Wednesday, December 1, 2010

Rejection

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Doctor Richard Edwards, a chiropractor from Oklahoma and the nation's third double hand transplant, was recently in the news again.  This time it a report that he “may lose the fingertips on his right thumb and pinkie because his body started to reject the new limbs.”
Dr. Edwards’ surgery was live tweeted when it was done in August by Louisville surgeons at The Jewish Hospital Hand Care Center.
Jeff Kepner, the first patient in the United States to receive two hands simultaneously, experienced an episode of rejection which was dealt with successfully.
Rejection is never a good thing in a transplant patient not matter which organ or part transplant.  Even though I applaud the advances being made, we must always consider the cost of the proposed treatment and ask if there a better option for this individual?
Hand or arm transplantation is not possible for all.  A missing arm can bring (social) rejection to the individual as it did for this woman, Tammy Chinander (photo credit, shown with her daughter Krystal).  [H/T from @vpmedical]
The Rudd native lost her arm at the age of 2 when she caught it in a wringer washing machine. The arm was amputated above the elbow.
For years, she managed with an arm with a hook, but at the age of 31, she decided she was through with it.
"I got tired of it hanging there," she said. "It wasn't working. It looked bad. My son was scared of it."
 
The best choice for her turned out to be a German-manufactured Otto Bock DynamicArm, typically $75,000 to $100,000 in cost which will be paid by her insurance.
Chinander's goal is to get the new arm to work as well as her other arm. Right now, it takes serious concentration to use it.
"I'm going through the second part of my life learning to do everything two-handed," she joked.
…..Krystal could not hold back the tears as she described what it is like for them.
"Getting that first two-armed hug from your mom that you see all the other kids getting is really wonderful," she said.
 
 
REFERENCES
Hand Transplant Fact Sheet: History and Evolution of Hand Transplantation;  UPMC/University of Pittsburgh Schools of the Health Sciences 
Transplantation — A Medical Miracle of the 20th Century; Peter J. Morris, F.R.S.; N Engl J Med 2004; 351:2678-2680December 23, 2004
Immunosuppression and Rejection in Human Hand Transplantation; Schneeberger S, Gorantla VS, Hautz T, Pulikkottil B, Margreiter R, Lee WP;  Transplant Proc. 2009 Mar;41(2):472-5.

Tuesday, November 30, 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.

Colorado Health Insurance Insider is the host for this week’s Grand Rounds! You can read this week’s edition here.
Welcome to Grand Rounds.  As we get back into the work week routine after the Thanksgiving weekend, we have a great collection of health care articles for you to browse through.  Enjoy! ……..
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MedGadget is hosting a new contest: Imagine Medicine: The Photography / Photoshop Contest

…………Welcome to the Imagine Medicine contest!
We are looking for fascinating medical photography that... imagines medicine.
Nothing is off the table: portraits, group shots, happy shots, tragic shots, clinical shots, photoshop illustrations, macro, micro, and anything in between. Can you imagine medicine, showcase it as art, and make us wonder?
Here's the lowdown. The contest is open to all. Upload your photograph(s) to Flickr, and tag them with "imaginemedicine" and "medgadget" keywords. Make sure you add at least one sentence describing your work. The deadline for submissions is 11:59pm ET on December 5, 2010. The winner will be announced on December 10th and the prize is a brand new 16GB iPad with Wi-Fi. ………
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Information is Beautiful has some wonderful grafts on Vitamin D (photo credit) which includes this one:
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The above is very timely as NPR presented a story by Richard Knox on vitamin D this morning:  Medical Panel: Don't Go Overboard On Vitamin D.
The Institute of Medicine is throwing cold water on the latest dietary supplement fad: big doses of vitamin D.
Humans make vitamin D when they are exposed to the sun. But many worry that clothing, indoor living and sunscreen are depriving most people from enough of the sunshine vitamin. It's also hard to get enough vitamin D from the diet, proponents say, despite fortification of milk and orange juice.
But the Institute's Food and Nutrition Board, which makes official recommendations on dietary intake, says advocates of high-dose vitamin D are going overboard.
After two years of study and debate, the panel says children and most adults need 600 international units of vitamin D a day. People over 70 need 800.  ……
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Via twitter from @doctorwes:  Barbara Walters discussed her aortic valve replacement candidly: 4 'second-opinions' and a change of cardiologist http://bit.ly/g6Jtom
………. Here’s the great news. You are not allowed to go to the dentist for at least three months after the surgery, because bacteria from your teeth can travel to your heart and cause an infection. No dentist. Also, no vigorous exercise for weeks. You experience great fatigue. No one raises an eyebrow if you take a nap every day. Finally, open-heart surgery sounds so awful that everyone worries about you, and what with the phone calls, the notes, and the flowers—all extolling your virtues and letting you know how wonderful you are — you feel as if you were reading your obituary. That’s the good news. The bad news is that, even though the operation is relatively routine, there is still a 1-to-2-percent chance that you won’t make it. Someone actually could wind up reading your obituary.  ………….
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Another via twitter comes from @drdavidballard: How early psychologists looked to magicians to turn illusions into reality .... http://bit.ly/emGQ3D
It is a link to an article in the December issue of Psychologist by Peter Lamont:  The misdirected quest
At the end of the 19th century, Hermann and Kellar were the two greatest conjurors in the world, though who was greatest depended upon whose publicity one believed. In the United States they competed over audiences and advertising space, and each considered the other his arch-rival. When Hermann died in 1896, Kellar was free to establish his reign and, aside from his notable achievements in the world of magic, he was almost certainly the inspiration for the Wizard of Oz. But before Kellar became the grand wizard, and shortly before Hermann’s death, the two great rivals agreed to compete in a quite different environment – the psychological laboratory. ………
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This quilt was shared with me by two people on twitter (@KnittingNephron and @jdcmlewis).  It was posted on “The Daily What” yesterday.  (photo credit)
iPhone Baby Quilt of the Day: By Harriet Rosin for her grandson, Gabriel.  Benjamin Stein adds: “There’s a Nap for That!” (Obligatory.)
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I’m hoping to attend with a couple of friends -- Arkansas Women Bloggers Meetup Scheduled! (photo credit)
When: December 11, 2010 11am-1pm
Where: Museum of Discovery @ 500 President Clinton Avenue
Why: Meet other bloggers and help decide future activities/goals for AWB
We will keep you updated with event details as we pull them together.
To RSVP, you can leave a comment on this post. If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at arkansasbloggers@gmail.com.

Monday, November 29, 2010

Suture Material and Skin Irritation

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 have written about Suture Allergy vs Suture Reactivity so was very interested in this new article accepted for publication in the journal of Plastic and Reconstructive Surgery (online ahead of publication). 
The article comes from researchers in Greece who chose to use digital image analysis to evaluate the erythema  associated with tissue reaction to suture material. 
The sutures evaluated were polydioxanone (PDS II(R), Ethicon, Sint-Stevens-Woluwe, Belgium), polypropylene blue (Polypropylene(R), Assut Sutures, Ascheberg-Herbern, Germany), polyamide 6 (Ethilon(R), Ethicon, Neuchatel, Switzerland), metallic clips (APPOSETM, ULC Tyco, Hampshire, UK), and polyglactin (Vicryl Rapid(R), Ethicon, Norderstedt, Germany).
Digital photos of 100 patients(70 females, 30 males; all Caucasian) were compared by software, evaluating red color superiority (mean value of red color) in the region surrounding the wound.  Most of the patients were Fitzpatrick skin type II and III (46 and 47 respectfully).  Mean age was 42 years old, ranging from 15 to 86 years. Each underwent the excision of cutaneous and subcutaneous lesions.
Surgical wounds included those after excision of skin or subcutaneous lesions on the face (68%), neck (14%), abdominal wall (12%), axilla (1%) and back (5%). All other anatomical areas were excluded from this study in order to produce sample homogeny as concerns the healing of skin wounds in different body areas.
The researchers excluded wounds which could not be primarily closed without tension or were located over a bony prominence to minimize other confounding factors as were wounds with any kind of post-operative complications, e.g. hematoma, dehiscence or infection for the same reason.
The researchers used two different suture materials in each patient to improve comparison between suture material and skin type.  This was done by dividing each surgical wound into two halves.  Each half was sutured with two different suture materials for each wound. The same number of sutures were used on each half of the wound.  The patients were randomly assigned a pair of suture materials by the means of a sealed envelope method.
The pairing of five different kinds of suture material yielded ten pairs (PDS II- Polypropylene, PDS II - Ethilon, PDS II -metallic clips, PDS II – Vicryl Rapid, Polypropylene - Ethilon,  Polypropylene-metallic clips, Polypropylene-Vicryl Rapid, Ethilon - metallic clips, Ethilon – Vicryl Rapid, metallic clips-Vicryl Rapid).
Each pair was tested on ten patients.  Sutures were removed on the 10th post-operative day.
According to the aforementioned comparisons polydioxanone was found to have the best performance, followed by polyglactin, polyamide, polypropylene and metallic clips. All the above mentioned differences between suture materials were statistically significant (p<0.05).
Their conclusions:
The absorbable sutures used for skin closure in our study were removed after the period of time which is indicated for non-absorbable suture material and respective to the site of the wound. Less skin erythema was observed after the use of absorbable materials (polydioxanone and polyglactin) than with the three nonabsorbable materials (polypropylene, polyamide and metallic clips).
This leads to the conclusion that, when used in skin closure and removed after 10 days, absorbable materials produce less tissue reaction in the form of erythema than non-absorbable sutures do.
So their small study would indicate that PDS II created the least skin redness at 10 days, followed by Vicryl Rapid, Polypropylene, Ethilon, and metallic clips.


REFERENCE
Significant differences in skin irritation of common suture materials assessed by a comparative computerized objective method; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 17 November 2010; doi: 10.1097/PRS.0b013e3182043aa6; Original Article: PDF Only

Friday, November 26, 2010

Ethan's Baby Quilt

Our nephew Ethan was born on Thanksgiving Day 2004.  He was a month early, but is healthy and very smart!   This is another of my “crazy” scrappy quilts.  It is machine pieced and quilted.  It is 35 in X 46 in .

Here you can find a pink rabbit, sunflowers, butterflies, flags, a witch, and a bear.
Here you can find a frog, birds, a parrot, pumpkins, and planets.
Here you can find faces, a tiger, a car, planets, and more.

Wednesday, November 24, 2010

Engaging with Grace Blog Rally

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

The past couple of years during Thanksgiving weekend, many of us bloggers have participated in a “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

The original mission – to get more and more people talking about their end of life wishes – hasn’t changed.  At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:


Think about them, document them, share them. 

Wishing you and yours a holiday that’s fulfilling in all the right ways.


To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. If you want to reproduce this post on your blog (or anywhere) you can download a ready-made html version here


While you are engaging your family in a health care discussion, perhaps, you could engage your family into creating a medical family tree. 
Map out your family medical history
Here’s how to create your medical family tree.
1. Find out your ancestry. Include the country or countries where you ancestors came from originally. Some ancestries, like Jews of Ashkenazi (Eastern European) descent, have a higher risk for certain cancers.
2. List blood relatives. Include your first- (parents, siblings, children) and second- (nieces, nephews, aunts, uncles, grandparents) degree relatives. Add the current age of each or the age when they died.
3. Add cancer diagnoses, if any. Include the age when they were diagnosed with cancer, if you can find that out. List details, such as the part of the body where the cancer started and how the cancer was treated (chemotherapy, radiation therapy, surgery).
4. Include any birth defects or genetic disorders that you learn about.
Use the Surgeon General’s Office Family Health Portrait. This online tool helps track all family-related diseases, not just cancer………….

L-Brachioplasty – 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.

With the increase number of patients receiving weight-loss surgery, there is has been an increase in those asking for procedures to remove the remaining excess skin such as panniculectomy, abdominoplasty, lower body lift, brachioplasty (arm lifts), and thigh lifts.
The scars involved in brachioplasty surgery are not a good trade-off if there is minimal skin excess or looseness.  These individuals are better served by upper arm exercises to increase the muscle mass.
Brachioplasty (arm lift) is defined as the removal of excess skin and subcutaneous tissue to reshape the upper arm (axilla to elbow). (photo credit)
The L-brachioplasty described in the Hurwitz article from the July/August 2010 issue of the Aesthetic Surgery Journal addresses significant excess upper arm skin and the excess which often extends to the chest wall lateral to the breasts (photo credit).
The article very clearly described the procedure from the beginning to middle to end to postoperatively.  If you do brachioplasty surgeries, it is an article worth reading.
The operative time for each arm is approximately 40 minutes. The incisions are covered with sponge dressing and then wrapped in ACE bandages (BD, Franklin Lakes, New Jersey) with the hands elevated. The sponges and bandages are removed and replaced with tightly fitting elastic sleeves five days postoperatively.
Hurwitz mentions 13 women and two men were treated over the past four years using this procedure.  Complications included one seroma (treated by aspirated on one occasion) and incision dehiscence limited to less than 1 cm in five patients.  No patients had contractures across the axilla. 
Most insurance companies (as with Aetna and Cigna) consider brachioplasty surgery a cosmetic procedure.


REFERENCES
L-Brachioplasty: An Adaptable Technique for Moderate to Severe Excess Skin and Fat of the Arms; Hurwitz, Dennis J., Jerrod, Keith; Aesthetic Surgery Journal, July/August 2010 30: 620-629;  doi:10.1177/1090820X10380857
Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. Sep 1995;96(4):912-20.
Arm Lift Photo Gallery from Sean Younai, MD, FACS

Tuesday, November 23, 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.

Amanda Brown, DVM is the host for this week’s Grand Rounds! You can read this week’s edition here (photo credit).
I'd like to welcome you all to the Thanksgiving 2010 edition of Grand Rounds (ok, actually this is Grand Rounds Vol. 7, No. 9 - but who's counting?) - it is VERY gratifying to me that so many of you have contributed, offered support, and generally welcomed me into this traditionally human-only medical blog carnival. At this time of year, I always stop and think about what I'm thankful for, and this year I'd say the medical blogging community is definitely on my list. And the office call drinking game! That, and Starbucks, of course. Triple grande nonfat latte FTW! Oh. Um. Sorry, I got a little carried away. I'm also incredibly grateful that my clinic microscope got tuned up today - I may actually have let the Nikon tech see me do the happy dance, in fact. So...anyway... Here we go!
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MedGadget is hosting a new contest:   Imagine Medicine: The Photography / Photoshop Contest

…………Welcome to the Imagine Medicine contest!
We are looking for fascinating medical photography that... imagines medicine.
Nothing is off the table: portraits, group shots, happy shots, tragic shots, clinical shots, photoshop illustrations, macro, micro, and anything in between. Can you imagine medicine, showcase it as art, and make us wonder?
Here's the lowdown. The contest is open to all. Upload your photograph(s) to Flickr, and tag them with "imaginemedicine" and "medgadget" keywords. Make sure you add at least one sentence describing your work. The deadline for submissions is 11:59pm ET on December 5, 2010. The winner will be announced on December 10th and the prize is a brand new 16GB iPad with Wi-Fi. ………
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I wish I could go see this exhibit of work from Street Anatomy at the International Museum of Surgical Science in Chicago, IL.  Initially, the exhibit was to run from September 3 through November 19, 2010, but has been extended to December 19th!  Congratulations, Vanessa! (photo/info credit)
  ………This exhibition, the latest in the Museum's ongoing "Anatomy in the Gallery" program, is guest curated by Vanessa Ruiz, the author of a popular niche blog, www.streetanatomy.com, that has covered the intersections between medicine, art, and design for the past two and a half years……
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Via tweeter: RT @blogborygmi RT @poisonreview: Did astronomer Tycho Brahe die of mercury poisoning or voluntary urinary retention? http://bbc.in/cfoRxU
BBC News article: Danish astronomer Tycho Brahe exhumed to solve mystery
Tycho Brahe was a Danish nobleman who served as royal mathematician to the Bohemian Emperor Rudolf II.
He was thought to have died of a bladder infection, but a previous exhumation found traces of mercury in his hair.
A team of Danish and Czech scientists hope to solve the mystery by analysing bone, hair and clothing samples. ……
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My siblings and I are very different.  I have always been fascinated and sometimes befuddled by this.  It’s probably why I enjoyed this piece on NPR by Alix Spiegel:  Siblings Share Genes, But Rarely Personalities
…………In fact, in terms of personality, we are similar to our siblings only about 20 percent of the time. Given the fact that we share genes, homes, routines and parents, this makes no sense. What makes children in the same family so different?…………
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I’m hoping to attend with a couple of friends --  Arkansas Women Bloggers Meetup Scheduled! (photo credit)

When: December 11, 2010 11am-1pm
Where: Museum of Discovery @ 500 President Clinton Avenue
Why: Meet other bloggers and help decide future activities/goals for AWB
We will keep you updated with event details as we pull them together.  
To RSVP, you can leave a comment on this post.  If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at arkansasbloggers@gmail.com.
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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me” and is included in this weeks quilts being auctioned off.
Click on an auction week below to view or download an auction guide for that week.
Week Four: Monday, Nov. 29-Monday, Dec. 6
The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern.
All proceeds will support the AAQ and its projects.
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There does not seem to be any Dr Anonymous’ show scheduled for this week. 
You may want to listen to the shows in his Archives. Here are some to get you started:
GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

Monday, November 22, 2010

Risks of Fat Grafting in Breast Cancer Patients

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.

Fat grafting as a means of either (cosmetically) enlarging breasts or (reconstructively) correcting defects / asymmetries after breast cancer surgery/radiation therapy has been gaining ground as an acceptable method in the past few years.  True, much debate is still occurring but research is being encouraged to answer questions regarding safety (short and long-term) and efficacy.
The two articles (full references below) from researchers at the University of Pittsburgh School of Medicine suggests that it is NOT safe to use adipose-derived stem cells (ADSC) that may be part of fat grafting in any patient with active tumor cells. 
From the first article’s abstract (bold emphasis is mine):
Adipose-derived stem cells (ASCs) have been proposed to stabilize autologous fat grafts for regenerative therapy, but their safety is unknown in the setting of reconstructive surgery after mastectomy. ….
Here, we ask whether ASC promote the in vitro growth and in vivo tumorigenesis of metastatic breast cancer clinical isolates. Metastatic pleural effusion (MPE) cells were used for coculture experiments. ASC enhanced the proliferation of MPE cells in vitro (5.1-fold). ……… The secretome profile of ASC resembled that reported for MSC, but included adipose-associated adipsin and the hormone leptin, shown to promote breast cancer growth. Our data indicate that ASC enhance the growth of active, but not resting tumor cells. Thus, reconstructive therapy utilizing ASC-augmented whole fat should be postponed until there is no evidence of active disease.
From the second article’s abstract (bold emphasis is mine):
There is often a pressing need for reconstruction after cancer surgery. Regenerative therapy holds the promise of more natural and esthetic functional tissue. In the case of breast reconstruction postmastectomy, volume retention problems associated with autologous fat transfer could be ameliorated by augmentation with cells capable mediating rapid vascularization of the graft. …..
. Available evidence from case reports, cell lines, and clinical isolates favors the interpretation that regenerating tissue promotes the growth of active, high-grade tumor. In contrast, dormant cancer cells do not appear to be activated by the complex signals accompanying wound healing and tissue regeneration, suggesting that engineered tissue reconstruction should be deferred until cancer remission has been firmly established.
The early research suggest that fat grafting as a reconstructive tool in breast cancer survivors is safe (non-tumor causing) as long as care is taken to be sure any remaining tumor cells are dormant and non-active.
It must be remembered that fat grafting is a surgical procedure and as such is not risk free.  All surgical procedures carry the risks of infection, bleeding, etc.  The fifth reference below reminds us that fat grafting is not always a simple, benign procedure.
Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting. ………. 
Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.



REFERENCES
Regenerative Therapy and Cancer: In Vitro and In Vivo Studies of the Interaction Between Adipose-Derived Stem Cells and Breast Cancer Cells from Clinical Isolates; Ludovic Zimmerlin, Albert D. Donnenberg, J. Peter Rubin, Per Basse, Rodney J. Landreneau, Vera S. Donnenberg; Tissue Engineering Part A. September 2010, ahead of print.
Regenerative Therapy After Cancer: What Are the Risks?; Vera S. Donnenberg, Ludovic Zimmerlin, Joseph Peter Rubin, Albert D. Donnenberg; Tissue Engineering Part B: Reviews. November 2010, ahead of print.
Fat Grafting to the Breast Revisited: Safety and Efficacy; Coleman, Sydney R.; Saboeiro, Alesia P.; Plastic & Reconstructive Surgery. 119(3):775-785, March 2007; doi: 10.1097/01.prs.0000252001.59162.c9
Autologous Fat Grafting to the Reconstructed Breast: The Management of Acquired Contour Deformities; Kanchwala, Suhail K.; Glatt, Brian S.; Conant, Emily F.; Bucky, Louis P.; Plastic & Reconstructive Surgery. 124(2):409-418, August 2009; doi: 10.1097/PRS.0b013e3181aeeadd
Sepsis With Multiple Abscesses After Massive Autologous Fat Grafting for Augmentation Mammoplasty: A Case Report; Keu Sung Lee, Seung Jo Seo, Myong Chul Park, Dong Ha Park, Chee Sun Kim, Young Moon Yoo and ll Jae Lee; Aesthetic Plastic Surgery, November 2010; DOI: 10.1007/s00266-010-9605-8

Friday, November 19, 2010

Scrappy Log Cabin Baby Quilt

This quilt is made from fabric in my scrap bags.  I didn’t hold the “logs” to any set width, but cut each block to a finished 10.5 in (including seam allowances) when each was finished.  The quilt is machine pieced and quilted.  It is 40 in X 40 in.

I have given it to my niece who is pregnant with her first baby due this spring.

Here you can see some of the fabrics used.  It has some wonderful “I spy” effects:  find the rabbit, the frog, the carolers.
Here you will find a tiger, a snail, a road sign, stars.
Here you can find people, horses, race cars, colors (green, yellow, red, white, black), stars, strips, bees.
Here you can find a parrot, a weasel, a lady bug.

Thursday, November 18, 2010

Saline or Silicone?

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.

There really is no simple answer to saline or silicone whether the choice is for a reconstructive or cosmetic patient.  For me it comes down to discussing the pros and cons of each with the patient and trying to help them decide which is best for them.
A recent article in the journal Cancer suggests that reconstructive patients are more satisfied with silicone implants over saline.  Upon looking at the information closer, it is an ever so slight increase in satisfaction as to be laughable.
Colleen M. McCarthy, MD, MS, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues conducted a multicenter, cross-sectional survey of 482 postmastectomy, implant-based reconstruction patients.  A total of 672 women were asked to complete the BREAST-Q (Reconstruction Module), but only 482 completed them (176 women had silicone implants and 306 chose saline).
BREAST-Q Reconstruction Module scores satisfaction in 15-items including  breast shape, feel to the touch, appearance, feelings of "normalcy," and integration into self.  The score averaged 58.0 for silicone implants versus 52.5 with saline implants on a 100-point scale in a univariate analysis.
Why are the scores so low (58.0 and 52.5)?   This study wasn’t planned to discern those answers though it did note that the addition of radiation to the mix lowered the satisfaction scores.

The article by Scott Spear, MD is a wonderful review of the pros and cons of each.  It is well worth reading.  He summarizes at the end of his article:
As implant choices have evolved, certain concepts have proven useful. When the main determinant for patient satisfaction is the shape and feel of the implant (and in cases where the implant might be especially visible), a silicone gel implant is the better choice. In cases where the primary concerns are safety (real or perceived), minimal access incisions, and ease of monitoring, saline may prove to be a better choice.


Related posts
Patient Satisfaction Following Breast Reconstruction Using Implants (June 7, 2010)
Silicone vs Saline Breast Implants (March 4, 2008)



REFERENCES
Patient Satisfaction with Postmastectomy Breast Reconstruction: A Comparison of Saline and Silicone Implants; McCarthy CM, et al; Cancer 2010; DOI: 10.1002/cncr.25552.
Breast Implants: Saline or Silicone?; Spear, Scott L., Jespersen, M. Renee; Aesthetic Surgery Journal July/August 2010 30: 557-570, doi:10.1177/1090820X10380401

Wednesday, November 17, 2010

Rationing

 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.

Do you recall the severe rationing of food and water the Chilean miners had to endure to survive?   The rationing was done to stretch their limited resources.
I would argue the state of Arizona’s new policy to not cover organ transplants for patients on Arizona Health Care Cost Containment System (AHCCCS) or their version of Medicaid is a similar form of rationing.
AHCCCS, as many Medicaid programs, is underfunded.  They are trying to operate on a limited budget.  Something has to give.
Sadly in this case, many (NPR reports 98) had already been granted approval for organ transplants which they may not receive.  Francisco Felix, 32, who due to Hepatitis C needs a liver transplant, is reported to have made it to the operating room, prepped and ready for his life-saving liver transplant when doctors told him the state's Medicaid plan wouldn't cover the procedure.  The liver he was to receive went to someone else.
In this prolonged economic downturn, I wonder how many parents have had to tell their children who were accepted into their dream college they will not be able to go, the family income has changed and it is no longer affordable?
In a perfect world, everyone would have health insurance.  Health insurance companies (private, state, and federal) would have unlimited resources so that all “evidence-based” medically necessary care/procedures/medications would be covered.
Hell, in a perfect world, we wouldn’t need health care.
It isn’t a perfect world.  There are limited resources.  Tough decisions must be made in doing the most with the available resources.
Is this the sort of rationing of medical care we will be seeing more of in the future?

P.O.U.R.

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.

A patient with postoperative urinary retention forced me to review the topic, conducting my private M&M conference.
Without giving away too much on my patient – female, less than 50 yo, general anesthesia used, length of surgery 4 hrs, ambulatory/outpatient, foley used intraoperatively, fluids used judicially (though I do not know the exact amount given by anesthesia), pain meds (Toradol, fentanyl, and sent home with script for Percocet).
From the first reference article below
I made my usual call to the patient the evening of surgery, asked how she was, “how’s the pain?”, “any concerns?”, “any nausea?”, “are you eating and drinking?”. I don’t recall specifically asking about whether she had peed or not, but I do recall her saying she needed to end the call so she could go to the bathroom.
I received a call from her the next afternoon. “Dr. Bates, I can’t pee. I keep trying and all I can do is dribble.”
The surgery center graciously agreed to catheterize her. I received a call from them immediately afterwards, “Dr. Bates, her residual volume is 1000+ cc.”
The patient graciously agreed to have the foley left in place for the next 24 hrs. I called her later the same evening and we agreed on a time for her to come into my office for the removal of the foley the next day (and yes, I gave thought into leaving it for a second day).
The surgery center’s action kept my patient from having to check in through the emergency department, incurring a wait time and additional cost.
The patient’s agreement allowed me to treat her as an outpatient, helped me reduce the need for a second catheterization, and keep her from incurring more expense.
It was fortunate that the patient had weaned herself from the pain medicine by this time and was mostly taking only Tylenol. Her P.O.U.R quickly resolved.
I did not see this complication coming for this patient. Perhaps the foley could have been left in and removed in recovery. Perhaps anesthesia could have restricted fluids more (though they were careful).
I can think of no reason she might need a urology follow up. Am I missing anything? Where is KeaGirl when you need her?
REFERENCES
Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit; Anesthesia & Analgesia, August 2005 Vol. 101 No. 2 592-596; doi: 10.1213/​01.ANE.0000159165.90094.40
Postoperative Urinary Retention; Anesthesiology Clinics, Volume 27, Issue 3, Pages 465-484 (September 2009)
Patient Safety in the Office-Based Setting; Horton, J Bauer; Reece, Edward M.; Broughton, George II; Janis, Jeffrey E.; Thornton, James F.; Rohrich, Rod J.; Plastic & Reconstructive Surgery. 117(4):61e-80e, April 1, 2006; doi: 10.1097/01.prs.0000204796.65812.68
Urinary Retention in Adults: Diagnosis and Initial Management; Brian A. Selius, DO, Rajesh Subedi, MD; Am Fam Physician, 2008 Mar 1;77(5):643-650.