Shout Outs

Updated 3/2017--photos and all links removed as many no longer active. 

Paul Ware, Life with Huntington's, is (suppose to be) the host for this week’s Grand Rounds. You can read this week’s edition here.

Next week’s host is Dr. Rob (@doc_rob): What’s Grand and Round and Comes in an RSS Feed?

……To submit your GR post for next week’s GR, fill out the attached submission form. I must have submissions in before Sunday, March 4th at 6 PM EST……

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H/T to @jilltomlinson who asks.

Was this 27yo man's life lost in ill-conceived race to perform "World 1st" surgery? bit.ly/x2bGEJ #retrospectoscope

The link is to this Mai lOnline article: Man, 27, who had world's first quadruple limb transplant dies days after operation.

A 27-year-old Turkish man who underwent the world's first would-be quadruple limb transplant died yesterday, hours after the limbs were removed due to metabolic failure, the hospital said…….

I thought it was too risky when I first heard about the transplant prior to them having to later remove the limbs. We are certainly pushing the limits with transplants these days with double hand, face, multiple organ, etc.

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From Letters of Notes a letter that gives a glimpse of breast Cancer in 1855. This woman had surgery with no pain meds: 'Deep Sickness Seized Me"

In September of 1855, Lucy Thurston — a 60-year-old missionary who had been living in Hawaii with her husband since 1820 — underwent a mastectomy after being diagnosed with breast cancer. Incredibly, she somehow endured the operation wide-awake, without any form of anaesthetic. She wrote the following letter to her daughter a month later and described the unimaginably harrowing experience.

The procedure was a success. Lucy Thurston lived for another 21 years………………

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From @Skepticscalpel comes a post with his take on the survey in the Archives of Surgery: Surgeons and alcohol abuse.

“Prevalence of alcohol use disorders among American surgeons” appeared in the February, 2012 issue of Archives of Surgery.

A survey of 7197 surgeons, all members of the American College of Surgeons [ACS], had a 28.7% response rate and revealed that 15.4% had scores on an alcohol use assessment test that indicated abuse of or dependence on alcohol. This is consistent with the rate of such alcohol problems in the general public…………….

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VIDEO: Kyle Dyer, 9NEWS anchor, interviews with the Denver Post

Channel 9 news morning anchor Kyle Dyer talked to the Denver Post on Wednesday, February 23, 2012, about the injuries she sustained from a dog bite and her road to recovery.……. Video by Mahala Gaylord

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H/T to @impactednurse ‏for this tweet:  “Very cool. Federico Carbajal's anatomical sculptures made with galvanized wire: bit.ly/yRSvFk”

Communicating

My malpractice is through SVMIC.  They periodically sent out a newsletter with upcoming seminars and an article or two on ways to improve your practice/ decrease your risk of getting sued.  The current issue’s article is “Communicating with Patients Who Are Deaf.”

The article reminds us in health care of the Americans with Disabilities Act (ADA) which prohibits all physician's offices (except those operated by religious entities but notes the similar Rehabilitation Act of 1973 covers physician’s offices operated by religious entities) from discriminating against people with disabilities, including those who are deaf.

Key Points:

1.  The physician’s office must provide effective communication which meet the patient’s individual needs.

2.  The physician’s office must pay for the cost – qualified interpreter, video interpreting service, etc.

3.  If there are two equally effective methods or sources, the physician has the right to chose the most cost effective.  The caveat here is equally effective for the individual patient. 

4.  The physician’s office is prohibited from passing along the cost of providing the auxiliary aids/services to the the patient.

5.   The ADA does allow physicians to refuse to provide a specific auxiliary aid/service if doing so will create an undue financial burden (significant difficulty or expense).  This is hard to prove, as it isn’t as simple as weighing the cost of the service against the payment for the appointment.

Examples of auxillary aids and service include 1) qualified interpreter, 2) note takers, 3) open or closed captioning, 4) video interpreting services, and 5) exchange of written notes.

REFERENCES

1.  Deaf Patients, Doctors, and the Law:  Compelling a Conversation about Communication (pdf file); 2008, Florida State Law Review, Vol 35:947

2.  Communication with Deaf and Hard-of-hearing People: A Guide for Medical Education; Barnett, Steven MD; Academic Medicine: July 2002 - Volume 77 - Issue 7 - p 694-700

3. Department of Justice ADA Enforcement page 〈http://www.usdoj.gov/crt/ada/enforce.htm〉. Accessed 2/26/12. United States Department of Justice, Washington, DC, 2001.

Patriotic Medallion Quilt

Though I haven’t in the past year, I have made several quilts for QOV (Quilts of Valor).   This is one I made starting with an orphan block which I used as a center medallion, then used left over squares to add the border.  To gain more length, I used two other orphan blocks and strip pieced the added portion.  I added a simple white border to increase the overall size.  I’m not sure of the overall size, but I think it is in the 50 in X 70 in range.  The top was machine pieced, then hand quilted.

Sorry the photos are better.  This quilt (& photos) are from around 2003 or 2004 (I think).

Hawaiian Quilt for a Friend

Years ago a friend asked me to make a quilt for his wife for their anniversary.  He wanted a queen size.  She like frogs and tropical stuff.  I took on the ambitious project of a Hawaiian appliqué quilt using fabric with frogs, parrots, lizards, etc for the center.  The entire appliqué was done by hand and took me almost 6 months.  I then had my friend Scottie Brooks to do the hand quilting.  I regret that I didn’t get a photo of the finished quilt.  This photo is of the finished top.  The quit was finished in November 2001 (quilted and bound).  It measures 104 in square.

I cropped the above photo to try to show more of the detail, but these photos do not do it justice.  And while I am still friends with the husband, he and she are no longer together, so I can’t get new and better photos. 

Spinal Accessary Nerve Injury

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

This injury will never result in an individual qualifying for SSI disability.  Not even when it occurs on the side of  your dominant hand.  That doesn’t mean it isn’t a serious problem and can result in significant shoulder dysfunction and pain.  It simply means it will never “meet” an SSI disability listing and will not result in more than a one-arm light RFC (residual functional capacity) rating. 

The spinal accessary nerve  supplies the sternocleidomastoid (SCM) and trapezius muscles.  So when the nerve is injured your ability to rotate, tilt, flex your head may be impaired (SCM).  Your ability to elevate your shoulder and draw your head back so the face is upward may also be impaired (trapezius muscle involvement).  The shoulder may exhibit a winged scapula which may be more apparent or exaggerated on arm abduction.

Causes of SAN injury include iatrogenic, traumatic, and neurologic. 

Most iatrogenic SAN injury occur following diagnostic lymph node biopsies of the posterior triangle of the neck. Injury rates from these procedures are reportedly 3-8%.   Functional neck dissections are another source of iatrogenic SAN injury.

As with other nerve injuries, if the injury is a transection and is recognized it can be repaired.  This may be done immediately or within 3 to 6 months after the injury. 

If it is uncertain if this nerve was indeed cut or is a closed injury (ie trauma), then close follow-up with serial electrical tests helps determine if surgery will be required. Physical therapy is the mainstay of treatment regardless of whether surgery is indicated. It improves range of motion and encourages a return of strength once contraction occurs.

Nerve regeneration can take 3-12 months, during which time physical therapy is performed. Patients with a spinal accessory nerve injury older than 1-2 years may not be a candidate for nerve surgery.  So the sooner the injury is recognized and diagnosed, the better. Options for these patients may include tendon/muscle transfer techniques to stabilize the scapula and reduce pain.

REFERENCES
1.  Cranial Nerve XI: The Spinal Accessory Nerve – Clinical Methods
2.  Accessory Nerve Injury; Rohan Ramchandra Walvekar, MD, et al; eMedicine, July 20, 2010
3.  Spinal Accessory Nerve Injury; NYU Medical Center

Sampler Quilt

I made this quilt several years ago and gave it to a friend (a nurse anesthetist I worked with at a local surgery center) who was diagnosed with pancreatic cancer.  I’m not sure how large it is.  I do recall the blocks are 12 in squares and I think the sashing is 2 in wide.  So I would estimate it as being 52 in X 66 in.  It is machine pieced and quilted.

Beginning from the top left to right, the blocks are:
1.  Hole in the Barn
2.  Double Four Patch
3.  Double X
4.  Dutchmans Puzzle
5.  Economy
6.  Double Four Patch
7.  Double Four Patch
8.  Louisiana
9.  Buzzard Roost
10.  Anvil
11.  Airplane
12.  Evening Star

Shout Outs

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

Dr. Jen Dyer, Endogoddess, is hosting this week’s Grand Rounds.   You can read this week’s edition here.

I am a total news junkie and always have been (which is probably why I started out college as a journalism major before deciding that I wanted to be a doctor). So, this week's edition of Grand Rounds features the news themes of the prior week and their relationship to health: politics, football fever, the power of facebook, red heart disease awareness, and the impact of pink. ...….

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Head’s up:  @drjohnm is asking for posts for next week’s edition of Grand Rounds which he will be hosting.  Here’s his tweet:

Dear Med Bloggers: Please send me your posts for the Valentine's day version of @grandrounds http://ow.ly/8Xmze

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

Thank you @tbtam  for the information in your post:  Alternatives to Komen for Channeling Your Dollars & Energy to Fight Breast Cancer:

One option, of course, is to give to Planned Parenthood, The other option is to donate to one of the other charities on the front lines in the battle against breast cancer. Komen, after all, is not the only game in town.

Here are a few other places where your dollars will be put to good use fighting breast cancer. All of the following groups get high ratings from the American Institute of Philanthroy and/or Charity Navigator-……..

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White Coat is attempting to shine light on the issue of Amanda Trujillo: 

I finally took the time to read some other blogs today. One of the issues that I found disturbing was the case of Amanda Trujillo…………….

I’ve tweeted to Amanda to contact me …..

I’ll request the patient’s permission for release of the patient’s medical records from the hospital. ….

And I’ll get the name of the surgeon who allegedly does not take the legal doctrine of informed consent too seriously and who allegedly uses temper tantrums as a means to bully people into submission. Maybe we can look into his background a little. If he did have a “tantrum” in a patient care area, has the hospital investigated him for his conduct?

Everything will be published here.

And if ends up that Amanda was wrong for what she did I’ll publish that as well.

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A New York Times article by Melissa Greene:  Wonder Dog

In May 1999, Donnie Kanter Winokur, 43, a writer and multimedia producer, and her husband, Rabbi Harvey Winokur, 49, beheld the son of their dreams, the child infertility denied them.  ……………..“Sometime after their 3rd birthdays, our wonderful fairy tale of adopting two Russian babies began to show cracks,” said Donnie Winokur,……….

For children with autism or behavior disorders, dogs were trained in “behavior disruption.” For children with seizure disorder or diabetes or respiratory issues, dogs were trained to alert the parents at the onset of an episode, and there have been a few able to predict the medical incidents 6 to 24 hours in advance. (How they do this is something of a mystery.)…………..

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Dogs are so cool! in my humble opinion.  There’s the above story and then there’s this one I heard tonight on ABC Evening News which made me think of my three dogs who died of cancer.  I actually called a drug company way back when to see if she qualified for a drug trial.  There was no registry then.  Oh well.  Here’s the story:  Canine Cancer Studies Yield Human Insights

Some of the most promising insights into cancer are coming from pet dogs thanks to emerging studies exploring remarkable biological similarities between man and his best friend.

Cancer is the leading cause of death in dogs. Every year, millions of dogs develop lymphomas and malignancies of the bones, blood vessels, skin and breast……………….

Jack Sevey Jr. created the website MyCancerPet.com in January 2011 after his 5-year-old boxer Bull died from T-cell lymphoma. Sevey wanted to create an online community for fellow owners of cancer-stricken pets and also steer them to helpful resources. Those include lists of clinical trials compiled by several organizations: the AKC Canine Health Foundation, Animal Clinical Investigation, the National Cancer Institute's Center for Cancer Research, the Morris Animal Foundation and the Veterinary Cancer Society……………..

Baby Surprise Jacket

Recently finished this baby jacket for my niece who’s first baby is due this month.  Also made her a baby quilt.

The pattern is Elizabeth Zimmerman’s Baby Surprise Jacket.    I used Baby Bee Sweet Delight Baby in Crayon Ombre.

I found these buttons in my old button jar which worked nicely.


I’ll be making more of these little jackets.  I may even try one in the adult size.

A Day in My Life

Inspired by @GregSmithMD’s post:  A Day In The Life

Reviewing disability cases, here are the allegations from a recent day.  Each bullet represents one individual and their allegations of medical determinable impair (MDI):

• Hx surgery knee, reflex sympathetic dystrophy
• Sickle Cell Anemia
• Hypertension, Arthritis, and depression
• Buttock and elbow contusion
• Seizures
• Broken Ankles
• Stage II breast cancer, FM, chronic pain, asthma, sleep apnea, emergent rhinitis, urinary incontinence, migraines, eczema, adenomyosis, nephrolithiasis, RLS, HTN, GERD, lymphedema, plantar fasciitis, and mental
• Frozen RT ankle
• HIV/AIDS complicated by CMV

re-su yukata Sweater

I undertook this challenge back in October 2011.  I recently finished it.  I love/hate it. 

The sweater is a shortened version of the re-su yukata pattern from the book Knit Kimona Too. The yarn is The Fibre Company Terra in black walnut.

I like how the sleeves fit.  I like how the back looks.

I’m not happy with the tension of my band edge which always it to “wave.”  The neck looks unsymmetrical to me.
I love the button and the I-cord closure.

I’ve put it aside for now.  Trying to decide whether to keep it or give it to someone who wouldn’t see the flaws and would love it.

Sitting All Day is Damaging

I take this type of information even more seriously than I used to given my new job which is very sedentary.  Thanks DoctorMama for the link to this LifeHacker article:  How Sitting All Day Is Damaging Your Body and How You Can Counteract It

Related posts:

Pedometers and Physical Activity  (November 30, 2007)

Getting Back Into Shape  (November 13, 2008)

Exercise Only Good if Done (March 18, 2009)

Finger and Wrist Exercises (April 19, 2010)

Get Up and Move (January 28, 2010)

Mindful of Two Breast Implant Scandals

This year began with a breast implant scandal.  This one has brought back memories of the one early in my private practice.

The current one involves the PIP-branded breast implants produced by the French company Poly Implant Prothese and rebranded by the Dutch company Rofil as Rofil M-implants breast implants.  The first one involved silicone implants made by American companies including Dow Corning who no longer makes breast implants.

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.

My post Breast Implants -- Some History (March 3, 2008) covers much of the history of implants in the United States.  Kira Cochrane, The Guardian, wrote about the first patient to receive a breast implant:

It was in 1962 that Timmie Jean Lindsey was offered a solution to a non-existent problem. A factory worker from Texas, ….. And the doctors had another proposal. Had she ever thought about breast implants?

Lindsey had not. ….

……...She's 80 today, still living in Texas, working night shifts in a care home, and those first, experimental globes remain in her chest. ……

I would love to know if they are soft or have become hardened by capsular contractures.  The article doesn’t say.

In the current breast implant scandal, I haven’t noticed anyone urging a class action lawsuit against the French company Poly Implant Prothese or the Dutch company Rofil.  The big issues are 1. do the implants need to be removed or just checked and 2. who will pay for the removal, the government or the private clinics.  The issue isn’t just a European one, it affects women in South American, Mexico, and the United States.

The old scandal in the early 1990s was handled by a class action lawsuit.  I had not been in practice long enough for it to truly affect my then current patients, but I saw many who’s doctors were no longer in practice or non-plastic surgeons who has decided due to the scandal to quit doing breast implants.  I did exams for free, but not the surgeries.  I did, however, not raise prices or take advantage of the situation. 

When I was in practice, I encouraged my breast implant patients to return every year or two for a complimentary breast exam.  This keep us in contact so if anything (ie ALCL and implants, or faulty implants) came up I had current addresses.  I made sure each woman had the information on her implants and encouraged her to keep up with it.  I also encouraged the extended warranty on the implants.  This helps settle who pays for what, at least for the first 10 years.

Women and their doctors need to be mindful that implants are foreign bodies we are placing into the human body.   Women and their doctors should be mindful of future costs that might be incurred from breast implant surgery.   In the United States, many things related to implants, especially those placed for cosmetic reasons only, are not covered by insurance or the extended warranty.

Related posts:
Breast Implants -- Some History (March 3, 2008)
FDA Updates Safety Data for Silicone Breast Implants  (June 23, 2011)
ALCL and Breast Implants  (January 31, 2011)

REFERENCES
1.  Breast implant scandal: now women with Rofil M-implants 'are at risk';  The Telegraph, Matthew Holehouse, January 5, 2012
2.  Breast implants – a brief history of the first 50 years; The Guardian, Kira Cochrane, January 11, 2012
3.  Q&A: PIP breast implant s health scare; BBC Health News, James Gallagher, January 11, 2012
4.  Confusion Reigns Abroad Over Faulty Breast Implants; MedPage Today, Cole Petrochko, January 13, 2012
5.  PIP breast implants: European Commission says reform needed;  BBC Health News, James Gallagher, January 14, 2012
6.  Keeping patients safe: The case for a breast implant registry; The Atlantic,  Anna Yukhananov, January 5, 2012