Dr. Ralph Millard,

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Dr. D. Ralph Millard (1919-2011) is known in the plastic surgery community for his contribution to improved surgical techniques for the correction of cleft palates.  He died Sunday, June 19, 2011. (photo credit)

PSNews tribute:  Plastic surgery pioneer D. Ralph Millard Jr., MD, dies at age 92
NBC Miami tribute:  Cleft Palate Pioneer Ralph Millard Laid to Rest

……He trained more than 180 young, and not so young, men and women in whom his legacy is entrusted.  The “Chief,” as he was known to his residents at the University of Miami, was an exacting task master, an elegant surgeon and a consummate teacher.  His surgical greatness cannot be denied, but his most profound legacy may be as a teacher of Plastic Surgery.  Through the gift of his text books and manuscripts he tried to pass on to all Plastic Surgeons his vision of our specialty.  ……

The Millard technique or the rotation-advancement cleft lip technique (photo credit)

Dr. Millard was a “giant” in plastic surgery who will be missed.  My condolences to his family.

REFERENCES to just a few of Millard’s articles (full bibliography)
1.  Millard DR Jr. Rotation-advancement versus Giraldes’ cleft lip technique. Plast Reconstr Surg Transplant Bull. 1961;28:595-7.
2.  Millard DR Jr. Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg. 1964;33:26-38.  (pdf file)
3.  Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J. 1964;12:246-52.
4.  Millard DR Jr. The unilateral cleft lip nose. Plast Reconstr Surg. 1964;34:169-75.
5.  Millard DR Jr. Closure of bilateral cleft lip and elongation of columella by two operations. Plast Reconstr Surg. 1971;47(4):324-31

Ideal Dressing for STSG Donor Site – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

In the 2009 review (2nd reference below),  Voineskos and colleagues did a literature review of skin graft donor-site dressings.  They noted that although there is no clear evidence that moist dressings are any better overall when compared with dry dressings,  there is evidence that moist dressings tend to be less painful than dry dressings.

Donor sites take an average of 7 to 21 days to heal, depending on their size, location, and the patient's health status. 

This latest study (first article referenced below) compared Aquacel and a modified (perforated) polyurethane dressing modified (MPD).  The study is a prospective randomized double-blind clinical trial which included 50 adult patients. 
The authors state (bold emphasis is mine):

The ideal dressing should protect the wound from desiccation and at the same time permit gas exchange to accelerate reepithelialization. It should be impermeable to exogenous microorganisms, comfortable for the patient and the ward staff and associated with only minimal labor input. Moreover, the dressing should be flexible and pliable to permit conformation to irregular wound surfaces. Resistance to linear and shear stress are required as well as good tensile strength to resist fragmentation and retention of membrane fragments when removed. It should, furthermore, be adaptable to the varying dimensions of donor sites and, in spite of everything; it should also be of low cost. Existing dressing materials meet some of these criteria but fail to fulfill all of them, especially in larger donor sites.

Dornseifer and colleagues had previously (4th reference) noted that the “single disadvantage of polyurethane film dressings is an uncontrolled leakage” which they solved by modifying it by perforating the polyurethane film.  This  permits a controlled leakage into a secondary absorbent dressing.

They chose to compare this MPD to Aquacel ® (ConvaTec, Skillman, NJ, USA), a sodium carboxy-methylcellulose hydrocolloid polymer that is claimed to have a high fluid-absorptive capacity and was also described to be a new preferred donor site dressing. (5th reference)

Half of the skin graft donor sites were dressed with an application of Aquacel(R) and half with MPD.  The dressings were kept unchanged for ten days at which time they were removed and the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day, as well as during dressing removal.

In this small study, MPD was found to best Aquacel ®.  More MPD donor sites completely reepithelialized by 10 days than the Aquacel ® sites (86.4% vs 54.5%).

MPD was significantly less painful until and during removal of the dressing (p < 0.001).

Pain at the donor site during the postoperative period was consistently low after wound coverage with both materials, considering that 90% of the values assessed by the six-items pain scale were equal to or less than 1 (minimal intermittent pain) at both sites.
However, when patients were asked to compare both sites, a significantly higher percentage of MPD sites were rated superior to the Aquacel® sites

Dornseifer and colleagues note the costs of the Aquacel® dressing turned out to be about four times more expensive, relating to a donor site of 8 x 20 cm2 and depending on the
respective price level.

Scarring was inconspicuous in both groups 60 days following surgery and no significant differences were detected between the MPD and Aquacel® treated donor sites.

REFERENCES

1.  The ideal split-thickness skin graft donor site dressing: a clinical comparative trial of a modified polyurethane dressing and Aquacel(R); Dornseifer, Ulf; Lonic, Daniel; Ivo Gerstung, Tristan; Herter, Frank; Max Fichter, Andreas; Holm, Charlotte; Schuster, Tibor; Ninkovic, Milomir; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 June 2011; doi: 10.1097/PRS.0b013e3182268c02

2.  Systematic Review of Skin Graft Donor-Site Dressings; Voineskos, Sophocles H.; Ayeni, Olubimpe A.; McKnight, Leslie; Thoma, Achilleas; Plastic & Reconstructive Surgery. 124(1):298-306, July 2009; doi: 10.1097/PRS.0b013e3181a8072f

3.  The theoretically ideal donor site; Birdsell, D. C., Hein, K. S., Lindsay, R. L.; dressing. Ann Plast Surg 2: 535-537, 1979.

4.   The ideal split-thickness skin graft donor site dressing: rediscovery of polyurethane film;  Dornseifer, U., Fichter, A. M., Herter, F., et al.; Ann Plast Surg 63: 198-200, 2009.

5.  Clinical comparative study of aquacel and paraffin gauze dressing for split-skin donor site treatment; Barnea, Y., Amir, A., Leshem, D., et al.;   Ann Plast Surg 53: 132-136, 2004.

Recent Knitting

Here are two recently finished knitting projects. The first is the Shalom Sweater. It is knitted using Louet Euroflax Chunky Weight, the same yarn I used for the Linen Miragamo Bag.

I gave it to my friend @gastromom who loves linen.

Here is the button detail.

This scarf is made using Artyarns Cottonspring and the pattern Dayflower Lace Scarf pattern (free pdf).   I haven’t decided who will receive the scarf.  It was made from an extra skein of yarn from a previous project (see below).

This top was made using the Drops pattern 107-8 top with lace pattern.   Yes, that’s me modeling it.

FDA Updates Safety Data for Silicone Breast Implants

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

 

Yesterday, the FDA published this press release:  FDA provides updated safety data on silicone gel-filled breast implants

In November 2006, the FDA approved silicone gel-filled breast implants for breast augmentation in women over age 22 and for breast reconstruction in all women. 

This latest report includes preliminary safety data from post-approval studies conducted by each of the two breast implant manufacturers (Allergan and Mentor), a summary and analysis of adverse events received over the years by the FDA, and a comprehensive review and analysis of recent scientific publications that discuss the safety and effectiveness of silicone gel-filled breast implants.

Based on the report, women should know:

• Breast implants are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely she is to experience complications. One in 5 patients who received implants for breast augmentation will need them removed within 10 years of implantation. For patients who received implants for breast reconstruction, as many as 1 in 2 will require removal 10 years after implantation.
• The most frequently observed complications and outcomes are capsular contracture (hardening of the area around the implant), reoperation (additional surgeries) and implant removal. Other common complications include implant rupture, wrinkling, asymmetry, scarring, pain, and infection. Check out the FDA booklet for patients:  Breast Implants Complications Booklet.
• Preliminary data do not indicate that silicone gel-filled breast implants cause breast cancer, reproductive problems or connective tissue disease, such as rheumatoid arthritis.  However, in order to rule out these and other rare complications, studies would need to enroll more women and be longer than those conducted thus far.

At this time, the FDA is recommending that health care professionals and women who have silicone gel-filled breast implants do the following:

• Follow up. Women should continue to routinely follow up with their health care professionals.  The FDA recommends women with silicone gel-filled breast implants undergo MRI screening for silent implant ruptures at 3 years post-implantation, and every 2 years thereafter.
• Be aware and pay attention to changes. Breast implants are not lifetime devices. Breast implants are associated with significant local complications and outcomes, including capsular contracture, reoperation, removal, and implant rupture. Some women also experience breast pain, wrinkling, asymmetry, scarring and infection.  Women should notify their health care professionals if they develop any unusual symptoms.
• Stay in touch. If a woman has enrolled in a manufacturer-sponsored post-approval study, she should continue to participate. These studies are the best way to collect information about the long-term rates of complications.

Related Posts: 
It’s Happened Again (June 5, 2007)
Breast Implants -- Some History (March 3, 2008)
Silicone vs Saline Breast Implants (March 4, 2008)
Silicone Implants and Health Issues  (March 5, 2008)
Saline or Silicone? (November 18, 2010)
More on Link Between Breast Implants and ALCL (April 25, 2011)

………………………………

Okay, now I want to rant just a bit about some of the headlines I found on this story.  All of these headlines were under the Google news/health section this morning.  I am not fond of misleading or sensationalized headlines, especially when it comes to health news.  This topic is serious to all women who have implants and they don’t deserve to be misled or inappropriately scared.

I did not read each of the following articles.  I am only commenting on my “gut” reaction to their titles.

Examples of headlines I find appalling:

Celebs who should worry about FDA's breast implant alarm (PHOTOS) (International Business Times)

Hollywood celebrities will not keep breast implants for life (Daily Gossip)
FDA: Silicone breast implants have expiration date (The Imperfect Parent) 
Bummer! FDA Says Women Can't Keep Breast Implants for Life (HyperVocal (blog))

Women who are celebrities are no different when it comes to implants than other women.  No implant has a specific expiration date.  Implants are man-made and wear out over time.  A small percentage fail in the first few years, about 20% fail by 10 years, the other 80% last more than 10 years.

The FDA did not say “women can’t keep breast implants for life.”  The FDA did make it clear that no implant currently on the market has a life expectancy equal to the normal life expectancy for a woman.

These headlines I applaud:

FDA: Silicone Implants 'Mostly Safe' and None Last Forever (33 KDAF-TV)
Silicone implants not a lifetime device (UPI.com)
Both are simple with no fear tactics included.

These headlines I find acceptable:
FDA stands by decision to put silicone breast implants back on market (Los Angeles Times)
FDA Says Silicone Breast Implants Are Safe For Women (SmartAboutHealth)
FDA Leaves Silicone Implants on Market Despite Risks (Wall Street Journal)
Breast Implants Basically Safe but Not Lifetime Devices, Say Experts (ABC News)
Breast implants reasonably safe (Washington Post)
Breast implants 'relatively safe' (BBC News)
FDA urges caution for silicone breast implant recipients (Boston Globe)
FDA Sees No New Safety Signals for Silicone Breast Implants (MedPage Today)
Most women with silicone breast implants need more surgery (msnbc.com)
Breast implants safe but not problem-free, FDA says (CBS News)
Silicone Breast Implants Deemed Safe in FDA Side Effects Review (Bloomberg)
Long-Term Complications Likely With Silicone Breast Implants (Medscape)

Does Negative Pressure Promote Wound Healing? -- article review

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

There was a recent EurekAlert which caught my attention:  No healing in a vacuum. 

Negative-pressure wound therapy probably does not promote healing. This is the conclusion of Frank Peinemann and Stefan Sauerland's meta-analysis in the current edition of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[22]: 381-9).

The press release actually contained a link to a pdf file of the article (full reference and link below).

Negative-pressure wound therapy (NPWT), also known as vacuum assisted closure,  involves covering the wound with an an airtight film and an adjustable negative pressure is applied using an electronically controlled pump.  The vacuum or negative pressure drains wound exudate.   NPWT is used for chronic persistent wounds and complicated wounds.

The article by Peinemann and Sauerland is a systematic review of the literature (English and German), aimed at  evaluating wound healing and adverse events following NPWT in comparison to conventional treatment in patients with acute or chronic wounds.  From the beginning summary:

We found reports of 9 RCTs in addition to the 12 covered by earlier IQWiG reviews of this topic. Five of the 9 new trials involved NPWT systems that are not on the market. The frequency of complete wound closure is stated in only 5 of the 9 new reports; a statistically significant effect in favor of NPWT was found in only two trials.The results of 8 of the 9 new trials are hard to interpret, both because of apparent bias and because diverse types of wounds were treated.

Data analysis used complete wound closure as the primary endpoint.  This was based on the U.S. Food and Drug Administration’s (FDA) 2006 Guidance for Industry definition for complete wound closure as “skin closure without drainage or dressing requirements.”

The following dependent variables were used as secondary endpoints:
● Adverse events, such as death, secondary amputations, fistula formation, and wound infection
● Time to complete wound closure
● Reduction in wound size
● Health-related quality of life.

In the discussion section of the article, some key summaries:

Regarding the primary endpoint of “wound closure” – results were not homogenous.  The authors notes it is currently impossible to be sure that NPWT performs better than control treatments.

Regarding the secondary endpoints

– Most articles reported “time to wound closure”  occurred quicker in NPWT groups.  The authors note “However, there were considerable differences between trials in terms of the methods used to measure and evaluate wound closure; particularly problematic is the fact that no blinding was used when this endpoint was measured.”  So for now, as with the  primary endpoint, it remains undecided.

--  The results on adverse events were not homogenous and varied depending on the specific complications.   For a number of other adverse events no statistically significant difference was detected.

The authors note that most trials of NPWT were conducted in hospitals.  They make this point in regard to the FDA report (3rd reference below):

The FDA recently issued a report on six deaths and 77 other complications that were reported within a two year period in connection with NPWT . All the deaths were caused by acute hemorrhages, and known contraindications for NPWT (e.g. a large blood vessel
exposed) had clearly been overlooked. Many of the deaths occurred in outpatient care or care homes, which highlights the need to monitor therapy.

The authors conclusion:

Although NPWT may have a positive effect on wound
healing, there is no proof that it is either superior or inferior to conventional wound treatment. Further RCTs of good methodological quality are required.

REFERENCES

Peinemann F, Sauerland S: Negative pressure wound therapy—systematic review of randomized controlled trials; Dtsch Arztebl Int 2011; 108(22): 381–9; DOI: 10.3238/arztebl.2011.0381

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds (Last updated: May 2001)

FDA: Serious complications associated with negative pressure; 2009 (last updated 02/24/2011)

Dysport or Botox for Crow’s Feet?

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

A new study published online in Archives of Facial Plastic Surgery suggests Dysport (abobotulinumtoxinA) is better for treating Crow’s feet than Botox (onabotulinumtoxinA).

Let’s look at the study which only had 90 patients, all older than 18 years of age (mean age 54½, 77 women), were enrolled in a randomized, double-blind, split-face study.

The authors include this history of both products:

….in 2002, the FDA approved Botox Cosmetic (onabotulinumtoxinA) (Allergan Inc, Irvine, California) for the treatment of corrugator-mediated glabellar lines.

Concurrently, another botulinum toxin type A product manufactured by Medicis Aesthetics (Scottsdale, Arizona), Dysport (abobotulinumtoxinA), had been used in other countries since 1991. It was approved for cosmetic use in Europe in 2001, before being approved by the FDA in April 2009 for the treatment of moderate-to-severe glabellar lines.

Today, the cosmetic applications for onabotulinumtoxinA and abobotulinumtoxinA have expanded to the treatment of hyperfunctional lines related to the orbicularis oculi, frontalis, transverse nasalis, and depressor anguli oris, among other muscle groups.

The 90 patients were seen and treated between December 2009 to August 2010. To be included in the study, the men (n=13) and women (n=77) had to have moderate to severe lateral orbital rhytids at maximal contraction and NOT had botulinum neuromodulator treatment to the crow's feet within the prior 6 months.

Other exclusion criteria included: prior face-lift, brow-lift, or blepharoplasty; prior periocular laser or chemical resurfacing; prior adverse reaction associated with botulinum neuromodulator; or a history of degenerative neuromuscular diseases.

Each of the 90 participants were photographed prior to treatment and during each subsequent follow-up visit (posttreatment days 2, 4, 6, and 30).

A standard 5-view photographic series was taken for each patient at rest and at maximal contraction.

Patients and investigator separately assessed the crow’s feet at rest and at maximal contraction on each side, according to a validated 5-point photographic scale (0, no wrinkles; 1, very fine lines; 2, fine lines; 3, moderate wrinkles; and 4, severe wrinkles). This assessment was done prior to treatment and at each follow-up visit.

The treatment consisted of 10 U of Botox on one side of the face while the contralateral side received 30 U of Dysport with treatment sides of the face being randomized by computer-aided software. The recommended dosage ratio of Dysport to Botox varies from 5:1 to 3:1. The article sites the reason for this dosage “recent studies and the clinical experience of the senior investigator point to a 3:1 ratio as being optimal.”

Sixty-seven percent of patients preferred the side treated with Dysport, while 33% of patients chose the side treated with Botox. This difference was statistically significant (P = .002).

On post-treatment day 30, the investigator-assessed efficacy score at maximal contraction averaged 2.60 for the Dysport-treated side of the face and 2.33 for the Botox-treated side (P=0.01).

However, two other secondary end points, investigator and patient assessments of resting lateral orbital rhytids, did not achieve statistical significance (P = .42 and P = .28, respectively).

I would say this is a start in determining which might be better, but it needs to be remembered that this is a very small study and has not been duplicated.

REFERENCE

An Internally Controlled, Double-blind Comparison of the Efficacy of OnabotulinumtoxinA and AbobotulinumtoxinA; Kartik D. Nettar, Kenneth C. Y. Yu, Sumit Bapna, John Boscardin, Corey S. Maas; Arch Facial Plast Surg. 2011;Published online June 20, 2011. doi:10.1001/archfacial.2011.37

Shout Outs

Updated 3/2017:  photos and all links removed as many no longer active and it was easier than going through each one.

Shrink Rap is the host for this week’s Grand Rounds.  You can read this week’s Summer Solstice “Hot” edition here.

Shrink Rap is hosting our third Grand Rounds today on June 21, which is the first day of Summer. In keeping with the summer solstice theme, we asked for submissions that have a theme of "hot." However, "hot" may refer to not just  temperature, but also spiciness, luck, passion, anger, popularity, etc.

Our first Grand Rounds in 2007 featured a clicky brain, and the second featured the then-new iPhone 3G, complete with clicky iPhone apps. This time, we've used clicky pictures that exemplify the "hot" theme. . ……..

……………………………

Yesterday,  NPR ran this  article by Alix Spiegel on inattentional blindness:  Why Seeing (The Unexpected) Is Often Not Believing

……The goal of all this was to answer a question: Is it possible to see something really, really obvious and not perceive it?  …….

When psychologists Chabris and Simons ……..They do research on something called inattentional blindness, or how people fail to see things that are directly in front of them when they're focused on something else. And in Conley they felt they had found a compelling example.  ……….

This topic is important to patient safety as seen in this article:  Inattentional blindness: What captures your attention?

A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies. ……

Expectation has a powerful effect on our ability to pay attention and notice information. If the medication we are looking for comes in a carton with a highly stylized label, we come to expect this presentation every time we look for the medication…….

………………………….

Dr. Cynthia Bailey has a nice post on sunburn:  What is a sunburn?  

A sunburn tells you that damage and inflammation have happened inside your skin from UV exposure; you exposed yourself to more sun than your skin type can handle…..and there’s simply no good news about it!   ….

In this Sunburn Series I’m going to give you a dermatologist’s explanation of what happens in your skin when you get

• a sunburn (i.e. why it’s red and hurts)
• a tan (i.e. how much sun protection you get from one)

I’m also going to give you some helpful information to heal sunburned skin and explain how to prevent ever getting a sunburn again. …….

………………………………..

Dr Val, Better Health, is now hosting a radio show called, "Healthy Vision with Dr. Val Jones."  It is currently available here on iTunes.  The show has three segments (one about the importance of regular eye exams, one about contact lens care, and one about UV protection for eyes). It's available as a full show (20 minutes) and as individual segments.

……………………………….

Dr. Kathryn Clancy, Assistant Professor of Anthropology at the University of Illinois, answers the question:  Why do we menstruate?

…..I will answer three different ones for you: Why do we menstruate? What did we do back in the day? and What is appropriate today?

Why do we menstruate?

Humans are not the only animals to undergo cycles of growth and regression in our endometrial lining. Yet, only a few animals actually menstruate. Menstruation has occasionally been observed in other great apes (this is the primate group where humans belong, with the chimps, bonobos, gorillas and orangs), and a few other animals. As far as we can tell, everyone else resorbs the lining before growing a new one. It seems to be that those animals who menstruate, do so because the amount of lining they have is greater than what they are able to resorb.  …….

…………………………………….

Dr. Lisa, Call Me Dr. Lisa, write about her relationship with her physical therapist:   An S&M relationship for good!  (photo credit)

I’m in a Sadistic/ Masochistic relationship, and I like it.  Now don’t get any crazy ideas, but really I let this guy strap electrodes to my leg, put me in a 40 pound flack jacket and then do exercises, and that is just the beginning.  Yep, I’m talking about my physical therapist.  Still I go back twice a week because he knows what he’s doing and I’m getting better.  ………

I go, I go twice a week.  I spend 3 +/- hours there and I do whatever he says.  My reward, today he had me run on a treadmill.  5 months after my surgery and I’m starting to run again.  I’m well on the road back.  It feels great.  I’m good with this S&M thing we have going on! ……..

……………………………………………..

Sarah McFarland, Threads Magazine, has a piece announcing:  New Sewing Show, "It's Sew Easy," Starts June 30 on PBS

You may have heard about it through the sewing grapevine, but now it's nearly here - the premiere of "It's Sew Easy" is June 30 on PBS stations across the country. It's great news when a national audience is exposed to the fun of sewing!

"It’s Sew Easy" replaces "America Sews with Sue Hausmann," promising to give faithful viewers a new spin on sewing where America Sews left off.  …….

Sensible Treatment of Warts

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

I was alerted to this not too sensible way of treating warts (H/T Doctor Grumpy)  --- Security guard tries to remove wart from finger with a shotgun (bold emphasis is mine)

A SECURITY guard from South Yorkshire shot himself in the hand to try to remove a wart from his finger.

Sean Murphy, 38, lost most of his left middle finger after using the stolen 12-bore Beretta shotgun at a garden centre in Doncaster.  ……

But he said: “The best thing is that the wart has gone. It was giving me lot of trouble.”   ………

My post from September 2009 gives much more sensible treatment methods for wart removal.  Here it is: 

I’m sure I don’t see as many patients with common skin warts as my family practice or dermatology colleagues, but these patients still make it to my office.  Sometimes it’s the primary complaint, sometimes it’s an afterthought.  In reviewing the topic, it occurred to me that most patients don’t need to see any of us for this problem.  They mostly need to accept the fact that the treatment takes TIME.  So if you will persist, then you will often be successful without the expense of seeing a doctor.  (photo credit)

Common warts (Verruca vulgaris) are caused by the human papillomavirus (HPV).  Warts on the hands or feet do not carry the same clinical consequences of HPV infection in the genital area.  It is estimated about 10% of children and adolescents have warts at any given time.  As many as 22% of children will contract warts during childhood.

Common warts can occur anywhere on the body, but 70% occur on the hand.  Often they will disappear on their own within a year.  Even with treatment, warts can take up to a year to go away.

Before heading to the doctor, there are treatments you can try at home:  salicylic acid or duct tape.

When using the 17% salicylic acid gel (one brand name: Compound W), it must be applied every day until the wart is gone.  Only apply to the wart, not the skin around the wart.  This treatment is enhanced by covering the wart with an occlusive water-proof band-aid or duct tape after applying the acid.  It can also be enhanced by gently filing the wart with an emery board daily to remove the dead cells prior to applying the salicylic acid.  Treatment can take weeks to months.  Don’t give up early.

Duct Tape can take weeks or months to be effective.   Apply the duct tape to the wart and  keep it in place for six days.  After removing the tape, soak the wart, and pare it down with a filing (emery) board.  Repeat the above until the wart disappears.  Once again, don’t give up early.

The two  treatments (salicylic acid and duct tape) can be combined.  Apply the salicylic acid liquid to the wart before bedtime.  After letting it air dry for a minute or so,  then apply the duct tape over the wart, completely covering the area. Remove the duct tape the following morning. Each time you remove the tape, you will be debriding some of the wart tissue. Repeat the application each night, until there is no remaining wart tissue.  As with using only one treatment, don’t give up early.

If the above don’t work or you just don’t want to take the time, then you may wish to see your physician for removal.  He can use cryotherapy to destroy the wart.   This method may involve repeated treatment over several weeks.  You can do the following to “get the wart ready for removal” and make the cryotherapy more effective:

1. Every night for 2 weeks, clean the wart with soap and water and put 17% salicylic acid gel (one brand name: Compound W) on it.
2. After putting on the gel, cover the wart with a piece of 40% salicylic acid pad (one brand name: Mediplast). Cut the pad so that it is a little bit bigger than the wart. The pad has a sticky backing that will help it stay on the wart.
3. Leave the pad on the wart for 24 hours. If the area becomes very sore or red, stop using the gel and pad and call your doctor's office.
4. After you take the pad off, clean the area with soap and water, put more gel on the wart and put on another pad. If you are very active during the day and the pad moves off the wart, you can leave the area uncovered during the day and only wear the pad at night.

If none of the above work, then your wart may need to be removed surgically.  Remember the above all take time, so give them time to work.  Even if the wart disappears with any of the above treatments, it may recur later.

Sources

Treatment of Warts; Medscape Article, May 27, 2005: W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD

What Can Be Done About a Hand Wart That Keeps Reappearing After Removal?; Medscape Article, May 31, 2007; Richard S. Ferri, PhD, ANP, ACRN, FAAN

Duct tape and moleskin equally effective in treating common warts; Medscape Article 2007; Barclay L.

Duct Tape More Effective than Cryotherapy for Warts; AAFP, Feb 1, 2003; Karl E. Miller, M.D.

Arkansas Jurors Find Cancer Therapy a Fraud

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

I hope @oracknows, Respectful Insolence, will write more about this. He is much better than I at sussing out fraudulent medical treatments.

I have lived and practiced in Little Rock, AR for over twenty years and I did not know this was in my backyard until my local paper (Arkansas Democrat-Gazette) reported on the outcome of the trial last week. The article title caught my eye as I was skimming the news: Jurors: Cancer therapy a fraud, Award in suit is $2.5 million (subscription only unfortunately).

A federal jury awarded $2.5 million in damages Tuesday to a California woman who paid $6,250 to undergo alternative treatments from a Jacksonville woman who promised a “100 percent success rate” in destroying cancerous breast tumors.

Antonella Carpenter, the former Jacksonville woman who has since moved to Broken Arrow, Okla., and continues to proclaim on her website that she has found a simple, painless way to kill cancerous tumors, wasn’t present for the verdict against her and her company, Lase Med Inc. …….

I don’t recall every hearing of Lase Med Inc: LIESH Therapy.

The plaintiff in the lawsuit is Therese Westphal, 54,

a mother of three sons, said she read about the treatment in a flier she found in a health-food store in California where she went to research nontraditional cancer treatments shortly after being diagnosed in September 2007 with a 2 1/4-inch tumor in the upper right corner of her left breast.

A local oncologist, Bill Tranum, MD, testified Westphal had a 75% to 90% chance of beating the cancer immediately after being diagnosed, the delay dropped her chances to 20%.

The Arkansas Democrat-Gazette article notes Carpenter refers to herself on the website as a “doctor.”

Bond (Will Bond of the McMath Woods law firm in Little Rock) says she’s not a medical doctor, but claims to have a doctorate in physics, possibly from an online university.

A local television station, KTHV, has a segment (open access) on the trial: Company defends laser treatments, despite loss in court

….."I am a physicist. I never claim to be a medical doctor, that's why the patients come to me because those are the ones who want alternative," Carpenter said.

It's an alternative using lasers to kill cancerous tumors. Carpenter says the heat activated in the process does the job.

"Elevated temperature, the tumor reached 134 degrees Fahrenheit, and that is the temperature sufficient to kill the tumors. I have the science that backs it," Carpenter said. ….

Rooster Quilt

This miniature quilt is made using a feed sack which held rice.  The rooster logo is framed by a black and then a red/black sash.  The quilt measures 10.5 in X 12.75 in.  It is machine pieced.  It is machine and hand quilted.

This photo shows the rooster and quilting better.  The rooster is quilted with cross-hatching while the outer area is an intertwined cable.  These were hand quilted.  The area next to the black strip was machine quilted “in-the-ditch.”
The back has a sleeve for hanging.

Impact of Obesity on Breast Surgery Complications – article review

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

Obesity is an ever increasing presence in today’s world.  Thirty-four percent of U.S. adults are now estimated to be obese (BMI>30), up from just 15% three decades ago.

Obesity increases the risk of complications in many medical/surgical situations which has pushed some Ob-Gyns in Florida to refuse to care for pregnant women over a certain weight.

Martin A. Makary, MD and colleagues designed a study to measure the impact on complication rates in obese patients presenting for a set of elective breast procedures.

The PRS journal article referenced below has been published online ahead of print and looks at the impact obesity has on breast surgery complication.

The researchers used claims data from seven Blue Cross and Blue Shield Plans covering individuals with employer-provided coverage and residing in Hawaii, Iowa, Michigan, North Carolina, Pennsylvania, Tennessee, and South Dakota to identify a cohort of obese patients and a non-obese control group who underwent elective breast procedures covered by insurance between 2002-2006.

Criteria for the patient  to be included:
Enrolled in the insurance plan for at least one month before and after surgery

Have a paid claim for breast augmentation, breast reduction, breast lift (mastopexy), or breast reconstruction during the period between 2002-2006

Have either 1) a BMI of 30 kg/m2 or greater, 2) a diagnosis of obesity (using ICD 278.x or V85.x code closest to the date of surgery), or 3) at least one comorbidity associated with obesity (diabetes, hypertension, metabolic syndrome, obstructive sleep apnea, hyperlipidemia, or gallbladder disease) within one year of undergoing the breast procedure

There were 2,403 patients (mean age 42.1 yrs)  in the obese group who were compared to a non-obese control group of 5,597 patients (mean age 48.4 yrs).  Breast reduction was the most commonly performed procedure in the obese and control groups (80.7% vs 63.8%), followed by breast reconstruction (10.3% vs 24.2%), augmentation (4.0% vs 8.9%), and mastopexy with or without augmentation (5.0% vs 3.2%).

Overall, 18.3% of obese patients had a complication compared to only 2.2% in the control group (p<0.001). After adjusting for other variables, the researchers found obesity status increased the odds of experiencing a complication by 11.8 times.

Among the obese patients, at least one complication was observed in 50.5% of patients undergoing breast augmentation (vs. 4.4% of controls), 24.1% undergoing mastopexy (vs. 11.4%), 38.9% mastopexy with augmentation (vs. 5.6%), 29.4% of reconstruction (vs. 1.8%), and 14.6% of breast reduction patients (vs. 1.7%).

The differences between the two groups were most pronounced
in complications such as inflammation (OR=22.2), infection (OR=13.4), pain (OR=11.7), the development of seroma (OR=11.4) and hematoma (OR=10.9).

Obesity status  increased the odds of experiencing a complication (OR = 10.1, adjusted 11.8).  Diabetes (OR = 1.37, adjusted 1.16) and a history of prior chest wall irradiation (adjusted OR = 1.4) were associated with a higher odds of complication.

Hypertension, COPD, a history of neoadjuvant chemotherapy and undergoing a bilateral procedure were not significantly associated with the development of complications.

Makary and colleagues write in their discussion (bold emphasis is mine):

Our data demonstrate that obesity is a major risk factor for complications following elective breast procedures. In light of current trends towards pay-for-performance-based reimbursement, although obesity is currently not accounted for in quality metrics, based on our study, it increases the odds of experiencing any complication within a 30-day postoperative period by 11.8 times. This is in marked contrast to previous studies, which showed either no significant difference in complications between
obese and non-obese patients undergoing elective breast surgery, or just a slight increase.

Although pay-for-performance strives to reward healthcare providers for meeting certain performance measures for quality and efficiency, there is no guarantee that the measures being used accurately reflect the quality of surgical care being provided. For example, the current assumption behind pay-for-performance is that high-quality care reduces surgical
complications.  Our results suggest that variations seen in the rate of complications may be, in part, related to the characteristics of the population--in this case, body habitus. These complications could even occur despite adherence to process measures such as administering appropriate antibiotic prophylaxis. Thus, any measure of quality should consider the effect of obesity on these measures.

REFERENCES
The Impact of Obesity on Breast Surgery Complications; Chen, Catherine L.; Shore, Andrew D.; Johns, Roger; Clark, Jeanne M.; Manahan, Michele; Makary, Martin A.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 9 June 2011; doi: 10.1097/PRS.0b013e3182284c05

New FDA Sunscreen Labeling

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

Yesterday, the U.S. Food and Drug Administration released the new rules regarding labeling of sunscreen.  The goal is to make it easier for the average person to chose a sunscreen. 

The new labels will not be in place until next summer, so you need to be aware.

When the new labels are in place, NO sunscreen will be allowed to be labeled as a SUNBLOCK or as WATERPROOF.  

Under the new labeling rules

• Products that have SPF values between 2 and 14 may be labeled as Broad Spectrum if they pass the required test.
• Only products that are labeled both as Broad Spectrum with SPF values of 15 or higher may state that they reduce the risk of skin cancer and early skin aging, when used as directed.
• A warning statement will be required on any product that is not Broad Spectrum, or that is Broad Spectrum but has an SPF between 2 to 14 stating that the product has not been shown to help prevent skin cancer or early skin aging.

In addition to the final rule for sunscreen labeling, the FDA released a Proposed Rule which would limit the maximum SPF value on sunscreen labels to “50 +”, because there is not sufficient data to show that products with SPF values higher than 50 provide greater protection for users than products with SPF values of 50.

Sunscreens who use the claim of being water-resistant will be required to note how long the product resists being rinsed away while swimming.  In other words, will it rinse off within 15 minutes in the water or last 2 hours.  It is important to remember, no sunscreen is “towel resistant” and can easily be removed toweling off.  It is important to reapply your sunscreen.
It is recommended that a sunscreen labeled as both broad spectrum and SPF 15 be used to protect against both ultraviolet A (UVA) and ultraviolet B (UVB) radiation.  Both types of radiation contribute to skin cancer and premature skin aging.  Sunburns are primarily caused by UVB rays, so simply preventing of a sunburn doesn’t necessarily mean good protection from future skin cancer.

Proper Use of Sunscreen: 

• Apply the sunscreen 20-30 minutes before going outside.  Reapply every two hours when outside at a beach, etc. for adequate protection.
• Use enough. To ensure that you get the full SPF of a sunscreen, you need to apply 1 oz – about a shot glass full.
• Reapply after getting out of the water or toweling off. Even "water-proof" sunscreens are not usually "towel-proof".
• Use even on a cloudy day, up to 80% of the sun's ultraviolet rays can pass through the clouds. In addition, sand reflects 25% of the sun's rays and snow reflects 80% of the sun's rays.
• Don't forget to apply lip balm with SPF 15 or higher.

Other Sun Safe Practices:

• Staying in the shade, especially between the sun’s peak hours (10 a.m. - 4 p.m.).
• Covering up with clothing, a brimmed hat and UV-blocking sunglasses.
• Avoiding tanning and UV tanning booths.

ABC News has a nice piece:  Consumer Reports Health Rates Sunscreens

After testing 22 spray-on, cream and lotion sunscreens, Consumer Reports gave top honors to the least-expensive products.

The magazine recognized three "Best Buys" that provided excellent water-resistant protection for less than 88 cents per ounce: Up & Up Sport SPF 30 by Target; No-Ad with Aloe and Vitamin E SPF 45; and Equate Baby SPF 50.  ……..

Related blog posts:
Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)
Skin Cancer (March 24, 2010)
Safety of Sunscreens (June 14, 2010)
Dear 16-Year-Old Me (May 18, 2011)


REFERENCES
FDA Press Release; June 14, 2011;  FDA Announces Changes to Better Inform Consumers About Sunscreen
FDA:  Sunscreen