Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Sharp Brains is the host for this week’s  Grand Rounds!  You can read this week’s edition here.

Wel­come to Grand Rounds, the weekly col­lec­tion of best health and med­ical blog posts. This week we invite you to enjoy a broad range of insights, tips, and first-hand sto­ries, pre­sented as a Q&A con­ver­sa­tion with blog­gers will­ing to answer, below, a total of 22 good questions. ………….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 7) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to Change of Shift!
While this is a bit of a “mini” version of the nursing blog carnival, it is far from “lite”.
There are old friends and new blogging colleagues; musings, opinions and rants…it’s all here!
Let’s get it started! …………..

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Interesting NPR segment last Thursday on their show Here and Now:   “The Skinny on Supplements”  (photo credit)

More than half of all adult Americans spent nearly 27 billion dollars last year on dietary supplements to get healthy, stay healthy, lose weight and gain an edge on the sports field and in the bedroom. And in the process, some of them got seriously sick. We talk with Nancy Metcalf, senior program editor for Consumer Reports-Health about the findings of their recent investigation, “Dangerous Supplements, What You Don’t Know, Could Hurt You.”

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From  tweeter@grahamwalker last Thursday (September 30)

I'm announcing my new website: TheNNT.com -- an evidence-based resource for medical interventions. Spread the word! #sa10 #thennt

NNT stands for “number needed to treat” and is explained:

There is a way of understanding how much modern medicine has to offer individual patients. It is a simple statistical concept called the “Number-Needed-to-Treat”, or for short the ‘NNT’. The NNT offers a measurement of the impact of a medicine or therapy by estimating the number of patients that need to be treated in order to have an impact on one person. The concept is statistical, but intuitive, for we know that not everyone is helped by a medicine or intervention — some benefit, some are harmed, and some are unaffected. The NNT tells us how many of each.

Check out Graham’s new website.  It is full of useful information.

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If you are free later this morning (11:30 am CST, my local time) you might want to join in on the first #MDchat on twitter.

@MD_chat: Let's nudge more physicians onto Twitter. Tuesday 10/5 12:30pm EDT is #MDchat - http://MDchat.org #hcsm Plz support them! :)

For more information on MDchat, check out Phil Baumann, RN’s explanation:

………..So rather than waiting for doctors’ orders, I am launching @MD_chat for physicians to participate in advancing our collective understanding of the influences of emerging technologies on our culture, health, privacy, dignity and many other aspects of the human condition.

Below is a slideshow introducing MDchat and explaining how it works (if you can’t see it, you can view it here or here): ……………….

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An article in Evansville Courier Press by Karen Owen-Phelps:  Quilts help old barns become art form -- Local quilters use them like a canvas (photo credit)

An old barn is more than a storehouse for hay and livestock in the eyes of some area folk-art lovers. It's a canvas for their favorite art form — the quilt.

Quilting enthusiasts in Western Kentucky are encouraging farmers to let them hang large panels painted in traditional quilt patterns on their barns.

"The first time I saw a barn quilt I thought, 'I want one of those!'" said Judi Inge, 55, of Owensboro, Ky., who is active in the Owensboro Area Quilters Guild. "My mother felt the same way."  ……….

The article provides links for more info and photos:

Ohio County Barn Quilt Trail
Kentucky Arts Council:  Quilt Trails
Ohio Barns:  Quilt Barns  (photo credit)

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Dr Anonymous’ guest this week will be Dana Lewis & Swedish 2010 Health Care Symposium.      The show begins at 9 pm EST.

Upcoming shows:       
10/9 : From Seattle
10/14 : About Social Health Track at BlogWorld Expo
10/16 : On Location
10/21 : About DigPharm Mtg
10/23 : Saturday Nite
10/28 : About FMEC Mtg
10/30 : On Location

Running in Heels

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

October has become known as “breast cancer awareness” month. The Susan G. Komen Race for a Cure will be held here in Little Rock, Arkansas on October 16th. It will not be run in heels!

Last Tuesday, Venus Embrace Closest Stiletto Race took place in Sidney, Australia. The racers wore 3 in stilettos!
The Pinkette, Brittney McGlone, Laura Juliff, Casey Hodges and Jessica Penny, set the world record for the fastest stiletto relay race. (photo credit)

Here is a video that includes the relay race:

Related posts:
Breast Self-Exam (October 8, 2009)
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms (October 13, 2008)
ARM Technique (October 15, 2008)
Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)
Breast Cancer Reconstruction Webcast (April 2008)
Silicone Implants and Health Issues (March 2008)

Rani's Baby Quilt

This quilt was made for my cousin Sherry’s daughter.  I made it using a quilt-as-you-go technique that makes hexagon blocks.  I found the technique in an old quilt magazine (sorry I don’t recall the name or date of the magazine).

I used 6.5 in circles to make the hexagons which are approximately 3.5 in.  The quilt measures 32 in X 48 in.  I finished the quilt in February 2001. 

The photos of the quilt were supplied to me by my cousin, so I apologize for not having a “full” photo.

You can see the details of the pink rabbits in the yellow fabric with this photo, as well as the added quilting (wanted to ensure it would hold together with use).  The back of the quilt looks like the front.

Okay, I’m going to try to give instructions on how to make the hexagons.   Begin with a circle at least twice as wide as you want the finished hexagon to be.  I used 6.5 in circles.

I press the circles into halves to find the center.  You will then fold the two points labeled “A” to meet at the center.

I press after each new fold though I’m not sure it is necessary.  Next, the two points labeled “B” get folded into the center.

Next the points labeled “C” get folded into the center.
Thus creating a hexagon!  Before placing a tacking stitch to hold the points together, you want to place a hexagon of scrap batting inside.
The hexagons can then be sewn together by hand or machine.  If by machine, use a faggoting or zigzag stitch.

I hope these instructions are clear enough.

Postoperative Management of CMC Joint Fracture Dislocation of the Hand

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

I haven’t seen or treated any wrist dislocation injuries since my hand surgery fellowship, but still read an article regarding their treatment every now and then. I stumbled across this one (full reference below) via MDLinx. The full article is available for free online.

The authors of the article note in their literature search that most multiple carpometacarpal (wrist) fracture/dislocation injuries are due to motor vehicle accidents. They were unable to find any large studies of multiple CMC dislocations. One of the “largest” had only 10 patients.

Multiple CMC dislocations are uncommon and occur from high-energy trauma. Treatment of these injuries require operative fixation. The reduced fractures/dislocations are stabilized using K-wires which remain in place for 6-8 weeks.

Prolonged immobilization can result in stiffness of hand joints, tendon adhesions, and muscle weakness. The authors of the CJPS article note that early controlled motion must be balanced with sufficient immobilization of the fractures/dislocations to allow healing.

The main purpose of their case presentation is to describe a novel postoperative rehabilitation regimen in their multiple CMC fracture dislocation patient (a 28 yo male).

The wrist and hand were immobilized in the neutral position for two weeks in a short arm splint and for an additional four weeks in a short arm circumferential cast.

The Kirscher wires were removed at the outpatient clinic at eight weeks. Radiographs confirmed union…

Hand therapy, consisting of protective splinting and active-assisted ROM, was initiated eight week following injury. ….

Hand therapy was then progressed to the use of a novel circumferential carpal stabilization brace that the patient wore at all times. The carpal brace extended from the metacarpal heads to the radiocarpal joint. This permitted movement of the radiocarpal and metacarpal joints, while firmly supporting the CMC articulations. Following removal of the cast, the brace was worn at all times. ……

REFERENCE

Postoperative management of carpometacarpal joint fracture dislocation of the hand: A case report; T Bell, SJ Chinchalkar, K Faber; Canadian Journal of Plastic Surgery, Autumn 2010, Volume 18 Issue 3: e 37-e 40

Carpometacarpal Fracture Dislocation; Wheeless’ Textbook of Orthopaedics (accessed Sept 16, 2010)

Hand, Metacarpal Fractures and Dislocations; eMedicine Article, August 20, 2009; James Neal Long, MD, James A Chambers, MD, MPH, Jorge I de la Torre, MD, FACS,

Comparison of Repair Incisions for Complete Unilateral Cleft Lip – an Article Review

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

For disclosure, I have not done a cleft lip repair in years.  The referrals of cleft lip patients in Arkansas funnel them to Arkansas Children’s Hospital where they get very good care.  That has not keep me from reading the articles in my journals.

This one (full reference below) with a following commentary caught my eye.  It offered a comparison of three incisions used for repair of unilateral cleft lip:  Millard incision, Pfeifer incision, and Afroze incision.

The Millard incision is based on a rotation flap on the noncleft side coupled with an advancement flap on the cleft side.   In one form or another, it is the most widely practiced method today. (photo credit)

The Pfeifer incision is a straight line repair for unilateral cleft lips.  The “straight-line” incisions on cleft and noncleft sides are made of equal lengths by incorporating a series of waves leading to a final scar that should follow the lateral line of the philtrum.

The Afroze incision is described in the article as a variant incision combining the Millard incision on the noncleft side (medial side) and the Pfeifer incision on the cleft side (lateral side).

The authors of the comparison study conducted a prospective cohort study of 1200 patients with complete unilateral cleft lip with or without cleft palate over a period of 4 years.  The first cohort of 400 patients was treated using the Millard incision between September of 2001 and October of 2002; the second cohort of 400 patients was treated using the Pfeifer incision between November of 2002 and January of 2004; and the last cohort of 400 patients was treated using the Afroze incision between February of 2004 and March of 2005.

Outcome assessments were performed 2 years postoperatively and consisted of assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, nostril symmetry, and appearance of alar dome and base.

The authors concluded that the Afroze incision was superior:

With regard to white roll, vermilion border, scar, Cupid's bow, and lip length, the Afroze incision always gave superior results compared with the Millard or Pfeifer incision.

Depending on the cut-off for treatment success, the Afroze incision also showed better results regarding nostril symmetry.

With respect to the alar base and alar dome, all three incisions showed comparable outcomes.

I wish I could show you the photos included in the article as for me and Dr. Wolfe, the photos don’t agree with the authors conclusions. 

The patient with the bull's eye on his glabella preoperatively was operated on with a rotation advancement, and I feel he has the best result of the three. There is a very nice white roll and a discrete Cupid's bow, and the scar comes close to mirroring the normal philtral column on the noncleft side. …..

The second patient, with the “1” on his glabella, repaired with the Pfeifer incision, I think has the worst result of the three. The scar runs straight up into the nostril, giving him the appearance of having a runny nose, the lip on the cleft side is a bit short, there is no Cupid's bow, and there is a slight alar slump beneath the soft triangle.

The third, with the glabellar black spot, was repaired with the Alfroze technique. He has a nice Cupid's bow, but the lip scar wanders away from the desired area of the philtral column and is distracting. There is a very significant vestibular web, and the alar base on the cleft side lacks definition, as does the footplate area of the medial crus. The commissure-to–high point distance on the cleft side also appears a bit shorter than on the noncleft side.

Perhaps if they had chosen different photos for the article it would have been better.  The ones chosen, unfortunately, don’t back up the authors conclusions.

REFERENCES

Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Reddy, Srinivas G.; Reddy, Rajgopal R.; Bronkhorst, Ewald M.; Prasad, Rajendra; Kuijpers Jagtman, Anne Marie; Bergé, Stefaan; Plastic & Reconstructive Surgery. 125(4):1208-1216, April 2010;  doi: 10.1097/PRS.0b013e3181d45143

Discussion: Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Wolfe, S. Anthony; Plastic & Reconstructive Surgery. 125(4):1217-1219, April 2010; doi: 10.1097/PRS.0b013e3181d45017

Unilateral Cleft Lip Repair; eMedicine article, June 19, 2009; Pravin K Patel, MD, Raja Ramaswamy, MS,  Mitchell F Grasseschi, MD, David E Morris, MD

Shout Outs

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

Dr. Grumpy is the host for this week’s  Grand Rounds which marks the first edition at the beginning of GR’s 7th year!  You can read this week’s edition here (photo credit).

Thank you all for coming. Coffee and bagels are in back. Sign in on the sheet. Medical students, please remember that you're allowed to sit ONLY if there are chairs left after the attendings, fellows, residents, and homeless people (here for the bagels) have been seated.

Food was provided by our drug rep Rikki, on behalf of Wirfliss Pharmaceuticals. She asks that when writing a prescription, please keep their many Wirfliss products in mind. …...

And we're off! The topic was: THINGS THAT MAKE ME GRUMPY!
To start, I present: THE PHARMACISTS!

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A beautiful post in many ways by @epi_junky , a Paramedic who blogs at Pink Warm and Dry.  The post is 89 Years and Two Days.

65 of them married to her first love.  Her only love.  The man she’d spend her entire adult life with.  The only man she ever looked at according to her daughter.

62 of those years spent taking care …...

5 years spent grieving the death of her husband and best friend.

7 months living with pancreatic cancer.  …...

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Want to know more about ADHD and adults.  Then check out these post with video interviews:

Dr. Rob, Musings of a Distractible Mind: Better Health Interviews – Fact or Fiction: Attention Deficit Disorder

Last Thursday (9/17/10) I had the pleasure of attending a conference on Attention Deficit Disorder.  The following are my two interviews.  They are both very interesting, and both apply greatly to my practice as a primary care physician.

The first is Dr. Ari Tuckman, author of the book More Attention, Less Deficit, as well as the podcast with the same name: ….

Kevin, MD:  Fact or Fiction: ADHD in America, panelist video interviews

On September 16, 2010, I attended Fact or Fiction: ADHD in America, a Capitol Hill Forum, along with Val Jones of Better Health and Rob Lamberts of Musings of a Distractible Mind.

The event, coinciding with ADD/ADHD Awareness Week, was a panel discussion discussing the impact ADHD has on our society.

It was sponsored by Shire, in partnership with the Entertainment Industries Council (EIC) and the Lab School of Washington [Disclosure: I received a stipend for covering the event.]

Below are interviews Rob and I did with some of the panelists.  …………

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Much discussion about improving our diets/nutrition.  Here are some links with cooking tips/recipes/etc.

H/T to @gastromom for two links.
The first is to a WSJ Health article, Teaching Healthy Ways To Doctors in the Kitchen, by Melanie Grayce West.  I would enjoy taking this class.

Thirteen of Lenox Hill Hospital's doctors-in-training gather for one more class at the end of another long day of lectures and rounds: How to peel onions and chop garlic. ……

The program—which organizers say is the first of its kind in the city—includes six seminars on everything from nutrition, to weight management to exercise and a cooking class at the Institute of Culinary Education in Manhattan. It is based loosely on a joint project of the Culinary Institute of America and Harvard Medical School called Healthy Kitchens, Healthy Lives. …….

The second one is a NY Times Health article, Expert Tips From the Stir-fry Chef.

Grace Young, author of the recently published “Stir-Frying to the Sky’s Edge,” from Simon and Schuster, recently joined the Consults blog to answer readers’ questions about healthful stir-fry cooking.  ……

I too hate eggplant that is greasy. I find that if you steam the eggplant first, you can dramatically reduce the amount of oil necessary for stir-frying. Cut about a pound of eggplant into bite-size pieces and place them in a heatproof bowl. Then steam the eggplant for five to eight minutes, depending on the size of your pieces, until the eggplant is just tender when pierced with a knife. Don’t overcook it, as the eggplant will be stir-fried. I find that I don’t need more than 3 tablespoons of oil and that the steamed eggplant can be stir-fried within one to two minutes with your seasonings.  ….

Here’s an inspiring story:  H/T to @bobcoffield

RT @boltyboy: Kaiser Permanente's own Jamie Oliver and the reason they have 30 farmers markets http://nyti.ms/aRfRG4

The NY Times article, Doctor’s Orders: Eat Well to Be Well, by Katrina Heron features two physicians (father and son)

DR. PRESTON MARING ……. Though Dr. Maring blithely refers to himself as “that food nut around the hospital,” he is serious about the role he believes doctors should play in creating awareness of healthy food choices. To that end, he has worked to obtain fresh local food for hospital trays and in cafeterias. He began a Web site and blog that offers recipes and advice on meal planning and budgeting. He spent the summer working on a series of three-minute Web videos to explain the basics of shopping for healthful foods and efficient preparation techniques.   ……

Dr. Maring’s Farmers’ Market and Update  -- a great source of healthy recipes.

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Here’s more on diet and health.  This comes from @JoshuaSchwimmer    who blogs at InfoSnack. 

Uremic Frost: The Kidney Diet: How to Eat in Order to Protect Your Kidneys and Avoid Dialysis http://bit.ly/byA7II

The link takes you to an eBook, The Kidney Diet:  How to Eat in Order to Protect Your Kidneys and Avoid Dialysis,  which you can read online, download, or print out.  It is full of great information.

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The Quilting Gallery has a post, Caps for Good, which tells of a project by Save the Children.

Baby caps are a simple and effective tool that can keep babies warm and ultimately contribute to reducing newborn deaths in the developing world.

In many developing countries, something as simple as a knit or crocheted cap can help the baby keep warm, which is key to helping newborns survive. ……

This is where you can help by making a cap! Your caps will be sent to Save the Children’s newborn health programs in Africa, Asia and Latin America.

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Dr Anonymous’ guest this week will be EMS Newbie Podcast.     The show begins at 9 pm EST.

Upcoming shows:       
10/7: Dana Lewis        

Teenagers Use of Self-Tanners

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

Skin cancer rates continue to rise. Exposure to UV radiation and the resulting damage to the skin is major reason. It doesn’t matter whether this exposure is from outdoor or indoor sources.

Use of self-tanners should (intuitively) decrease the exposure to UV radiation as the desired “tan” is obtained from an alternative source. Not necessarily, especially in teens.

The Archives of Dermatology article referenced below reports on a study survey done by Vilma E. Cokkinides, Ph.D., of the American Cancer Society, Atlanta, and colleagues. Their survey was telephone-based conducted, conducted from July 1 through October 30, 2004. A total of 1600 youths and 1589 primary caregiver paired interviews using nearly identical questionnaires were done with an overall response rate of 44.0%.

The Sun Survey assessed the use of sunless tanning products by the adolescents in the past year, along with details about demographics, skin type, attitudes and perceptions of sunless tanning and other sun-related behaviors.

Among the teens surveyed, 10.8% reported using sunless tanning products in the past year. Approximated 14% of their parents used them. Self-reporting teen users tended to be older and female, to perceive a tanned appearance as desirable, to have a parent or caregiver who also used these products and to hold positive beliefs or attitudes about them.

Amazing to me was the finding by the researchers that the teens who used the self-tanners had just as many sunburns the previous summer, were just as likely to use indoor tanning beds, and did not routinely use sunscreen.

The conclusion I draw from this is: Teenagers use self-tanners to augment UV exposure to get (and keep) the level of tan to their skin. Teenagers aren’t thinking about skin cancer.

How do we change this? Gentle nudges as Dr. Luks suggests with exercise. Same thing here – gentle nudges.

Sources
"Use of Sunless Tanning Products Among US Adolescents Aged 11 to 18 Years"; Vilma E. Cokkinides, PhD; Priti Bandi, MS; Martin A. Weinstock, MD, PhD; Elizabeth Ward, PhD; Arch Dermatol. 2010;146(9):987-992. doi:10.1001/archdermatol.2010.220

Hawking Surgery

“Hawking” surgery makes me grumpy.
Glossing over the risks involved with surgery to promote your product makes me grumpy.
E! Reality Show is “hawking” plastic surgery as part of the prize package for brides in their new show “Bridalplasty.” 

Woodland Paths Quilt

I made this quilt for my baby brother Glen for his 30th birthday (1998).  The pattern is called woodland paths.  I found it in Barbara Brackman’s Encyclopedia of Pieced Quilt Patterns.  It is found on p 246 and is #1962.  It is listed as a Nancy Cabot pattern from 1934.

The quilt is machine pieced and quilted.  It is 80 in X 100 in.  The photos were taken recently by my sister-in-law.  You can see that I used brown in the pattern to  create a border. 

 
Even though I pieced it, designed it, and did the binding, I paid Peg Reese (Peg’s Quality Quilting) to do the machine quilting.

Old and Unused Drug Disposal

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

I’ve written before about this topic.  It was difficult to dispose of the unused prescription drugs when my brother-in-law died.  I was not involved in my mother’s old drug disposal, but can’t imagine it was easy (if done at all). 

Old and unused drugs don’t just happen when someone dies.  They can occur because your surgeon gave you a script for more pain pills than you needed.  This is commonly done as it is difficult to gage just how much pain someone is going to have postop.  Then there are the pills unused because you didn’t tolerate the side effects or had an allergic reaction.  Other are left over when patients are placed on new /different drugs for their conditions.

We have been reminded frequently of late that prescription drugs are now the most commonly abused drugs.  These unused drugs are a major source for that abuse.

The Drug Enforcement Administration (DEA) has initiated a prescription drug “Take-Back” campaign to help remove these old and unused drugs from our medicine cabinets.   September 25th has been designated as National Take-Back Day.

More than 2,700 sites nationwide have joined to participate in the event which will collect potentially dangerous expired, unused, and unwanted prescription drugs for destruction. 

National Take-Back Day will take place on Saturday, September 25th from 10 am to 2 pm local time.  The service is free and anonymous.  No questions will be asked about how the drugs came into the person’s possession.

Prescription and over the counter solid dosage medications, i.e. tablets and capsules accepted.  Intra-venous solutions, injectables, and needles will not be accepted.  

Collection sites in every local community can be found by going to www.dea.gov . This site will be continuously updated with new take-back locations.
In Little Rock/North Little Rock region, the sites include:
If you do not find a collection site near you, please check back frequently, sites are added every day.
Arkansas Game & Fish Commission
War Memorial Stadium Parking Lot
1 Stadium Drive, Little Rock, AR
UAMS Police Department
Reynolds Institute on Aging, First Floor
629 Jack Stephens Drive, Little Rock, AR
Cammack Village Police Department
Cammack Village City Hall
2710 N McKinley, Little Rock, AR
UALR Police
University Plaza Parking Lot
2801 S. University Ave, Little Rock, AR
Pulaski County Sheriff’s Department
Pulaski County Regional Detention Center
3201 W Roosevelt Road, Little Rock, AR
Little Rock Police Department
Pulaski County Regional Detention Facility
3201 W Roosevelt Road, Little Rock, AR
North Little Rock Police Department
NLR High School
Charging Wildcat Arena
2200 Main Street, NLR, AR
Pulaski County Sheriff’s Department
Oak Grove Volunteer Fire Department
18122 Hwy 365 N, NLR, AR

Cost of Hand Transplantation?

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

The recent double hand transplant and catching up on my journal reading has prompted me to look into the cost of hand transplantation. My personal identity seems to me to be tied up in my hands. I am a surgeon. I cook for my husband. I am a quilter.

I have at times tried to imagine loosing a finger or a hand. It difficult to the point of almost being unimaginable for me. Which hand would I give up? Which digit?

I am so right handed, I find it difficult to brush my teeth using my left hand. Yes, I could learn in time. Same with using a pen. Even my limited use of my left arm when I had olecranon bursitis brings my dependency on my hands/arms into sharp focus. It was humbling.

The PRS article (first reference) in assigning utility surveyed participants asking them “to imagine as vividly as possible that they had experienced an amputation of the dominant hand or bilateral hand amputations.”

For example, our survey asks the respondent to choose between living for 40 years with a prosthetic hand and living for x years with a healthy hand. The value of x is varied until the respondent feels that the choices are equivalent. If the respondent judges that living for 40 years with a prosthetic hand is equivalent to living for 20 years with a healthy hand, the utility of living with a prosthetic hand is calculated as 20/40, or 0.50.

I have yet to decide what my answer would be. The article survey of 100 second-year, third-year, and fourth-year University of Michigan Medical School students determined utility as follows:

Transplantation with minor complications (unilateral = 0.78; bilateral = 0.73)

Transplantation with major complications (unilateral = 0.59; bilateral = 0.53)

Prosthetic device use (unilateral 0.75; bilateral 0.63)

Emotionally most would agree that hand transplantation is a worthy goal. Physically, it is possible. The outcome is not always as good as envisioned. Never is the transplanted hand as functional as a non-injured hand. Never.

The function of a transplanted hand has been found to be similar to a replanted hand.

to put it in the words of one physician from the Louisville team that performed the first U.S. hand transplant, the patient will likely “have difficulty with buttons, perhaps not be able to pick up a dime.”

Gerald Fisher, the second of the Louisville recipients, returned to work hanging gutters just two months after his operation
According to the Lyon team, the world’s first double-hand transplant recipient is able to shave and take care of other personal hygiene tasks that he was unable to do before his transplant

With much physical/occupation therapy afterwards, the transplanted hand can be functional. It’s not likely I would be able to pick up a needle to sew/hand quilt again, but I would be able to brush my hair and teeth.

The ethics of a non-life threatening diagnosis (loss of one or both hands) being treated with a procedure that requires immunosuppressive drugs for life is still being debated and should be. From the PRS article (first reference)

The toxicity of immunosuppressive medication, however, brings about an ethical dilemma. In solid organ transplantation, 40 percent of posttransplant deaths were attributed to infection; transplant recipients have a seven-fold 5-year risk over the general population of developing malignancies.

This all brings us back to the actual costs of hand transplantation which is very difficult to determine though Dr. Oda and colleagues have done a good job in attempting to do so. I think they may have underestimated the costs.

Lifetime costs for single hand transplantation average $528,293, whereas costs for double hand transplantation average $529,315.

Total costs of prosthesis adoption for unilateral and bilateral amputation are $20,653 and $41,305, respectively.

The mean surgical cost, including preoperative evaluation, hospitalization, and physician fee, are $13,796 for single hand transplantation and $14,608 for double hand transplantation.

The cost of immunosuppressive therapy for 40 years, including drugs and clinic visit, is $433,283 ($362,894-503,672).

The cost of productivity loss for hand transplantation and prosthetic adaptation are $42,265 and $9753, respectively.

Oda and colleagues doubled the traditionally cost-effectiveness threshold of $50,000/QALY (employed based on the acceptance of kidney transplantation) to $100,000 for their analysis.

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03).

Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the accepted cost-effectiveness threshold of $100,000/QALY.

As pointed out by Dr. Concannon in the discussion of Oda’s article, I and others can muse all we want but it will most likely ultimately be out of our hands.

Ultimately, while the costs and worthiness of this technique may be debated in scientific journals, it will certainly not be decided in them. There are industry and governmental agencies with far sharper pencils than we have that will look very closely at the cost-benefit ratio before deciding whether this will be an acceptably “covered” procedure for their respective constituents. Perhaps the biggest hurdle in the implementation of limb transplantation will involve mastery not of the immune system but of actuarial tables.

REFERENCES

An Economic Analysis of Hand Transplantation in the United States; Chung, Kevin C.; Oda, Takashi; Saddawi-Konefka, Daniel; Shauver, Melissa J.; Plastic & Reconstructive Surgery. 125(2):589-598, February 2010.; doi: 10.1097/PRS.0b013e3181c82eb6

Discussion: An Economic Analysis of Hand Transplantation in the United States; Concannon, Matthew J.; Plastic & Reconstructive Surgery. 125(2):599-600, February 2010.; doi: 10.1097/PRS.0b013e3181c831e5

Hand transplantation not cost-effective; AAOS Now, January 2010 Issue; Peter Pollack

Hand Transplantation; Brown University Biomed Course Info (2001); accessed September 15, 2010

Shout Outs

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

Pallimed.org is the host for this week’s  Grand Rounds.  You can read this week’s edition here.

I am not sure if Nick(@blogborygmi) realized this when he approached me about a date to host, but this is the last edition of Grand Rounds for Volume 6.  A hospice blog as final chapter to a great year of medical blogging, there are things in life that are more serendipitous than this of course.  But of course here at Pallimed (@pallimed), we do cover things beyond just the last few days of life. So feel free to take a look at our 1,000 other posts.

On to the best of the medical blogosphere!  No themes here but I did ask (like GruntDoc) to include a post of  other than your submission to help broaden our reach this week…….

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 6) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)

I can’t believe two weeks has passed already, but the calendar says that, indeed, it is time for the latest edition of Change of Shift!

Quite the eclectic collection of stories this week!

Before you begin, I just want to remind everyone that I still have discount codes available for BlogWorld/New Media Expo 2010. We’ll be getting together in Vegas next month! Check the button on the top bar for details.  I’d love to meet as many nurse bloggers as possible!

And now, I am proud to present……..

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Great Diane Rehm Show this past Thursday on Thalidomide and the FDA

Fifty years ago, a newly appointed medical officer at the FDA stood up to corporate pressure and refused to approve thalidomide, the drug already used for morning sickness in other parts of the world. The case transformed how Americans think about medicine and the FDA's drug-testing policy. Diane and guests explore how thalidomide is being used today and discuss how Frances Kathleen Oldham Kelsey saved thousands of babies from the perils of thalidomide.

I have posted about Thalidomide in the past.

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Orac has written a thoughtful response to the New York Time story  by Amy Harmon:    New Drugs Stir Debate on Rules of Clinical Trials.  His post is titled:  Balancing scientific rigor versus patient good in clinical trials

A critical aspect of both evidence-based medicine (EBM) and science-based medicine (SBM) is the randomized clinical trial. …..

The ethics of clinical trials, however, demand a characteristic known as clinical equipoise. Stated briefly, for purposes of clinical trials, clinical equipoise demands that there be a state of genuine scientific uncertainty in the medical community over which of the drugs or treatments being tested is more efficacious and safer……

In oncology clinical trials, as in clinical trials for treatments of any life-threatening disease, there is always a tension between wanting the "cleanest" possible results versus doing the best for each individual patient. It is a balancing act that relies on the ethics of physicians and a combination of hope and altruism in the patients who become subjects in such trials. … How to maximize the good for as many patients as possible is the goal, but, as we have seen, this is a goal that is not so easily accomplished, just as clinical equipoise is a concept that is easy stated but not so easily applied. PLX4032 teaches us that.

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This is worth reading (and listening to):  New York Times article by The Voices of Schizophrenia by Tara Parker-Pope (photo credit)

Few mental illnesses are as complex and confusing as schizophrenia, a mental disorder in which people may experience hallucinations or delusions, hear voices or have confused thinking and behavior.

Although the word “schizophrenia” means “split mind,” the disorder does not cause a split personality, as is commonly believed.

The latest Patient Voices segment by Karen Barrow, a Web producer, offers rare insights into schizophrenia and schizoaffective disorder, a related condition that combines thinking and mood problems, as seven men and women share their experiences.  ………….

To hear these and other stories of schizophrenia, click on the Patient Voices audio link. And then please join the discussion below.

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I love Jimi Hendrix’ music, so really enjoyed this piece on NPR last week:   Send My Love To Linda: An Untold Jimi Hendrix Story

January 16th, 1970.

The greatest rock guitarist to ever play the instrument, Jimi Hendrix, has eight months and two days to live. He spends part of the day at New York City's Record Plant laying down some tracks. After a few busted takes, Jimi launches into one of the most amazing instrumentals that few people have ever heard.

Hendrix called the piece "Sending My Love to Linda," and ……. Despite being a Hendrix fan, I had to go back and find out more about who this Linda was……….

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Dr Anonymous show this week will be a follow-up school name change & value of alumni.   The show begins at 9 pm EST.