Suture for a Living to Host Grand Rounds

I’ll be your host next Tuesday, September 20th, for Grand Rounds Volume 7 Number 52.   It will be my sixth time as host of this the weekly compilation of the best of the medical bloggers.  I have no specific theme in mind.

Submissions should be recent.  Please, only submit one (your best) post per blog.  Submissions are welcome until noon (CST) Monday September 19th. 

Send an email to me ---  rlbatesmd(at)gmail(dot)com  ---   with Grand Rounds in the subject line.  Please help me out by including your site name, site url, your post  title, post url, your name and a sentence or two about why you think your submission is great. 

 

In the meantime check out my previous five editions:

Grand Rounds 4:33 (May 6, 2008)

Grand Rounds Vol. 5 No. 52 (September 15, 2009)

Grand Rounds Vol 6, No 26 (March 23, 2010)

Grand Rounds Vol 7 No 20 (February 8, 2011)

Grand Rounds Volume 7 Number 48 (August 23, 2011)

Make Sure Your Surgeon is Trained for Your Procedure

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Don’t simply look for a surgeon who is board certified.  Make sure they are trained to do the procedure you are having.  Yes, board certification is important, but the training is more so (in my humble opinion).

If you are having a breast augmentation, you don’t want a board certified maxillofacial surgeon or Ob-Gyn or neurosurgeon.  You want someone trained in plastic surgery.  It is a bonus if they are board certified.  By the same token, if you need brain surgery you don’t want a board certified plastic surgeon you want someone trained in neurosurgery. 

This rant was prompted by the USA Today article written by Jayne O’Donnell:  Lack of training can be deadly in cosmetic surgery

……….Sant Antonio is one of a soaring number of doctors who trained in other medical specialties, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery. Because state laws governing office-based surgeries often are lax, levels of training vary so widely that some doctors are performing cosmetic procedures after only a weekend observing other doctors. Sant Antonio himself has offered three-day liposuction training at his office for the last few years, according to interviews with doctors who have trained under him.

Some dentists trained in oral surgery now do breast implants; OB/GYNs perform tummy tucks, and radiologists are doing liposuction. The results can be disastrous, according to interviews with scores of victims, plaintiffs' lawyers and plastic surgeons, and a review of lawsuits. ………….

Genetic Breast Cancers Show Up Earlier in Next Generation

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

Somewhere along the line I learned to encourage women with a family history of breast cancer to begin getting mammograms at an age 10 years prior to when their mother was diagnosed and to encourage their daughters to begin getting mammograms at an age 10 years prior to when they themselves were ever diagnosed. 

I learned this prior to the discovery of BRCA genes.  It was a trend that had been noted among women with strong family histories.  The new study (see full reference below) in the journal Cancer verifies that genetic breast cancers show up earlier in the next generation – on average by 8 years.

The study from MD Anderson looked 2 generations of families with the BRCA gene to assess the age at diagnosis.  Using the pool of 132 BRCA-positive women with breast cancer who participated in the high-risk protocol at The University of Texas MD Anderson Cancer Center (Gen 2), 106 women could be paired with a family member in the previous generation (Gen 1) who was diagnosed with a BRCA-related cancer (either breast cancer or ovarian cancer).

The median age of cancer diagnosis was 42 years (range, 28-55 years) in Gen 1 and 48 years (range, 30-72 years) in Gen 2 (P < .001). In the parametric model, the estimated change in the expected age at onset for the entire cohort was 7.9 years (P < .0001). Statistically significant earlier ages at diagnosis also were observed within subgroups of BRCA1 and BRCA2 mutations, maternal inheritance, paternal inheritance, breast cancer only, and breast cancer-identified and ovarian cancer-identified families.

It is reasonable to encourage these women with significant family history of breast cancer to begin surveillance at an earlier age than the general population. 

REFERENCE

Earlier age of onset of BRCA mutation-related cancers in subsequent generations; Litton JK, et al;  Cancer 2011; DOI: 10.1002/cncr.26284.

Breast Cancer Patients With BRCA Gene Diagnosed Almost Eight Years Earlier Than Generation Before; Science Daily, September 12, 2011

Mom's Cancer Shows Up Earlier in Daughters; Michael Smith, Dori F. Zaleznik, MD; MedPage Today, September 12, 2011

Shout Outs

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

There were no takers for hosting this week’s Grand Rounds.  If you would like to be a future host:

… Send an email to Nick Genes (you can find his contact info at blogborygmi.com) and request to be considered as a future host. Include a link to your blog. Host bloggers must have been blogging regularly for at least 6 months, have a health theme, demonstrate good writing skills, professionalism, and respect for scientific medicine. If your blog meets those requirements (and is approved by Nick or Val) they’ll contact you via email to schedule your host date.

If you missed last week’s edition, then check it out.  Dr. Rich, Covert Rationing,  was the host. You can read last week’s edition here.

ZDoggMD will be hosting on September 27th. His theme will be Funny Medical Stuff but he will accept good submissions on almost any medical topic.  You can email submissions to him at zdoggmd (AT) gmail (DOT) com

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Dr. Charles is “Calling for Entries in the 2011 Charles Prize for Poetry Contest.”

Announcing the second annual Poetry Contest!

An award will be given to the writer who submits for consideration the most outstanding poem within the realm of health, science, or medicine. ……….

The contest began Wednesday August 31st and ends September 31st, 2011. The winners will be chosen shortly thereafter by an elite group of 8 judges (other doctors, friends with literary training, and select bloggers).  The contest is open to everyone.

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In case you missed it, I just want to point you to this lovely post by @doctorwes:  The Flywheel

(With apologies to Harry Chapin)

"Welcome to BA Cardiology Associates, young doctor, we're thrilled you've decided to join us. As you recall, we guarantee your salary for the first several years then when you're practice is established, your salary will be proportional to your productivity. Oh, and if you need anything, just let us know."

A child arrived just the other day. He came to the world in the usual way...

"I had the most amazing case today! His heart rate was so slow..."
"Doctor, we're impressed at how things are going."

He learned to walk while I was away...

"Thanks for helping out……

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (September 2011)! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to the September, 2011 edition of Change of Shift!

This is quite the eclectic selection of posts from across the nursing blogosphere, composed of those submitted for inclusion and those I found in my travels through the neighborhood.

Remember, submissions are always accepted for Change of Shift, there is never a deadline to meet, so don’t hesitate to submit a post at any time.

Let’s begin! …………………….

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H/T to @scanman for retweeting this “@JenniferAdaeze: I helped found a Journal of #NarrativeMedicine theintima.org follow @the_intima & spread the word :) #meded”. 

It will be interesting to follow The Intima, a Journal of Narrative Medicine.  There are sections for poetry, fiction, non-fiction, and art inspired by medicine.  Check out this fictional story by Dana Gage about a medical student struggling with a dying child:  Nightwatch

Rane entered the room hesitantly; she didn’t want to enter at all; she had pleaded with the intern and then to the resident, who just shook his head and said it wasn’t up to him. The Chief Resident had ordered, had insisted upon it, that she see this particular child, work her up. …………

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H/T to @evidencematters who alerted me to this Guardian article by Patrick Barkham:  Nazis, needlework and my dad (photo credit)

Not many men belong to a stitching group, but Tony Casdagli picked up his enthusiasm for the craft from his father, who kept himself sane by fashioning subversive messages as a PoW  ………….

Reviewing

The past few weeks have been filled with writing letters to organizations and patients to announce the closing of my medical practice, sorting through 21 years of stuff and deciding what to do with it (keep, give away, sell, donate), canceling accounts (Pitney Bowes, credit card processing, yellow page ads, etc), trying to sublease the office space (as I am caught midway in my lease), getting a PO Box so journals, etc don’t come directly to my home (as we all know our data is sold to marketing), and copying records as the requests come in.

Much of this has been a review of my past 21 years.  I seem to have used my office (and the draws, filing cabinet space) to store not just professional correspondence, but also personal.  I had a couple of drawers that I routinely keep filled with cards (birthday, thank you, condolence, encouragement, just because).  I love mailing cards to family and friends.  My desk was a nice space to sit down and do this before the day began.

I have been amazed at the number of letters I have “squirreled” away in my desk drawers.  Many of these are from loved ones now dead (my mother, my old high school math teacher, a plastic surgery mentor).  Others are thank you notes from nieces and nephews who had just learned to write.  These made me smile, as they are now in high school, college, or grown with their own children.

Coping the charts bring many emotions.  I did the right thing here.  Did I miss something here?  What if I had done this one differently?  If I did this one today I would do it like this, not like that?  I would do this one the very same way.  I wonder how this one is doing. 

So many emotions in reviewing the past 21 years.

CraftGossip’s Fork and Talk Night

 Updated 3/2017-- photos and all links removed removed as many no longer active.

I was invited to attend this event (photo credit) by Scarlett (Quilting editor) who is one of the four local employees of this Australia-based network. The other three are Denise (needlework editor), Stacie (Jewelry Making editor) and Anne (Sewing editor). It was sponsored by CraftGossip.com and EKSuccess.

I enjoyed meeting other women who blog and love to make things with their hands. I sat next to Barbara Moore who is a gourd artist from Flippin, Arkansas who blogs at Mo(o)re Gourd Whimsies. Her work is exquisite! Here is a sample of it from her blog header:

After having a great lunch (food by Trio’s), we were split from our original tables. The new groups then decorated hats together. My group didn’t win, but I liked ours. Seen here, modeled by Suzanne who blogs at UnRuffled (sorry I can’t a link to her blog). She is a newly graduated respiratory therapist.

Then we were asked to try out this craft kit. The kit includes the needle and thread as well as the die-cut fabric pieces needed to create the bows. You then have a choice of it being a barrette or a pin. The hardware is included for each.
It was amazing the goodies we were given to take home. Not much in the way of fabric or yarn (my favorite mediums), but I love the acid-free pens and the scissors!
Here are some of the things I did bring home (I gave twice as much to a woman who puts craft kits together for the cystic fibrosis patients at Arkansas Children’s Hospital. I wish I had given her all of my stuff (well, not the pens and scissors).

This bead kits look wonderful for kids (which I don’t have). I think Methodical Madness’ will like them.
These stickers would be great for a scrap booker or maybe my teenage niece will like them.
These kits would be great fun to do with kids.
I did find some possible quilt inspiration in thumbing through the beading booklet.

Gold Rush SF Santa Quilt

This small quilt (9 in X 10.5 in) began as a needlepoint project back in 1993 from a kit I bought on a trip to San Francisco.  The kit is a DeDe’s needlework design  (Dede Ogden).  It is her Gold Rush S.F. Santa.  I had long ago finished the Santa, but for some reason did not do the background and then misplaced or lost the thread needed for the background.

When I “stumbled” upon it again recently, I decided to turn it into a small quilt.  I added a white fabric background and then a border.  I then machine and hand quilted it.

The back has triangles to add in hanging the quilt.  A small bamboo stick can be placed and hung on a picture hook (see where the pin is).
Here is the Gold Rush S.F. Santa design which makes it a little easier to appreciate the San Francisco elements included.

There’s the pan of gold Santa is holding in his left hand, the sourdough bread in his right.  Just off his right elbow is the Golden Gate bridge and below that the cable car.  The “E” area is the Coit Tower.  The “I” area is the Crooked Street.  The “J” flowers are poppies.

I sent this quilt to our fellow blogger Doc Gurley.

Bariatric Surgery Should Come Before Breast Reduction

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

Many women with large breast and weight issues seek breast reduction.  I was taught to encourage them to lose weight first.  Now there is a very small study that backs this up  (full reference below).

The American Society of Plastic Surgeons issued a press release entitled “Breast Reduction and Bariatric Surgery—Which Should Be Done First?” and provided the answer “ Final Results May Be Better When Weight Loss Comes First.”  I agree, but find it odd that such a small study was published.  There should have been more patients included.

Jeffrey A. Gusenoff, MD, and colleagues reviewed two groups of patients who sought consultation for body contouring surgery August of 2008 and February of 2010 after massive weight loss (defined as a weight loss of greater than 50 pounds).

Group I (n=15) included any patients who underwent reduction mammoplasty for symptomatic macromastia before massive weight loss.  Group II (the control group, n=14) included any patients who did not undergo breast surgery before massive weight loss.

The patients were given a prospective phone survey to assess self-ratings of breast appearance before and after breast reduction and after massive weight loss, ability to exercise, which would have preferred to have first—massive weight loss or breast reduction surgery—and what they would recommend to a friend.

Of the 15 patients (7.9%) in group I, 14 completed the survey (93%). 

For group I, all patients felt the appearance of their breasts improved after reduction (p < 0.001) but felt appearance worsened or stayed the same after weight loss (p = 0.003).

Seventy-one percent of patients were able to exercise more and 64 percent were able to lose weight on their own because of their reduction. ……..

Ten patients (71 percent) would recommend that a friend lose weight before breast reduction surgery. …

For group II, 79 percent of patients felt the appearance of their breasts worsened or stayed the same after massive weight loss (p = 0.03). ……

All 14 patients (100 percent) would recommend losing weight before undergoing breast surgery.

Even though I tend to agree that patients should loss weight prior to breast surgery.  It is much easier to achieve the cosmetic goals of the patient if she is at or near her goal weight.  Otherwise, the surgeon and patient are left to guess at how her skin will retract with weight loss and how much deflation or loss of volume will occur.

I wish the study had ask how many of the Group I patients desired an augmentation as part of their revision. 

Eleven patients (79 percent) felt a secondary lift following massive weight loss should be covered by insurance, and seven patients (50 percent) plan on having revision breast surgery.

They noted it with Group II patients

Eleven patients (79 percent) wished their breasts currently appeared different, with eight (57 percent) desiring lifted breasts, seven (50 percent) desiring general reshaping, two (14 percent) desiring reduced breasts, and two (14 percent) desiring larger breasts.

I have augmented four patients over my 21 years of practice who had previous breast reductions prior to losing weight (one was mine).  This should be included in the discussion as well as the high probability that a revision to reshape or re-lift the breasts will be needed if the reduction is done prior to the (massive) weight loss.

Related posts:
Reduction Mammoplasty (December 19, 2007)
Breast Reduction: Safe in the Morbidly Obese?—Article Review  (August 25, 2008)
Tennis Star Brings Breast Reduction Surgery into Press (June 4, 2009)
Impact of Obesity on Breast Surgery Complications – article review  (June 16, 2011)


REFERENCE

Reduction Mammaplasty, Obesity, and Massive Weight Loss: Temporal Relationships of Satisfaction with Breast Contour; Coriddi, Michelle; Koltz, Peter F.; Gusenoff, Jeffrey A.; Plastic & Reconstructive Surgery. 128(3):643-650, September 2011; doi: 10.1097/PRS.0b013e318221da6b

Shout Outs

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

Dr. Rich, Covert Rationing,  is the host for this week’s Grand Rounds. You can read this week’s edition here.

While Grand Rounds is normally the highlight of everybody’s week here in the medical blogosphere, this time it’s different. …………..

But be assured that there is good stuff to follow. So, if you find yourself incapable of focusing your attention on Grand Rounds at the moment, simply bookmark this page, and return to it once your sense of soaring happiness returns (as it inevitably must) to a more normal state. Be assured that this week’s entries are timeless enough to outlive your ecstasy (an emotion which – alas! – to be effective, must always be transient).

So let us begin.  ………

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Dr. Charles is “Calling for Entries in the 2011 Charles Prize for Poetry Contest.”

Announcing the second annual Poetry Contest!

An award will be given to the writer who submits for consideration the most outstanding poem within the realm of health, science, or medicine. ……….

The contest began Wednesday August 31st and ends September 31st, 2011. The winners will be chosen shortly thereafter by an elite group of 8 judges (other doctors, friends with literary training, and select bloggers).  The contest is open to everyone.

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Fellow blogger Margaret Polaneczky, MD, TBTAM, is one of the authors of the American Academy of Pediatrics Textbook of Adolescent Healthcare!  She writes:

I wrote the chapter on contraception, but it’s just a teeny-tiny piece of this amazingly comprehensive text, available either in hardcopy or as an e-book from the AAP Bookstore.

Great work, Peggy!

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H/T to @doctorwes for tweeting this:  “One to bookmark: a website that manages medical expenses simplee.com”

The site looks like it would be very helpful in keeping track of medical expenses, especially from multiple sources (doctors, hospitals, labs, etc).  I plan to bookmark it and look at it closer.

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H/T to @hrana for the link to this Scientific American article by Larry Greenemeier:  Medical Mystery: How can some people hear their own eyeballs move?  (photo credit)

It sounds like something out of an Edgar Allen Poe tale of horror. A man becomes agitated by strange sounds only to find that they are emanating from inside his own body—his heart, his pulse, the very movement of his eyes in their sockets. Yet superior canal dehiscence syndrome (SCDS) is a very real affliction caused by a small hole in the bone covering part of the inner ear. Such a breach results in distortion of hearing and, often, impaired balance.   …………….

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I stumbled upon a new-to-me quilting blog – A Quilting Life – by Sherri.  Here is a recent post: Quilt in a Day! (photo credit)

I wonder how many of us started quilting with Quilt in a Day quilts by Eleanor Burns.  I know I made about 8 quilts from her Double Irish Chain book before feeling confident enough to try other patterns. (I happened to get on an elevator with her at Spring Quilt Market, and  thanked her profusely for her inspiration during my quilting beginnings--she probably thought I was crazy; I kept going on and on about all the quilts I made from her patterns those first couple of years)!  Anyway, because of procrastination I needed to make a baby quilt in a day.  And I had just a jelly roll and yardage for backing.  ………….

Recent FDA Advisory Meeting on Implants

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

It’s amazing what you will find sorting through more than 20 years of stuff.  This picture of 3 implants includes:  top -- an old McGhan double lumen (silicone gel implant surrounded by a saline implant); bottom left – Dow Corning textured silicone implant; and bottom right – Dow Corning smooth silicone implant.  Dow Corning has not made breast implants since approximately 1992.

Last week the FDA met to discuss and make recommendations on postmarketing issues related to silicone gel-filled breast implants.  As a condition of placing silicone implants back on the market in 2006, both Mentor and Allergan (McGhan) were suppose to enroll patients in 10-year-long follow up studies on side effects related to implants.  The aim was for 80,000 women.

I agree these studies are needed, but it is difficult to get women to return year after year.  This is evident in the data presented at the meeting:

After two years, about 60 percent of Allergan patients were still participating, but just 21 percent of Mentor patients were involved.

I, like Dr Rob Oliver (Plastic Surgery 101 Blog),  found the requirement of routine MRI screening at three years after getting implants and every two years following to look for silent ruptures to be unrealistic and unnecessary.  Insurance often did not cover this expense to the patient.  The FDA has now removed this requirement.

Several advisory panel members said the FDA's requirement that women have frequent MRIs to make sure the implants haven't ruptured is unrealistic and should be removed from the product label. Insurance usually doesn't pay for the scans, so most women don't get them done. But it's the only way to find out whether the implant has ruptured in the absence of symptoms.

The advisory panel did recommend the creation of a nationwide database to follow women who have had silicone-gel breast implants for at least a decade after they had the surgery.  I think it should be for 20 years.

Related posts:
Breast Implants -- Some History (March 3, 2008)

FDA Updates Safety Data for Silicone Breast Implants  (June 23, 2011)

REFERENCES
Breast Implant Safety to Be Focus of FDA Panel; Emily P. Walker, Washington Correspondent, MedPage Today; August 29, 2011

Breast Implant Follow-Up Far Short of FDA Goals; Emily P. Walker, Washington Correspondent, MedPage Today; August 30, 2011

FDA Panel Calls for Silicone Breast Implant Registry; Emily P. Walker, Washington Correspondent, MedPage Today; August 31, 2011

F.D.A. Affirms Safety of Breast Implants; Gardiner Harris, NY Times, August 31, 2011

Color Wheel Wall Hanging

I finally finished the color wheel wall hanging quilt!  As you may recall, it is from a 1993 color wheel kit designed by Susan McKelvy (author of Color for Quilters).  I began the quilt earlier this summer and finished it a few weeks ago.

It is machine and hand pieced.  It is machine quilted.  It is 29 in square in size.

Here is a closer photo to show the quilting better.
Here you can see the quilting of the border.

The back is a black cotton.  I tried to get a good photo of the quilting from the back, but it didn’t work out.

Kids and Boxing

I can’t say I am a fan of boxing, but I can appreciate the discipline required both mentally and physically.  The American Academy of Pediatrics has recently (full reference below, free access) issued a policy statement on participation of children and adolescents in the sport of boxing (bold emphasis is mine).

Thousands of boys and girls younger than 19 years participate in boxing in North America. Although boxing provides benefits for participants, including exercise, self-discipline, and self-confidence, the sport of boxing encourages and rewards deliberate blows to the head and face. Participants in boxing are at risk of head, face, and neck injuries, including chronic and even fatal neurologic injuries. Concussions are one of the most common injuries that occur with boxing. Because of the risk of head and facial injuries, the American Academy of Pediatrics and the Canadian Paediatric Society oppose boxing as a sport for children and adolescents. These organizations recommend that physicians vigorously oppose boxing in youth and encourage patients to participate in alternative sports in which intentional head blows are not central to the sport.

I would tend to agree that children should be encouraged to participate in sports that have less risk of concussion injury.

Related posts:
Cauliflower Ear  (September 21, 2007)
Mangled Ear--a badge of honor?  (August 4, 2008)
Hematoma of Ear (Boxer's Ear) – 1908 TX  (October 14, 2009)


REFERENCES

Policy Statement—Boxing Participation by Children and Adolescents; American Academy of Pediatrics, Council on Sports Medicine and Fitness, Canadian Paediatric Society, and Healthy Active Living and Sports Medicine Committee; Pediatrics 2011; peds.2011-1165; published ahead of print August 28, 2011, doi:10.1542/peds.2011-1165