SurgeXperiences 316 – Call for Submissions

Updated 3/2017:  links removed as many no longer active.

Dr DJ, a private surgeon in India,  will be the host for SurgeXperiences 316 (February 7th).  The author behind this blog describes himself this way: 

A surgeon with a penchant for writing and a passion for revealing the truth behind the farce that is the Indian Medical Industry.

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.  You are encouraged to submit your surgery related posts.   The deadline for submissions to be included in the 316 edition is midnight on Friday, February 5th.  Be sure to submit your post via this form. 

If you would like to be the host  for a future edition of SurgeXperiences, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Timing

“Dr. Bates, your patient’s EPT is positive.”

“Let the OR know, I’ll go tell Meg.”

Knocking softly, I enter. “Meg, we’ll have to reschedule your surgery. Your EPT is positive.”

“Oh.” Meg exhales. Tears run down a cheek as she smiles, “We wanted another one.”

Rainbow Blooming Nine Patch

My friend Vivian asked me to make a quilt for her grand-daughter K.  Vivian speaks of K as her daughter and is raising her as such.  K’s mother (Vivian’s daughter) died a few years ago leaving both of them stunned with grief.   Yet Vivian is one of the most hopeful, resilient people I know.  I was very happy to make the quilt for her.

I choose to make her a bright quilt.  The result is this rainbow blooming nine patch.  It is 45 in X 54 in.  It is machine pieced and quilted.

This near photo shows some of the very simple cross-hatched quilting done.

I found some wonderful fabric for the backing/binding which looks to me like fireworks exploring in all the colors of the rainbow.   The world needs more people like Vivian.

ACS’s Surgical Case Log for Haiti Workers

Updated 3/2017 -- links removed as many no longer active.

H/T to Dr. Val, Better Health and her post  The American College Of Surgeons Creates Case Log For Surgeries Performed In Haiti.  I’d like to help her get the word out on this web-based tool the ACS has created to help medical workers in Haiti keep track of surgical procedures.

The ACS has a case log system in place already for College members which they have expanded and opened to non-College members as well.

Non-ACS members can register here.  The system will automatically add Haiti as a location, and surgeons can start adding cases right away.

ACS members who have used the case log system before can log in here.  ACS members who have not registered to use the case log system can register at here.  Once ACS members are logged in, they can add “Haiti” as a location for cases associated with relief activities.

The system currently works with both Palm and Pocket PC phones.  The iPhone and Blackberry editions will be released in the next 1-2 weeks.

Get Up and Move

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.

Last week, researchers  at the Swedish School of Sport and Health Sciences published an editorial online in the British Journal of Sports Medicine, warning us of the dangers of prolonged sitting.

Dr. Elin Ekblom-Bak and colleagues note the benefits of regular physical activity for several major health diseases is clear and unanimous, but warn that recent studies suggest that prolonged bouts of sitting time and lack of whole-body muscular movement can undo some of the benefits even for someone who is considered “in shape.”

The editorial mentions a study published last year that tracked more than 17,000 Canadians for about a dozen years. Peter Katzmarzyk  and colleagues found people who sat more had a higher death risk, independently of whether or not they exercised.

Our bodies are designed to be active.  I, like many of you, sit too much.  It’s a hazard of our jobs and our hobbies.  It is important to do as Dr. Ekblom-Bak says: "It is important to have a five minute break from desk work every 45 minutes.”

I don’t have to give up my computer time or my sewing/knitting or my reading or my TV.  What I have to do (and what you should do) is make a conscious effort to remember to stand up and move for a few minutes ever 30-45 minutes of prolonged sitting.

When  watching TV, use the commercials as reminders.  It’s a great time to get up and stretch or do a few lunges or maybe a jumping jack or two.

In my sewing room, I have to get up when I need to press seams.  This breaks up the sitting time.  I don’t always have automatic “breaks” when knitting, reading, or using the computer.  I have to remind myself to do so. 

Last week, Dr Anonymous posted Warning: Sitting Can Kill You.   How about David Bowie’s Let’s Dance?  Anyone want to join me?

REFERENCES

“Are we facing a new paradigm of inactivity physiology?"; British Journal of Sports Medicine Online First 2010; doi 10.1136/bjsm.2009.067702; Elin Ekblom-Bak, Mai-Lis Hellénius, Björn Ekblom

Sitting time and mortality from all causes, cardiovascular disease,
and cancer;  Med Sci Sports Exerc 2009;41:998–1005; Katzmarzyk PT, Church TS, Craig CL, et al.

Black Market Botox

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.

Earlier today I listened to NPR’s broadcast of the Diane Rehm show:  Implications of a Global Black Market for Botox (link removed 3/2017 -- no longer active).  The guests were

Col. Randall Larsen, executive director of the bi-partisan, Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism and the founding director of The Institute for Homeland Security (2000-2003)

Marina Voronova-Abrams, biosecurity or biothreat reduction expert, formerly based in Central Asia and Russia, now works for the nonprofit environmental group Global Green

Dr. Tina Alster, clinical professor of dermatology at Georgetown University Medical Center and the Director of the Washington Institute of Dermatologic Laser Surgery.

Kenneth Coleman, a Senior Fellow, for the Chemical & Biological Weapons Nonproliferation Program (CBWNP) of the James Martin Center for Nonproliferation Studies at the Monterey Institute of International Studies

In full disclosure, Diane Rehm begin by mentioning the use of Botox for her own vocal spasmotic dystonia.  Very interesting show.  

The reason for the show was the Washington Post article by Joby Warrick  “Officials fear toxic ingredient in Botox could become terrorist tool” posted Monday, January 25, 2010.

….Obtaining the most lethal strain of the bacterium might have posed a significant hurdle for would-be terrorists in the recent past. But today, the prospect of tapping into the multibillion-dollar market for anti-wrinkle drugs has spawned an underground network of suppliers and distributors who do most of their transactions online, the researchers found. Customers don't need prescriptions or identification, other than a shipping address………..

So lethal is the undiluted toxin that at least three countries -- the United States, the then-intact Soviet Union and Iraq -- explored its possible use as a possible biological or chemical weapon. All three gave up on the idea, partly because botulinum toxin degrades quickly when exposed to heat, making it poorly suited for delivery by missile or bomb

Having taken a few courses on Disaster Preparedness, it is always pointed out botulinum toxin is not a great toxin for mass destruction as it would be difficult to weaponize the bacteria as noted above and here.

Botulinum toxin is the most poisonous substance known.  A single gram of crystalline toxin, evenly dispersed and inhaled, would kill more than 1 million people, although technical factors would make such dissemination difficult. The basis of the phenomenal potency of botulinum toxin is enzymatic; the toxin is a zinc proteinase that cleaves 1 or more of the fusion proteins by which neuronal vesicles release acetylcholine into the neuromuscular junction.

BOTOX is currently licensed for treatment of cervical dystonia, strabismus, blepharospasm,  primary axillary hyperhidrosis, and glabellar wrinkles.  It is also used "off label" for a variety of more prevalent conditions that include migraine headache, chronic low back pain, stroke, traumatic brain injury, cerebral palsy, achalasia, and various dystonias.

REFERENCES

Botulinum Toxin as a Biological Weapon;  JAMA. 2001;285:1059-1070 (consensus statement)

Bogus Botox® (botulinum toxin type A) Suspected in Botulism Outbreak; Medpage Today, November 30, 2004; Jeff Minerd

Caution About a Bioterror Attack on the U.S. Milk Supply; June 2005; Marguerite Rigoglioso

US Diagnosis of Closed Tendon Injuries

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.

I found the article on using ultrasound to diagnosis closed flexor tendon injuries interesting.  I  still rely on history and physical exam to make the diagnosis, but can see how the use of ultrasound (US) could be useful particularly in children.

The article is a retrospective audit of the accuracy of US in diagnosing closed flexor tendon ruptures and ruptures following recent flexor tendon repair in 80 patients between January 2001 and December 2006.  The accuracy of US was found to be higher than clinical examination alone (95% vs. 79%, Z = 2.00, p = 0.03).

US findings were 100% accurate when imaging was undertaken between 1 and 7 days following injury, but only 88% accurate when undertaken on the same day as injury and 85.7% accurate when performed after 1 week (X ² = 6.4, p = 0.04).

If the flexor tendon injury is not clear on physical exam, then US might have a role. 

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Most injuries to the flexor tendons are due to a cut of some kind (ie knife, saw, etc).  Closed injuries to the flexor tendons are often athletic injuries that occur when one player grabs another's jersey, and a finger (usually the ring finger) gets caught and pulled.  The forceful hyperextension of a digit leads to the avulsion of the flexor digitorum profundus (FDP) tendon from the distal phalanx.  This mechanism has given the injury the common name: "jersey finger."

Closed injuries to flexor tendons can also occur when the tendon is stretched (strained) or ruptured.  These mechanisms are more common in sports like rock climbing or in persons with rheumatoid arthritis.

Clinical assessment can often be difficult as swelling and pain may limit movement of the injured digit irrespective of the integrity of the flexor tendon mechanism.  The integrity of FDS and FDP tendons should be tested independently and in tandem.

• To test the FDP tendon, the examiner holds the other fingers in extension and stabilizes MCP and PIP joints. The patient is then asked to flex the distal phalanx.
• To test the FDS tendon, the examiner holds the other fingers in extension, but the MCP and PIP joints are released. The patient is asked to flex the finger. The PIP joint and, to a lesser degree, the MCP joint should flex. About 20% of patients are missing a FDS tendon in the little finger and will therefore have limited or no PIP flexion during testing.
• For flexor pollicis longus (FPL) testing, the thumb MCP joint is stabilized in neutral position. The patient is asked to flex the interphalangeal (IP) joint against resistance. A communication may exist between the FPL and the index FDP. The examiner stabilizes the other 3 digits. The patient opposes his or her thumb to the little finger MCP joint. Flexion of the index distal phalanx proves the existence of this anomalous communication.
• Passive manipulation of the wrist through flexion and extension should result in extension and flexion of the digits, respectively. This uses the tenodesis effect of the antagonistic tendons. If a tendon is transected, then there can be no tenodesis effect.
• Compression of the forearm flexion muscles also can be used to test the integrity of the flexor tendons in the hand. As the forearm is compressed, the digits are drawn into flexion. Transected tendons in the digits do not flex with this maneuver.

Successful treatment depends on prompt diagnosis and treatment, preferably within 48 hours of the injury. Delays in treatment may result in fibrosis in the tendon sheath and retraction of the flexor tendon.

This MRI of a closed FDP  is from the blog Musculoskeletal and Orthopedic MRI (photo credit):

Sagittal image of the ring finger reveals the gap (red arrows) between the torn ends of the FDP and also depicts the intact flexor digitorum superficialis tendon (green arrows)

REFERENCES

The accuracy of ultrasound in evaluating closed flexor tendon ruptures; European Journal of Plastic Surgery, published online January 2010, DOI 10.1007/s00238-009-0378-8; Onur Gilleard, David Silver, Zeeshan Ahmad, and Vikram S. Devarai

High-Risk Injuries and Infections of the Hand; ACEP Presentation Oct 28, 2008; Scott C. Sherman, MD

Shout Outs

Updated 3/2017:  all links removed as several no longer active and it was easier than going through each one.

Kim, Emergiblog, is this week's host of Grand Rounds. It is the LOL edition  which can be read  here

Welcome to the LOL edition of Grand Rounds!

I just adore the I Can Has Cheeseburger – LOL Cat site and the kittehs provide our background theme for the week.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 15) ! You can find the schedule and the COS archives at Emergiblog.

It’s time again for Change of Shift, the bi-weekly nursing blog carnival!

It’s an eclectic selection this week: hospital to office, students and veterans, money and…well, poo-poo, disasters and preparedness…………..

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The need for help to Haiti continues. Anyone wishing to donate or provide assistance in Haiti is asked to contact the Center for International Disaster Information. Here is a list of organizations who need your help in providing care to Haiti:

• Clinton Foundation -- Donate online or Text "HAITI" to 20222 and $10 will be donated to relief efforts, charged to your cell phone bill.
• American Red Cross International Response Fund – Donate
• Doctors Without Borders
• The International Rescue Committee
• International Medical Corps
• Mercy Corps Haiti Earthquake Fund (1-888-256-1900)
• Partners in Health
• UNICEF (1-800-4UNICEF)
• UN World Food Program
• National Disaster Search Dog Foundation (SDF)
• The International Fund for Animal Welfare (IFAW)

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Dr. Val has a few posts which feature first hand accounts on giving care in Haiti from physicians:

• Trauma Surgeon Flees Chaos Of Haiti: Needed Protection Of Jamaican Soldiers With M-16s To Escape Alive
• Live Reporting From Haiti: Dr. Paul Auerbach Calls Dr. Val Via Skype
• Dr. Paul Auerbach’s Update From Haiti
• Audio: What Is Needed Most In Haiti Now? Live Report From Hospital In Port Au Prince

and from ACP Internist comes the link to Mustard Seed Missions with more accounts from the ground in Haiti.

Jan Davis is in Les Cayes, a town of about 70,000 people about 100 miles southwest of Port-au-Prince. Her husband, Paul Davis, was expected to leave Hatfield this week to join his wife there. Two Northampton doctors, Ann Markes and her husband, Matt Kane, both of whom have worked in Haiti before, were planning to travel with him.

The Davises are the founders of Mustard Seed Missions Inc., a nonprofit group that organizes teams of local volunteers who, about twice a year, travel to Haiti to bring medical care to several remote villages outside Les Cayes.

and via Dr Wes: Haiti relief - getting the USNS Comfort there

and some thoughts on public affairs and how things are portrayed. An email from a Vietnam-era vet who is working aboard USNS Comfort.

and from Paul Levy, Running a Hospital: Dr. Smith's Sunday report

Here are excerpts of an email report received yesterday from Dr. R. Malcolm Smith, Chief of the Orthopaedic Trauma Service at Massachusetts General Hospital, hard at work in Haiti with the team there and with support folks back in Boston.(Embedded links are mine.)

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MedGadget has announced the finalists for the medical blog awards. Polls will be open from Wednesday, January 27, 2010 and will close 12 midnight on Sunday, February 14, 2010 (EST).  Se the list of finalist here.   Voting begins on January 27th.

The categories for this year's awards are:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2009)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

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Dr Anonymous does not appear to have a show scheduled this week.

Upcoming Dr. A Shows (9pm ET)
2/4 : Dean Brandon from Pediatric Dentistry blog
2/11 : Drew Griffin from Wound Care Education Institute
2/18 : Rhett and John from FireFighter Netcast

Neoumbilicoplasty

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 umbilicus is perhaps the only scar that all of us want.  The umbilicus forms after birth as a result of the placental cord being transected as the infant is “detached” from his/her mother.  As the stump of the cord necroses, the scab falls away as the base heals leaving a scar:  the umbilicus.

The umbilicus has been described as a depressed scar surrounded by a natural skin fold that measures 1.5 to 2 cm in diameter and lies anatomically within the midline at the level of superior iliac crest.

Neoumbilicoplasty in simple terms is the creation or reconstruction of a new umbilicus to replace the missing or deformed umbilicus. 

Craig et al. reported on the ideal female umbilicus, but it should always be remembered  “the ideal umbilicus should be regarded as one that is satisfying to the patient.” 

The most aesthetically pleasing umbilicus is small in size, T or vertical in shape, and possesses a superior hood or shelf.

Those characteristics found to be unappealing include a large overall umbilical size, a horizontal or distorted shape, and the presence of umbilical protrusion.

In reconstructing the umbilicus, plastic surgeons should strive to attain these attractive characteristics and incorporate a modest size, with a superior shelf or hood and a T or vertical shape.

Reconstruction of a new umbilicus is indicated in congenital conditions associated with umbilical agenesis, loss of umbilicus due to omphalocele or gastroschisis repair, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump, and in surgical procedures for wide ventral herniorrhaphy.

In my humble opinion, the site of the new umbilicus should correspond to where “nature” would have placed it.  If there is any of the old umbilicus present, this can be used as an indication of where the new umbilicus should be placed.  If not, then  Dr. Susam Park, et al has this suggestion:

Based on our study, it is usually 3 cm above the level of the anterior superior iliac spine in a baby and 6 cm above in an adult, although differences in height and weight may affect these measurements.

Or as  Dr. Suhas Abhyankar, et al put it:

1. The distance between the xyph0sternum and umbilicus-distance between the umbilicus and the pubic symphysis ratio is approximately 1.6:1.

2. Also, the distance between the umbilicus and the anterior superior iliac spine-distance between the right and left anterior superior iliac spines ratio is 0.6:1.  This implies that when each of the anterior superior iliac spines is taken as a center, and arcs are drawn with a radius 0.6 times that of the inter-anterior superior iliac spine distance, the point of intersection of these arcs is the location of the umbilicus, taking into consideration the above ratio (1.6:1).

Surgery varies depending on whether a completely new umbilicus is being created or simply an “outie” being turned into an “innie” or maintaining the umbilicus with other surgery (ie abdominoplasty).

 
  
REFERENCES
*****After noticing the first referenced article below on MDLinx, I did a search of articles in the Journal of Plastic and Reconstructive Surgery first using “neoumbilicoplasty” and then “umbilical reconstruction.”  The second gave me a great list of articles (only a few listed below).

Neoumbilicoplasty is a Useful Adjuvant Procedure in Abdominoplasty; Can J Plast Surg 2009; 17 (4): e20-e23; AA Al-shahan

In Search of the Ideal Female Umbilicus; Plast Reconstr Surg 105: 389, 2000; Craig, S. B., Faller, M. S., and Puckett, C. L.

New Technique for Scarless Umbilical Reinsertion in Abdominoplasty Procedures; Plast Reconstr Surg 102(5):1720-1723, 1998; Schoeller, Thomas M.D.; Wechselberger, Gottfried M.D.; Otto, Angela M.D.; Rainer, Christian M.D.; Schwabegger, Anton M.D.; Lille, Sean M.D.; Ninkovic, Milomir M.D.

A Simplified Technique for Umbilical Reconstruction; Plast Reconstr Surg 114(2):619-621, 2004; Korachi, Ali; Oudit, Deemesh; Ellabban, Mohammed

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis; Plast Reconstr Surg  104(1):204-207, 1999; Park, Susam; Hata, Yuiro; Ito, Osamu; Tokioka, Kazuyuki; Kagawa, Koji

Simplified Technique for Creating a Youthful Umbilicus in Abdominoplasty; Plast Reconstr Surg 109: 2136, 2002; Lee, M. J., and Mustoe, T. A.

Anatomical Localization of the Umbilicus: An Indian Study; Plast Reconstr Surg 117(4):1153-1157, 2006; Abhyankar, Suhas V.; Rajguru, Anirudha G.; Patil, Prajakta A.

Placement of the Umbilicus in an Abdominoplasty;  Plast. Reconstr. Surg. 61: 291, 1978; Dubou, R., and Ousterhout, D.

Umbilical Reconstruction in Abdominoplasty; Melvin A. Shiffman;  International Journal of Cosmetic Surgery and Aesthetic Dermatology. September 2000, 2(3): 171-176. doi:10.1089/153082000750062830

SurgeXperience 315 is Up

Updated 3/2017:  all links removed as some blogs/posts no longer active. 
Education of a Knife  is the host of this edition of SurgeXperiences. Here is the beginning of this edition which you can read here. 

The host of the next edition (316) will be Dr DJ, a private surgeon from India, has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline:  midnight on Friday,February 5th. 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 SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Mother’s Wisdom

“Never put sharp knives in the sink.”

I hear Mom’s voice, as I pull my hand out of the dish water. Blood flows from my left palm. I make a fist, the index finger remains straight.

“It isn’t nice to point your finger at anyone.”

My husband rushes into the room.

Overall Sam Quilt

This quilt is made from antique quilt blocks found at an estate sale in the mid-1990s.  The pattern is the male version of Sun Bonnet Sue and is called Overall Sam.  Five of the six blocks have a red handkerchief in the Sam’s back right pocket.  I put the blocks together and then had a friend hand quilt it for me using Baptist Fan quilting.  The blocks are 14” square.  The quilt is 35.5” X 53.5”.

Here are close photos of two of the blocks.