Assessing and Managing Mammal Bites – 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 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.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.

Not sure how I got on the list to receive Emergency Medicine journal, but I always look through it before I recycle it.  There are often decent articles in it.  The one referenced below is a nice quick review on the problem of mammal bites.  This is an issue most doctors will encounter at some point in time.

About 1% of emergency department and urgent care visits each year are for mammal bite injuries or their complications. Ten to 20 people die each year from mammal bites. In 2006, 310,710 injuries from dog bites alone were reported to the Centers for Disease Control and Prevention. The actual number of bite wounds from all mammals is estimated to be around 2 million each year, but that figure underestimates the true incidence because most animal bites are unreported.

Animal bite injuries come in many forms:  lacerations, punctures, crush injuries, tears, rips, avulsions, fractures, hemorrhage, and contusions. The type and severity of the injury will depend on the location of the bite, the animal involved, and size of the patient. 

More than two-thirds of bite injuries occur in children younger than 10 years old—boys more often than girls. Children most commonly pre-sent with bite wounds to the face, neck, and head. Adults more commonly present with bites to the extremities.

The article gives helpful “History and Physical Exam Tips”

• Patients usually seek medical care for repair of the wound or because the wound has become infected.

A thorough history of the event includes asking about the timing of the injury, the kind of animal involved, its health history (including vaccination status and current health), and its behavior. Other important information about the animal includes whether it can be observed or captured.

• 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.

The article gives a nice review of principles for reducing the risk of infection.   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.
Most wounds can be closed primarily.  It’s expected that a small percentage of wounds will become infected and require early suture removal. Inform patients that wound infections may occur in spite of the appropriate care. Advise all patients at discharge to look for signs of infection, such as redness, increasing pain, and purulent drainage.
Some bite wounds have a higher risk of infection.

Animal Bites With a High Risk for Infection
•  crush injuries
•  hand wounds
•  puncture wounds
•  wounds with extensive devitalized tissue
•  heavily contaminated wounds
•  prolonged time from injury to treatment:
     6–12 hours on the body
     12–24 hours on the face

The article points out some specific considerations to keep in mind.

Dog bites. A big fear with dog bites is rabies, but the actual incidence among these dogs in the United States is low.  Similarly, few dog bites actually lead to infection. 

However, significant bites are at risk for infection, which is usually polymicrobial. About 50% of infected dog bites involve Pasteurella canis. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children (see table below). Duration of therapy is not clearly established.

Cat bites. In contrast to dog bites, most cat bites do become infected.

Pasteurella multocida is present in 70% to 90% of the infections. Antibiotic post-exposure prophylaxis that is effective for P. multocida is recommended for all cat bites; unfortunately, P. multocida is resistant to clindamycin, dicloxicillin, cephalexin, and erythromycin. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily in adults, 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.

Cats have the highest incidence of rabies of all domestic animals in the United States. However, transfer to humans remains rare. 

Primate bites.  A subgroup of primates called the macaques (rhesus and green monkeys) carry B virus (Cercopithecine herpesvirus 1), usually by the age of 2.

Though asymptomatic in the macaques, B virus causes fatal encephalitis in humans; 24 of the 25 humans known to be infected have died. The incidence of transmission is unknown, but it has been documented to occur from even trivial wounds. Due to the high mortality, post-bite prophylaxis is recommended for any macaque bite. First-line therapy is valacyclovir 1 gram orally every 8 hours for 14 days.

Rodent and rabbit bites. Rodents, rabbits, and hares carry Francisella tularemia and can transmit this to humans through bites. The CDC does not recommend routine prophylaxis for tularemia from the bite of a rodent.

Domestic and wild rats in the United States carry and transmit Streptobacillus moniliformis, which causes rat bite fever. The CDC recommends post-bite prophylaxis after wild or domestic rat bites.The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.

Overall, a very nice review article.  Especially good for students and residents.  The article includes tables of appropriate antibiotics and dosages.

Related Blog Posts:

Cat Bites

Dog Bite Prevention

REFERENCE
Assessing and Managing Mammal Bites; Emerg Med 41(1):35, 2009; Lisa D. Mills, MD, and John Lilley, MD

Sulfonamide Associated Hepatic Failure

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

First off, let me say I have never seen this complication of sulfonamides.  I was only vaguely aware that it existed.  A patient came in to discuss a cosmetic procedure.  Like always, I was going through the allergy section.  She had marked yes on the sulfa drugs.  I asked what kind of reaction.   I want to know if it was a true problem or just an unwelcome side effect.

She then told me about her son who died of acute hepatic failure from a reaction to Bactrim (Sulfamethoxazole/Trimethoprim), and how a few years after his death she got very ill after taking Bactrim.  So now their family refuses to take sulfa drugs.  It prompted me to do a review.

Sulfamethoxazole/Trimethoprim (SMX/TMP) is a commonly used antibiotic for respiratory, gastrointestinal and urinary tract infections caused by a range of aerobic gram-positive and gram-negative bacteria. It also has activity against Listeria monocytogenes, Nocardia and Pneuomcystis jiroveci.

SMX/TMP is generally well tolerated in non-HIV-infected patients.  Adverse reactions occur in this group in approximately 6 to 8 percent of individuals. In comparison, the adverse reaction rate is as high as 25 to 50 percent in HIV-infected patients and many of the reactions are severe.

The most common adverse reactions include nausea, vomiting, anorexia, dermatological reactions such as pruritis, urticaria and less commonly Steven Johnson Syndrome.

Life-threatening adverse reactions include neutropenia, exfoliative dermatitis (a severe skin disorder with generalized erythema and scaling) and toxic epidermal necrolysis (an acute severe reaction with widespread erythema and detachment of the epidermis). Acute liver failure has only been reported in a few cases worldwide, and has been attributed to the sulphonamide component of the drug.

The sulfamethoxazole component of SMX/TMP is responsible for most of its' side effects including liver failure.
Three forms of SMX/TMP induced liver damage have been described.
1) hepatocellular
2)  mixed hepatocellular cholestatic
3) bile duct injury with ductopenia or Vanishing Bile duct syndrome

The onset of symptoms usually occurs within a few days of exposure, but can take up to a 1–2 months.  Patients will usually present with  nausea, vomiting, jaundice, and pruritis (if cholestatic).  Liver function tests (LFTs)  may show a hepatocellular or cholestatic pattern depending on the type of injury. Patients might have other feature of an allergic reaction such as skin rash, eosinophilia. 

Diagnosis is suspected from the clinical presentation, and absence of other causes.

The severity of SMX/TMP induced liver injury can range from mild symptoms with elevated liver enzymes to fulminant hepatic failure with hepatic encephalopathy and coagulopathy. Outcome can be favorable with spontaneous resolution or unfavorable leading to death.

Treatment is generally supportive, liver transplantation has been successful for both fulminant hepatic failure and vanishing bile duct syndrome

REFERENCES

Acute Liver Disease Associated with Erythromycins, Sulfonamides, and Tetracyclines; Annals of Internal Medicine, Vol 119, Issue 7, Part 1, pp 576-583, Oct 1993;  Jeffrey L. Carson; Brian L. Strom; Amy Duff; Anand Gupta; Michele Shaw; Frank E. Lundin; and Kiron Das

Case Report: Sulfamethoxazole/Trimethoprim induced liver failure: a case report; Cases Journal 2008, :44doi:10.1186/1757-1626-1-44; Salaheldin Abusin, Swapna Johnson
Harrison’s Online; Chapter 299 (Merck’s)-- Trimethoprim-Sulfamethoxazole Hepatotoxicity (Idiosyncratic Reaction)

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. 

The Health Care Blog is this week's host of Grand Rounds.  Read this edition here.  

Welcome to Grand Rounds. It's been quite some time since THCB hosted the medical blogosphere's major compendium. So sit back and enjoy a stroll through the gardens of medical and health care obsession.
It's still a fresh political season, so we start with the wonks:

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.

 

The third edition of Change of Shift (Vol 3, No 16) for 2009 is hosted by Digital Doorway!   It’s the “fish bowl” edition. I hope you will check it out (photo credit).  You can find the schedule and the COS archives at Emergiblog. 

In the days leading up to hosting this edition of Change of Shift, I gave a great deal of thought to the phenomena of the internet, blogging, Twitter, iPhones, Facebook, and the many technological advances that now keep us all connected and communicating.

That said, as much as I love these manifestations of our Digital Age, I also see these forums as proverbial fish bowls in which we all stew ourselves in the waters of public communication, often rendering ourselves vulnerable and naked as the observing masses watch our every move.

Pallimed has begun a new grand rounds for palliative care.  The inaugural edition (Vol 1, Issue 1) can be read here.

Welcome to the inaugural edition of Palliative Care Grand Rounds, a monthly blog carnival bringing you the best and most interesting blog posts about hospice, palliative care, death and dying, grief, quality of life, communication in the medical arena, and anything else that strikes the fancy of the host that month.
If you are interested in becoming one of the upcoming hosts, please comment or email me at ctsinclair @t g-m-a-i-l d0t c0m. Here is the website with the archives and upcoming hosts.

Rhinoplasty Surgery Blog has a nice post titled "Pablo Picasso's Girl in the Mirror:  The Agony of Imagined Ugliness".  (photo credit)

Most clinicians involved in the treatment of patients with facial deformities will encounter the patient who is excessively concerned with a minor or imperceptible defect in their appearance or patients who reveal extreme dissatisfaction despite good treatment results. In cases in which such a preoccupation with appearance causes the patient marked distress in their social or occupational functioning, the patient may have nondelusional dysmorphophobia, also known as body dysmorphic disorder (BDD).

Ant Ears is back! 

It has been some time since I last posted.  Busy trauma rotation, holidays, ABSITE, killer call schedule - suddenly 3 months went by.

This week Dr Anonymous will be talking about  Podcamp Ohio.  The show will be back at it’s usual time,  9 pm EST. 

Integrating Radiation Therapy & Breast Reconstruction – 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.

Let me begin by saying – this review article is worth your time to read. The Medscape article examines the most recent literature on breast reconstruction in patients receiving post-mastectomy radiation therapy (PMRT) and presents it in a fashion that is meant to assist in making the best treatment decisions.

They introduce the subject by reviewing the evidence that supports the use of post-mastectomy radiation therapy.

PMRT can improve survival and local-regional control in selected patients with invasive breast cancer treated with mastectomy and systemic therapy.

Local-regional and survival benefits of PMRT for patients with lymph node-positive disease.

Survival advantage associated with PMRT was evident both for patients with 1-3 positive lymph nodes and those with 4 or more positive lymph nodes.

Accordingly, the use of PMRT for patients with stage II breast cancer is increasing

Breast reconstruction following mastectomy is also an important aspect of care for many patients with breast cancer. It is important that reconstruction does not compromise the goal of breast cancer treatment: to maximize the probability of cure and permit patients to return to a normal quality of life.

So what is the optimal timing and technique of breast reconstruction in patients requiring PMRT? It is controversial. Like most medical treatment, “one size doesn’t fit all.” This article does a nice job of making some sense of it.

Implant-Based Breast Reconstruction in Patients Receiving PMRT

Studies evaluating the outcomes of 2-stage breast reconstruction (placement of a tissue expander followed by placement of a permanent breast implant after PMRT) consistently reveal high rates of acute and chronic complications and poor aesthetic outcomes.

Capsular contracture that results from PMRT can distort the appearance of the breast and cause potentially significant chronic chest wall pain and tightness.

Many surgeons attribute the poor outcomes with implant-based breast reconstruction to older, less precise techniques of radiation delivery. However, even with modern radiation delivery techniques, complication rates with implant-based reconstruction are high.

In addition, fibrotic changes around breast implants associated with PMRT can continue to evolve years after treatment; early results of new techniques often underestimate the true incidence of complications.

Current Role of Reconstruction With a Latissimus Dorsi Flap

Evans and colleagues found that the addition of the tissue flap -- either a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi myocutaneous flap -- did not appear to protect against capsular contracture, a common complication of PMRT.

…………………………………………………………….

In 2007, Spear and colleagues concluded that in patients with unsatisfactory outcomes after 2-stage implant-based reconstruction as a result of the adverse effects of radiation, breast contour can be improved by adding a latissimus dorsi flap, generally to the inferior pole of the breast.

Effect of Immediate Implant-Based Breast Reconstruction on Radiation Treatment Field Design

Not only can PMRT adversely affect the aesthetic outcome of immediate implant-based breast reconstruction, but there is increasing evidence that such reconstructions may interfere with the delivery of PMRT.

Chest wall treatment in patients who have undergone reconstruction must be accomplished by using traditional, 2-beam tangential fields alone rather than the modern, 3-beam technique. As mentioned, this can deliver potentially harmful doses of radiation to the heart or lung.

This is something that truly needs to be considered in woman who need or may need post-mastectomy radiation therapy. The article has some nice visuals that help explain the physics for those interested.

Autologous Tissue Breast Reconstruction in Patients Receiving PMRT

Although the consensus in the literature is that autologous tissue is preferable to breast implants within an irradiated operative field, autologous tissue reconstructions may also be adversely affected by PMRT.

However, autologous tissue reconstructions can interfere with the radiation field design and can also lead to adverse changes in the aesthetic reconstruction outcome.

This issue of the reconstruction, no matter which technique, is a requiring theme. This needs to be considered. Delayed reconstruction may be the best option in patients who are known at the time of mastectomy to require PMRT.

Effect of Immediate Autologous Tissue Breast Reconstruction on Radiation Treatment Field Design

Immediate reconstruction substantially compromised treatment of the internal mammary nodes and made it less possible to use a modern, 3-beam technique with a separate medial electron beam to treat this region.

In patients with right-sided reconstructions, the chest wall and internal mammary chains were treated with deeper tangential beams (traditional, 2-beam tangential beam technique) at the expense of irradiation of more lung parenchyma.

In patients with left-sided reconstructions (accounting for 67% of the compromised treatment plans), the heart and lung were spared at the expense of suboptimal coverage of the chest wall and internal mammary nodes.

Sixty-five percent of patients with compromised internal mammary node coverage also had compromised coverage of the chest wall and suboptimal sparing of lung and epicardial heart structures (including the left anterior descending branch). Thus, even if the internal mammary nodes had not been treated, these patients' plans would not have been optimal.

Delayed-Immediate Breast Reconstruction

It is best to do delayed breast reconstruction in women who will need radiation therapy. This is not always known prior to the mastectomy as it may hinge on the receptor studies. However, by delaying the reconstruction, the benefits of immediate reconstruction are lost. These benefits include the ability to preserve of the breast skin envelope and the natural contour of the inframammary crease which give the opportunity for the best aesthetic outcome.

One option that decreases the adverse effects of PMRT through more targeted therapy and helps ensure optimal radiation delivery after immediate breast reconstruction is delayed-immediate reconstruction.

This approach involves placing a tissue expander at the time of mastectomy to preserve the initial shape and thickness of the breast skin flaps and the dimensions of the breast skin envelope until the final pathology results are available. In patients found not to require PMRT, preservation of the breast skin envelope enables the plastic surgeon to achieve optimal aesthetic outcomes. The outcomes are found to be similar to those obtainable with immediate breast reconstruction.

In patients who require PMRT, the tissue expander can be deflated before the start of PMRT to create a flat chest wall surface and permit modern, 3-beam radiation delivery. The expander can be reinflated after PMRT to permit "skin-preserving" delayed reconstruction.

REFERENCE
Integrating Radiation Therapy and Breast Reconstruction: Which Comes First?; Medscape Article, January 30, 2009; Thomas A. Buchholz, MD, FACR; Steven J. Kronowitz, MD, FACS
Related Blog Posts
Breast Reconstruction – Part I
Breast Reconstruction – Part II

SurgeXperiences 217 – Call for Submissions

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 next edition (217) of SurgeXperiences will be hosted by Dr Cris, Scalpel’s Edge, on February 15th.  

Dr Cris is a general surgical trainee based at the Austin Hospital in Heidelberg, Australia. She is working on her PhD in surgery: "Hyperbaric Oxygen improves survival in severe acute pancreatitis."

The deadline for submissions is midnight on Friday, February 13th.  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.

Home-Health Models in Arkansas Praised

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

There was a really nice article by Carolyne Park in my local paper on Sunday, Feb 1, 2009, that states that the National Association for Home Care and Hospice would like to use our local Baptist Home Health model as the model for a national pilot program.

Baptist Health’s home-health model for treating chronically ill patients uses technology and a team approach to identify obstacles and help patients better manage their diseases. 

Patients are provided a small telehealth computer.  The patient then must use the secure network to send daily data (ie heart rate, blood pressure, oxygen level, blood sugar levels, etc) via phone line to Baptist’s main home health office in Little Rock.   A team of registered nurses and advanced practice nurses check the results for any potential problems.  If anything is noted, a team member will phone the patient.

The Center for Disease Control and Prevent states that 45% of Americans (133 million in all) have at least one chronic disease, such as heart disease, cancer, stroke, chronic obstructive pulmonary disease or diabetes.  The percentage is 60% in older adults who often have two or more chronic conditions.  These chronic diseases are the leading cause of death and disability in the US.  They also account for more than 75% of the nation’s $2 trillion health-care costs.

The home-health model is being viewed as a possible way to lower these deaths and decrease the overall cost.  Home-health nurses have time on their side.  By working closely with the patients, the nurses help the patients learn about their disease(s), care, and prescriptions.  By making home visits, they see the conditions they patient lives in (ie food in cabinets/refrigerator), whether there are family/friends for support, and can better access the patients for depression.  By doing this, the hope is that there will be fewer hospitalizations and fewer complications from the chronic diseases.

Medicare has been collecting data for many years on home health agencies and the outcomes of the patients they serve. This data is reported on the Medicare websites. The Baptist Health website list (last updated June 20, 2008) gives their numbers:

The quality of care you will receive from BAPTIST HEALTH Home Health is demonstrated by our outcomes in these 3 crucial areas (from data reported by our Little Rock office*):

• Only 21% of our patients needed urgent, unplanned medical care.  This is among the lowest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 23%
  • National average is 21%
• Only 24% of our patients needed to be rehospitalized while under our care.  This is the lowest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 32%
  • National average is 28%
• A total of 72% of our patients were able to remain at home after they discharged from our agency.  This is the highest percentage of all home health agencies located in Pulaski County.
  • Average for all home health agencies in Arkansas is 63%
  • National average is 68%

St. Vincent Health System’s Visiting Nurse Association also combines technology with home health care. It has used telehealth computers to monitor patients in their homes for several years.  The Arkansas Gazette article states that “the technology has helped St. Vincent reduce hospital visits by its 400 home-health patients in 11 central Arkansas counties. In 2007, about 4.5 percent of the association’s heart-attack patients were rehospitalized, compared with a national rate of 37 percent.”

REFERENCES
Home-health program seen as national model; Arkansas Democrat-Gazette, Feb 1, 2009; Carolyne Park (subscription required)
Baptist Health Home Health Network
St. Vincent Health System’s Visiting Nurse Association
National Association for Home Care and Hospice

Wreath Quilt Block

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

My fall block of the Four Seasons Quilt is called Wreath. Like the Wild Rose block, it comes from the “Award Winning Quilts” by Effie Chalmers Pforr book. It was submitted by Mrs Russell A Warehime of Westminster, Maryland. She states that is is a very old pattern

The pattern has been handed down from my mother, who quilted quite a few of them.”

The leaves’ center veins were machine stitched with brown or green thread prior to the block stitched into the quilt and quilted.

To enhance this quilt block, I planned the quilting to have a “leaf” that I found in Better Homes and Gardens America’s Heritage Quilts (page 23, published 1991). The “leaf” and the stems of the Wreath were done with a brown thread. The background is cross-hatched as the other blocks have been.

Related Posts

New Year’s Resolution—Finish This Quilt

Dresden Plate Quilt Block

Windblown Tulips Quilt Block

Wild Rose Quilt Block

Benefits of Quitting

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

This post is for Trauma Junkie, Surviving RT School,  who has recently quit smoking (applauding you) and is starting a new carnival, A Source of Inspiration.   The first edition is planned for Friday, February 13th.  You have to love this logo (photo credit)!

Yes, it may be difficult to quit smoking, but the health benefits are many.  So I would encourage you to halt your habit/kick your addiction to cigarettes. 

Mark Twain said, "Quitting smoking is easy. I've done it a thousand times."

It often takes more than one try (maybe more than a thousand) to actually quit smoking, but it will be worth the effort. 

No matter how old you are or how long you've smoked, quitting can help you live longer and be healthier.  You will heal quicker.  Your skin will age slower.  If you stop smoking before age 50, you can  cut your risk of dying in the next 15 years in half compared with those who keep smoking.

If you are a young woman who wants to have children, you can reduce the risk of having a low birth-weight baby by quitting smoking before or during the first 3-4 months of pregnancy.  The act of quitting smoking will improve not just your health, but that of your child.

Immediate Health Benefits of Quitting

Here are some of the benefits that you will notice right away if you stop smoking. 

• your breath will smell better
• your stained teeth get whiter
• your clothes and hair will smell better
• the yellow stains on your fingers and fingernails will disappear
• food will begin to taste better
• your sense of smell will return to normal

Benefits to Your Health Over Time
These are improvements you will notice to your health over time if you remain smoke free.

20 minutes after quitting:

Your heart rate and blood pressure drops.

12 hours after quitting:

The carbon monoxide level in your blood drops to normal.

2 weeks to 3 months after quitting:

Your circulation improves and your lung function increases.

1 to 9 months after quitting:

Coughing and shortness of breath decrease.

Risk of lung infection goes down.

1 year after quitting:

The excess risk of heart disease is half that of a smoker's.

5 years after quitting:

Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting.

10 years after quitting:

The lung cancer death rate is about half that of a continuing smoker's.

The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease, too.

15 years after quitting: The risk of coronary heart disease is the same as a non-smoker's.

An additional benefit is cost savings.  Smoking is expensive and becoming more so as states continue to increase the sales taxes on cigarettes.

Source
American Cancer Society

Other articles of interest:
Memorial to Virginia Johnson
Smoking:  Become a Quitter
Arkansas Proposes 56 Cents Increase in Cigarette Tax

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.