobe - CS Lewis
37. The Kite Runner - Khaled Hosseini
38. Captain Corelli’s Mandolin - Louis De Bernieres
39. Memoirs of a Geisha - Arthur Golden
40. Winnie the Pooh - AA Milne
41. Animal Farm - George Orwell
42. The Da Vinci Code - Dan Brown
43. One Hundred Years of Solitude - Gabriel Garcia Marquez
44. A Prayer for Owen Meaney - John Irving
45. The Woman in White - Wilkie Collins
46. Anne of Green Gables - LM Montgomery
47. Far From The Madding Crowd - Thomas Hardy
48. The Handmaid’s Tale - Margaret Atwood
49. Lord of the Flies – William Golding
50. Atonement - Ian McEwan
51. Life of Pi - Yann Martel
52. Dune- Frank Herbert
53. Cold Comfort Farm - Stella Gibbons
54. Sense and Sensibility - Jane Austen
55. A Suitable Boy - Vikram Seth
56. The Shadow of the Wind - Carlos Ruiz Zafon
57. A Tale Of Two Cities - Charles Dickens
59. The Curious Incident of the Dog in the Night-time - Mark Haddon
60. Love In The Time Of Cholera - Gabriel Garcia Marquez
61. Of Mice and Men - John Steinbeck
62. Lolita - Vladimir Nabokov
63. The Secret History - Donna Tartt
64. The Lovely Bones - Alice Sebold
65. Count of Monte Cristo - Alexandre Dumas
66. On The Road - Jack Kerouac
67. Jude the Obscure - Thomas Hardy
68. Bridget Jones’s Diary - Helen Fielding
69. Midnight’s Children - Salman Rushdie
70. Moby Dick – Herman Melville
71. Oliver Twist - Charles Dickens
72. Dracula - Bram Stoker
73. The Secret Garden - Frances Hodgson Burnett
74. Notes From A Small Island - Bill Bryson
75. Ulysses - James Joyce
76. The Bell Jar - Sylvia Plath
77. Swallows and Amazons
78. Germinal - Emile Zola
79. Vanity Fair - William Makepeace Thackeray
80. Possession - AS Byatt
81. A Christmas Carol - Charles Dickens
82 Cloud Atlas - David Mitchell
83. The Color Purple - Alice Walker
84. The Remains of the Day - Kazuo Ishiguro
85. Madame Bovary - Gustave Flaubert
86. A Fine Balance - Rohinton Mistry
87. Charlotte’s Web - EB White
88. The Five People You Meet In Heaven – Mitch Albom
89. Adventures of Sherlock Holmes - Sir Arthur Conan Doyle
90. The Faraway Tree Collection – Enid Blyton
91. Heart of Darkness - Joseph Conrad
92. The Little Prince – Antoine de St. Exupery
93. The Wasp Factory – Iain Banks
94. Watership Down - Richard Adams
95. A Confederacy of Dunces – John Kennedy Toole
96. A Town like Alice- Nevil Shute
97. The Three Musketeers - Alexandre Dumas
98. Hamlet- William Shakespeare
99. Charlie and the Chocolate Factory - Roald Dahl
100. Les Miserables – Victor Hugo
I would also suggest:
Angel of Repose by Wallace Stegner
You Can't Go Home Again by Thomas Wolfe
Out of Africa by Isak Dinesen
Midwives by Chris Bohjalian
Mountain Time by Ivan Doig
Ramona by Helen Hunt Jackson
Tony Hillerman's mysteries (featuring Chee and Leaphorn)
Linda Barnes mysteries (featuring Boston PI Carlotta Carlyle)
Stephen White's mysteries (featuring psychologist Dr Alan Gregory)
Susuan Wittig Albert's mysteries (featuring China Bayles, owner of a herbal shop)

Would welcome any suggestions for myself or to give to my nieces and nephews (ages 2 yo to mid-30's).

SurgeXperiences 203 -- Call for Submissions

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

Bongi, other things amanzi, will be your host for the next edition of the second season of SurgeXperiences (Sunday, August 3rd). He has no theme planned, so just write some surgery related posts and send them his way (here).

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on Friday, August 1st. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Memory Quilt #5

I was only asked to make three quilts from all those shirts--one for each son, but I made four so the widow would have one. Then there were all those remaining squares from the car-fabric shirt and I couldn't resist making one more using them. This time around, I limited the different shirt fabrics to only three and did a modified-nine patch. Then to make it large enough, I added some left-over (from this project) flannel that makes you think of hunting/outdoors. Besides cars, hunting was a favorite pastime of the deceased. This quilt is 48 in X 68 in.

The quilt is machine pieced and quilted. The back fabric is the Route 66 fabric. Here is a close up that show one of the patches the family wanted added to the quilts.

Behavior of Surgeons

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

Did you happen to see this news article? It reported on the orthopedic surgeon who gave his patient (female) a temporary tattoo as he put it "to lighten their spirits". I ran this by the crew I worked with in the OR this morning and didn't give them all the details, just this:

"Did you guys hear the news report of the orthopedic surgeon who did a lumbar procedure on a woman and then put a temporary tattoo on her lower abdomen, in the panty region? The patient found it when she went to get dressed in front of her husband. She was reportedly very emotionally traumatized by it."

All of them had somehow missed this news item. Questions came.
"Did he know this person? I mean were they friends outside of the professional relationship?"
"Was the surgeon and patient joking about tattoos in the pre-op?"
"How much is she suing for?"
"The other members of the OR crew allowed him to do this?!"

In the end we all agreed that this was not appropriate for the surgeon to do. My crew would have felt comfortable to have pointed this out to me (had I foolishly tried to do such a thing).

I do not in any terms want to "justify" this behavior, but neither do I think that what these two blog sites and their commenters (here and here) are doing with this incident is appropriate either. It is unfair to "lump" all physicians or all surgeons in a group with this one.

I ran across a post on "A Doctor's Touch" yesterday. It is worth reading the entire posts and it's comments. I think that most of us physicians/surgeons try to do just this with both "touch" and "interaction".

In conclusion, as you can see, a doctor’s touch is an action which, if used wisely and professionally can provide a variety of benefits from psychological to diagnostic. Also, you can see that touch is missing when the doctor-patient relationship involves phone, video or e-mail communication. It is understandable why we who teach medical students stress touch as an important medical tool in its many ways. ..Maurice.

It's the wisely and more importantly the professionally that stands out for me in the above paragraph. I try to keep things professional. I try to treat each patient with respect. Read these wonderful blogs by fellow surgeons and you will quickly see that many of us are in awe that patients place their trust in us.

Surgeonsblog
other things amanzi
Reflections in a Head Mirror
Buckeye Surgeon
Someonetc (an orthopedic attending)

Breast Masses in Adolescent Girls

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

Breast masses in adolescent girls are usually benign.
Fibroadenoma

• is the most common discrete breast mass in the adolescent female (70%).
• As many as 15% of patients may have multiple fibroadenomas.
• On examination, these masses are smooth, mobile, and round.
• They may occasionally become larger just before the patient's menstrual period.
• They are well-circumscribed lesions that can be enucleated from the surrounding tissue at surgery. A true capsule is not typically present.
• If the mass has the characteristics of a fibroadenoma, then it may be monitored with repeated careful physical examination every 1-3 months. Alternatively, an excisional biopsy may be performed if the patient and family request it.

Juvenile, or giant, Fibroadenomas

• are unusually large (>5 cm) and are termed giant when greater than 8 cm.
• The rapid increase in size is what usually brings the patient in to be seen.
• They are benign, do not appear to become malignant or to be familial.
• Management consists of surgery. Histologically, juvenile fibroadenomas have more cellularity than typical fibroadenomas. They should be differentiated from cystosarcoma phyllodes.

Cystosarcoma phyllodes tumors

• manifest as a painless breast mass. Most occur later in life (the third or fourth decade).
• Often the patient will have a history of sudden enlargement of a previously stable mass. The mass may be dramatically large; thinning of overlying skin and increased vascularity of the area may be present.
• Ultrasonography cannot usually be used to distinguish between a fibroadenoma and a phyllodes tumor. That differentiation lies in histologic examination. Phyllodes tumors have a more cellular stroma with nuclear atypia and mitotic figures.
• Usually quoted as 90% benign and 10% malignant. There are reports that state as many as 25% of phyllodes tumors may be considered malignant.
• The management for either benign or malignant phyllodes tumor is wide excision with a margin of normal breast tissue. Malignant phyllodes tumors rarely metastasize to the axilla. Axillary dissections are indicated for patients with palpable lymph nodes.

Pseudoangiomatous Stromal Hyperplasia (PASH)

• is a rare type of benign mesenchymal proliferative disease of the breast.
• Histologically, it is composed of a proliferation of spindle cells with inter-anastomosing vascular-like arrangement in the interlobular or interductal stroma.
• Clinically, PASH is usually found in premenopausal women as a discrete, painless mass, which is firm and movable.

Trauma to the breast, iatrogenic or blunt, may result in a palpable mass.

• The trauma can cause fat necrosis, or breakdown of the adipose tissue. This can lead to a "mass" of scar tissue.
• To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event.
• Upon physical examination, the mass is sometimes indistinguishable from a cancer. Ultrasonography, mammography, and even MRI of the breast may not be able to discern the difference, leading to biopsies in concerning masses.
• Key radiologic features (thought of as pathognomonic for) of fat necrosis include peripheral calcifications, fibrotic scar, and echogenic internal bands. However, these may also be consistent with breast cancer. Findings of lipid cysts or ultrasonographic evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy.

Fibrocystic changes of the breast

• are very common in the adolescent population. Physical examination findings may reveal discrete breast cysts or diffuse small lumps throughout.
• Breast tenderness and heaviness may be experienced by the patient, especially before her menstrual period.
• The patient is advised to avoid caffeine. Evening primrose oil (1 tablespoon at bedtime) may be used to alleviate breast pain associated with fibrocystic changes of the breast.
• A single dominant lump that is present for several months likely requires excisional biopsy.
• Single dominant cysts may be aspirated in an outpatient setting. Cytopathologic examination should be conducted if the fluid is bloody.
• Fibrocystic changes are histologically classified into 3 categories: nonproliferative changes, proliferative changes without atypia, and proliferative changes with atypia. Patients with proliferative changes and/or atypia have a higher risk for future malignancies.
• There is no specific data available in adolescents that would describe their risk of developing breast cancer. It is well described in adults.

1. There is a 1.5-2 fold increase in women with proliferative fibrocystic disease (described histologically as moderate or florid hyperplasia, sclerosing adenosis, or papilloma with a fibrovascular core).
2. There is a 4.4 fold increase in patients with atypical or lobular hyperplasia. This risk increase to 9 fold with a positive family history.
3. Screening guidelines for patients with a history of atypia on breast biopsy findings are still evolving. In adults, current recommendations include yearly physician examinations and yearly mammography.

Malignant breast disease is uncommon in children and in adolescents. Risk factors for breast malignancies include history of familial breast cancer, previous benign disease associated with malignancy (ie, fibrocystic changes with atypia), other malignancies, or irradiation to the neck and chest areas. The most common malignant mass in the breast of a child or adolescent is a metastatic lesion.

Cautionary Note: In very young and preadolescent children, a biopsy should be considered with extreme caution because the developing breast bud may be irreparably harmed, even with a needle aspirate. That said, discrete masses should almost always be removed regardless of age.

REFERENCES

Disorders of the Breast; eMedicine Article, Jan 24, 2008; Margorie J Arca, MD and Denise B Klinkner MD

What is this Girl's Rapidly Enlarging Breast Mass? How we diagnosed and treated a juvenile fibroadenoma; Contemporary Surgery Vol 64, No 7, pp 328-331; Sheetal M Patel MD and Matthew J Hyser MD

Pseudoangiomatous Stromal Hyperplasia of the Breast in Two Adolescent Females; Am Surg 2004; 70(7):605-8; Gow KW, Mayfield JK, Lloyd D, Shehata BM (abstract)

Breast, Fibroadenoma; eMedicine Article, Feb 16, 2007; Marilyn A Roubidoux MD

Cystosarcoma Phyllodes; eMedicine Article, June 12, 2006; Donald R Lannin MD and Anastasios K Konstantakoes MD, John H Raaf MD

Pseudoangiomatous Stromal Hyperplasia Tumor: a Clinical, Radiologic, and Pathologic Study of 26 Cases; Mod Pathol 2008; 21(2):201-7; Ferreira M; Albarracin CT (abstract)

Fast-growing Pseudoangiomatous Stromal Hyperplasia of the Breast: Report of a Case; Surg Today 2007; 37(11): 967-70; Yoo K; Woo OH; Yong HS; Kim A; Ryu WS; Koo BH; Kang EY (abstract)