Shout Outs

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Health Blogs Observatory is this week's host of Grand Rounds. You can read it here.

Welcome to the Grand Rounds Diversity Edition, Vol. 5 No. 34 - where we celebrate the differences that make the health/medical blogosphere so beautiful and rich.

If this is your first visit to the Health Blogs Observatory, please feel free to look around and explore. Consider submitting your blog to our directory, to gain better exposure and participate in our future research. We are conducting open research of the health/medical blogosphere and would be delighted if you would consider joining us.

We wish to dedicate this edition of the Grand Rounds to Florence Nightingale who was born on this day, May 12, 189 years ago.

Dr Christian Sinclair, Pallimed, writes “Losing the Ability to Smell and Taste Didn't Miss You, Til Ya Left Me”

The Journal of Supportive Oncology (my favorite free journal with excellent practical palliative care articles) published a fantastic review of taste and odor dysfunction in cancer patients. If you read this article you could become a local expert because so few clinicians appreciate the implications or understand the treatment options for these significant quality of life markers. Obviously with this kind of endorsement it qualifies as a teaching file article.

Dr David finally blogs about Mike and I’m glad he did. What a great story! What a wonderful week for Mike (and those around him)! You really need to go over and listen to Mike play and sing.

It’s been a good week for Mike……….
Mike is a really cool kid. He plays guitar. No... I play guitar. Mike performs and makes records…….

Dr Isis, On Becoming a Domestic and Laboratory Goddess, continues "The Letters to Our Daughters Project".

• Dr Pascale Lane (May 1, 2009)
• Dr. Barbara Goodman (May 4, 2009)
• Wendee Holtcamp (May 9, 2009)
• Janet Stemwedel (May 10, 2009)

This week Dr Anonymous doesn’t seem to have a guest, but he always finds something interesting to discuss so I hope you will join us. The show begins at 9 pm EST.

You can check out the archives of his Blog Talk Radio show.

Dermatitis and Eczema – an Article Review

Updated 3/2017-- all links removed as many are no longer active and it's easier than checking each one.

Being a plastic surgeon, I have a great interest in the skin and no I don’t see or treat much dermatitis as the primary physician.  Patients do occasionally ask me about patches / rashes they have.  It’s always nice to be up on the topic and to know when it’s important to make sure they see a dermatologist.

The article listed below is a nice, simple  review of conditions that fall into the eczema / dermatitis categories.  The article discusses atopic dermatitis (AD), nummular (coin-shaped)eczema,  contact dermatitis, and stasis dermatitis.  It is not a deep article on the subject, but did include some nice reminders and tips.

The article points out that allergic dermatitis is not uncommon in patients with chronic wounds.  They site an article which documented more than 51% of leg ulcer patients acquire contact allergic dermatitis to local dressings and other topical treatment.  This is important to any of us who treat wounds, acute or chronic.  Sometimes the wound fails to heal due to this.

There is a nice table which lists the common allergens in patients with chronic wounds.  If your chronic wound patient has a contact allergy to these products, it can certainly complicate their wound healing.

• lanolin (common in moisturizing creams and ointments)
• perfumes/fragrances
• cetylsterol alcohol (used as an emulsifier, stabilizer, and preservative in creams, ointments, and paste bandages)
• preservatives:  quaternium 15, parabens, chlorocresol  (all are used to prevent bacterial contamination in creams, but are not in ointments)
• rosin (colophony)  -- a component of some adhesive tapes, bandages, or dressings
• rubber / latex

Key to treatment and prevention of future exacerbations is identification of any provocative factors so that they may be avoided as there is no absolute cure for dermatitis.   Here is a summary of tips the article gives:

Laundry and Clothing Suggestions

• Avoid wearing wool or nylon next to their skin as they may exacerbate itch.  Choose materials made of cotton or corduroy which are softer.
• Rather than use fabric softeners and bleach, which may be irritating to the skin, add a white vinegar rinse in the washing machine rinse cycle cup/dispenser to remove excess alkaline detergent.

Moisturizers

• Keep water exposure to a minimum.
• Use humectants or lubricants regularly to replenish skin moisture.  Apply these agents immediately after bathing while the skin is damp.
• For severe hand eczema, cotton gloves may be worn at night to augment the moisturizing effect of humectants and other topical treatments.

Topical Steroids

• Topical steroids continue to be the mainstay therapy for treating dermatitis.
• Topical steroid creams can be kept in the refrigerator or combined with 0.5% to 1% of menthol (camphor and phenol are alternatives) to give a cooling effect.   This often helps.
• Treat the dermatitis with a topical steroid when the skin is red and inflamed.  Tapering the topical steroid use by alternating  with moisturizers as the dermatitis resolves.
• Remember that  percutaneous absorption of topical steroids is greatest on the face and in body folds.  They suggest only weak or moderate preparations be used in these areas.
• Moderate to potent topical steroids should be used on the trunk and the extremities.
• The palms and soles are low-absorption areas, so may require very potent topical steroids

REFERENCE

The ABCs of Skin Care for Wound Care Clinicians: Dermatitis and Eczema; Advances in Skin & Wound Care: May 2009, Vol 22, Issue 5, pp 230-236;  Woo, Kevin Y. RN, MSc, PhD, ACNP, GNC(C), FAPWCA; Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med, Derm), ABIM DABD, FAPWCA (doi:10.1097/01.ASW.0000350837.17691.7f)

SurgeXperience 223 – Call For Submissions

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

The SurgeXperience 223 will be hosted by T, Notes of an Anesthesioboist, on May 17th.  The deadline for submissions is midnight on Friday, May 15th.  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.

 

Happy Mother’s Day!

Blooming Nine Patch Child’s Quilt

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

I first saw this pattern over at  Swooze’s Quilts.  She calls it “blooming nine-patch.”   I love the way the colors blend and mingle together.  I plan on using this again (and again).  This one is 42 in X 42 in.  I used up fabric left over from making a dress (the yellow) for another little girl and a previous quilt.  This quilt is for the TJ’s daughter who is a fan of pink.

Here is a close photo of the center.  The quilt is machine pieced and quilted.

And another of the edges.  Here you can see the “hearts” used in quilting the solid blocks.

BOTOX -- Black Box Warning

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

The U.S. Food and Drug Administration recently announced that safety label changes including a boxed warning and a Risk Evaluation and Mitigation Strategy (REMS) will now be required for all botulinum toxin products.  The agency took the action because of two main reasons.  The first one is the potential for serious risks that may occur from the spread of the botulinum toxin beyond the injection site.  The second reason is associated with the lack of interchangeability among the three licensed botulinum toxin products.

When the botulinum toxin spreads beyond the area of injection, symptoms similar to botulism may occur.  These symptoms include unexpected loss of strength or muscle weakness, hoarseness or trouble talking, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing, double vision, blurred vision and drooping eyelids.

This “spreading effect” has been reported in both children and adults.  It has been reported most often in children with cerebral palsy being treated with the products for muscle spasticity.  Treatment of muscle spasticity is an off-label use of the drug.  The “spreading effect” has been reported in patients being treated for both approved and unapproved uses.

Botulinum toxin products include:

• Botox and Botox Cosmetic (botulinum toxin type A), marketed by Allergan
• Myobloc (botulinum toxin type B), marketed by Solstice Neurosciences
• Dysport (abobotulinumtoxinA),  a new FDA-approved product marketed by Ipsen Biopharm Ltd.

All are approved by the FDA for the treatment of  cervical dystonia.  Botox Cosmetic and Dysport are approved by the FDA for treatment of glabellar frown lines.  Botox is approved for the treatment of severe underarm sweating (primary axillary hyperhidrosis), crossed eyes (strabismus), and abnormal tics and twitches of the eyelids (blepharospasm).    All other uses are considered off-label.

The FDA has not identified any definitive serious adverse event reports of a distant spread of toxin effect producing symptoms consistent with botulism when these products are used in accordance with the approved label.

It is important for those of us who use botulinum toxins to remember that the dosage strength between the products is not the same.  One unit of Botox is not equal in strength (potency) as one unit of Myobloc or Dysport. 

BOTOX® Cosmetic Insert (pdf)

Dilution Technique:  Using a 21-gauge needle and an appropriately sized syringe draw up a total of 2.5 mL/100 Unit vial or 1.25 mL/50 Unit vial of 0.9% sterile saline without a preservative…….
Injection Technique: Glabellar 

Using a 30-gauge needle, inject a dose of 0.1 mL into each of 5 sites, 2 in each corrugator muscle and 1 in the procerus muscle for a total dose of 20 Units. Typically the initial doses of  reconstituted BOTOX® Cosmetic induce chemical denervation of the injected muscles one to two days after injection, increasing in intensity during the first week.

MYOBLOC® Insert (pdf)

The recommended initial dose of MYOBLOC® for patients with a prior history of tolerating botulinum toxin injections is 2500 to 5000 U divided among affected muscles. Patients without a prior history of tolerating botulinum toxin injections should receive a lower initial dose.  The duration of effect in patients responding to MYOBLOC® treatment has been observed in studies to be between 12 and 16 weeks at doses of 5000 U or 10,000 U.

Dysport®  Insert 

The units of Dysport are specific to the preparation and are not interchangeable with other preparations of botulinum toxin.

Glabellar lines Dosage

The dosage is dependant on the severity of the lines and the specific muscle being treated.

For the corrugator and procerus muscles 40 to 60 units divided between injection sites as follows:

8 to 12 units in each of 5 sites, 2 in each corrugator muscle and 1 in the procerus muscle for a total dose of 60 units

Improvement of severity of glabellar lines generally occurs within 72 hours after treatment and persists for 3 to 6 months.

It is important for us to educate patients and their caregivers of the potential adverse effects.  Some of these effects have been reported as early as several hours and as late as several weeks after treatment.  Patients should seek immediate medical attention if they develop any of these symptoms  --  unexpected loss of strength or muscle weakness, hoarseness or trouble talking, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing, double vision, blurred vision and drooping eyelids.

Adverse events may be reported by health care professionals and/or consumers to the FDA's MedWatch Adverse Event Reporting program   by four ways:

• Online: www.fda.gov/MedWatch/report.htm
• Regular Mail: use postage-paid FDA form 3500 available at: www.fda.gov/MedWatch/getforms.htm and mail to MedWatch, 5600 Fishers Lane, Rockville, MD 20852-9787
• Fax: 800-FDA-0178 (the same form you would mail)
• Phone: 800-FDA-1088

REFERENCES

FDA News (April 30, 2009)

BOTOX® Injections; eMedicine Article, Sept 25, 2008; Robert A Hauser, MD, MBA, Mervat Wahba, MD, Theresa McClain, MSN, ARNP

Cleveland Clinic’s Connie Culp

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

Last evening, as I watched the ABC Evening News I was mesmerized by Connie Culp. She is still not the physically beauty she was prior to her 2004 gun shot injury to her face, but what an amazing woman!

Culp, 46, received the first U.S. face transplant in December 2008. The 22 hour procedure took place at the Cleveland Clinic. At the time nothing was revealed about the patient. Yesterday, she came forth and stepped in front of the camera at a Cleveland Clinic press conference.

The gun shot wound, inflicted by her husband, in 2004 had removed most of her mid-face, leaving her forehead and chin area, but taking her nose, lips, palate, and maxilla. With no bony or soft tissue to support up upper airway, she breathed through a tracheostomy (a surgical opening in her neck). The palate and soft tissue loss made it difficult to speak.

I was impressed with her soft voice and poise. She is still learning to speak so not all of her words are perfectly articulated, but her speech is clear enough. She reports that she can now smell. She is now able to eat foods that require chewing such as hamburgers and pizza. Before the surgery she was only able to drink through a straw. She laughs easily with joy.

Culp, a mother of two, focused on her gratitude, "I want to focus on the donor family that allowed me to have this Christmas present."

She asked the public to have empathy for people with facial disfigurements. "When somebody don't look as pretty as you do, don't judge them," she said. "You don't know what might happen to you. Don't judge the people who don't look the same way as you do. You never know when it may be taken away from you.

Her new face has given her the ability to be in the public with less judgment than before. She recalled how children where often scared by her old face.

Dr Siemionow, the head surgeon, noted "The last resort and the last option was to consider face transplantation." Transplant recipients have to take immunosuppressing, anti-rejection drugs for the rest of their life. Those issues must be stressed.

Jacob Goldstein, WSJ, has some references to some nice articles in his post Face Transplants: Further Reading for anyone who wishes to look “for more detail about the surgical technique, its aftermath and the broader implications might consider digitally thumbing through some of the key papers published on the subject in the past few years.”

REFERENCES

Face Transplant: 'Resilience' Saw Woman Through By Dan Childs;
May 6, 2009; ABC News

Cleveland Clinic face transplant patient Connie Culp hopes her story teaches people not to judge by Brie Zeltner/Plain Dealer Reporter; Tuesday May 05, 2009, 5:00 PM; Cleveland.com

Related Posts

Face Transplant (March 24, 2008)

For Lisette (& Yoland) -- Hope Hike 2009

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

My friend Lisette who died of ovarian cancer last year is being honored by her hiking buddy Ellen Lowitz and other friends with the first (hopefully to be annual) Hope Hike 2009.  This spring another friend and colleague, Yoland Condrey-Tinker, died of ovarian cancer.  Both are missed.

The memorial hike organized by Ellen is to raise money for ovarian cancer research.  Here are the details of their flyer:

What:  Hope Hike 2009  -- “Shout It From the Mountain!” --  A Memorial Hike to Benefit Ovarian Cancer research, in memory of the life of Lisette C. Johnson, 1952-2008.

When:  Saturday, May 9, 2009.  Check in 8:00 am; Kick-off ceremony 9:00 am.  Hike ends at 2:00 pm.

Who:  Hikers, walkers, runners, cancer survivors, family, friends, loved ones, leashed pets & owners, & other supporters are invited to participate.

Where:  Pinnacle Mountain State Park.  Registration, check-in, & opening program at park’s West Summit Pavilion.

How:  Hike, walk, or run the Pinnacle Mountain trail of your choice.  Choose from 8 trails in varying lengths or be a virtual hiker.

Register:  Free 2009 registration –‘09 Hike registration fees are waived.  Donations accepted and appreciated.  Register 3 ways:  Register online; down-load the registration for, complete, and mail; or complete registration form and submit at check-in on day of hike.

For more information about how you can get involved with Hope Hike contact them at HopeHike@gmail.com or at (501) 224-0636.

For more information on ovarian cancer:

National Cancer Institute -- Ovarian Cancer Page

Center for Disease Control -- Ovarian Cancer

Ovarian Cancer Awareness Organization

Ovarian Cancer Symptoms --TBTAM

Shout Outs

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

NurseAusmed is this week's host of Grand Rounds.  You can read it here.

Welcome to Nursing Handover! This is my first time hosting Grand Rounds. I hope you enjoy your weekly medblog binge!

I’ve chosen to present this week’s rounds without a theme, although a suggested topic for those with blogger’s block was “best (or worst) experience with inservice training, clinical education or CME”. All submissions have been included, with the best (in my highly subjective judgement) featured.

Here at Nursing Handover I’ve been displaying some of the interesting images available under the Creative Commons licenses with posts. I’ve featured some more particularly evocative photography here.

The latest edition of Change of Shift (Vol 3, No 22)  is hosted by Gina over at Code Blog: Tales of a Nurse!   You can find the schedule and the COS archives at Emergiblog. 

Happy Spring everyone!  Welcome to this edition of Change of Shift.

I typically do not ask for themed submissions, but I did this time.  The theme of this CoS is being human - describing those moments of human error or letting our less-than-professional side show.  I described my own less-than-professional moment here.  Yes, it’s an old post, but relevant to theme.

Dr Isis, On Becoming a Domestic and Laboratory Goddess, has begun a project I will be watching and reading with interest "The Letters to Our Daughters Project".  Thinking I will forward them to my nieces, hoping to inspire them.

It's not a secret that the largest attrition among female scientists happens in the transition between trainee and faculty. I also think that, for better or worse, there are things that are unique to being a female scientist that affect the ability/willingness of women to pursue careers in science.  ……….

The first letter is from Dr Pascale Lane.

Kim, Emergiblog, writes about the new Showtime series, Nurse Jackie, in her post Negative nurse stereotype promoted by Showtime in attempt to capture House MD ratings?

My first reaction?
Oh..my..god, they did it!
They made a show with a strong nurse protagonist, and damn! if they didn’t get the ER environment down!
I had goosebumps, literally.
I was ready to (a) start getting Showtime, (b) spread the word far and wide and (c) take the job.
But then…

JSE Booth, The Scut Report, has a nice list of references related to reading chest x-rays.

I like chest x-rays. They make me feel warm and fuzzy inside. So much so, in fact, that I’ve created this nifty little reference sheet. Please note, however, that I am not a radiologist nor do I play one on TV. In fact, at the time I am writing this, I’m not technically a doctor yet. One more month. ……….

Check out this link from “A Repository for Bottled Monsters” in their post – Paper Cutting Wow!   Amazing work!

This is a paper cut by American artist Hunter Stabler called "Baba Yaga Misquotes the Face to Steeleye Span." Not all of his work is anatomical, but it's all fantastic. What skill and patience.

This week Dr Anonymous  doesn’t seem to have a guest, but he always finds something interesting to discuss so I hope you will join us.  The show begins at  9 pm EST. 

You can check out the archives of his Blog Talk Radio show.  

Torn Earlobe Repair

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

Early in my blog life, I did an article on torn earlobe repair.  As I mentioned then, I had not figured out how to put sketches in my posts.  Over the past two years, I have learned how to add them, so am redoing the post with sketches.  I hope they help.

Torn earlobes is a complication of pierced earlobes.  Some preventive tips include:

• Not wearing heavy ear rings.
• Being careful when putting on or removing clothing so as not to "catch" the earring.
• Being careful around babies/toddlers who want to play with shiny/dangling objects can help prevent the lobe from being torn.
• Use the "earlobe support" which is a stick-on disc that help support the earlobe when heavy earrings are worn.

 Once the stretching occurs or the tear is completed, then the only way to fix it is to repair it. For me, this is an office procedure done using a simple local block.  I mix 0.5% Xylocaine with Epi and 0.25% Marcaine without Epi. 

There are variations on "how" this is done, but they all require excising (freshing) the edges so they can be sewn back together. The variations are mainly in how the excision is structured–straight, z-plastied, or L-shaped. 

I do not think the straight excision is the best way to do the repair. If the scar "shortens" at all (as straight scars are prone to do), then the lobe is "gathered" up and ends up "W" shaped at the bottom. Another reason is that unless you (the patient) are very good at repositioning the new hole to the side (either) of the scar (which is weaker by at least 20% of the surrounding skin), the tear is very likely to re-occur as the earrings pull-through the scar over time.

The Z-plasy or L-shaped scar avoid the "W" by changing the scar into a non-straight scar. Which one is best will depend on the tear and shape of the earlobe being repaired. Also, it may depend on whether there is an intention to re-pierce the earlobe. Not all do. Another alternative to pierced ears is magnetic Earrings.

Most insurances will not cover this procedure as they consider it cosmetic in nature.

A really good article with nice, clear instructions on the Z-plasty technique is:
REPAIR OF THE SPLIT EARLOBE USING A HALF Z-PLASTY; Journal of Plastic & Reconstructive Surgery, Vol 101(3):855,856, March 1998; Gajiwala, Kalpesh M.S., M.Ch.
Dr. Michael Bermant, MD ‘s website has some very nice photos of before and after repair.


Related posts
Mending a Hole (June 26, 2007)

SurgeXperience 222 is Up!

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

This edition (222) of SurgeXperiences is hosted by bongi, other thing amanzi. You can read this edition here.

surgexperiences 222... short and sweet.
a masterpiece by a master writer. surgeons sometimes don't allow the facts to get in the way of their hard headedness.

The host of the next edition (223), May 17th will be T from Notes of Anesthesioboist. The deadline for submissions is midnight on Friday, May 15th. 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.

Stamp Out Hunger 2009

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

For the 17th year, the National Association of Letter Carriers will be collecting non-perishable food items like canned meats and fish, canned soup, juice, pasta, vegetables, cereal and rice in their yearly drive to “stamp out hunger.”  This year the date is Saturday, May 9th. 

You and I can help by placing food donations at the mailbox on May 9th before the letter carrier arrives. The food donations will then be taken to the Post Office. Later it will be delivered to local food banks or pantries. Please make sure the food items do not have expired use dates. They also ask that there be no glass containers.

For more information check out these sites:
Help Stamp Out Hunger
National Association of Letter Carriers Community Service

Crazy Quilt Finished

Last week began the story of this quilt. It will be entered into a crazy quilt contest to benefit the Alliance for American Quilts. Here is my crazy quilt pieced together from the old one. It is 16 in X 16 in as the rules demand.

Here is the quilt after I finished adding more embroidery and embellishment.
And here are some detail photos of the work.