Breast Cancer Screening in Childhood Cancer Survivors – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.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

Breast cancer is a recognized complication of chest irradiation for childhood cancer.  The article by Dr Kevin C. Oeffinger and colleagues (first reference below) was recently published in JAMA.  Their stated objective was:

To characterize the breast cancer surveillance practices among female pediatric cancer survivors who were treated with chest radiation and identify correlates of screening.

To do this, they used a 114-item questionnaire which was given to a random sample of 625 women (551 participated in the study, response rate, 88.2%).  This was done between June 2005 and August 2006, and included women aged 25 – 50 years of age who had survived pediatric cancer, who had been treated with chest radiation, and who were participating in the Childhood Cancer Survivor Study (CCSS).  CCSS is a North American cohort of long-term survivors diagnosed from 1970-1986.   They then compared these women to 639 similarly aged pediatric cancer survivors who had not been treated with chest radiation (561 participated, response rate 87.8%)  and 712 siblings of the  CCSS cohort (622 participated, response rate, 87.4%).

Breast cancer surveillance practices, including screening and diagnostic mammograms, were characterized using 25 questions adapted from the National Health Interview Survey 2000 Cancer Control Module .

Childhood Oncology Group (COG) guidelines currently recommend surveillance for breast cancer in this group of women include:

• yearly clinical breast examination from the age of puberty until age 25 years, and then every 6 months if the survivor was treated with irradiation of at least 20 Gy to mantle, minimantle, mediastinal, chest (thoracic), or axillary fields
• annual mammography and an adjunct breast magnetic resonance imaging (MRI) starting at age 25 years or 8 years after radiation, whichever is last

The effectiveness of the standard mammogram in detecting pre-invasive and invasive breast cancer is known to be relatively poor in young women due to the density of breast tissue in this age group.  This  increases the importance of MRI in the detection and diagnosis of breast cancer in younger women with dense breast tissue.

Results from the survey showed
Among women aged 25-39 years with chest RT

• only 36.5%  reported a screening mammogram within the past 2 years
• 47.3% of  had never had a mammogram
• only 23.3%  of had a screening or diagnostic mammogram within the previous year

Among women aged 40 through 50 years with chest RT

• 76.5%  reporting a screening mammogram within the past 2 years
• only 52.6% engaged in regular screening (at least 2 mammograms within 4 years)

Key characteristics -- predictor of screening mammography

• Age was an important predictor of screening mammography. For each 5-year incremental increase in age, the likelihood of reporting a mammogram increased nearly 2-fold.
• The strongest predictor of mammography in women aged 25 through 39 years was having a physician recommend the test.

Barriers to having screening mammogram

The 2 most important barriers ranked by women in this age group who did not have a mammogram in the previous 2 years were "put it off" or "didn't get around to it" (27%) and "too expensive" or "no insurance/cost" (17%).

This article is an important reminder of the ongoing health issues of childhood cancer survivors. 

REFERENCES
Breast Cancer Surveillance Practices Among Women Previously Treated With Chest Radiation for a Childhood Cancer; JAMA. 2009;301(4):404-414.; Kevin C. Oeffinger, Jennifer S. Ford, Chaya S. Moskowitz, Lisa R. Diller, Melissa M. Hudson, Joanne F. Chou, Stephanie M. Smith, Ann C. Mertens, Tara O. Henderson, Debra L. Friedman, Wendy M. Leisenring, and Leslie L. Robison
Surveillance for Breast Cancer After Childhood Cancer (editorial); JAMA. 2009;301(4):435-436; Aliki J. Taylor, MD, MPH, PhD; Roger E. Taylor, MD, MA


Related Blog Posts:
Breast Self-Exam (BSE)
Mammograms

Shout Outs

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

Samurai Radiologist, Not Totally Rad, is this week's host of Grand Rounds. It is his one year blogiversary.  Hope he has many more. Read this edition here.  

Welcome to the latest edition of Grand Rounds!
This edition coincides almost exactly with my first anniversary as a blogger. Therefore, as a loose theme for this week, I've suggested an anniversary theme, and have asked contributors to write about something cool or imporant that they have learned in the past year.
Read on to find out what has recently crawled out of the tasty brains in the medical blogosphere...

Let’s support Shadowfax again this year as he  gets ready to shave his head for pediatric cancer research (photo credit).

I will be participating in the St Baldrick's program to raise funds for pediatric cancer research. I will be shaving my head at Fado's Pub in Chicago on March 13, sacrificing my beautiful locks to the cause of finding cures for these terrible diseases. Last year, we did the same, and Nathan's Network raised just about $40,000. You, my readers, were instrumental in helping us achieve that goal.

So, again, I ask you to consider donating whatever sum you can -- simply click on the image below and it will take you to the secure online donation site. The top donor will get first swipe with the razor, should he or she care to come to Chicago! All donors will receive an image of my glistening bald scalp and an extra helping of good karma.

TBTAM takes on Oprah in her post Oprah’s Talking Hormones (photo credit).

I should have expected it. Today, while counseling a patient about hormone replacement, I heard those three little words that I predict will haunt me from this day forward - "But Oprah says.."
You see, Oprah's in menopause.

Now Oprah's taking hormone replacement, which of course means that America's women are now heading back on the HRT roller-coaster, wondering if they should be forgetting everything they heard in 2002 and doing the same thing as Oprah.

On Friday, Feb. 6, show your support of the Go Red For Women movement by wearing red.  (photo credit)

The Go Red for Women campaign was launched by the American Heart Association in 2003. It is a nationwide movement that celebrates the energy, passion and power women have to band together and wipe out heart disease. It is a campaign to educated women about cardiovascular disease in women.

This week Dr Anonymous’ guest will be  Chris Seper. Chris recently left The Plain Dealer in Cleveland where he was the online medical editor so that he could start MedCity News, a medical industry news service.  Dr Anonymous will  be broadcasting live from the launch party for  MedCity News.   This week the show will be an hour earlier, so 8 pm EST (rather than 9 pm EST). 

Field Triage Guidelines for Trauma Patients

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

Getting the trauma patient to the right place at the right time has been shown to save lives.  Arkansas is working to get a trauma system going.  Gov Mike Beebe has proposed a 56 cents sales tax on cigarettes to pay for it.  There are others who feel that the money should come from the ones who cause the trauma.  In their view that includes the folks who speed or drink and drive.  Their proposal is to increase the fines on speeding and DUIs. 

I personally think that burn traumas often come from those who smoke.  How many homes burn due to smoking in bed each year?   Also, there is an increase in motor vehicle accidents due to “trying to light a cigarette” while driving. 

So I would agree with either or a combination of the proposed ways to fund the trauma system.  I just want them to get it in place and working.   The risk of death of a severely injured person is 25 percent lower if the patient receives care at a Level 1 trauma center, which has additional resources  and specifically designed for care of severe trauma.

Last week, the Center for Disease Control and Prevention (CDC) published the MMWR Reports and Recommendations for field triage.  These guidelines are aimed at ensuring that trauma patients with more severe injuries are taken to trauma centers designed to handle such injuries.  These guidelines were developed by CDC and key experts in trauma care.

The recommendations are designed to standardize decision-making at the scene of injury.  They also offer guidance on new technologies such as vehicle crash notification systems, which alert emergency services that a crash has occurred and automatically summon assistance. 

Key revisions include:

• Recommendations for the right place and right time to best use crucial emergency care resources
• Vehicle crash damage criteria which can help determine which patients may require care at a trauma center

The Decision Scheme was developed in collaboration with the American College of Surgeons-Committee on Trauma with support from the National Highway Traffic Safety Administration (NHTSA). It was reviewed by the 36-member National Expert Panel on Field Triage, which included representatives from EMS, emergency medicine, trauma surgery, the automotive industry, public health, and several federal agencies.

The revised guidelines are in line with the 2006 Institute of Medicine report on the state of emergency care. The report envisioned a highly coordinated emergency services system that assures that each patient receives the most appropriate care, at the optimal location, with the minimum delay.

With additional funding from NHTSA, CDC is developing a companion educational initiative for local EMS medical directors, state EMS directors, public health officials, and EMS providers.   This toolkit also will be available at no charge from CDC at http://www.cdc.gov/FieldTriage.

For a complete copy of the MMWR report, please visit here.

SOURCE
Center for Disease Control and Prevention

SurgeXperiences 216 is Up!

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

This edition (216) of SurgeXperiences is hosted at “Frankie’s Hideout“ by Dr Frank Drackman.    You can read this edition here.

He calls it the Superbowl Edition

Welcome Everyone to Surgexperiences CCXVI I'm Frank, and I'll be serving you tonight...
But first, for you Internists out there... a little EKG Test....
No 40 page differential diagnosis, just tell me WTFs goin on there.......and no fair scrollin down to the answer....
Could I interest anyone in a crisp little 87' Sublimaze?? Fresh as the day it was picked in the Afghani Foothills... OK, you might guess I'm not a real Surgeon, but neither was Alan Alda, and that didn't keep him from pontificating on social issues for the last 30 years... So first, allow myself to introduce...myself.

The host of the next edition (217), February 9th, does not have a host yet. The deadline for submissions is midnight on Friday, February 7th. Be sure to submit your post via this form.

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.

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.

Eight Too Many

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

I want to begin this post by basing it on “facts” reported in the news (ABCNews, Reuters, LA Times, Times Online):

• single 33 yo mother, self described “professional student”

Nadya Suleman, who describes herself as a “professional student” who lives off education grants and parental money, broke up with her boyfriend before the birth of her first child seven years ago.

• six children, ages 7 yo, 6 yo, 5 yo, 4 yo, 3 yo, and 2 yo twins
• residing with her parents in a three bedroom home 
• single mother’s own mother reports that her daughter used infertility treatments
• recently gave birth to EIGHT babies, 

  The babies were born by Caesarean section nine weeks premature and ranged from 1 pound, 8 ounces to 3 pounds, 4 ounces. The woman was carrying 24 pounds of baby.

• plans to breast feed (or more correctly use breast milk donated by other women to supplement her own)
• source of income  (see above) – education grants and parental money though recently reported

THE single mother of octuplets born in California last week is seeking $2m (£1.37m) from media interviews and commercial sponsorship to help pay the cost of raising the children.

• no mention of her insurance coverage, if there is any

I want to try to avoid the issue of fetal reduction and concentrate on some the other issues I find troubling.  
She seems (evidence is the six children she already has) to have had no need for infertility treatments.  So why did any fertility clinic take her own as a patient?  Were they more greed driven than patient driven?  That is my (outsider) view.
Human females were not made to have litters, and that is what eight babies to me is.  Sorry if I offend someone, but the risk of health issues related to such a pregnancy are multiple and serious: 

• miscarriage, pregnancy-induced hypertension/stroke, preeclampsia, gestational diabetes, acute polyhydramnios, vaginal/uterine hemorrhaging, and preterm labor & delivery.

The preterm labor and delivery is a “given”.    The length of pregnancy is usually 39 weeks for singletons, 35 weeks for twins, 33 weeks for triplets, and 29 weeks for quadruplets.  Generally, once the pregnancy reaches about 32 weeks, the complications associated with premature delivery are significantly reduced. 
Risks of complications to mother from premature delivery (incomplete list)

• Surgical and medical issues related to C-section
• Emotional issues
• Fatigue even if she has enough support

Risks of complication to each baby from premature delivery (incomplete list)

• Inability to breathe or breathe regularly on their own because of underdeveloped lungs
• Feeding and growth problems because of an immature digestive system
• Intracranial hemorrhage (bleeding into the brain)
• Hearing or vision problems related to immature nerves or treatment side effects
• Developmental delay and learning disabilities from brain damage related to immaturity
• Special problems for low birth weigh babies (less than 3.5 lbs)

Who pays for all of this and should we care?
Each one of these babies weighed less than 3.5 lbs.   Lets assume they all live (and I hope they do and that they beat the odds and don’t have any major long-term health issues). 
Median cost for NICU care (29 wk, 58 day stay in 1999) $61, 724 for each baby

The state of California is bankrupt.  The cost of each of these babies just for the first year of life is going to cost the California taxpayer more than I can imagine. 

I agree that the woman has the right to have more children, but I only agree to that IF she has the ability and resources to take care of them at the time she has them (I’m allowing for future unforeseen calamity).  I do not think she or anyone has the right to take money from my pocket that I could use to help my children (if I had any) or my nieces or nephews get their medical care or allow them to go to college.  Nor should I support her children instead of helping out my elderly parent.

Though it appears now from the Times Online that she is attempting to turn the birth of her eight babies into a source of income.  I hope she will remember to pay the hospital and doctors.  I hope she will put money into the continued health expenses these eight preemies will have. 

Although still confined to an LA hospital bed, she intends to talk to two influential television hosts this week - media mogul Oprah Winfrey, and Diane Sawyer, who presents Good Morning America.

Other Blog Posts on This Topic
Fat Doctor – Six and Eight
Medical Quack -- Obsessed with Having Babies?  Update on the Octuplets Story
Survive the Journey --Nadya Suleman's Octuplets -- How Many is too Many?
Dr Rob -- Don’t Forget the Kid(s)
NeoNurseChic – The Ethics of Octuplets
Moof -- Ooooopsie
Dr Cris – Making Babies or Saving Lives


REFERENCES
Multiple Pregnancies, Maternal Risks – Womens Health Channel
Multiple Birth Pregnancy – University of Pennslyvania
Premature Babies – Medline Plus
Premature Births – March of Dimes

Wild Rose Quilt Block

The summer block of my Four Seasons quilt is the wild rose block. I found it in the “Award Winning Quilts” by Effie Chalmers Pforr (published in 1974). It was submitted by Mrs Rex Watson of Valparaiso, Indiana. She is quoted

“I chose the Wild Rose pattern because it makes such a beautiful quilt, and it brings back memories of girlhood days on the farm, where we had the delicate wild rose blooming along the fence row.”

It could have been my own words. I love wild roses.

I replaced the “satin-like” fabric center with a slightly smaller yellow cotton center. I like it much better. I did the machine stitching on the leaves, buds, and flowers BEFORE doing the quilting. I have outlined quilted the roses/leaves and then cross-hatched the background.

Refinements in Nasal Reconstruction – an Article Review

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

The article “Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap” and the “discussion” both recently published in the Journal of Plastic and Reconstructive Surgery (see full references below) give a truly nice review of the procedure.

Nasal reconstruction is often challenging. The forehead flap is a workhorse flap in nasal reconstruction. It provides similar skin color, texture, structure, and reliability. A disadvantage of the forehead flap includes a difficult arc of rotation. This can displace the medial eyebrow hair. The vertical design can encroach on the scalp which can risk incorporating unwanted hair into the nasal reconstruction.

Historically, the median forehead flap was based on a wide pedicle whose base sit in the center of the forehead. Both supratrochlear vessels were included. This pedicle did not extend below the eyebrows. This wide pedicle had the potential to increase the torsion on vessels which could then lead to compromising the blood flow to the flap.

The paramedian flap design is centered directly over the supratrochlear artery (note: only one vessel, not both) above the medial side of the eyebrow. The proximal flap does not extend below the eyebrow, resulting in shorter flap length.

The midline forehead flap combines features of both the median and the paramedian forehead flaps. The skin paddle is centered in the midline based on a unilateral supratrochlear vessel. The pedicle can be dissected at its emergence from the superior medial orbit.

The article describes the authors' modification of the established oblique paramedian forehead flap.

Stage 1

The cross-paramedian forehead flap is based on the supratrochlear vessel contralateral to the nasal defect. The flap is designed to extend across the midline of the forehead to the contralateral side. The flap is an axial pedicle flap until it crosses the midline. The distal third of the flap crosses the midline to become a random flap.

The flap is elevated in the subgaleal plane from distal to proximal to the supraorbital region. The dissection plane becomes subperiosteal at the level of the upper eyebrow. Inferior dissection is carried into the orbit in the subperiosteal plane to facilitate a safe arc of rotation without tension.

The periosteum is incorporated at the most inferior extent of the pedicle and carefully freed toward the supratrochlear vessels to facilitate flap rotation. The pedicle is designed with a narrow skin bridge 8 mm in width with a sufficiently wide subcutaneous and galeal pedicle to safely include the supratrochlear vessels. The narrow skin pedicle is carried below the medial eyebrow toward the medial canthus.

The forehead flap is mobilized and rotated downward into the nasal defect. If the flap appears robust, the frontalis muscle can be thinned from the distal half. The flap is folded on itself distally to replace the nasal lining if necessary. This design provides a longer hairless flap, which is advantageous when reconstructing lining. The donor site is closed primarily. We prefer to base the pedicle on the contralateral side of the defect because it provides a smooth arc of rotation and a longer non-hair-bearing flap.

Stage 2

The flap is divided and inset at 2.5 to 3 weeks. The skin width is narrow proximally and is excised in or parallel to the glabellar frown line. This results in a linear scar in the glabella region.

Secondary refinements of the forehead flap may be necessary to defat the flap and refine the aesthetic contour.

Both article and discussion are worth your time to read and study.
REFERENCES

Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009, pp 87-93; Angobaldo, Jeff M.D.; Marks, Malcolm M.D.

Discussion of Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 94-97; Menick, Frederick J. M.D.

Prophylactic Mastectomy

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

The article recently published online in the journal Cancer (due in print in their March issue) looks at the risks factors that increase the likelihood of a woman being diagnosed with breast cancer in her “other” breast after being diagnosed with breast cancer.

The article was done at MD Anderson Cancer Center in Houston.  It looked at 542 women with breast cancer diagnosed in one breast (unilateral breast).  All of the women decided to have this and the other breast (contralateral prophylactic mastectomy).

The researchers identified are three factors that increases the chance of cancer in the other breast.  These three factors are:

• having more than one tumor in the same breast at the time of initial diagnosis of breast cancer
• having invasive lobular breast cancer, which begins in the milk-producing glands called lobules rather than in the milk ducts, and then invades surrounding tissues
• having a high score in the so-called Gail model that calculates breast cancer risk and considers things such as age at first menstrual period, age when first child was born and whether close relatives like mother or sister had the disease.

Factors that did not help determine the risk of developing a future cancer in the other breasts included:  race and hormone receptor status of the cancer.

The study did not focus on whether mutations in the genes called BRCA1 and BRCA2 that raise the risk of breast cancer also raised the risk of having cancer later develop in the initially unaffected breast.  Often women with these mutations or a strong family history of breast cancer get preventive mastectomies even before any tumor has developed in either breast.

Having a breast surgically removed when you have breast cancer in the other breast has long been an option, but there appears to be a renewed interest among women (and their doctors). 

When I was a plastic surgery resident and early in my practice, prophylactic mastectomies were an accepted way to deal with the “high risk” of breast cancer.   We often did bilateral prophylactic mastectomies.   I found my copy of the American Society of Plastic and Reconstructive Surgeons Position Paper on Prophylactic Mastectomy (recommended criteria for third-party payer coverage) from 1994.  Here are the indications listed:

Prophylactic mastectomy is recommended for either the treatment of breast symptoms or to prevent cancer from developing in the breast.  Accepted indications for mastectomy include the presence of biopsy-proven tissue of uncertain behavior, the presence of microscopic foci of lobular carcinoma or ductal carcinoma in-situ, and both personal and family histories of breast cancer.  In these high-risk patients, statistics support prophylactic mastectomy.  Fibrocystic mastopathy may generate enough fibrosis to render mammography useless for cancer detection.

Other indications for mastectomy and reconstruction include injected silicone mastopathy, a history of multiple breast biopsies, cancerphobia, progressive fibrocystic mastopathy preventing adequate examination, and refractory mastodynia.

Definite indications for prophylactic mastectomy include lobular or ductal carcinoma in-situ; proliferative atypical dysplasi; severe dysplasia; personal history of breast cancer; personal history of breast cancer in opposite breast; one first-order relative with bilateral, premenopausal breast cancer; two first-order relatives with premenopausal breast cancer; desmoid tumor of the breast or giant fibroadenoma; cystosarcoma phylloides; significant virginal hypertrophy, and post-injection silicone mastopathy.

Two or more of the following conditions also represent indications for prophylactic mastectomy:  one first-order relative with premenopausal breast cancer, one first-order relative with postmenopausal breast cancer, obscured mammograms due to fibrosis, history of multiple breast biopsies, and refractory fibrocystic mastodynia.

It is nice to have this new study as it reinforces many of the reasons I was taught, but it also “refines” the reasons.  However, this is not a new treatment.  It is a “resurgence” of an old treatment.  It fell out of favor because it became difficult to get insurance to pay for it.

REFERENCE

Predictors of Contralateral Breast Cancer in Patients with Unilateral Breast Cancer undergoing Contralateral Prophylactic Mastectomy; CANCER Print Issue Date: March 1, 2009; Published Online: January 26, 2009; DOI: 10.002/cncr.24129 (abstract); Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, Banu K. Arun, Isabelle Bedrosian, Gildy V. Babiera, Rosa F. Hwang, Henry M. Kuerer, Wei Yang, and Kelly K. Hunt.

Shout Outs

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

Jenni Prokopy, Chronic Babe, is this week's host of Grand Rounds. It is the “totally Babelicious!” edition and can be read here.

Call us biased, but we think chicks rule. There's a ton of health information on the 'net, but often, medical research and reporting focus more on men—so we thought it was high time the ladies got a little attention in Grand Rounds, a showcase for the best health and medical writing on the web.

We had a stand-out winner this week:

Normally when we host Grand Rounds, we don't play favorites...but this time we made an exception. Doc Gurley takes the video approach in teaching Babes anything and everything they need to know about (drum-roll, please) The Lost Tampon! It's a serious women's health topic, with a very un-serious approach. Watch, giggle, and learn.

The second edition of Change of Shift (Vol 3, No 15) for 2009 is hosted by Kim, Emergiblog! Kim, as always, did a great job. I hope you will check it out. You can find the schedule and the COS archives at Emergiblog.

Welcome back to Emergiblog, for the post-inaugural edition of Change of Shift!
If you didn’t get a chance to check out this week’s Grand Rounds, hosted by Dr. Val of Getting Better With Dr. Val and presented at MedPage Today, be sure to do so!
As is the custom on Emergiblog, since the “theme” is nursing, I’ll present the submissions themselves as the theme of the edition.

MedGadget has announced the winners of the 2008 Medical Weblog Awards. Wow, what a great list of blogs!

Best Medical Weblog

• Kevin, M.D.

Best New Medical Weblog (established in 2008)

• Life in the Fast Lane

Best Literary Medical Weblog

• Running for My Life: Fighting cancer one step at a time

Best Clinical Sciences Weblog

• Clinical Correlations

Best Health Policies/Ethics Weblog

• Respectful Insolence

Best Medical Technologies/Informatics Weblog

• Life as a Healthcare CIO

Best Patient's Blog

• Six Until Me

Let’s support Shadowfax again this year as he gets ready to shave his head for pediatric cancer research.

I will be participating in the St Baldrick's program to raise funds for pediatric cancer research. I will be shaving my head at Fado's Pub in Chicago on March 13, sacrificing my beautiful locks to the cause of finding cures for these terrible diseases. Last year, we did the same, and Nathan's Network raised just about $40,000. You, my readers, were instrumental in helping us achieve that goal.

So, again, I ask you to consider donating whatever sum you can -- simply click on the image below and it will take you to the secure online donation site. The top donor will get first swipe with the razor, should he or she care to come to Chicago! All donors will receive an image of my glistening bald scalp and an extra helping of good karma.

Hat tip to Uveal Blues: How Our Eyes See vs. How Our Cameras See by Allen Weitz

The human eye, with support from the brain (the fastest CPU on the planet), visually reconstructs our surroundings in real-time as we go about our days and nights. Describing the human eye and how it interprets the world around us in terms of camera optics is a tricky process to explain, and that's before we even get to the 'how does it compare to my camera' part of the story.

Hat tip to WhiteCoat. It is a very moving story which many of us will be able to relate to.

An extremely powerful story about an intern on her first day in the emergency department in Medscape Emergency Medicine
Some of my most vivid memories of emergency medicine involve situations such as hers.

Maxillofacial Injuries and Violence Against Women – an Article Review

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

The referenced article below has recently been published in Archives of Facial Plastic Surgery.  It takes a look at the ugly side of facial fractures.  They stated their objective as

To determine if patterns of facial injuries differed between those of female assault victims with maxillofacial injuries and those of female patients with maxillofacial injuries from other causes.

To accomplish their objective, they reviewed the records for adult (over 18 yrs) women who received treatment for facial trauma between January 1998 and December 2004 at the University of Kentucky Medical Center and the Kentucky Medical Services Foundation.  There were 481 (234 + 247) such women identified.  Of these 481 patients, 140 (67 + 73) had to be excluded due to missing or incomplete medical records.  There were 14 (3 + 11) others excluded due to duplication of records, etc.  This left them with 326 (164  + 162) cases to review. 

The records were then combed for information that included

… demographic data (patient age and ethnicity), date of injury, date of earliest presentation for medical attention, diagnosis codes, and treatments.

Patients were grouped as to whether their injuries were caused by IPV (ie, assault perpetrated by a current or former spouse, partner, or dating relationship), family violence (ie, assault perpetrated by a parent, sibling, or other blood relative), fall, work-related injury, assault by a known assailant not domiciled with the victim (ie, assault perpetrated by a friend, neighbor, or acquaintance), assault by an unknown assailant, motor vehicle crash, self-inflicted gunshot wound, sporting accident, other accident, or unknown/undocumented cause.

Most recorded injuries were grouped as bruising, lacerations, nasal fractures, mandible fractures, zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries.

For the target population, additional information extracted included whether assault victims did or were able to identify their assailant(s) and whether there was documentation of notification to the police or a social worker when the patient presented for care. The method of injury (ie, gunshot, stabbing, punching, kicking, hitting, biting, burning, bludgeoning, pushing, throwing) was also recorded when available.

They found that the most common cause of facial trauma in the adult female patients was motor vehicle crashes (42.9%), followed by falls (21.5%), assault (13.8%), undisclosed or undocumented mechanisms of injury (10.7%), sporting injuries (including all-terrain vehicle accidents,7.7%), other accidental causes (2.4%), self-inflicted gunshot wounds (0.6%), and work-related accidents (0.6%).  

Of the 45 assault victims, 19 (42.2%) were documented victims of IPV or family violence.  Of these 19, most were IPV cases (18 [94.7%]).  Of the other 26 assault victims, most (92.3%) could not or did not identify their assailant.

Several causes of injury were found to correlate with pattern of injury. 

• Assault was associated with mandible fractures, zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries.
• Specifically, higher than expected numbers of zygomatic complex fractures, orbital blow-out fractures, and intracranial injuries were found in IPV victims.
• Victims assaulted by unknown or unidentified assailants were more likely to have mandible fractures than were other assault victims.
• In contrast, higher than expected counts of mandible fractures, alveolar ridge fractures, intracranial injuries, and facial lacerations were found in motor vehicle crash victims.
• Nasal fractures, which were the most common injuries, correlated with family violence, falls, work-related injuries, assault by a known assailant (not IPV), sporting accidents, other accidents, and unknown/undocumented cause of injury.
• Patients with falls as the cause of injury were more likely than expected to have nasal fractures, alveolar ridge fractures, and facial lacerations.
• Alveolar ridge fractures also correlated with unknown/unspecified cause of injury.

Sadly,  25-33% of American adult women are affected by intimate partner violence abuse by a spouse or significant other.   Of these victims, 88% to 94% will seek medical help for head and neck injuries.  More than half (56%) of these women will have facial fractures.

Because of these numbers, facial plastic surgeons and other health care providers who treat maxillofacial injuries need to be able to identify these victims.  These women should then be referred to local domestic violence service programs where they can get help with safety planning, information and referrals, support services and advocacy.

National Domestic Violence Hotline:  1-800-799-SAFE (7233) or TTY 1-800-787-3224.

Source Article
Maxillofacial Injuries and Violence Against Women; Arch Facial Plast Surg. 2009;11[1]:48-52; Oneida A. Arosarena, MD; Travis A. Fritsch, MS; Yichung Hsueh, MD; Behrad Aynehchi, MD; Richard Haug, DDS

SurgeXperiences 216 – Call for Submission

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

The next edition (216) of SurgeXperiences will be hosted at “Frankie’s Hideout“ by Dr Frank Drackman on February 1st.   The welcome to his blog reads:

The recollections of one Frank Drackman, complete with flashbacks and derogative colliloquy. Hideout Rules of Engagement are written for your safety and for that of your team, They are not flexible, nor am I, either obey them or you are history, is that clear?

The deadline for submissions is midnight on Friday, January 30th.  Be sure to submit your post via this form.

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.

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.

Hands Across America Flag Quilt

Taking a break from my four seasons quilt, let me show you this flag quilt that I made in 1999.  I was inspired by the stars and bars flag of the American Civil War, by the eagle motif I found in an old book, and a sign I saw around the same time with the @ overlying a hand.  The name of my quilt is “hands across America”.  I designed three hands with the letters “U”, “S”, and “A” (using @ for my A).  I appliqued this shapes using small flags for the fabric.  The quilt is 23 in X 39 in, both machine and hand sewn/quilted.

Here is a close photo of the eagle.  I used the machine trapunto method for the “relief” effect.  That’s correct, the eagle is machine quilted.  The “rays” are hand quilted.

Here is the back to show the quilting of the eagle.

Here is a close view of the letter “A”/hand.

It is my hope that as America moves forward with her new President that we will all work together for her good.