Thoughts on the AIDS/HIV 30th

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

The first reports of the infection which would come to be known as AIDS appeared in the June 5, 1981 issue of CDC’s MMWR.  The 5 cases reported in the MMWR involved young homosexual men being treated for Pneumocystic carinii pneumonia.  All were in Los Angeles, California during the period October 1980-May 1981.

I did not become aware of this disease until the fall of 1982 as an intern in Baton Rouge, LA.  Our patient presented with Kaposi sarcoma.

Last week I had a short discussion with a friend who is an HIV expert here in Little Rock, AR.  He graduated from medical school a year ahead of me.  He first recalls hearing of HIV when the NEJM article appeared in December 1981.  He mentioned taking note of the article and thinking he would never see any of those cases.

We both marveled over how the diagnosis of HIV has gone from an automatic death sentence to a chronic disease the person can live with.  LIVE with HIV.

He noted the change came in the 1995 with the introduction of highly active antiretroviral therapy (HAART).  My friend went from feeling like he might need to give up treating AIDS/HIV patients (too many deaths were taking it’s toil on him) to feeling hopeful for his patients.

We both noted that prevention continues to fail.  He mentioned he often will have a patient with a birth date of 1987 or so who will present to his office.  Not good as this age group has always had HIV prevention discussed in the media, etc during their lifetime.

Even though HIV is not the death sentence it once was, prevention needs to remain a major focus.

It is important to know your HIV status so that treatment can begin early. It is especially important to be tested yearly if you participate in any of these behaviors:

• Have injected drugs or steroids or shared equipment (such as needles, syringes, works) with others
• Have had unprotected vaginal, anal, or oral sex with men who have sex with men, multiple partners, or anonymous partners
• Have exchanged sex for drugs or money
• Have been diagnosed with or treated for hepatitis, tuberculosis (TB), or a sexually transmitted disease (STD), like syphilis
• Have had unprotected sex with someone who could answer yes to any of the above questions

If you test positive for HIV, then it is important to see a doctor, preferably one with experience treating people living with HIV.

REFERENCES
Pneumocystis Pneumonia --- Los Angeles: CDC MMWR, June 5, 1981 / 30(21);1-3

Gottlieb et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men. NEJM (1981) 305:1425-1430

Kent A. Sepkowitz, M.D.; AIDS — The First 20 Years; N Engl J Med 2001; 344:1764-1772

CDC:  HIV

Aging with AIDS: Living longer, living with loss; Linda Dahlstrom; MSMBC News, June 2, 2011

MyPlate – Size Matters

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

The new food “pyramid” was unveiled this past Thursday.  It is now in a much simpler form – a plate.  What I didn’t find defined at the ChooseMyPlate website is the plate size. 
So I googled “standard dinner plate size.”  Here is the answer:

It can be helpful to know the manufacturers intended use for an item, but it is important to remember that you can use the item in whatever way that works for you!

Dinner plate 10 to 10 3/4"
Luncheon plate 9 to 9 1/2"
Salad plate 8 to 8 3/4"
Bread and butter plate 5 to 7 3/4" (usually about 6")

When found, dessert plates are generally somewhere between salad plates and bread and butter plates in size. Dessert plates are not common, so the salad plate doubles as a dessert plate in most patterns.

Another size that you might see in a pattern is one that is larger than a dinner plate. These are frequently call buffet plates, service plates or chargers and are usually 11" to 12" in diameter.

Chris Maddera makes this point in his essay:  The Psychology of Dinner Plates  (bold emphasis is mine)

….the size of our dinner plates was a major contributing factor of Americans becoming overweight.

Here’s the way it works: the diameter of a typical American dinner plate is 11 inches; the diameter of a typical European dinner plate is 9 inches. r² shows that the 2-inch difference amounts to the 11-inch plate having 50% more surface area than the 9-inch plate. If, like most people, you fill your plate, you’re putting 50% more food on it than a person with the 9-inch plate.

This means we’re eating 50% more food, since we usually eat whatever is on our plates. Or, to look at it differently, we feel full when our plate is empty.

By the way, some restaurants use 13-inch plates, which means it’s twice as big as the 9-inch plate.

Size of the plate matters as does the choice of food we put on it.  Don’t use the larger plates for your children or if you are a petite female.  Consider not covering up the entire surface area.

And don’t forget to get up and move – walk, swim, dance, bowl, etc. 

Miniature American Flag Quilt

This miniature American Flag quilt is similar to this one and this one, only much smaller.  It is a basic brick pattern for the strips. Each brick measure 0.5 in X 1 in.  I placed a purple heart in the star field.
The quilt is machine pieced and quilted.  It measures 7.25 in X 11.5 in.
The purple heart is machine appliqued.
The back features “fast triangles” for hanging ease.

Caring for Horse and Donkey Bite Wounds

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

Earlier this week this tweet from @prsjournal caught my eye

Most Popular: Management of Horse and Donkey Bite Wounds: A Series of 24 Cases: No abstract available http://bit.ly/lgNkCS

I missed this article when it came out in the June 2010 issue of the Plastic and Reconstructive Surgery Journal.  As I have covered fire ant bites, cat bites, and snake bites.  Fellow blogger Bongi has written about hippo bites.  It’s time to cover horse and donkey bites. 

Dr. Köse, Department of Plastic and Reconstructive Surgery, Harran University Hospital, Turkey and colleagues presented a retrospective evaluation of 24 patients treated for animal bites (19 horse and five donkey bites) from 2003 to 2009.  The head and neck were the most frequent bite sites (14 cases), followed by the extremities (8 cases) and the trunk (2 cases).

The article is very short, representing their personal viewpoint and experience. 

Our experience shows the safety of primary closure for horse and donkey bite wounds, provided that careful debridement and good cleansing with antibiotic prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary repair and reconstructive procedures.

Dr. Köse note that horse and donkey bites often result in tissue loss wounds.  Their review of the literature (not sure how extensive) found one reported case of anaphylaxis after a horse bite and one case of a deep crush injury with hematoma, fat necrosis, and muscle rupture without an external wound in a woman bitten on her thigh by a horse.

As I shared in my post Assessing and Managing Mammal Bites – an Article Review

• Thoroughly examine patients with bites.  Especially with children, check the entire body to identify additional injuries.
  
• Examine the wound itself meticulously. It’s easy to miss things.
• Be alert for injuries to the vasculature, nerves, tendons, bones, and joints.
• Bites from large mammals can damage and even fracture bone.  Plain radiographs should be viewed after the exam.
• Large mammals who bite and shake can dislocate joints. Have patients perform active range-of-motion with joints that are near bite wounds.
• Use plain radiography to assess for retained foreign bodies and skeletal injuries. Computed tomography and magnetic resonance imaging have increased sensitivity for foreign bodies and subtle fractures.

As with all wounds, standard wound care applies.  This means copiously irrigate and debride as needed.  Bites are tetanus-prone wounds. Review the patient’s immunization records.  Give updates, etc as needed.

REFERENCE

Management of Horse and Donkey Bite Wounds: A Series of 24 Cases; Köse, Rüstü; Sögüt, Özgür; Mordeniz, Cengiz; Plastic & Reconstructive Surgery. 125(6):251e-252e, June 2010; doi: 10.1097/PRS.0b013e3181d515dd

Recovery of Sensation Post-Facial Transplantation

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

Have you ever lost your sense of smell or taste?  Recall how it feels when your face/mouth don’t work properly until the nerve blocks wear off after a dental procedure.

Those are all things (and more) a facial transplant patient has to deal with.  The article discussing recovery of sensation after facial transplantation in the May issue of Plastic and Reconstructive Surgery discusses this topic (first reference below).

In addition to reviewing their own face transplant patients (n=4), Dr. Maria Siemionow and colleagues did a literature review (English literature for peer-reviewed articles published between 1940 and 2010) of sensory recovery after various standard nerve repair techniques. 

These other nerve repair techniques included repair of the peripheral branches of the trigeminal nerve; sensory return after free tissue transfer (ie noninnervated flaps, including radial forearm, lateral thigh, anterolateral thigh, latissimus dorsi, trapezius, et al and innervated free flaps, including radial forearm, anterolateral thigh, and rectus abdominis musculocutaneous flaps); and sensory recovery following replantation of scalp and forehead.

Image: Pathways of sensory recovery in face transplantation are summarized.

(1) Direct sensory nerve growth through microsurgical nerve repair.

(2) Trigeminofacial communications.

(3) Nervi nervorum of the facial nerve.

(4) Somatic afferents of the facial nerve.

(5) Adrenergic plexus of the vascular pedicle.

Siemionow and colleagues report that only one of the four face transplant recipients underwent direct repair of the sensory nerves.  In the other three cases, it was impossible to reconnect the nerves because of technical difficulties or the severity of the patient's injuries.

Even so, all four patients began regaining sensation in the transplanted face as early as two weeks after surgery and had normal or near-normal sensory function by the end of the first year.

The extent of recovery was similar to that achieved with simple repair of injured sensory nerves in the face-and even better than that of grafting procedures where tissues are transferred to the face from different areas of the body without reconnecting the nerves.

Siemionow and colleagues note in their discussion:

Based on the results of our comparative analysis, we can conclude that, in the absence of extensive soft-tissue injury, simple repair of facial sensory nerves leads to restoration of nearly normal sensation. ….. Interestingly, face transplantation is the only clinical condition where, in the absence of sensory nerve repair, good functional outcome is achieved despite severe trauma causing soft-tissue and sensory nerve damage.

As they also note (bold emphasis is mine)

An important issue that emerged from the comprehensive review of the literature is an evident lack of universal methods of neurosensory assessment and an urgent need for establishment of guidelines that will help with comparative analysis of the sensory recovery data. This applies to the reported cases of face transplantation, where documentation of sensory recovery is either marginal or overlooked.

For the face transplants, as with head injury patients, the olfactory nerve function needs to be assessed as well and it wasn’t in this study.   If the person can’t smell smoke or gas leaks, then extra care or caution has to be taken at home.

REFERENCE

Pathways of Sensory Recovery after Face Transplantation; Siemionow, Maria; Gharb, Bahar Bassiri; Rampazzo, Antonio; Plastic & Reconstructive Surgery. 127(5):1875-1889, May 2011; doi: 10.1097/PRS.0b013e31820e90c3

Discussion: Pathways of Sensory Recovery after Face Transplantation; Chong, Tae; Plastic & Reconstr Surgery 127(5):1890-1891, May 2011; doi: 10.1097/PRS.0b013e31820e88c9

ASPR Press Release, May 9, 2011:  Sensation Recovers to 'Near-Normal' After Face Transplant, Study Finds

Setting Goals, Rehabilitating After Brain Injury; NPR, May 16, 2011

Shout Outs

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

Grand Rounds is  taking a break this week. If you would like to host a future edition of Grand Rounds send an email to Nick Genes (you can find his contact info at here).   The most recent edition can be found here at Medgadget.  Other editions can be found here on the Grand Rounds Facebook page.

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@movinmeat  wrote a post recently, A case study in applied ethics, which lead @inwhiteink to write an educational post on decisional capacity

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“Decisional capacity” refers to a person’s ability to make a decision for a specific clinical issue. This issue is usually related to treatment. After assessment, physicians can opine whether someone possesses or lacks decisional capacity for something specific: ……

Appelbaum and Grisso published an important paper that provides a four-point rubric to assess decisional capacity. (At only four pages, it is a short, high-yield article.) Most psychiatrists apply this rubric when assessing decisional capacity in medical settings. …….

Movin Meat’s followup post:  Ethics of refusing informed consent

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From twitter:   @Mtnmd The Twitter chat that killed Sermo http://bit.ly/ipw4au

Her link is to an article by Joe Hage which I encourage you to read:  The Twitter Chat that Killed Sermo | #MedDevice

I’m not a physician. I don’t play one on TV. And I’d never heard of Sermo, the largest online physician community in the US (boasting 120,000 members) until @HJLuks mentioned them the week before.

Mine was an innocent invitation to talk during last night’s #MedDevice chat (Thursdays, 8 pm EST).

Who knew it could unravel the company.  …….

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Yesterday NPR aired this story:  Army Nurse Helps Soldiers Heal From Burn Wounds

As part of NPR's ongoing series, 'The Impact of War,' guest host Allison Keyes explores one of the tragic consequences of combat - burn wounds. Such wounds can subject victims to a painful and unpredictable recovery. Army Lt. Col. Maria Serio Melvin shares her experiences at the military's largest burn center, the Brooke Army Medical Center in San Antonio, TX, where she treated service members injured in the Iraq and Afghanistan wars …………

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Some inspiring stories of healthcare workers during the Joplin tornado

H/T @Mtnmd -- 45 Seconds: Memoirs of an ER Doctor from May 22, 2011

H/T @SeaSpray – Operating Through the Tornado

James D. "Dusty" Smith, MD, and his surgical team were midway through a routine case, the draining of a patient's infected hip, when the tornado hit St. John's Regional Medical Center in Joplin, Mo., Sunday.  ……….

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From @scutmonkey, her piece on Psychology Today:  The Radical Notion that Doctors are People, Too

Though there are few subjects as immediate to my experience as that described in Gardiner Harris's article in The New York Times, "More Doctors Say No to Endless Workdays," (April 1st, 2011), perhaps the truest indication of my opinion on the matter may be the fact that, upon first glance at the headline, I didn't feel much need to read the rest of the article.  More doctors say no to endless workdays?  Well, of course we do.  Duh.  …..

Her tweet of the article led @DarrellWhite to tweet a link to his view on the same topic:  Residency Training and the Modern Physician

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H/T to @brainpicker and @ctsinclair for the link to this:  Anatomy made of LEGO (photo credit) 

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Last Tuesday (May 24, 2011) NPR celebrated Bob Dylan Turning 70.  Near the top of the story written by Linda Fahey is a button “Visit FolkAlley.com To Hear The Mix” which links you to a wonderful mix of Dylan music sung by Joan Baez, Tim O'Brien, Rosanne Cash, Jimmy Lafave, many others — and Dylan himself.  Thanks NPR.

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Threads has a nice article by Susan Khalje on Creating Perfect Bias Fabric Loops  (photo credit)

……..we decided that loops and buttons would be a cleaner alternative.
Here are a few samples to show you what we did:
We started with strips of bias-cut fabric, making a sample or two to determine just how narrow we wanted the finished loops to be. ……….

War Advances in Medicine

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

Medicine has much to be grateful for to war, but I wish we’d find a peaceful way to make these advances.

Here are just a few

In 1718, Jean Louis Petit, a French surgeon, invented a screw tourniquet to control bleeding. The screw tourniquet made thigh amputations possible and reduced the risks associated with amputations below the knee.

Dominique-Jean Larrey (French Army, joined army in 1792) is credited with setting up the first field hospitals (though the golden hour wasn’t known, this provided quicker care) and “flying ambulances” to rapidly evacuate wounded soldiers from the battlefield to the hospital.

The trench warfare of WWI produced extreme facial injuries.  Interdisciplinary teams (dentist, plastic surgeons, etc) set a standard for the care of complex maxillofacial injuries.

WWII saw advancements in treatment of shock.  Colonel Edward Churchill discovered that shock was not only related to blood fluid loss but also to electrolyte loss. This led to improvements in intravenous solution preparation.

The Korean War provided us with advancements in vascular reconstruction and repair, better understanding of frostbite,  and the  Mobile Army Surgical Hospital (MASH).

The wars in Iraq and Afghanistan are increasing our understanding and treatment of head injuries and PTSD.  They are also leading to major advances in limb prosthetics.

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Thank you to all Veterans and active duty military for your service.  Thank you to all the families behind these men and women.

For those interested, here is some additional reading:

CBS Sunday Morning (June 2006):  The Medical Frontlines Of War-- Throughout History, Advances In Emergency Care Originate On Battlefield

The second sacrifice: costly advances in medicine and surgery during the Civil War; E. D. Weiss; Yale J Biol Med. 2001 May–Jun; 74(3): 169–177.  (pdf file)

How the Civil War Changed Modern Medicine: The bloodiest conflict on American soil ushered in a new era of medicine; Emily Sohn;  Discovery News, Apr 8, 2011

Medical advances consequent to the Great War 1914-1918; J D Bennett; J R Soc Med. 1990 November; 83(11): 738–742. (pdf file)

U.S. Military Builds on Rich History of Amputee Care: During every major conflict, combat injuries have caused large numbers of service members to lose one or more of their limbs; in fact, these individuals are one of the most visible and enduring reminders of the cost of war; Military inStep, 09/18/2008

Science Museum:  War and Medicine

"Battlefield Surgery 101: From the Civil War to Vietnam"; National Museum of Health and Medicine (2004)

NHS Choices:  War’s Medical Advances

The value of war for medicine: questions and considerations concerning an often endorsed proposition; Leo Van Bergen, Department of Medical Humanities, VU Medical Centre,  Amsterdam  (pdf file)

History of the American Association of Plastic Surgeons, 1921-1996; Randall, Peter; McCarthy, Joseph G.; Wray, R. Christie; Plastic & Reconstructive Surgery. 97(6):1254-1292, May 1996

War Wounds: Lessons Learned from Operation Iraqi Freedom; Geiger, Scott; McCormick, Frank; Chou, Richard; Wandel, Amy G.; Plastic & Reconstructive Surgery. 122(1):146-153, July 2008; doi: 10.1097/PRS.0b013e3181773d19

Dallas' Patriotic Quilt

I made this quilt for my nephew when his mother mentioned the one I had made for him previously was getting quite worn.  This time I chose to make him a patriotic quilt.  I began with the 8-pointed star which was left over from some long forgotten project and used it as the center of the medallion.

The quilt was sort of a personal “round-robin” as I added sections.  The quilt is machine pieced and quilted.  I finished it in October 2003.  It is 77 in X 79 in. 

I want to thank Amy, his mom and my sister-in-law, for taking the photos for me.  Sorry they don’t show the entire quilt.

This shows the center a little better.

As we begin Memorial Day weekend, I want to thank all active and retired military, as well as their families, for the service and sacrifices they have made and make for us all.

Plastic Surgery in Ethnic Groups

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

Earlier this week @hrana twitted this:

News: Plastic surgery boom as Asians seek 'western' look http://bit.ly/ifQFBs - Don't get me started on this topic. #health

The link is to the CNN article by Kyung Lah:  Plastic surgery boom as Asians seek 'western' look

The article is an interview of a 12 yo Korean girl, her mother, and Dr Kim Byung-gun (head of Seoul, South Korea's biggest plastic surgery clinic, BK DongYang).

The young girl doesn’t like her eyes and wants to have a double fold created in her eyelids to give her a more western look.

Is it wrong to want to look like another ethnic group rather than your own?  Are you slighting your heritage or family if you chose to change your eyes, your nose, etc?

I was taught, as a surgeon, the neoclassical canons of facial attractiveness (1st reference below).  These don’t necessarily translate well into all ethnic groups (ie Asians, African-American).  Neither does the Marquardt facial mask. 

Media and the cross-culture of our society affects the idea of beauty.  M. Jain in her college paper (3rd reference below) notes “that women of different generations and locations have felt the globalization of a Western ideal- skinny, "white" features, tall, and non-curvaceous body.”

Is it a form of self-hatred to want to change the identifying ethnic trait -- Asian eyelids, Mediterranean nose (ie Roman), African-American nose?  Is this somehow different than someone who wants more hair, wants bigger/smaller breasts, fuller buttocks, anti-aging cosmetic surgery?

REFERENCES

1.  History and Current Concepts in the Analysis of Facial Attractiveness; Bashour, Mounir; Plastic & Reconstructive Surgery. 118(3):741-756, September 1, 2006.

2.  Ethnic trends in facial plastic surgery; Sturm-O'Brien AK, Brissett AE, Brissett AE; Facial Plast Surg. 2010 May;26(2):69-74. Epub 2010 May 4.

3.  The Cultural Implications of Beauty; Meera Jain; course paper at Bryn Mawr College, Spring 2005

4.  Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients; Talakoub L, Wesley NO; Semin Cutan Med Surg. 2009 Jun;28(2):115-29. (pdf file)

5.  The Legacy of Narcissus; Scott Isenberg, J.; Plastic & Reconstructive Surgery. 110(7):1815, December 2002

6.  Putting Beauty Back in the Eye of the Beholder; Little, Anthony; Perrett, David; The Psychologist Vol 15 No 1, January 2002 (pdf file)

7.  Physical appearance and cosmetic medical treatments: physiological and socio-cultural influences; Sarwer DB, Magee L, Clark V; J Cosmet Dermatol. 2003 Jan;2(1):29-39.

8.  Motivating factors for seeking cosmetic surgery: a synthesis of the literature; Haas CF, Champion A, Secor D; Plast Surg Nurs. 2008 Oct-Dec;28(4):177-82.

9.  Correlates of Young Women’s Interest in Obtaining Cosmetic Surgery; Charlotte N. Markey & Patrick M. Markey; Sex Roles (2009) 61:158–166; DOI 10.1007/s11199-009-9625-5 (pdf file)

10. Orthodox Jewish Law (Halachah) and Plastic Surgery; Westreich, Melvyn; Plastic & Reconstructive Surgery. 102(3):908-913, September 1998

Transaxillary Breast Augmentation and Sentinel Lymph Node Integrity

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

I’m not a huge fan of transaxillary breast augmentation (TABA).  One of the major selling points for the transaxillary approach is the lack of scars on the breasts.  As a woman living in the south, my arm pits are much more likely to be seen in public than my breasts. 

As a surgeon, I also know that when revisions need to be done (capsule issues, etc) most recommend using an inframammary approach so why not just start there.  In my opinion, all women with implants will have a repeat surgery at some point in the future – implant failure (deflation, rupture) being a given.

I admit I had not thought about how the incision might interfere with future sentinel lymph node assessment prior to this article (full reference below).

Dr. Ana Claudia Weck Roxo, Rio de Janeiro State University, Brazil and colleagues conducted a small study to evaluate changes in axillary lymphatic drainage in patients who underwent TABA.

The authors share this information as to why this is important (bold emphasis is mine):

The sentinel lymph node is the first node in the lymphatic chain and the first to receive tumor cells via lymphatic drainage. Therefore, sentinel lymph node analysis allows physicians to predict the status of the lymphatic chain. The recent validation of the capacity of the sentinel lymph node to stage breast cancer patients and to help identify those who require axillary dissection has dramatically improved surgical treatment and reduced morbidity. Thus, sentinel lymph node biopsy has become an alternative to axillary dissection in patients with T1 and T2 breast cancer and is a gold standard for axillary staging because of its high sensitivity (84%-98%) and low false-negative rates (2%-8.8%).  Nevertheless, it is contraindicated in patients with palpable axillary metastatic lesions, multicentric breast disease, previous mammary or axillary radiotherapy, and/or previous axillary or mammary procedures.

The prospective study enrolled 27 patients who underwent preoperative mammary lymphoscintigraphy, a subsequent TABA (using a subglandular placement of round, textured, high-profile silicone implants through a 4-cm incision at the anterior axillary fold), and postoperative lymphoscintigraphy at 21 days and six months after the procedure.  

The postoperative imaging results examining the axillary lymphatic chain and the first axillary lymph node were analyzed and compared to the preoperative images.

None of the patients showed any changes between the preoperative and postoperative images at six months.  Only one of the 27 patients (4.5%) demonstrated a lower rate of lymphatic drainage at 21 days postoperatively compared to preoperative values.

The sentinel lymph node remained visible in all patients at all time points, and all breasts showed drainage primarily to the axillary lymphatic chain.

Their data showed preservation of lymphatic drainage and visible sentinel lymph nodes even after transaxillary breast augmentation.  I would love a larger study to confirm, but am pleased they looked at this.

REFERENCE

Evaluation of the Effects of Transaxillary Breast Augmentation on Sentinel Lymph Node Integrity; Ana C Weck Roxo, Jose H Aboudib, Claudio C De Castro, Maria L De Abreu, and Margarida M Camões Orlando; Aesthetic Surgery Journal May 2011 31: 392-400, doi:10.1177/1090820X11404399

Shout Outs

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

Medgadget is the host for this week’s issue of Grand Rounds! You can read this week’s edition here.

Welcome to Grand Rounds, the weekly recap of the best in the medical blog universe! And welcome to Medgadget, where our team of researchers, doctors and engineers cover the world of medical devices and health-related technology news.

For Grand Rounds this week, we suggested bloggers send us technology-related material, and they rose to the challenge; we received some amazing links. Of course, there was great non-techie material too. It’s all below, loosely categorized, with photos and quotes lifted from posts of note.   …….

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Amazing story from BBC science reporter Neil Bowdler: Bionic hand for 'elective amputation' patient (photo credit)

An Austrian resident has voluntarily had his hand amputated so he can be fitted with a bionic limb.

The patient, called "Milo", aged 26, lost the use of his right hand in a motorcycle accident a decade ago.

….. what is called a "brachial plexus" injury to his right shoulder left his right arm paralysed. Nerve tissue transplanted from his leg by Professor Aszmann restored movement to his arm but not to his hand. ….

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angienadia, MD, Primary Dx, has written a thoughtful post on resident work hours which can be read both on her blog or on KevinMD: New ACGME work hour regulations for interns: friend or foe?

…..Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – ………

The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. …... Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem

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Sandnsurf, LITFL, give praise to an inspiration patient: Nathan Charles

Patients are often a source of inspiration and hope.
One such stand out individual is Nathan Charles.

I first met Nathan in January of this year in my role as team doctor for the Emirates Western Force rugby union team. Nathan is a 21 year old elite athlete playing number 2 (hooker) for the Western Force. But what makes this achievement even more admirable is that he has cystic fibrosis. …………

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NPR’s Robert Krulwich writes about women in science: The Ghost Of Madame Curie Protests...

……….. I got to thinking about the not-so-subtle way women have been treated in science, even the most celebrated ones.

A few months back, I wrote a post about how the Nobel Committee (a committee of guys) in 1911 tried to get Madame Curie NOT to come and collect her second Nobel Prize. ……….

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From @enochchoi via twitter:   my #TedXHayward talk on Disaster Medical Relief http://ow.ly/4ZTt2

Disaster Medical Relief on Prezi

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Fellow medical blogger @DrJohnM wrote about some things he observed on his recent trip to Germany:   A Kentucky Doc goes to Europe

……..For now, may I highlight a few of the more striking differences between Europe and the States, as noted by a Kentuckian on his first trip across the Atlantic?

(I realize that sophisticated well-traveled people already know this stuff, but I can’t help myself.)

First...The transportation system in Europe uses much smaller vehicles……….

Second…The bikes! I was stunned by the sheer numbers of smart-looking people pedaling around on the sidewalks and streets of Hamburg……….

On healthcare:

(A disclaimer: I am only making observations and asking questions; I am not suggesting we adopt the German healthcare system after a five-day visit.)

I quickly learned that all German citizens get free healthcare. But those who desire ‘more’ care can buy additional private coverage.  ……….

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You can find some of my iPhone photos here. They are not nearly as good as the ones in this HuffPost Arts article from John Seed: The Art of iPhone Photography in Orange County (PHOTOS)

If Cartier-Bresson was still taking photos today, he would ditch his Leica and be taking photos with an iPhone. At least, that is the view of Knox Bronson, a curator, composer and iPhoneographer who has been gathering a stunning gallery of iPhone photos on his site: P1XELS the art of the iPhone.

Bronson, who is a purist, is only interested in collecting photos that have not in any way been manipulated outside of the phone by a computer:

This is one of mine (Instagram photo app with Inkwell filter of a pink rose in full bloom):

Customer Service via Twitter

It seems that over the years I have ended up with a different Norton Anti-virus product key for three different computers rather than one for all three.  The renewal emails are staggered through the spring.

This week I decided to tackle the issue and see if I could get it changed.  I visited the website and when I saw the option of contacting them via twitter I did just that.

Twitter worked!

I sent my question to @nortonforumsusa which began an email correspondence.   Within less than 24 hours I had all three computers running Norton 360 Premier under the same product key.

The first contact, TL, even forwarded my question regarding refund or credit from the other two to customer relations rep RV who gave me two options (I chose the credit one).

One reason it worked for me was I did my homework before I contacted them.  I helped them help me by having all three product key numbers available, giving them a working email address, and responded to their questions quickly.

This post is simply meant to be a public expression of gratitude and thanks for how well Norton’s customer service worked.  Thanks to TL and RV.

……

But I will take it further ----

Perhaps hospitals and clinics could use twitter the same way for non-emergency/non-diagnostic/non-treatment issues like billing, scheduling, etc. 

First, a public request for help.  Second, take the help to a private venue (email or phone).