Happy 40th Birthday to my brother

 Updated 3/2017--photos and all links removed as many are no longer active and it was easier than checking each one.

My baby brother turns 40 today!    He inadvertently taught me my first surgical lesson.  As a 5-6 week old infant, he began having projectile vomiting.  When you have seen "projectile vomiting", you never forget it.  It is not the little bit of drool with a burp.  It is not just upchucking on your shirt.  It is literally projected across the room.

I don't know if he had  a palpable "olive" (a firm, nontender, and mobile hard pylorus that is 1-2 cm in diameter) on physical exam.  He was always hungry and wanted to eat, but it all came back up almost immediately.  His is a diagnosis (pyloric stenosis) and exam I was good at in medical school and residency.
He had an open pyloromyotomy (pie-lore-oh-my-ot-toe-me)  and in no time began to thrive.  He now has a very small scar from that surgery.  He is 6'5" tall and weighs about 250 lb and other than his high blood pressure  he is fairly healthy.

Happy Birthday Baby Brother!  Hope you have many, many more.

For more information on pyloric stenosis:
Pediatrics, Pyloric Stenosis; eMedicine Article, Jan 22, 2008; Jagvir Singh MD, Dara Kass MD, and Richard Sinert DO
Pyloric Stenosis; American Pediatric Surgical Association (has a video of the pyloromyotomy procedure)
Pyloric Stenosis -- Mayo Clinic Article

Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know -- An Article Review

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

The number of patients post-bariatric surgery is increasing. It is important for all physicians to be aware of the nutritional needs of these patients. This article is directed at plastic surgeons (see reference below), but would be of value to all of us.

The aim of this article is to highlight the nutritional deficiencies of the weight loss surgery patient as they may relate to the patient's subsequent planned plastic surgery procedures. The clinical manifestation of these nutritional deficiencies and their prevention and treatment are the subjects of a subsequent publication

The article begins by noting that the two most common bariatric operations are the laparoscopic adjustable banding and the Roux-en-Y gastric bypass.

Laparoscopic adjustable banding is a restrictive procedure, in which a small gastric pouch with a small outlet is created, resulting in early and prolonged satiety. Because the normal absorptive surface is left intact, specific nutrient deficiencies are rare.

The Roux-en-Y gastric bypass procedure involves both restrictive and malabsorptive components. The stomach size is decreased to less than 30 ml with a 75- to 150-cm Roux-limb connected as an enteroenterostomy to the jejunum. By reducing the stomach, the patient loses storage capacity and hydrochloric acid, pepsinogen, intrinsic factor, gastrin, and mucus. In addition, elimination of the body of the stomach severely restricts the process of food grinding, which is important in releasing vitamins and minerals. By forming the Roux-en-Y anastomosis, the coordination between gastric emptying and release of pancreatic enzymes is lost, which could lead to maldigestion and malabsorption. Finally, bypassing the duodenum and proximal jejunum leads to diminished absorptive surface area.

The method used for this article was a review of an extensive literature search using PubMed and Ovid databases. It used search terms including "bariatric surgery" and "nutrition". It covered over 600 articles from 1980 to present.

Vitamin Deficiency
It is important to know which weight-loss procedure the patient had.

Because the small intestine remains intact after vertical banded gastroplasty, micronutrient deficiencies are rare provided that adequate food intake is maintained.

In contrast, micronutrient deficiencies are common in Roux-en-Y gastric bypass and biliopancreatic diversion.

Vitamin B12

Vitamin B12 plays an important role in DNA synthesis and neurologic function. Vitamin B12 deficiency and folate deficiency are fairly prevalent after bariatric operations as early as 6 months postoperatively but most commonly at 12 months or longer.

Vitamin B12 and folate deficiencies occur most often in Roux-en-Y gastric bypass patients, although other malabsorptive procedures can also increase the risk.

Absorption of dietary vitamin B12 is a complex process that requires an intact stomach, coordinated pancreatic enzyme release, and an adequate length of terminal ileum.

Roux-en-Y gastric bypass alters the physiologic mechanisms of vitamin B12 absorption in several ways. It alters consumption of meat, milk, and other foods that contain a high level of vitamin B12.

Decreased gastric acid and pepsin hydrolysis results in incomplete liberation of food-bound vitamin B12.

Bypassing of the duodenum results in incomplete release of vitamin B12 from salivary R-binder proteins by the pancreatic enzymes.

Finally, reduced intrinsic factor (from the parietal cells) release causes diminished absorption of vitamin B12 at the terminal ileum.

The recommended daily allowance for vitamin B12 is 2.4 microgram/day. The majority of Roux-en-Y gastric bypass patients cannot maintain normal vitamin B12 levels with an oral diet alone and will require supplementation. It is important to stress to our patients the importance of supplemental vitamins.

Because only approximately 1% of free vitamin B12 is absorbed, recommendations for postsurgical patients range from 500 to 600 micrograms/day in an oral form or 100 micrograms monthly by means of intramuscular injection. Despite the recommended B12 supplementation, 3.6 percent of post–laparoscopic Roux-en-Y gastric bypass patients continue to be deficient in vitamin B12 at 1 year.

Folate

Folate is a generic term for the water-soluble B-complex vitamin that exists in many different forms. It is an essential cofactor in metabolic pathways, especially amino acid conversion and DNAsynthesis, and is necessary for erythrocyte formation and growth.

Serum folate deficiency has been observed in 45% of obese patients before gastric bypass surgery and 9 to 35% after bypass operations. It appears to be less common than vitamin B12 and iron deficiencies.

Folate is found in green leafy vegetables, liver, and yeast. It's absorption in the intestines is inhibited at high intraluminal pH (alkali environment) in the absence of the gastric hydrochloric acid. In Roux-en-Y gastric bypass, malabsorption and short bowel can quickly lead to deficiency if folate is not continuously supplemented.

Similar to vitamin B12, most Roux-en-Y gastric bypass patients with folate deficiency are asymptomatic or suffer from subclinical disease. However, those with severe deficiency can present with megaloblastic anemia.

This can be prevented by ingestion of regular vitamin preparations, containing 400 micrograms of folate, after Roux-en-Y gastric bypass.

Vitamin B1 (Thiamine)

Thiamine is a water-soluble vitamin obtained in the diet chiefly through plant sources. Deficiencies lead to impaired digestive function in mild cases and beriberi (cardiac or nervous system dysfunction) in severe cases. Thiamine is absorbed in the small intestine, mostly in the jejunum and ileum. In post– bariatric surgery patients, however, thiamine deficiency is likely to be subclinical.

Thiamine deficiency is particularly associated with vertical banded gastroplasty procedures because of reduced dietary intake.

In Roux-en-Y gastric bypass patients on vitamin supplementation, the incidence of thiamine deficiency was 18.3 and 11.2 % at the 1- and 2-year follow-up, respectively.

However, clinical manifestations (e.g., weakness, peripheral neuropathy) are rare and were seen in only two of the 493 patients (0.4 %). The development of Wernicke encephalopathy is a rare long-term complication of weight loss surgery.

A multivitamin supplement is usually adequate in preventing thiamine deficiency. If deficiency occurs, it should be treated with parenteral thiamine, 50 to 200 mg/day until symptoms clear and then 10 to 100 mg by mouth daily.

Vitamin B2 (Riboflavin)

A water-soluble vitamin obtained in the diet through dairy products, green vegetables and meats. Riboflavin is not stored in ample amounts and thus a constant supply is needed. Deficiency in this vitamin is usually part of a multiple-nutrient deficiency and does not occur in isolation. Deficiencies lead to various problems including skin atrophy and cataracts.

It has recently been reported that riboflavin deficiency in Roux-en-Y gastric bypass patients was13.6 and 7.1% at the 1- and 2-year follow-up, respectively, despite vitamin supplementation.

Deficiency should be treated by 6 to 30 mg of riboflavin by mouth daily.

Vitamin B6 (Pyridoxine)

A water-soluble vitamin that is widely distributed in all foods. It is involved in the metabolism of some amino acids (building blocks of protein). In particular, it has been used to treat elevated homocysteine levels in the blood - an emerging heart disease risk factor. Deficiencies are rarely seen due to its ubiquitous nature; however, this can occur in some genetic defects and medication side-effects (e.g. isoniazid used to treat tuberculosis).

Despite vitamin supplementation, Clements et al have recently shown deficiency of vitamin B6 in 17.6 and 14.2% of post–laparoscopic Roux-en-Y gastric bypass patients at the 1- and 2-year follow-up, respectively.

Recommendation for treatment of deficiency is variable and depends on the clinical presentation. Recommended daily intakes for men and women over 50 years of age are 1.7 and 1.5 milligrams/day, respectively. For all younger adults 1.3 milligrams/day. Upper intake levels are established for all adults at 100 milligrams/day. Intake of 2000-5000 milligrams/day for months has caused central nervous system dysfunction.

MALABSORPTION OF FAT-SOLUBLE VITAMINS
The high degree of fat malabsorption associated with biliopancreatic diversion and Roux-en-Y gastric bypass tends to also cause malabsorption of fat-soluble vitamins, such as vitamins A, D, and K.

Vitamin A

A fat-soluble vitamin formed from the yellow pigments of plants (alpha, beta, and gamma carotene). It is essential for sound skin, tooth and bone health and development; it is also important in immune system function and the prevention of night blindness. It is found in animal fats, liver, carrots, tubers, and green leafy vegetables.

Dolan et al.21 reported vitamin A deficiency in 61% of patients following biliopancreatic diversion at 28-month follow-up. This was despite an 80% compliance rate with multivitamin supplementation.

Brolin and Leung observed that prophylactic supplementation of vitamin A did not prevent deficiency in up to 10% of those patients who had distal Roux-en-Y gastric bypass after 2 years.

Similarly, the incidence of vitamin A deficiency was 11 and 8.3% at the 1- and 2-year follow-up, respectively,despite vitamin supplementation.

The recommended daily allowance of vitamin A is approximately 3000 IU for men and 2300 IU for women, respectively. Although the recommended daily allowance is designed to meet the needs of the majority of healthy individuals, this amount may not be optimal for the post– bariatric surgery patient.

Calcium and Vitamin D

As with the other micronutrients, patients undergoing malabsorptive procedures are at higher risk of calcium and vitamin D deficiencies than patients who undergo a restrictive procedure.

Calcium is mostly absorbed in the proximal small intestine by an active, saturable process mediated by vitamin D. Bypassing these sections of the small intestine, along with reduced calcium and vitamin D intake, can lead to calcium deficiency.

The incidence of vitamin D deficiency in purely malabsorptive procedures varies from 17% at 9 to 18 months to 63% at 4 years after surgery.

The incidence in distal Roux-en-Y gastric bypass, which is a combination of restrictive and malabsorption procedures, was significantly higher.

Despite calcium and vitamin D supplementation after Roux-en-Y gastric bypass, Coates et al. found that within 3 to 9 months after surgery, patients have an increase in bone resorption associated with a decrease in bone mass.

Supplementation is recommended for all Roux-en-Y gastric bypass and biliopancreatic diversion patients. Current recommendations range from 1000 to 1500 mg/day for calcium and 8 micrograms/day for vitamin D.

Vitamin KA fat-soluble vitamin that aids in blood coagulation. It is found in fats, green vegetables, and various grains. Deficiencies are very uncommon, but can lead to hemorrhaging.

A study of 170 patients following biliopancreatic diversion and biliopancreatic diversion with duodenal switch found that the incidence of vitamin K deficiency was 68% by the fourth year. However, there was no clinical manifestation of increased bleeding.

Data are lacking on vitamin K deficiency in other weight loss surgery procedures, its implications, and recommendations on treatment in post– bariatric surgery patients.

MINERAL DEFICIENCIES
Iron

Iron is an essential mineral and an important component of proteins involved in oxygen transport and metabolism. Iron is also an essential cofactor in the synthesis of neurotransmitters such as dopamine, norepinephrine, and serotonin. About 15% of the body's iron is stored for future needs and mobilized when dietary intake is inadequate. The body usually maintains normal iron status by controlling the amount of iron absorbed from food. This is interrupted by the restrictive and malabsorptive procedures used for weight loss.

The incidence of iron deficiency in Roux-en-Y gastric bypass patients has been estimated to be between 30 and 50% and is higher in menstruating women.

Dietary iron is ingested in animal hemoglobin and myoglobulin (heme iron) or as plant inorganic iron. Heme iron is absorbed directly by intestinal mucosal cells after removal of the globin by proteolytic duodenal enzymes. In contrast, nonheme iron is first reduced from the ferric to the ferrous state by gastric hydrochloric acid for absorption in the duodenum and jejunum.

In Roux-en-Y gastric bypass patients, the pathophysiology of this deficiency is related to reduced intake of iron, bypassing the acid environment of the stomach, and reduced absorptive surface of the small intestine.

The recommended daily allowance for iron for men and nonmenstruating women is 10 and 15 mg/day, respectively. Roux-en-Y gastric bypass patients with limited energy intake of 1000 to 1500 kcal/day may only consume 6 to 9mg of iron from food ingested daily. Patients are usually treated with oral ferrous sulfate/gluconate. Many of the newer preparations also contain vitamin C to promote iron absorption and can be taken as single daily doses of 100 to 200 mg of elemental iron.

Occasionally, patients who are refractory to oral iron supplementation require parenteral iron infusions.

Zinc
Zinc is an essential trace mineral that is required for cellular growth and replication. Major food sources for zinc are proteins, and there is a direct correlation between dietary protein and zinc intake. Approximately 30 % of ingested zinc is absorbed from the small intestine.

A report by Madan et al. demonstrated a significant deficiency of this trace element in 30% of 100 preoperative morbid patients. Postoperatively, this increased to 36 % despite vitamin supplementation of the diet. In post– bariatric surgery patients, zinc deficiency is often subclinical and only manifests itself as hair thinning and loss.

The recommended daily allowance for zinc is 11 mg/day for men and 8 mg/day for women.

REFERENCES
Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 604-613; Agha-Mohammadi, Siamak M.B., B.Chir., Ph.D.; Hurwitz, Dennis J. M.D.

Blog Posts on Bariatric Surgery
Surgeonsblog

• On the bandwagon
• Groening of Weight-loss Surgery

Buckeye Surgeon

• Unforeseeen Consequences

Chris Oliver Blogspot (an orthopaedic surgeon who writes his story post-banding)

• Laparoscopic Gastric Band Adjustment

For Scanman

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

Several of my blog friends/colleagues are Mac users and very tech savvy. Vijay (Scanman) has gently nudged me into doing this one. In his recent post, he explains it

This post is my contribution to the series of posts that a bunch of us agreed to post following a conversation on twitter (relevant tweets here, here & here).

The theme: core Mac/iPhone applications for doctors / healthcare professionals.
DrCris’s post is here.
symtym’s is here.
Walter’s is here.
Theresa’s is here.
I was a bit apprehensive about posting after Tim’s masterpiece of Mac-geekery.
But I decided to go ahead and post a list similar to the ones posted by Cris, Walter and Theresa.

I am not a mac user, other than my recent addition of my iPhone. I do not feel that I am tech savvy, but Vijay is encouraging me to do this post. Part of my reason for blogging is to learn, so here goes.

I feel (know) that many of my online friends are much more tech savvy than I am (Moof, Enrico, Rob, Walter, symtym, Cris, and Vijay). They are slowly increasing my knowledge and tech use.

PC hardware that I use.

Toshiba Satellite A105 - My personal laptop. 2002 model, Windows XP operating system
Screen Size: 15.4 inches diagonal
Weight: 6 lbs
Processor Options: Core Duo, Intel Pentium M, 1.6 GHz came with 1 GB RAM which I recently increased to 1.99 GB
Graphics Options: Integrated, nVidia Go 7300 (Dedicated), nVidia Go 7600 (Dedicated)
Home Computer, etc

HP Pavillion -- model a6400f--our home computer. This was recently acquired after spring storm fried our hard drive on the old computer. Lightening came in through the phone line so bypassed all the surge protection. I was out-of-town at the Physics Reunion. My husband was working out-of-town, so no one home. Felt lucky that the house didn't catch on fire.

Intel Pentium Dual-Core E2200 Dual Core Processor; 3GB PC2-5300 DDR2 Memory; 500GB 7200rpm SATA Hard Drive; v.92 56Kbps Modem, Gigabit Ethernet; Vista Home Premium

Monitor is the HP w17e, a 17 in flat screen.

Home printer is the HP Officejet J5780 all-in-one. I used to be able to print from my laptop, but somehow haven't managed to get the new computer to allow me to do so. I admit I haven't spent much time trying to correct it.

We have a Linksys 2.4 GH wireless broadband router (allows me to use my lap top anywhere while my husband uses the main computer). We have DSL through AT&T for our Internet connection.

Office Computer, etc.
HP Pavillion -- model a1510n
AMD Athlon 64 Processor, 3800, 2.41 GHz, Graphics Adapter: nVidia GeForce 6150 LE , Total HD Size (GB): 200; MS Windows XP Professional Version 2002
Monitor is the HP vx17e, a 17 in flat screen.
Printers: HP Deskjet 3915, Epson Stylus CX 7800 (also a scanner/copier)
Fax (not hooked to my computer): HP 1040
Copier: Brother DCP 8045D
Type Writer: Smith Corona DX 4600 (when there are forms that need to be filled out and would take too much "fussing" to get lined up properly in computer/printer)

Browsers - AOL primarily, but have added Firefox to my laptop and office computers. I use IE when listening to Blog Talk Radio, as the techs there told me (via e-mail) that BTR was designed to work with IE). I am not sure I like the tab system, but am giving it a try. I have used AOL so long that I am much more comfortable with it and have things book marked and my favorites in the toolbar. I am beginning to get the Firefox toolbar set up with my favorites (Medscape, JPRS, NPR, etc)

Backup: I am not as good with backup as I should be. I know this, so about a year ago I bought on-line backup storage through Norton and now my laptop and office computer routinely backup without me having to think about it. I have it set to backup my documents, my patient information files, my photos, my Quicken files, etc. I have book-marked this post by Joshua Swimmer, MD regarding "Bulletproof Backup Strategies" so I can improve there.

Mobile Phone - the new 3G iPhone, which my husband gave to me for my birthday. I sync it to my laptop and office computer, but not my home computer since I share that one with my husband. I use the password protection feature. So far I have added the following apps: NYTimes, Twitterriffic, Facebook, Evernote, Weatherbug, Epocrates Rx, and Mediquations.

Cameras --

Canon Sure Shot Z115 -- I have had this camera since I started my practice in 1990. It is the camera that I use most often for patient photos. It is a 35 mm and takes good pictures.

Polaroid Spectra System -- Use to take photos in the office, especially when I need one the same day to send with a pre-approval letter.

Polaroid Macro 5 SLR -- Very nice for taking extreme close ups of small lesions, ie nevi or scars on faces.

Kodak EasyShare C713 -- I bought this camera shortly after I began to blog so I could share quilt and other photos. So far have only used for personal, blog pictures. I like having the negatives for patient photos, but am finding it more and more difficult to get them developed.

Core Software

On my laptop and office computer, MS Office Student and Teacher Edition 2003 -- Don't use this much at home, but it allows me to read documents e-mailed to me when Word is used. I much prefer Word Perfect for my letter writing, etc. I use the Outlook calendar and contact. To learn the ExCel, I made myself use it for keeping up with my CME's, breast implant patients (name, date of surgery, deflation, replacement/removal, etc), and other such information. I have never writer a power point presentation.

Windows Live Writer -- This is via Dr Rob who recommended it to me shortly after I started writing my blog. I have it on all my computers, so I can work on posts from any of them. It is a free download from MicroSoft. There are add-ons that allow you to insert videos, etc.

WordPerfect 11 on my office computer. This is the word processor program I use for letters, office procedure notes, yearly Christmas newsletter for my med school class, etc. I know how to justify the right and left sides of the letters with this program. I think it looks neater. [Vijay has recently in an e-mail told me how to do this with MS Word, so will have to try it.]

Adobe Reader for reading pdf documents, on all my computers. I have not learned how to write a pdf, but would like to do so.
Quicken to keep track of my bank accounts, etc.
TaxCut-- yes, I do my own taxes.

Physician Office Manager for dealing with patient addresses, insurance info/filing, etc. No I haven't managed to add a EMR system. I am able to file insurance electronically, but don't do so. It is more expensive for me to do it that way as I only file less than ten each month. So I print them out. Also, when it is a surgical procedure (ie a reduction mammoplasty) I need to send the operative and path reports with the insurance bill. That is not possible with electronic billing.

iTunes -- for music, podcasts, etc, on all my computers
AOL's Mail and GMail for email.

Now for some of the Fun stuff that I couldn’t do without…

I use Bloglines to keep up with the blogs I read. As I find more and more, that is getting more difficult to do. Anyone know what the limit is to follow and actually read?

Evernote - for saving interesting stuff for future perusal. Thanks to Cris. I really like this application!

I'll end my post with the end of Vijay's:

That brings me to the end of a rather long and an unusually technical post. I hope it wasn’t a total waste of your time. I’ll end with this tweet from twitter-pal Jen McCabe-Gorman. How True!!

Posts by others on this theme (in chronological order with twitter names and urls in parenthesis):

PF Anderson(@pfanderson): My Top Ten Tools Today
Cris Cuthbertson (@DrCris): Medical Software I Couldn’t Do Without
Tim Sturgill (@symtym): Core Mac Software, Hardware and Practices
Walter Jessen (@wjjessen): Core Biomedical Research Software and Web 2.0 Tools
Theresa Chan (@ruraldoctoring ): Web 1.69: Rural Doc’s Core Mac Apps, Hardware, Peripherals

If you are a healthcare professional or biomedical scientist, we invite you to share the hardware, software or Web 2.0 tools that you couldn’t live without. What are your core apps? Share in the comments below or write your own post and link back here or to Walter’s post.

Shout Outs

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

Laurie, A Chronic Dose, is this week's host of Grand Rounds. You can read this weeks grand rounds, Getting Some Education, here. Wonderful edition!

Welcome to this week’s Grand Rounds. As I revised syllabi and edited assignments for the upcoming semester, I couldn’t help but think that an Education theme was appropriate for a post-Labor Day edition. Whether you’re heading back to a classroom, an office, or a hospital today, hopefully this selection of posts will resonate with you.

For runners and hikers, especially, there have been some good posts in the past month on foot care:
Doctor Mama (a runner) -- Feets, Don't Fail Me Now answers this inquiry

My feet are trashed—ingrown toenails, blisters, corns, bunions. I fear they will end my running career. Any advice?

Medicine for the Outdoors -- Foot Blisters 1 is on ways to prevent blisters and about treating them.

As in all of medicine, prevention is paramount. To prevent blisters, one must minimize friction generated by the normal biomechanical forces of walking and the contributors to friction. ...............

A new blog to me called Revealed. Check out the posts on Ear and Eye Prosthetics Formation. The photo to the right is from this post.

I've never enjoyed taking care of drunks, but will admit that occasionally they end up being appreciative as this one that Dr Shazam writes about in "The Tale of the Drunken Cowboy"

“Well…you’re the first doctor who’s ever been nice to me.”

I don't think this documentary will come to Little Rock, but if it does I think I'll go see it. Perhaps it will be aired on the Documentary Channel.

A new documentary on aid workers in war zones shows the tough choices, dilemmas and limits faced by doctors providing emergency care in extreme conditions.

Shot in 2005-2006 and presented at the Venice film festival, "Living in Emergency" follows four Western volunteers working in Africa for Doctors Without Borders (MSF), the French-based aid agency which won the Nobel Peace Prize in 1999.

The Good, The Bad, and The Ugly from Karen, Just Up the Dose. Hilarious! Check it out.

This Thursday Crazy Girl will be the guest on the Dr Anonymous' Blog Talk Radio show. She is a flight nurse who loves her work. I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) as we help Dr A celebrate.

Early Surgical Intervention for Proliferating Hemagiomas of the Scalp -- An Article Review

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

First I want to repost this information on hemangiomas from last July. It was included in a post on Vascular Birthmarks.

Hemangiomas.

Hemangiomas are classified as superficial when they appear on the surface of the skin ("strawberry marks") and cavernous when found deeper below the skin's surface. They can be slightly raised and bright red and sometimes aren't visible until a few days or weeks after a baby is born. Cavernous, deep hemangiomas may be bluish because they involve blood vessels in deeper layers of the skin. Hemangiomas grow rapidly during the first 6 months or so of life, but usually shrink back and disappear by the time a child is 5 to 9 years old. Some, particularly larger ones, may leave a scar as they regress that can be corrected by minor plastic surgery. Most are on the head or neck, although they can be anywhere on the body, and can cause complications if their location interferes with sight, feeding, breathing, or other body functions.

Approximately 30% of all hemangiomas are visible at birth. The remaining 70% become visible within one to four weeks after birth. They affect approximately one in 10 to 20 Caucasian children, with a 3:1 predilection for the female sex. The incidence in non-Caucasian infants is lower.

Hemangiomas are endothelial neoplasms. To date, there is no universally accepted model for the etiology of hemangiomas. There is general consensus on the importance of endothelial cells, but the source of the endothelial cells is speculative and there is no consensus on the possible mechanisms by which the hemangioma endothelium interacts with surrounding cells. There is a scientific debate on whether they are of mutational or placental origin or fit in a developmental field disruption. In the past hemangiomas were once thought to be due to maternal behavior or thoughts during pregnancy. The term vascular birthmark itself implies a connection between birth and a vascular lesion. The term strawberry nevus indicates that the mother's intake of red fruits (strawberries) was once thought to cause birthmarks. It is important for the family to remember that the cause of hemangiomas has not been determined, and neither parent should bear guilt over the occurrence or appearance of one of these birthmarks. Approximately 83% percent occur on the head and neck area. The remaining 17% appear throughout the rest of the body (both externally and internally).

At birth, a precursor lesion may be present as an erythematous patch or a telangiectasia. Within weeks the lesion expands rapidly. Hemangiomas can grow for up to 18 months and then begin a long slow regression known as involution. This involution can last from 3- 10 years. This dramatic/fast growth of a hemangioma may seem alarming, but usually no treatment is indicated. This is because this rapid growth phase is followed by a gradual involution (regression) in the following years. At the age of 5 years, 50 percent of the hemangiomas have involuted, and at the age of 9 years 90 percent have.

The ones that do need treatment are the ones that ulcerate, obstruct the airway, or cause visual deficits or cardiovascular symptoms. Current treatment may include intralesional or systemic corticosteroid treatment, systemic interferon treatment, local bleomycin treatment, and surgery. Early intervention has been shown to reduce the need for corrective surgery after "involution" has occurred; or to, at least, minimize extensive corrective surgeries in the future. Psycho-social scarring which occurs when a child has been forced to live with a facial deformity until "involution" has been completed can be avoided by early, aggressive intervention.

Now, I want to review the information in the first reference below (photo to the right from that article). It is basically a report of six cases and how they were treated. Their conclusions are:

Although patience may be virtuous for many hemangiomas, we feel that large hemangiomas of the scalp deserve special scrutiny.

Besides the commonly accepted reasons for surgical intervention (e.g., ulceration, hemodynamic instability, airway obstruction), large (and even not so large) hemangiomas of the scalp may invite a more aggressive surgical approach for the following reasons.

First, even if a hemangioma undergoes complete involution, the remaining fibrofatty skin is often atrophic. The dermal layer is extremely thin and devoid of normal skin appendages. This can lead to large alopecic areas and/or derangement of the natural hairline..........

Second, hemangiomas of the parietal scalp may impinge on the ear. Because of the well-known pliability of the neonatal ear, thought to be secondary to the effects of maternal estrogens, extrinsic deforming forces may result in a permanent deformity. Thus, there is an opportunity to both remove the deforming force and reshape the ear within an early postpartum window of opportunity. As demonstrated in cases 4 through 6, permanent ear deformity was avoided by early removal of the deforming hemangioma.

Finally and perhaps most importantly, the scalp of a newborn infant possesses significant elasticity because of a relative tissue excess and an inherent pliability resulting from the absence of a thick fibrous galeal layer. As the infant ages, this considerable redundancy of scalp tissue dissipates, which may limit the possibility of primary closure (with or without scalp rotation flaps) without the need for tissue expansion. It should be noted that in the case of neonates born prematurely, the optimal timing for surgical intervention needs to be considered individually, as the relative operative risk will vary with the degree of prematurity.

One reason for traditionally waiting (other than that most will regress) is the concern that excision of hemangiomas in infants can be associated with life-threatening bleeding. They offer three important technical points are emphasized to minimize this risk.

First, all excisions are performed only after infiltrating the lesion and surrounding tissues with a tumescent solution of dilute epinephrine.

Second, hemostatic polypropylene sutures may be placed around the hemangioma to limit inflow to the lesion.

Third, the plane of dissection is outside of the lesion in the avascular galeal layer. Although bleeding of any amount in an infant is potentially dangerous, application of these simple principles will reduce the chance of a potentially disastrous hemorrhage.

I would encourage pediatrician and family doctors to go ahead and make the referral to a plastic or ENT surgeon if the hemangioma is large and in the head/scalp region. The surgeon may choose to watch with you, but the patient will already be in the pipeline if something needs to be done early.

REFERENCES:

Early Surgical Intervention for Proliferating Hemangiomas of the Scalp: Indications and Outcomes; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 457-462; Spector, Jason A. M.D.; Blei, Francine M.D.; Zide, Barry M. D.M.D., M.D.

Hemangiomas and Vascular Malformations in Infants and Children: A Classification Based on Endothelial Characteristics; The Pathogenesis of Hemangiomas: A Review; Plastic and Reconstructive Surgery:Volume 117(2)February 2006; Bauland, Constantijn G. M.D.; van Steensel, Maurice A. M. M.D., Ph.D.; Steijlen, Peter M. M.D., Ph.D.; Rieu, Paul N. M. A. M.D., Ph.D.; Spauwen, Paul H. M. M.D., Ph.D.

Progress to ward Understanding Vascular Malformations [Special Topic]; Plastic and Reconstructive Surgery:Volume 107(6)May 2001; Breugem, Corstiaan C. M.B.Ch.B.; van der Horst, Chantal M. A. M. M.D., Ph.D., and; Hennekam, Raoul C. M. M.D., Ph.D

Vascular Birthmarks: Hemangioma and Malformations. by Mulliken, John B. MD; Young, Anthony E. MD; Textbook--W.B. Saunder, Philadelphia, PA, 1988.

Hemangiomas and Vascular Malformations of the Head and Neck edited by Milton Waner, MD and James Suen, MD--Wiley-Liss, NY 1999

SurgeXperiences 205 is Up!

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

Dr Cris, Scalpel's Edge, is the host of this edition of  SurgeXperiences. It is her first time hosting.  I think she did an outstanding job!  Hope you will go read it here.

Welcome to SurgeXperience 205.  I was impressed by the variety of posts I received, and many fit the theme of “Evidence” . I have enjoyed reading through this content and I hope you do, too.

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 host for SurgeXperiences 206 will be The Sterile Eye on September 14th.  The deadline for submissions will be midnight on Friday, September 12th. 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.

Log Cabin Quilt in Blue & Green

A friend's niece was hit by a drunk driver earlier this month. Unable to do anything else for the girl, I ask if I could make her a quilt. I was told she likes blue and green. I like the log cabin pattern. It goes together quickly and the blocks can be arranged in various ways to showcase the colors -- straight setting, sunshine and shadow, furrows, and barn raising.

I picked out several blues and greens from my stash and made this scrappy furrows log cabin quilt. It is machine pieced and is 50 in X 63 in. I machine quilted it using the in-the-ditch method.

Here is a close up to show some of the fabrics.



Now I have a plea:
Please, have a safe holiday (Labor Day) weekend AND don't drink and drive.   Thank you.

My First Research Experience

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

Dr Cris, Scalpel's Edge, will be hosting SurgeXperiences on August 31, 2008, and has asked for a "research bent" post. I must admit I have not done much research during my training or in practice. Between my first and second years of medical school (summer of 1979) I had the opportunity to work in the Biomedical Research Division at Ames Research Center, Moffett Field, California. It was my chance to work for NASA and I took it! I didn't have good enough eyesight to be an astronaut (very near-sighted), but I could have a small brush with them. Well, not really, I never meet any astronauts.

I spent that summer helping collect data for an anti-gravity experiment. The experiment was to try to

determine whether a different body position during bedrest (BR) could induce physiological responses that would be closer to those observed after exposure to weightlessness.

I helped collect and enter data -- age, height, weight, BSA, body fat, heart rate, systolic blood pressure, etc. I helped in lower body negative pressure testing. The findings from the study were:

1)BR resulted in a general decrease of exercise tolerance in both groups
2) the negative 6 degrees BR appeared to simulate the effects of weightlessness more effectively than horizontal BR when comparable space flight data were presented.

I enjoyed my summer and got my name on my first published paper.

Effects of antiorthostatic bedrest on the cardiorespiratory responses to exercise; Aviat Space Environ Med. 1981 Apr;52(4):251-5; Convertino VA, Bisson R, Bates R, Goldwater D, Sandler H.

Arte y pico Award

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

I’ve just been given this award by Chrysalis Angel.  This is why she says I deserve it:

For creativity, her site can not be beaten. She not only sutures for a living, but she sutures for fun. She makes some of the most beautiful, amazing quilts. I don’t know how she finds the time. She is also someone I call friend. I felt a connection with her immediately. She understands how I feel about babies with fur (dogs). You all will love her blog. She is also a huge amount of support for me right now, which I appreciate.

Thank you CA! 
The rules are as follows:
1.You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

I, like CA, always worry about making these choices, but here goes:
1.  Penny Sanford's Porcelains -- Penny lives in Mississippi and is a sculptor, quilter, Westie dog rescuer, family historian, sharer of recipes, etc. 
2.  Nobody Important who describes herself as "Retired from hospital pharmacy, wasting too much time reading blogs and surfing the internet and now addicted to Second Life. Who said retirement was easy?"  Her blog covers books, family, travels, etc.
3.  Theresa, Rural Doctoring, who's blog I really enjoy.  She covers her medical practice (hospitalist and family doctor who delivers babies), books, rural life, and recently her time with Zippy the Lobster.
4.  T, Notes of an Anesthesioboist, who writes so well about practicing anesthesiology, learning to play the oboe, her family, books, etc
5.  The Sterile Eye who is a Norwegian medical photographer.  I love all the videos he shares with us.  He is very good at his job and writes well too.

Trigger Finger: Prognostic Indicators for Recurrence

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

Last July, I did this post on trigger finger (or stenosing tenosynovitis).

Stenosing tenosynovitis is more commonly known as trigger finger or trigger thumb. It involves the pulleys and tendons in the hand. These tendons and pulley work together to bend the fingers. The tendons work like long ropes going from the muscles in the forearm to connect to the bones of the fingers and thumb. In the finger, the pulleys are a series of rings (made of connective tissue) that form a tunnel that the tendons must pass through. This is very much like the guides on a fishing rod through which the line (or tendon) passes. These pulleys hold the tendons close against the bone. The tendons and the pulley (tunnel) have a slick lining that allows easy gliding.

When the tendon develops a nodule or swelling of its lining, it has difficulty passing through the pulley (which is not elastic, but fixed in diameter). The "popping" or "catching" feeling in the finger or thumb comes from the tendon "squeezing" through and giving as it makes it past the pulley. The swollen tendon is irritated more as it has to be squeezed through the pulley, producing more swelling. A vicious cycle of triggering, inflammation, and swelling. Sometimes the finger will become stuck (locked) and it may be hard to straighten or bend the finger. This is like having a finger swell and not being able to get your ring off.

So what causes this condition. Repetitive grasping of objects or an injury to the palm may irritate the flexor tendons. Medical conditions such as rheumatoid arthritis, gout, and diabetes may create swelling around the tendons which then lead to the "vicious" cycle of irritation/inflammation/swelling. Sometimes the cause is not clear.

The goal of treatment is to eliminate the catching or locking and allow movement without discomfort. To do this the swelling around the tendon must be reduced to allow smooth gliding of the tendon. Wearing a splint or taking anti-inflammatory medication by mouth or injection into the area around the tendon (a corticosteroid shot) are ways to reduce the swelling. Changing how the hand is used, better body mechanics to reduce the impact or repetitive motions helps. If nonsurgical forms of treatment do not improve symptoms, then surgery may be recommended. This surgery is usually performed on an outpatient basis. Most often it is done using local anesthesia, but a regional (where only the arm is numbed) or a general may be used. The surgery cuts the pulley (only one and the finger still has other pulleys to keep it near the bone) which gives the tendon more room to glide, removing the restriction (cutting the ring off the swollen finger). Active motion of the finger is generally begun immediately after surgery. Normal use of the hand can be resumed once comfort permits.

Recently, there was an article in the Journal of Bone and Joint Surgery on prognostic indicators that can be used to "predict" the recurrence of triggering after corticosteriod injection. See the reference below.

In the study, there were 124 trigger digits in 119 patients. Of these 70 digits (56%) had a recurrence of symptoms at a median of 5.6 months after the injection. Twenty-two digits (18%) underwent surgical release at a median of 7.4 months after the injection.

According to the Kaplan-Meier analysis, the estimated rate of freedom from symptom recurrence was 70% (95% confidence interval, 63% to 77%) at six months and 45% (95% confidence interval, 36% to 54%) at twelve months and the estimated rate of freedom from surgical release was 95% (95% confidence interval, 92% to 98%) at six months and 83% (95% confidence interval, 77% to 89%) at twelve months.

Insulin-dependent diabetes mellitus was identified as a strong predictor of symptom recurrence (p < 0.01). Younger age (p < 0.01), involvement of other digits prior to presentation (p < 0.01), and a history of other tendinopathies of the upper extremity (p = 0.02) were all independent predictors of a surgical release. The duration and severity of symptoms were not predictive of poor outcomes following injections.

Trigger Finger: Prognostic Indicators of Recurrence Following Corticosteroid Injection; The Journal of Bone and Joint Surgery (American). 2008;90:1665-1672; Tamara D. Rozental, MD, David Zurakowski, PhD and Philip E. Blazar, MD

Shout Outs

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

Theresa, Rural Doctoring, is this week's host of Grand Rounds. I submitted one of my posts from last week. You can read this weeks grand rounds here. Wonderful, scholarly edition!

Some of you may know I am an amateur Shakespeare scholar. I pursue the study of the Bard during my spare time, which means I don't pursue it very deeply. Medicine and blogging seem to be the great consumers of time lately, but this week's Grand Rounds gives me the chance to marry the three subjects together. I present to you a Shakespearean Grand Rounds, and I begin with a literary digression.

Change of Shift, Vol 3, No4, is up over at Emergiblog.

Chris, Made a Difference, recently posted regarding 73rd Cavalry volunteers who are treating Iraqi children and need supplies. For a list of the supplies and where to send them, so here.

I recently received from a friend, Deb, this great news about US troops at CSC Scania

(that's Convoy Support Center) south of Baghdad who are volunteering their time to run a clinic for Iraqis in need of medical care. These aren't people who were sent to Iraq as medical providers. Their official duty is to refuel trucks and keep them running on the convoy line running north and south through Mesopotamia. They treat up to 80 patients a day, many of them burned children. They report that they are seeing the same burns I saw so commonly: scald and oil spill burns from uncovered cooking sources in the home. They rely on donated service hours and donated supplies. If ever anyone needed a reason to be proud of our military, look no further than these troops.

Dr Smak will make you laugh with this post on Pelvic Dyslexia.
A Gory Eye Picture from Marianas Eye (you are forewarned).

What happens when one of the physicians in your practice gets injuried or dies? Read this -- Parables of Practice Management: A Tale of Three Clinics; Medical News of Arkansas, September 2--8; by Chad Carlson

When a physician has an equity stake in a medical practice and he or she is unexpectedly disabled or dies, the consequences for the rest of the partners (or the physician's heirs) can be severe. Failing to adequately prepare for forced transitions may seriously impair a successful practice and may even result in lawsuits................

Whether you're just beginning to write your story or you're already deep into the storyline, make updating your buy/sell agreement a priority. Establishing, structuring, and funding an adequate arrangement is a team effort. You should always have the involvement of a tax advisor and legal counsel.

Plan well and ensure for yourself, your family, and your practice, a very happy

Dr Wes shares with us "What your heart attack might be like" and includes a video ad from Great Britain. Well, worth watching and sharing!

Although one would hope the symptoms wouldn't get to this extreme, the ad makes the point that heart attacks aren't really just about chest pain: but also chest or arm tightness or a discomfort, dizziness, shortness of breath, nausea, vomiting, sweating, and the like..............

And one more thing to consider: if a friend wants to call an ambulance for you, let them. Remember they are objective observers, and might just save your life even despite yourself.

Check out Dino's recent two posts on Ramsay-Hunt Syndrome here and here. Then check out my own experience with Bell's Palsy here.

The patient's daughter had discovered a condition known as Herpes Zoster Oticus -- also called Ramsay Hunt syndrome. It is basically shingles of the geniculate ganglion, and it explains every single one of the patient's symptoms!

Essentially zoster of the ear, Ramsay Hunt consists of a painful vesicular rash in the external ear canal associated with a facial nerve palsy, vertigo, oral vesicles and taste disturbance. Treatment is with antivirals directed against herpes zoster, which I had already initiated, and steroids.

If you missed the Dr Anonymous' Blog Talk Radio show last week when I was his guest, you can listen to it here. Thank you all for showing up and calling in (Val, Theresa, Vijay, Bongi, Enrico, and Mary). This week is the ONE year anniversary show. I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) as we help Dr A celebrate.

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

For first time Blog Talk Radio listeners:

*Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.

*To get to my show site, click here. As show time gets closer, keep hitting "refresh" on your browser until you see the "Click to Listen" button. Then, of course, press the "Click to Listen" button.

*You can also participate in the live chat room before, during, and after the show. Look for the "Chat Available" button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.
*You can also call into the show. The number is on my show site. I'll be taking calls beginning at around the bottom of the hour. There is also a "Click To Talk" feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful!

Breast Reduction: Safe in the Morbidly Obese?--Article Review

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

I found the article regarding breast reduction in the morbidly obese (reference #1) to be quite interesting. It does seem to be an important question with the increasing obese population and with the "never events" list being expanded. They give their reason for looking at the topic:

Background: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to ≥40 kg/m²) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions.

The article is a retrospective review of 179 consecutive patients who had surgery at the University of Texas Medical Branch at Galveston during the time frame of June 1996 to April 2006. I hope they will do another review in a prospective manner and see how it compares.

... We obtained data points including height, weight, preoperative symptoms, medical history, smoking history, breast size, physical examination, type of reduction, amount of resection, and postoperative course including complications. All complications were recorded, and included hematoma, seroma, asymmetry requiring further surgery, stitch abscess, open wounds, cellulitis, fat necrosis, flap loss, changes in nipple sensation, nipple loss, nipple graft loss, and hypertrophic scarring. All were recorded, with no gradation as to severity. These were recorded throughout the patient's follow-up course, ranging from 1 month to 1 year.

The most common pedicle type was the inferior pedicle or central mound used in 134 patients. Free nipple grafts were done in 37 patients. There were 29 patients who had surgery for gigantomastia (more than 2000 gm per side). Six of these women had inferior pedicle/central mound reductions. The other 23 had breast amputations with free nipple grafting.

There patient population characteristics:
Average reduction mass -- 1259 gm per breast (117 - 4875 gm)
Average age -- 35 yrs (15 - 68 yrs)
Average body mass index -- 34 (range, 20.7 - 54.4)

World Health Organization: 18 to 24.9 kg/m² (normal weight), 25 to 29.9 kg/m² (overweight), 30 to 39.9 kg/m² (obese), and greater than 40 kg/m² (morbidly obese)

• 93 women in the obese category
• 34 women in the morbidly obese category

There were a total of 90 patients (out of 179) with complications, or an overall complication rate of 50 percent. The most common complication was delayed healing which accounted for 65% of the complications

The complications were broken down as follows:
Delayed wound healing -- 65%
Cellulitis -- 17.6%
Hypertrophic scarring -- 8%
Hematoma -- 3%
Seroma -- 3%
Fat necrosis -- 3%
Nipple graft loss -- 1%
Their Results:

The overall complication rate was 50 percent.

There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively).

Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and

comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072).

There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07).

They conclude that reduction mammoplasty is "a safe operation for patients regardless of their age, size of reduction, or body mass index." I don't insist that patient's loss weight prior to a breast reduction, but I do (and will continue to do so) tell them that they are at more risk of wound/healing issues.

REFERENCES

1. Breast Reduction: Safe in the Morbidly Obese?; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 370-378; Roehl, Kendall M.D.; Craig, E Stirling M.D.; Gómez, Victoria B.A.; Phillips, Linda G. M.D.

2. A Comparison of Complication Rates in Large and Small Inferior Pedicle Reduction Mammoplasty; Plast. Reconstr. Surg. 115: 736, 2005; O'Grady, K. F., Thoma, A., and Dal Cin, A.

3. Analysis of Breast Reduction Complications Derived from the BRAVO Study; Plast. Reconstr. Surg. 115: 1597, 2005; Cunningham, B. L., Gear, A. J., Kerrigan, C. L., et al.