SurgeXperiences 316 – Call for Submissions

Updated 3/2017:  links removed as many no longer active.

Dr DJ, a private surgeon in India,  will be the host for SurgeXperiences 316 (February 7th).  The author behind this blog describes himself this way: 

A surgeon with a penchant for writing and a passion for revealing the truth behind the farce that is the Indian Medical Industry.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  You are encouraged to submit your surgery related posts.   The deadline for submissions to be included in the 316 edition is midnight on Friday, February 5th.  Be sure to submit your post via this form. 

If you would like to be the host  for a future edition of SurgeXperiences, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Timing

“Dr. Bates, your patient’s EPT is positive.”

“Let the OR know, I’ll go tell Meg.”

Knocking softly, I enter. “Meg, we’ll have to reschedule your surgery. Your EPT is positive.”

“Oh.” Meg exhales. Tears run down a cheek as she smiles, “We wanted another one.”

Rainbow Blooming Nine Patch

My friend Vivian asked me to make a quilt for her grand-daughter K.  Vivian speaks of K as her daughter and is raising her as such.  K’s mother (Vivian’s daughter) died a few years ago leaving both of them stunned with grief.   Yet Vivian is one of the most hopeful, resilient people I know.  I was very happy to make the quilt for her.

I choose to make her a bright quilt.  The result is this rainbow blooming nine patch.  It is 45 in X 54 in.  It is machine pieced and quilted.

This near photo shows some of the very simple cross-hatched quilting done.

I found some wonderful fabric for the backing/binding which looks to me like fireworks exploring in all the colors of the rainbow.   The world needs more people like Vivian.

ACS’s Surgical Case Log for Haiti Workers

Updated 3/2017 -- links removed as many no longer active.

H/T to Dr. Val, Better Health and her post  The American College Of Surgeons Creates Case Log For Surgeries Performed In Haiti.  I’d like to help her get the word out on this web-based tool the ACS has created to help medical workers in Haiti keep track of surgical procedures.

The ACS has a case log system in place already for College members which they have expanded and opened to non-College members as well.

Non-ACS members can register here.  The system will automatically add Haiti as a location, and surgeons can start adding cases right away.

ACS members who have used the case log system before can log in here.  ACS members who have not registered to use the case log system can register at here.  Once ACS members are logged in, they can add “Haiti” as a location for cases associated with relief activities.

The system currently works with both Palm and Pocket PC phones.  The iPhone and Blackberry editions will be released in the next 1-2 weeks.

Get Up and Move

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

Last week, researchers  at the Swedish School of Sport and Health Sciences published an editorial online in the British Journal of Sports Medicine, warning us of the dangers of prolonged sitting.

Dr. Elin Ekblom-Bak and colleagues note the benefits of regular physical activity for several major health diseases is clear and unanimous, but warn that recent studies suggest that prolonged bouts of sitting time and lack of whole-body muscular movement can undo some of the benefits even for someone who is considered “in shape.”

The editorial mentions a study published last year that tracked more than 17,000 Canadians for about a dozen years. Peter Katzmarzyk  and colleagues found people who sat more had a higher death risk, independently of whether or not they exercised.

Our bodies are designed to be active.  I, like many of you, sit too much.  It’s a hazard of our jobs and our hobbies.  It is important to do as Dr. Ekblom-Bak says: "It is important to have a five minute break from desk work every 45 minutes.”

I don’t have to give up my computer time or my sewing/knitting or my reading or my TV.  What I have to do (and what you should do) is make a conscious effort to remember to stand up and move for a few minutes ever 30-45 minutes of prolonged sitting.

When  watching TV, use the commercials as reminders.  It’s a great time to get up and stretch or do a few lunges or maybe a jumping jack or two.

In my sewing room, I have to get up when I need to press seams.  This breaks up the sitting time.  I don’t always have automatic “breaks” when knitting, reading, or using the computer.  I have to remind myself to do so. 

Last week, Dr Anonymous posted Warning: Sitting Can Kill You.   How about David Bowie’s Let’s Dance?  Anyone want to join me?

REFERENCES

“Are we facing a new paradigm of inactivity physiology?"; British Journal of Sports Medicine Online First 2010; doi 10.1136/bjsm.2009.067702; Elin Ekblom-Bak, Mai-Lis Hellénius, Björn Ekblom

Sitting time and mortality from all causes, cardiovascular disease,
and cancer;  Med Sci Sports Exerc 2009;41:998–1005; Katzmarzyk PT, Church TS, Craig CL, et al.

Black Market Botox

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

Earlier today I listened to NPR’s broadcast of the Diane Rehm show:  Implications of a Global Black Market for Botox (link removed 3/2017 -- no longer active).  The guests were

Col. Randall Larsen, executive director of the bi-partisan, Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism and the founding director of The Institute for Homeland Security (2000-2003)

Marina Voronova-Abrams, biosecurity or biothreat reduction expert, formerly based in Central Asia and Russia, now works for the nonprofit environmental group Global Green

Dr. Tina Alster, clinical professor of dermatology at Georgetown University Medical Center and the Director of the Washington Institute of Dermatologic Laser Surgery.

Kenneth Coleman, a Senior Fellow, for the Chemical & Biological Weapons Nonproliferation Program (CBWNP) of the James Martin Center for Nonproliferation Studies at the Monterey Institute of International Studies

In full disclosure, Diane Rehm begin by mentioning the use of Botox for her own vocal spasmotic dystonia.  Very interesting show.  

The reason for the show was the Washington Post article by Joby Warrick  “Officials fear toxic ingredient in Botox could become terrorist tool” posted Monday, January 25, 2010.

….Obtaining the most lethal strain of the bacterium might have posed a significant hurdle for would-be terrorists in the recent past. But today, the prospect of tapping into the multibillion-dollar market for anti-wrinkle drugs has spawned an underground network of suppliers and distributors who do most of their transactions online, the researchers found. Customers don't need prescriptions or identification, other than a shipping address………..

So lethal is the undiluted toxin that at least three countries -- the United States, the then-intact Soviet Union and Iraq -- explored its possible use as a possible biological or chemical weapon. All three gave up on the idea, partly because botulinum toxin degrades quickly when exposed to heat, making it poorly suited for delivery by missile or bomb

Having taken a few courses on Disaster Preparedness, it is always pointed out botulinum toxin is not a great toxin for mass destruction as it would be difficult to weaponize the bacteria as noted above and here.

Botulinum toxin is the most poisonous substance known.  A single gram of crystalline toxin, evenly dispersed and inhaled, would kill more than 1 million people, although technical factors would make such dissemination difficult. The basis of the phenomenal potency of botulinum toxin is enzymatic; the toxin is a zinc proteinase that cleaves 1 or more of the fusion proteins by which neuronal vesicles release acetylcholine into the neuromuscular junction.

BOTOX is currently licensed for treatment of cervical dystonia, strabismus, blepharospasm,  primary axillary hyperhidrosis, and glabellar wrinkles.  It is also used "off label" for a variety of more prevalent conditions that include migraine headache, chronic low back pain, stroke, traumatic brain injury, cerebral palsy, achalasia, and various dystonias.

REFERENCES

Botulinum Toxin as a Biological Weapon;  JAMA. 2001;285:1059-1070 (consensus statement)

Bogus Botox® (botulinum toxin type A) Suspected in Botulism Outbreak; Medpage Today, November 30, 2004; Jeff Minerd

Caution About a Bioterror Attack on the U.S. Milk Supply; June 2005; Marguerite Rigoglioso

US Diagnosis of Closed Tendon Injuries

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

I found the article on using ultrasound to diagnosis closed flexor tendon injuries interesting.  I  still rely on history and physical exam to make the diagnosis, but can see how the use of ultrasound (US) could be useful particularly in children.

The article is a retrospective audit of the accuracy of US in diagnosing closed flexor tendon ruptures and ruptures following recent flexor tendon repair in 80 patients between January 2001 and December 2006.  The accuracy of US was found to be higher than clinical examination alone (95% vs. 79%, Z = 2.00, p = 0.03).

US findings were 100% accurate when imaging was undertaken between 1 and 7 days following injury, but only 88% accurate when undertaken on the same day as injury and 85.7% accurate when performed after 1 week (X ² = 6.4, p = 0.04).

If the flexor tendon injury is not clear on physical exam, then US might have a role. 

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Most injuries to the flexor tendons are due to a cut of some kind (ie knife, saw, etc).  Closed injuries to the flexor tendons are often athletic injuries that occur when one player grabs another's jersey, and a finger (usually the ring finger) gets caught and pulled.  The forceful hyperextension of a digit leads to the avulsion of the flexor digitorum profundus (FDP) tendon from the distal phalanx.  This mechanism has given the injury the common name: "jersey finger."

Closed injuries to flexor tendons can also occur when the tendon is stretched (strained) or ruptured.  These mechanisms are more common in sports like rock climbing or in persons with rheumatoid arthritis.

Clinical assessment can often be difficult as swelling and pain may limit movement of the injured digit irrespective of the integrity of the flexor tendon mechanism.  The integrity of FDS and FDP tendons should be tested independently and in tandem.

• To test the FDP tendon, the examiner holds the other fingers in extension and stabilizes MCP and PIP joints. The patient is then asked to flex the distal phalanx.
• To test the FDS tendon, the examiner holds the other fingers in extension, but the MCP and PIP joints are released. The patient is asked to flex the finger. The PIP joint and, to a lesser degree, the MCP joint should flex. About 20% of patients are missing a FDS tendon in the little finger and will therefore have limited or no PIP flexion during testing.
• For flexor pollicis longus (FPL) testing, the thumb MCP joint is stabilized in neutral position. The patient is asked to flex the interphalangeal (IP) joint against resistance. A communication may exist between the FPL and the index FDP. The examiner stabilizes the other 3 digits. The patient opposes his or her thumb to the little finger MCP joint. Flexion of the index distal phalanx proves the existence of this anomalous communication.
• Passive manipulation of the wrist through flexion and extension should result in extension and flexion of the digits, respectively. This uses the tenodesis effect of the antagonistic tendons. If a tendon is transected, then there can be no tenodesis effect.
• Compression of the forearm flexion muscles also can be used to test the integrity of the flexor tendons in the hand. As the forearm is compressed, the digits are drawn into flexion. Transected tendons in the digits do not flex with this maneuver.

Successful treatment depends on prompt diagnosis and treatment, preferably within 48 hours of the injury. Delays in treatment may result in fibrosis in the tendon sheath and retraction of the flexor tendon.

This MRI of a closed FDP  is from the blog Musculoskeletal and Orthopedic MRI (photo credit):

Sagittal image of the ring finger reveals the gap (red arrows) between the torn ends of the FDP and also depicts the intact flexor digitorum superficialis tendon (green arrows)

REFERENCES

The accuracy of ultrasound in evaluating closed flexor tendon ruptures; European Journal of Plastic Surgery, published online January 2010, DOI 10.1007/s00238-009-0378-8; Onur Gilleard, David Silver, Zeeshan Ahmad, and Vikram S. Devarai

High-Risk Injuries and Infections of the Hand; ACEP Presentation Oct 28, 2008; Scott C. Sherman, MD

Shout Outs

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

Kim, Emergiblog, is this week's host of Grand Rounds. It is the LOL edition  which can be read  here

Welcome to the LOL edition of Grand Rounds!

I just adore the I Can Has Cheeseburger – LOL Cat site and the kittehs provide our background theme for the week.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 15) ! You can find the schedule and the COS archives at Emergiblog.

It’s time again for Change of Shift, the bi-weekly nursing blog carnival!

It’s an eclectic selection this week: hospital to office, students and veterans, money and…well, poo-poo, disasters and preparedness…………..

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The need for help to Haiti continues. Anyone wishing to donate or provide assistance in Haiti is asked to contact the Center for International Disaster Information. Here is a list of organizations who need your help in providing care to Haiti:

• Clinton Foundation -- Donate online or Text "HAITI" to 20222 and $10 will be donated to relief efforts, charged to your cell phone bill.
• American Red Cross International Response Fund – Donate
• Doctors Without Borders
• The International Rescue Committee
• International Medical Corps
• Mercy Corps Haiti Earthquake Fund (1-888-256-1900)
• Partners in Health
• UNICEF (1-800-4UNICEF)
• UN World Food Program
• National Disaster Search Dog Foundation (SDF)
• The International Fund for Animal Welfare (IFAW)

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Dr. Val has a few posts which feature first hand accounts on giving care in Haiti from physicians:

• Trauma Surgeon Flees Chaos Of Haiti: Needed Protection Of Jamaican Soldiers With M-16s To Escape Alive
• Live Reporting From Haiti: Dr. Paul Auerbach Calls Dr. Val Via Skype
• Dr. Paul Auerbach’s Update From Haiti
• Audio: What Is Needed Most In Haiti Now? Live Report From Hospital In Port Au Prince

and from ACP Internist comes the link to Mustard Seed Missions with more accounts from the ground in Haiti.

Jan Davis is in Les Cayes, a town of about 70,000 people about 100 miles southwest of Port-au-Prince. Her husband, Paul Davis, was expected to leave Hatfield this week to join his wife there. Two Northampton doctors, Ann Markes and her husband, Matt Kane, both of whom have worked in Haiti before, were planning to travel with him.

The Davises are the founders of Mustard Seed Missions Inc., a nonprofit group that organizes teams of local volunteers who, about twice a year, travel to Haiti to bring medical care to several remote villages outside Les Cayes.

and via Dr Wes: Haiti relief - getting the USNS Comfort there

and some thoughts on public affairs and how things are portrayed. An email from a Vietnam-era vet who is working aboard USNS Comfort.

and from Paul Levy, Running a Hospital: Dr. Smith's Sunday report

Here are excerpts of an email report received yesterday from Dr. R. Malcolm Smith, Chief of the Orthopaedic Trauma Service at Massachusetts General Hospital, hard at work in Haiti with the team there and with support folks back in Boston.(Embedded links are mine.)

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MedGadget has announced the finalists for the medical blog awards. Polls will be open from Wednesday, January 27, 2010 and will close 12 midnight on Sunday, February 14, 2010 (EST).  Se the list of finalist here.   Voting begins on January 27th.

The categories for this year's awards are:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2009)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

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Dr Anonymous does not appear to have a show scheduled this week.

Upcoming Dr. A Shows (9pm ET)
2/4 : Dean Brandon from Pediatric Dentistry blog
2/11 : Drew Griffin from Wound Care Education Institute
2/18 : Rhett and John from FireFighter Netcast

Neoumbilicoplasty

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

The umbilicus is perhaps the only scar that all of us want.  The umbilicus forms after birth as a result of the placental cord being transected as the infant is “detached” from his/her mother.  As the stump of the cord necroses, the scab falls away as the base heals leaving a scar:  the umbilicus.

The umbilicus has been described as a depressed scar surrounded by a natural skin fold that measures 1.5 to 2 cm in diameter and lies anatomically within the midline at the level of superior iliac crest.

Neoumbilicoplasty in simple terms is the creation or reconstruction of a new umbilicus to replace the missing or deformed umbilicus. 

Craig et al. reported on the ideal female umbilicus, but it should always be remembered  “the ideal umbilicus should be regarded as one that is satisfying to the patient.” 

The most aesthetically pleasing umbilicus is small in size, T or vertical in shape, and possesses a superior hood or shelf.

Those characteristics found to be unappealing include a large overall umbilical size, a horizontal or distorted shape, and the presence of umbilical protrusion.

In reconstructing the umbilicus, plastic surgeons should strive to attain these attractive characteristics and incorporate a modest size, with a superior shelf or hood and a T or vertical shape.

Reconstruction of a new umbilicus is indicated in congenital conditions associated with umbilical agenesis, loss of umbilicus due to omphalocele or gastroschisis repair, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump, and in surgical procedures for wide ventral herniorrhaphy.

In my humble opinion, the site of the new umbilicus should correspond to where “nature” would have placed it.  If there is any of the old umbilicus present, this can be used as an indication of where the new umbilicus should be placed.  If not, then  Dr. Susam Park, et al has this suggestion:

Based on our study, it is usually 3 cm above the level of the anterior superior iliac spine in a baby and 6 cm above in an adult, although differences in height and weight may affect these measurements.

Or as  Dr. Suhas Abhyankar, et al put it:

1. The distance between the xyph0sternum and umbilicus-distance between the umbilicus and the pubic symphysis ratio is approximately 1.6:1.

2. Also, the distance between the umbilicus and the anterior superior iliac spine-distance between the right and left anterior superior iliac spines ratio is 0.6:1.  This implies that when each of the anterior superior iliac spines is taken as a center, and arcs are drawn with a radius 0.6 times that of the inter-anterior superior iliac spine distance, the point of intersection of these arcs is the location of the umbilicus, taking into consideration the above ratio (1.6:1).

Surgery varies depending on whether a completely new umbilicus is being created or simply an “outie” being turned into an “innie” or maintaining the umbilicus with other surgery (ie abdominoplasty).

 
  
REFERENCES
*****After noticing the first referenced article below on MDLinx, I did a search of articles in the Journal of Plastic and Reconstructive Surgery first using “neoumbilicoplasty” and then “umbilical reconstruction.”  The second gave me a great list of articles (only a few listed below).

Neoumbilicoplasty is a Useful Adjuvant Procedure in Abdominoplasty; Can J Plast Surg 2009; 17 (4): e20-e23; AA Al-shahan

In Search of the Ideal Female Umbilicus; Plast Reconstr Surg 105: 389, 2000; Craig, S. B., Faller, M. S., and Puckett, C. L.

New Technique for Scarless Umbilical Reinsertion in Abdominoplasty Procedures; Plast Reconstr Surg 102(5):1720-1723, 1998; Schoeller, Thomas M.D.; Wechselberger, Gottfried M.D.; Otto, Angela M.D.; Rainer, Christian M.D.; Schwabegger, Anton M.D.; Lille, Sean M.D.; Ninkovic, Milomir M.D.

A Simplified Technique for Umbilical Reconstruction; Plast Reconstr Surg 114(2):619-621, 2004; Korachi, Ali; Oudit, Deemesh; Ellabban, Mohammed

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis; Plast Reconstr Surg  104(1):204-207, 1999; Park, Susam; Hata, Yuiro; Ito, Osamu; Tokioka, Kazuyuki; Kagawa, Koji

Simplified Technique for Creating a Youthful Umbilicus in Abdominoplasty; Plast Reconstr Surg 109: 2136, 2002; Lee, M. J., and Mustoe, T. A.

Anatomical Localization of the Umbilicus: An Indian Study; Plast Reconstr Surg 117(4):1153-1157, 2006; Abhyankar, Suhas V.; Rajguru, Anirudha G.; Patil, Prajakta A.

Placement of the Umbilicus in an Abdominoplasty;  Plast. Reconstr. Surg. 61: 291, 1978; Dubou, R., and Ousterhout, D.

Umbilical Reconstruction in Abdominoplasty; Melvin A. Shiffman;  International Journal of Cosmetic Surgery and Aesthetic Dermatology. September 2000, 2(3): 171-176. doi:10.1089/153082000750062830

SurgeXperience 315 is Up

Updated 3/2017:  all links removed as some blogs/posts no longer active. 
Education of a Knife  is the host of this edition of SurgeXperiences. Here is the beginning of this edition which you can read here. 

The host of the next edition (316) will be Dr DJ, a private surgeon from India, has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline:  midnight on Friday,February 5th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Mother’s Wisdom

“Never put sharp knives in the sink.”

I hear Mom’s voice, as I pull my hand out of the dish water. Blood flows from my left palm. I make a fist, the index finger remains straight.

“It isn’t nice to point your finger at anyone.”

My husband rushes into the room.

Overall Sam Quilt

This quilt is made from antique quilt blocks found at an estate sale in the mid-1990s.  The pattern is the male version of Sun Bonnet Sue and is called Overall Sam.  Five of the six blocks have a red handkerchief in the Sam’s back right pocket.  I put the blocks together and then had a friend hand quilt it for me using Baptist Fan quilting.  The blocks are 14” square.  The quilt is 35.5” X 53.5”.

Here are close photos of two of the blocks. 

Breast Focused Microwave Thermotherapy

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

I noticed this AP article, Microwave heat, chemotherapy combine to shrink breast cancer tumors, reduce mastectomies, in the health news earlier this week with this claim:

A University of Oklahoma researcher has found that microwave heat treatment combined with chemotherapy actually kills large breast cancer tumors and could reduce the need for mastectomies by nearly 90 percent.

I would love for this to turn out to be true, having begun medical school when Halsted mastectomies were still the standard of care. 

Preoperative focused microwave thermotherapy (FMT) is the focus of multi-institutional clinical studies from OU, the Massachusetts Institute of Technology, the Los Angeles Biomedical Research Institute, the Comprehensive Breast Center of Florida and St. Joseph's Hospital in California. 

Dr. William Dooley, director of surgical oncology at OU Cancer Institute, and colleagues   have published the results from early clinical trials online in the journal Annals of Surgical Oncology.

Cancer cells are sensitive to microwave-generated heat. FMT uses a minimally invasive approach to introduce energy into the tumor creating irreversible cell damage.

The current study looked at the effectiveness of preoperative FMT treatment used alone and in combination with preoperative anthracycline-based chemotherapy for breast tumors ranging in ultrasound-measured size from 0.8 to 7.8 cm.

In a randomized study for patients with early-stage invasive breast cancer, the researchers found of no patients receiving preoperative FMT (0/34) had positive tumor margins, whereas 9.8% of patients (4/41) who had breast conservative surgery (BCS) alone had positive margins.

In a randomized study for patients with large tumors, based on ultrasound measurements, the researchers found  the median tumor volume reduction was 88.4% (n = 14) for patients receiving FMT and neoadjuvant chemotherapy, compared with 58.8% (n = 10) reduction in the neoadjuvant chemotherapy-alone arm.

FMT can be safely administered in a preoperative setting.   Larger randomized studies are required to verify these conclusions.

 

 

REFERENCES

Focused Microwave Thermotherapy for Preoperative Treatment of Invasive Breast Cancer: A Review of Clinical Studies; Annals of Surgical Oncology, Online First - December , 2009; William C. Dooley MD, Hernan I. Vargas MD, Alan J. Fenn PhD, Mary Beth Tomaselli MD, Jay K. Harness MD

Randomized Study of Preoperative Focused Microwave Phased Array Thermotherapy for Early-Stage Invasive Breast Cancer; Cancer Therapy Vol 6, 395-408, 2008; William C. Dooley, Hernan I. Vargas, Alan J. Fenn, Mary Beth Tomaselli, Jay K. Harness

The Halsted Mastectomy: Present Illness and Past History; West J Med. 1981 June; 134(6): 549–555; Cordelia Shaw Bland (pdf file)

Standardized Care Protocol for Postoperative Alcohol Withdrawal – an Article Review

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

It has been a while since I’ve had a patient with postoperative alcohol withdrawal.  I can still recall my first exposure to this problem as a 3rd year medical student at the Veteran’s Hospital.  It was my first clinical rotation – surgery service at the VA.

Browsing the CME articles on the JAMA website, I came across the article (full reference below):  Improved Outcomes in Patients With Head and Neck Cancer Using a Standardized Care Protocol for Postoperative Alcohol Withdrawal.  For me it was a nice review of the problem with updates on current drug use/protocol.

Their protocol is based on three distinct clusters of symptoms characterize alcohol withdrawal syndrome (AWS).

Type A symptoms represent central nervous system (CNS) excitation and include anxiety, dysphoria, enhanced reaction to abrupt stimuli, insomnia, mood lability, motor activity, and a sense of foreboding.  Central nervous system excitation usually occurs within 12 to 48 hours after the last drink.

Type B symptoms relate to adrenergic hyperactivity, which manifest as fever, chills, diaphoresis, hypertension, tachycardia, tremors, piloerection, mydriasis, nausea, and palpitations.  Autonomic hyperactivity usually peaks between 24 and 48 hours after cessation of alcohol consumption.

Type C symptoms include attention deficit, disorientation, hyper-alertness, short-term memory impairment, impaired reasoning, psychomotor agitation, and hallucinations signifying delirium. These symptom types may occur alone or in combination.   Delirium typically occurs later, with a variable time course.

The older term delirium tremens may be used in this context to describe the combined symptoms of confusion (type C), hyperadrenergic state (type B), and CNS excitation (type A)

The authors present their experience from March 2003 until March 2005 with 26 consecutive patients prospectively treated for AWS using a standardized care protocol from among 652 patients admitted for head and neck surgical procedures (see the two images below—credit) and compared them with a retrospective comparison group of 14 patients who met the inclusion criteria but were treated from March 2000 to December 2002, prior to the use of the AWS protocol.

Outcomes (preprotocol/protocol)

Transfers from the regular inpatient unit to the ICU for AWS-related cause  -- 29%  vs 4%.
Respiratory arrest -- 14%  vs 4%.
Mechanical restraints used  -- 57% vs 42% .
Delirium present --  79% vs 29%.  When present, delirium lasted a mean (SD) of 3.2 days in the preprotocol group and 3.3  days in the protocol group.
Violence (such as biting, scratching, kicking, verbal outbursts, and other violent manifestations) present  -- 36% vs 8%.
One or more wound complications present -- 50% vs 46%. 
No seizures, falls, or deaths occurred in either cohort during the inpatient stay. No patient developed delirium tremens.

The article  is worth the review even with the small number of subjects.

REFERENCE

Improved Outcomes in Patients With Head and Neck Cancer Using a Standardized Care Protocol for Postoperative Alcohol Withdrawal; Arch Otolaryngol Head Neck Surg. 2008;134(8):865-872; Christopher D. Lansford, MD; Cathleen H. Guerriero, RN, BSN; Mary J. Kocan, MSN; Richard Turley, MD; Michael W. Groves, MD; Vinita Bahl, DMD, MPP; Paul Abrahamse, MA; Carol R. Bradford, MD; Douglas B. Chepeha, MD; Jeffrey Moyer, MD; Mark E. Prince, MD; Gregory T. Wolf, MD; Michelle L. Aebersold, RN; Theodoros N. Teknos, MD

Shout Outs

Updated 3/2017: removed all links as several blogs/posts no longer active and it was easier than checking each one. 

 

Dr. John La Puma is this week's host of Grand Rounds. It looks at food and exercise in relationship to health.  You can read this week’s edition here.

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The need for help to Haiti continues.   Anyone wishing to donate or provide assistance in Haiti is asked to contact the Center for International Disaster Information.   Here is a list of organizations who need your help in providing care to Haiti:

• Clinton Foundation -- Donate online   or  Text "HAITI" to 20222 and $10 will be donated to relief efforts, charged to your cell phone bill.
• American Red Cross International Response Fund – Donate
• Doctors Without Borders
• The International Rescue Committee
• Mercy Corps Haiti Earthquake Fund (1-888-256-1900)
• Partners in Health
• UNICEF (1-800-4UNICEF) 
• UN World Food Program 

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Ever heard the story of  Phineas Gage?  Now you can read the story of how the first known photograph of him was identified in the Smithsonian article Phineas Gage: Neuroscience's Most Famous Patient written by Steve Twomey.

………….In December 2007, Beverly posted a scan of the image on Flickr, the photo-sharing Web site, and titled it “One-Eyed Man with Harpoon.” Soon, a whaling enthusiast e-mailed her a dissent: that is no harpoon, which suggested that the man was no whaler. Months later, another correspondent told her that the man might be Phineas Gage and, if so, this would be the first known image of him………..

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Jeffrey Leow, Vagis Surgicalis,  is a final year medical student at Monash University in Australia.  His article, Medical Trip to Vellore, India, on his recent mission trip is in the recent edition of The Lancet Student.

The last time I participated in a mission trip was back in January 2008 in Cambodia. That was part of my church’s 14-day evangelical and medical outreach. This time round, the medical trip had no religious component; it was organized by a student-run organization – Singapore Medical Society of Victoria (SMSV). SMSV aims to bridge the gap between medical students in Victoria and the healthcare industry in Singapore. They had previously organized a trip to Hainan Island, China. Past participants have commented they were able to step above and beyond their usual roles as medical students and do ’so much more’, e.g. perform a lipoma excision. As such, when I heard about an upcoming trip to India, I did not pass up the opportunity………….

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MedGadget is asking for nominations for the best of medical blogs.  You can make your nominations here by leaving a comment with your choice. Nominations will be accepted until Sunday, January 24, 2010

The categories for this year's awards are:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2009)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

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Chris, Coppola: A Pediatric Surgeon in Iraq, tells us about Knitting for Troops 20/365 The Ships Project.  The site has a great list of patterns, also requirements on yarn type and color.

….one way to support the troops is by knitting comfort items like hats, slippers and neck coolers. I can tell you that when I was in Iraq in JAN I was freezing my patootie off!! M. had knit me a green camouflage blanket and a desert camouflage hoodie and they were put to good use!

A great place to start is the Ships Project.

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The Alliance for American Quilts announces its 4th annual contest.  The theme this year is “New from Old."

The rules are simple: quilts must be 16" x 16" (including a 4" sleeve and a label) and consist of three layers.  Contest quilts must be sent to the AAQ by May 31, 2010. The contest is also a fundraiser; all quilts become a donation to the organization and will be auctioned on eBay Nov. 8 - Dec. 6, 2010 to benefit the AAQ and its mission to document, preserve and share the history of quilts and quilt makers. Visit the AAQ website for full contest information including a downloadable entry form.

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 Dr Anonymous does not appear to have a show  scheduled this week.   

Upcoming Dr. A Shows (9pm ET)
2/4 : Dean Brandon from Pediatric Dentistry blog
2/11 : Drew Griffin from Wound Care Education Institute

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

Histologic Relationship of Preauricular Sinuses to Auricular Cartilage: an Article Review

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

There is a nice article in the journal Archives of  Otolaryngology-- Head Neck Surgery (first reference below) which examines the relationship of preauricular sinuses to auricular cartilage. 

Preauricular sinuses are a congenital malformation of the preauricular soft tissues.   They can be both sporadic and inherited. They are bilateral in approximately 25% to 50% of patients. When bilateral, the sinuses are more likely to be inherited in an autosomal dominant pattern with reduced penetrance and variable expression. 

Although the true prevalence is not well established, preauricular sinuses are thought to occur most commonly in black populations. The incidence of preauricular sinuses has been estimated to be 0.1% to 0.9% in Europe and the United States.

Preauricular sinuses are the most common variant of all the periauricular cysts, fistulas, and sinuses. The cutaneous pit of the preauricular pit is most often located on or near the ascending limb of the helical rim but can also open along the superior posterior margin of the helix as well as the tragus. 

While both cutaneous opening and fistulous tracts are classically located anterior to the external auditory canal, a reported variant form has its opening behind an imaginary vertical line drawn at the posterior most aspect of the tragus and the posterior aspect of the ascending limb of the helix. This variant typically presents with postauricular swelling and requires both postauricular and preauricular incisions for its removal.

The article takes you through a review of the embryology and then takes you through surgical treatment

Classically, the surgical approach consists of a simple sinectomy with an elliptical island of skin removed around the opening of the sinus and excision of the epithelial sinus tract. Various authors have advocated the use of either methylene blue or gentle probing of the tract to carefully delineate the tract.   However, neither approach guarantees full removal of the tracts: reported recurrence rates are quite high, typically near 20%…………..

There conclusions

Because the present study is not a randomized controlled trial, our findings cannot be used to determine whether excision of cartilage or perichondrium prevents recurrence of preauricular sinuses. …… In over 50% of the specimens reviewed, the sinocartilaginous distance was less than 0.5 mm, and in nearly all of these cases, the epithelial tract was in continuity with stromal tissue histologically indistinguishable from the perichondrium.

The removal of a small piece of cartilage or perichondrium does not produce a visible cosmetic deformity or add any significant morbidity. Therefore, the routine removal of a small portion of perichondrium and/or auricular cartilage along with the sinus tract may yield a more thorough excision and help to prevent recurrence.

REFERENCE

The Histologic Relationship of Preauricular Sinuses to Auricular Cartilage; Arch Otolaryngol Head Neck Surg. 2009;135(12):1262-1265; Brian Dunham, MD; Martha Guttenberg, MD; Wynne Morrison, MD; Lawrence Tom, MD

Preauricular Sinuses; eMedicine Article, January 8, 2010; Noah Scheinfeld, MD, Valerie Nozad, DO, and Jeffrey Weinberg, MD

Surgical Treatment of Recurring Preauricular Sinus: Supra-auricular Approach; Acta Otorhinolaryngol Ital. 2008 December; 28(6): 302–305; G Leopardi, G Chiarella,  S Conti, and E Cassandro

The Preauricular Sinus: A Review of Its Aetiology, Clinical Presentation and Management; International Journal of Pediatric Otorhinolaryngology (2005) 69, 1469—1474; T. Tan, H. Constantinides, T.E. Mitchell

SurgeXperiences 315 – Call for Submissions

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

Education of a Knife will be the host for SurgeXperiences 315 (January 24th).  The author behind this blog describes himself this way: 

“A passionate 20 year old second year undergraduate medical student in Monash university Sunway Campus. Bite his teeth and tries to make the best out of his life. He writes occasionally and has strong aspirations for surgery.”

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  You are encouraged to submit your surgery related posts.   The deadline for submissions to be included in the 315 edition is midnight on Friday, January 22nd.  Be sure to submit your post via this form. 

My Personal Trainer

“Five more minutes,” I tell him as he nimbly places his paws on my knees, brown eyes imploring.
“Okay, you win.” 
Orange ball cap on my head, gloved hands grab the leash.
We exit the gate, the January sun cold as we jog toward the neighbors woods. 
Will there be ducks on the pond today?

Flower Power Baby Quilt

This baby quilt is for Kerri.  She’s expecting a little girl.  I used the court house step block pattern for this quilt.  It is machine pieced and quilted.  The quilt is 38 in X 38 in.  I love the flowered fabric!
Here you can see the fabric better and get a glimpse of the quilting done.  I used a large feathered “flower” and cross-hatching.
The back is a soft pale yellow flannel.  Here you can see the quilting better.

No Show

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

The clock reads 15 minutes past the hour. An hour saved for a new patient visit. No one comes through the door to claim the visit.
I sip my coffee, check my email, and reach for a journal.
My hand settles on a yellow highlighter, aching to hold a scalpel or needle.

……………………………….

***I love what WordDoc, Medical Moments in 55 Words, is able to do with 55 words or less. I was taught back in high school that words like “a” and “the” don’t count (you know when you had to write a 500 word essay), but apparently they do.

“Suitable” for Plastic Surgery?

A few years ago I wrote about the “Suitability” of a patient for plastic surgery. I was reminded of this topic by two cases in the recent lay media:

The first involves Heidi Montag, 23, who in November had multiple surgical procedures and is being compared to Joan Rivers.

According to People, Montag even kept her family in the dark about her intended transformation to become her “best me.” Telling only her husband Spencer Pratt, Montag had a nose job revision, chin reduction, mini brow lift, Botox in her forehead and frown area, fat injections in her cheeks, nasolabial folds and lips, neck liposuction, ear pinning, liposuction on her waist, hips, inner and outer thighs, buttock augmentation and breast augmentation revision.

The other involves Annette Edwards, 57, who has had multiple procedures so she could look like Jessica Rabbit. 

My post “Suitability” remains relevant. Here is part of it:

The bottom line is: Not everyone is a candidate for aesthetic surgery. Nor is it possible to eliminate every possibility of dissatisfaction or conflict that might arise. Here are some suggestions for doctor and patient
First

• Surgeon--Be a complete physician, not just a skilled technician.
• Patient--Be a partner in your care. Give a full and honest medical/surgical history. Don't leave out any medications. What you do when recovering often will have major impact on the final result.

Second

• Surgeon--Avoid hyping your "unique" talent.
• Patient-- Be honest about your reasons and expectations.

Third

• Surgeon--Strive to maintain good communication and rapport with your patient. Listen.
• Patient-- Do your part in maintaining that good communication and rapport. Listen. If you don't understand, say so. Have your surgeon try to explain in another way.

Fourth

• Surgeon-- Be honest about your skills. We are all better at some procedures than others.
• Patient -- Let your surgeon refer you to someone else, if they feel it is in your best interest. Don't "massage" his/her ego to try to get them to do it (I only want you to do it. I feel so comfortable with you. I know you are the best.)

Preoperative Skin Cleanser

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

Looks like it’s time for me to rethink my preference for preoperative skin cleanser. This past week there were two new prospective studies published in the Jan. 7 issue of the New England Journal of Medicine, along with an accompanying editorial.

The Centers for Disease Control and Prevention estimates that in American hospitals alone, there are 1.7 million healthcare-associated infections each year. Of these infections, 22% are surgical site infections (SSIs). So if simply changing the preop skin cleanser will reduce my patient’s SSI risk, then I will do so.

Rabih Darouiche, MD and colleagues found using chlorhexidine as the preoperative skin cleanser reduced infections by 41% compared with povidone-iodine. Their study involve randomly assigning 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I). Patients were assessed for occurrence of SSIs within 30 days postoperatively.

CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I), lower rates of superficial (4.2% vs. 8.6%) and deep (1.0% vs. 3.0%) incisional SSIs. There was no significant difference between the two groups where organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%) was involved.

Lonneke G.M. Bode, M.D and colleagues found that screening and decolonizing patients who are nasal carriers of S. aureus, combined with washing with chlorhexidine soap reduced the risk of SSIs by 58%.

"The weight of evidence suggests that chlorhexidine–alcohol should replace povidone–iodine as the standard for preoperative surgical scrubs," Dr. Wenzel writes. "The use of intranasal mupirocin and chlorhexidine baths for carriers of S. aureus who have been identified preoperatively by means of a real-time [PCR] assay could be reserved primarily for patients who are undergoing cardiac surgery, all patients receiving an implant, and all immunosuppressed surgical candidates. Currently, the incremental value of preoperative baths with chlorhexidine alone for all surgical patients is unclear, but this relatively straightforward procedure could be examined critically in future studies."

REFERENCES
Minimizing Surgical-Site Infections; N Engl J Med. 2010;362:9-17, 75-77; Richard P. Wenzel, M.D.
Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis; N Engl J Med 2010 Jan 7; 362:18; Darouiche RO et al.
Preventing surgical-site infections in nasal carriers of Staphylococcus aureus; N Engl J Med 2010 Jan 7; 362:9; Bode LGM et al.
Advances in Preventing Surgical-Site Infections. JWatch Infect. Diseases 2010: 1-1

Shout Outs

Updated 03/2017:  removed all links as several blogs/posts no longer exist and it was easier than going through each one

DrRich, Covert Rationing Blog, is this week's host of Grand Rounds. You can read this week’s edition here.

The Holidays may be over, but there’s no rest for Santa or his cute little Congressional elves. ………..

And so, to Santa, to the elves, and to anyone else enlightened enough to seek it out, DrRich is honored to present: Grand Rounds.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 14) !   It is the first edition of the new year.  You can find the schedule and the COS archives at Emergiblog.

Happy New Year and welcome to the first Change of Shift of the new decade!
Are you still writing “09″? I’m not! For some reason I have converted to “01″. Lord knows how many of my charts have the wrong dates on them!
It’s a new decade and the new year finds the nursing blogosphere is still going strong. Let’s get started!

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Dr. Steven Lomazow  has opened his blog, FDR's Deadly Secret, which includes post of many of the papers, videos, etc used in writing the book, 'FDR's Deadly Secret' with fellow author Eric Fettmann.

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I am included in this issue of General Surgery News on Women in Surgery.  It is humbling to be featured along with Dr. Kathrin Troppmann, Dr. Lori Brown, Dr. Sharona Ross, Dr. Julie Ann Freischlag, Dr. Celeste Hollands, Dr. Nicole Fox, Dr. Lyssa Neida Ochoa, Dr. Lori Lerner, and Dr. Dinee Collings Simpson, Dr. Danielle Walsh, Dr. Jennifer Rosen, Dr. Susan Kaiser, and Dr. Eva Wall. 

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Updated 3/2017:  all links removed as several blogs/posts no longer active and it's easier than going through each one.

 

MedGadget is asking for nominations for the best of medical blogs.  You can make your nominations here by leaving a comment with your choice. Nominations will be accepted until Sunday, January 24, 2010

The categories for this year's awards are:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2009)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

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I realize this post from Dino Doc, Musings of a Dinosaur, is from August 2009, but the start of the new year is a great time to update and print out a new health information card:  Public Service Announcement

Use your computer to print out a free wallet card with all your up-to-date medical information here.

…………………………………..

 Dr Anonymous does not appear to have a show  scheduled 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

MDLinx

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

Towards the end of this past year I learned about MDLinx and signed up for the newsletter on Plastic Surgery related articles. I was very impressed this past week to get the “Top Read Articles of 2009.” I noticed many articles of interest which I had not read. Most were in journals I don’t have full access to: Canadian Journal of Plastic Surgery, Australian and New Zealand Journal of Surgery, European Journal of Plastic Surgery, etc.

Here are five that caught my eye:

1. Decreasing expander breast infection: A new drain care protocol; The Canadian Journal of Plastic Surgery, Spring 2009, Volume 17 Issue 1: 17-21; JD Murray, ET Elwood, GE Jones, R Barrick, J Feng

2. A new validated otoplasty dressing technique; Eur J Plast Surg (2009) 32:119–121; Mohammad Mehdi Samim & David Mather & Sharif Al-Ghazal

3. The treatment of dermal scars by three-dimensional Z-plasty; Eur J Plast Surg (2009) 32:221–222; Bin Xu & Pengcheng Jiang & Bing Wang

4. Surgical Treatment of Rhinophyma; Advances in Dermatology and Allergology, 2009, XXVI, 3: 126-133; Edward Lewandowicz, Henry Witmanowski, Daria Sobiesze

5. The Oncological Safety of Skin Sparing Mastectomy with Conservation of the Nipple–Areola Complex and Autologous Reconstruction: An Extended Follow–Up Study; Annals of Surgery, March 2009 - Volume 249 - Issue 3 - pp 461-468; Gerber, Bernd MD, PhD; Krause, Annette MD; Dieterich, Max MD; Kundt, Günther PhD,†; Reimer, Toralf MD, Ph

MDLinx is a medical news and information source, free with registration. It reviews 1200 medical journals daily. The articles are indexed by 35 specialties and 845 subspecialties. I am finding it to be a nice source of information.

SurgeXperiences 314

Updated 3/2017:  links removed as many of the blogs/posts are no longer active and it was easier than going through all the links.

It is my pleasure to host the first edition of SurgeXperiences of the new year (2010) and new decade.  I hope you’ll grab something to drink and enjoy the reading.

Life in the Fast Lane (multiple authors) has had several surgery related post recently.  This first one is from Chris Nickson in which he presents William Ernest Henley’s poem Operation.   You’ll have to go over to read the entire poem, but it begins

You are carried in a basket,
Like a carcass from the shambles,
To the theatre, a cockpit
Where they stretch you on a table.
Then they bid you close your eyelids,
And they mask you with a napkin,
And the anaesthetic reaches
Hot and subtle through your being………

Mike Cadogan, sandnsurf,  presents with a wonderful primer on elbow dislocation over at Life in the Fast Lane. 


Also at Life in the Fast Lane, check out by Paul Young’s  post:  Renal Riddle-001.

…….It is important to remember that the commonest cause of the ‘classic’ presentation of renal colic amongst patients presenting to have a post-mortem is ruptured abdominal aortic aneurysm…….

MedZag, Training Grounds, writes about Flying Solo in the operating room for the first time.

……….Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches…..

I’m a sucker for a good dog/man friend story, so I greatly enjoyed the one told by Bongi, other things amanzi -- friend's best friend.   Not all the commenters agree with me.
Bongi also writes about a patient who needs a fasciotomy

being south african these days sometimes means we see things in a slightly skewed way. it seems to be the way we have become. i have touched on this before, but there is another story which illustrates the point.

the recent run of hijackings were fresh in all our minds because the perpetrators had shot and killed, execution style, a mother and her three year old child just the previous week.

Academic Life in Emergency Medicine shows us a Trick of the Trade: Finger nailbed laceration repair.

This technique requires that the fingernail has a simple linear laceration through it. The fingernail has to be relatively still adherent to the nailbed. The case below is a patient who sustained a fingertip laceration with an industrial skill saw.

SA Anaesthetist  writes about Comfort Zones - or "A day in the life of an anaesthetist who hasn't gone away for the holidays"

………….So what, you say, you are a cardiac anaesthesiologist, how hard could it be? And therein lies the rub. The biggest problem facing me now is not the pre-terminal patient. We get enough of those in our fine ivory tower on the hill. No, my problem is that I am going to be way out of my usual haunts. New hospital, new surgeon (although widely respected), and unfamiliar team = something approaching palpitations…………….

The Sandman tells us his Rule Number 10.  Read his post for the story that goes with it:

Response number two aka Rule #10:
A surgeon is assigned the anesthesiologist he/she deserves.

Oystein, Sterile Eye, tells (and shows) us how to  Remote Rig for Filming Open Surgery  (photo credit)

A couple of years ago I decided to make my own remote rig for filming open surgery. For a lot of operations in the abdomen and deep in the pelvis, the commercially available equipment could not provide the access I wanted. Designed by me and built at the hospital’s own instrument shop, the rig provides an excellent view of the surgical field and less strain on the cameraman………

Ask The Burn Surgeon has written an informative response with photos,  Management of 2nd degree superficial burns, to the following question:

Dear burn surgeon,
My daughter has a burn with hot soup on the hand with a lot of ugly looking blisters. Am worried as it’s quite painful. How will it heal and will it leave a scar?
Magaret p

Buckeye Surgeon discusses  Lymph Node Retrieval in Colon Cancer Surgery and ALS Entrapment.

GruntDoc tells us about removing The Foreign Body that Didn’t Exist

Except, of course, that it did…

A patient comes in with the entirely understandable complaint of “I have a fishbone lodged in my throat”. Came straight from dinner to the ED. When I ask a stupid question I’m given a stupid answer: “It feels like…a fishbone…”. Duh on me.

hjluks,  Sports Medicine and More.... , shares an x-ray with us simply entitled “ouch!”

Movin' Meat tells us the story that goes with this x-ray in his post, It's a wonder I survived my teen years

Movin' Meat also tells us the tale,  There's no bone in there, but it can still break, with MRI images included.

……So recently I saw an unhappy young man with such an injury.  It was sustained in the usual manner, but it was in fact the mildest one I have ever seen.  The hematoma was not large and the angulation of the injured member was slight.  I thought it was clearly a fracture, but the urologist who examined the patient was uncertain, and the patient, understandably, was quite unwilling to undergo surgery if the diagnosis was unclear.  We discussed diagnostic options.  Ultrasound apparently has a low sensitivity, but, the urologist had read, MRI was supposedly a useful tool.  I did not know that.  So I proceeded to order the first and only MRI of the penis of my entire career.  After an incredulous phone call from the radiologist to confirm the order, we obtained the following images……

Dr Toni Brayer writes about Regional Variations in Total Knee Replacement Surgery

……….Now that I am recovering from a total joint replacement, I am amazed to see the differences in how physicians, doing the same surgery, treat the patient. Total knee replacement (TKA) is one of the most common orthopedic procedures done today. Despite this, the patient cannot expect the same post op care.

I am in contact with a patient in rural Minnesota who had the same surgery 8 days prior to me. Here are some differences in treatment for the same surgery (TKA):………….

H/T to @nursingpins and @ThyroidMary who provided the link to cancer survivor Roger Ebert’s blog post: Nil by Mouth

………A third surgery was attempted, using a different approach. It seemed to work, and in a mirror I saw myself looking familiar again. But after a little more than a week, that surgery failed, too. Blood vessels intended to attach the transplanted tissue lost function, probably because they had been weakened by radiation. A fourth surgery has been proposed, but I flatly reject the idea. To paraphrase a line from "Adaptation's" orchid collector: "Done with surgery."

During that whole period I was Nil by Mouth………..

From Adam’s Heart Surgery Blog comes a reminder that often it is the scar that the patient remembers:  Even With A Crooked Scar, Sandy Is Extremely Thankful  

Well… I am extremely thankful ………..

However… I do have one small complaint that serves as a reminder of the fact that 10 months ago I was in an operating room with my mind blank and my chest opened up. My scar is crooked!

I have been following this story regarding baby Christopher who needs a heart transplant.  I first learned of him through a story via Arkansas Blog Christmas day.  Christopher was  born Nov. 30 in Oregon, but later flown by Angel One to Arkansas Children’s Hospital.   He was born with hypoplastic right heart syndrome and an AV canal defect.  As of this posting, he is still waiting for his transplant.  Here's a link where you can sign up to check in on family updates on the baby's situation.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  If you would like to be the host  for SurgeXperiences315 or a future edition, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Trip Around the World

This quilt is a variation of the drunkard’s path called “trip around the world.”  I began hand piecing the individual 3.25 in blocks in the mid-1990s thinking I might make a full or queen size bed quilt.  I was doing to feature the different variations of the drunkard’s path.   My project got pushed aside as I made nieces and nephews quilts.  In 2006, I put together the 100 blocks into a wall hanging.  The blocks are hand pieced, but then machine sewn together.  I hand quilted this one.  The quilt is 41.5 inches square (or maybe not, as it doesn’t hang quite even).

The quilt is a charm quilt, as each block contains a different fabric.  Here are some close photos to show some of the fabrics.

This one shows the back so the quilting can be seen.
Here is an orphan block using the variation “Boston Trail” or “falling timbers.”

Screening Mammogram Recommendations

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

You may recall, in November 2009, the US Preventive Services Task Force released new recommendations on screening mammography.  Here is a summary:

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
• The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.

For a complete discussion which I can not improve upon, check out  Dr. Margaret Polaneczky’s (aka TBTAM) post:  The New Mammogram Guidelines - What You Need to Know.

Now comes, recommendations from the American College of Radiology (ACR) and the Society of Breast Imaging (SBI).  Their guidelines for screening mammography are published in the January issue of the Journal of the American College of Radiology.  Their recommendations do not agree with the US Preventive Services Task Force.

The ACR and SBI recommendations:

• Screening mammography should begin at age 40 for women with average-risk of breast cancer.
• Women at higher-risk should begin by age 30, but no sooner than 25.
• Women who have at least a 20% lifetime risk of breast cancer, on the basis of family history, also should begin annual breast MRI by age 30, in addition to annual mammography.
• Breast ultrasound may also be recommended in addition to mammography for high-risk women and those with dense breast tissue that is often difficult to assess by conventional mammography

Women and their doctors can use assessment tools to calculate  individual risk for breast cancer.  The most commonly used risk assessment tool is the Gail Model which can give your individual risk of being diagnosed with breast cancer in the next 5 years.

Breast cancer causes about 4,500 deaths annually in women ages 40-49, and is one of the leading causes of death in women in this age group.

Neurotoxins: Dysport and Botox

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

Medscape has a nice CME article on neurotoxins (activity expired, link removed 3/2017), Dysport^® and Botox^® Cosmetic. Dysport is abobotulinumtoxinA. Botox Cosmetic is onabotulinumtoxinA. Dr Monheit begins with the interesting history of botulinum toxin.

1895: Clostridium bacterium identified

1940s: BoNT-A purified (Schantz and colleagues)

1950s: BoNT-A mechanism of action elucidated

1970s: BoNT-A investigated as a treatment for strabismus (Dr. Alan B. Scott)

1979 Botulinum neurotoxin type A was approved by the FDA [US Food and Drug Administration] and became a registered mechanism for use in ophthalmology. It was called Oculinum at first.

1987: Dr. Jean Carruthers notices effect on the glabella when treating patients with BoNT-A for blepharospasm.

1989: Botox approved by FDA for the treatment fo strabismus and blepharospasm (originally approved under the brand name Oculinum)

1992: Dr. Jean Carruthers and Dr. Alastair Carruthers publish seminal paper on the use of BoNT-A for the aesthetic treatment of glabellar rhytides.

2002: Botox Cosmetic approved by FDA for the treatment of glabellar rhytides.

2009: Dysport approved by FDA for the treatment of glabellar rhytides.

Dr. Monheit then procedes to describe the science beginning with the molecule itself and the subtypes. He points out that the active neurotoxin protein at 150 kD is the same for both Botox and Dysport. It is the surround complex that is different.

We have in the botulinum toxin molecule a heavy chain (100 kD) and a light chain (50 kD). It's actually the light chain that is responsible for the nicking and the final cleavage that occurs.

Upon absorption into the body, the complex disassociates, and we're left with the bare neurotoxin molecule.

As we understand the science and the technical variables, such as the neurotoxin protein at 150 kD, the hemagglutinin and nonhemagglutinin proteins, the difference in the complex sizes -- 300 kD and 900 kD (depending on whether we're talking about the Botox^® molecule or the Dysport^® molecule)..

Dr. Monheit proceeds to go through the clinical trials and tips/cautions for proper use of the neurotoxins. You can either listen to his lecture or read the transcript. I found it to be an enjoyable lecture.

The central difference between Dysport^® and Botox^® Cosmetic is the dosage units. The units of measurement for the 2 botulinum neurotoxin A products are proprietary measures that are different for each product. The injection points for the 2 products do not differ significantly, and the toxin molecules have the same molecular weight. Differences in onset of action have not been demonstrated in clinical trials.

One of the important things for you to feel comfortable with is the dilution [you] can [or] should use. As you know, as you add more saline, or dilute it more, you do get more spread. You also have more volume that you're putting in. The dilution used for all of the clinical studies was 1.5 mL. Many people are comfortable with 2.5 mL. In Europe, they're using either 2.5 or 1.5 mL, giving the number of units you see in both Botox^® and Dysport^® [units]. But rather than try to translate these units back and forth, you should learn to live in the units you're working with and learn the language of the units you're treating.

REFERENCE

Neurotoxins: Now and in the Future; Medscape article, Sept 9, 2009; written by Gary D. Monheit, MD (free registration required)

Shout Outs

Update 03/2017:  All links removed as several of the blogs/posts no longer exist and it was easier than going through them all.

Grand rounds founder Nick Genes, Blogborygmi,  is this week's host of Grand Rounds. You can read this week’s edition here.

Welcome to Grand Rounds,…This is the 327th edition of Grand Rounds, and navigating web is pretty different compared to when I first hosted. I've been stubbornly resisting social media to help spread the word about each week's location for Grand Rounds, figuring quality writing will find a way to reach interested readers. But when you consider that the Grand Rounds community of patients, providers and pundits is its own kind of social network, it only makes sense to adopt these new tools.

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 Joshua Schwimmer shared this on Facebook:  “Historic scientific books now available on the Web” with a link to

SCOPE - Stanford University School of Medicine

The U.S. National Library of Medicine has made six historic science books available on the Web in high resolution. The browsing experience is fairly good and the books are fascinating to look at. According ...

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Literature, Arts and Medicine Blog has a very nice post on medical writers, specifically nurses:  Remember The Nurses 

…Now name three nurse authors, who are either writing today or are part of the literary canon.
All right, I'll give you twenty-four hours to get back to me……

Though nurses' styles of self-expression differed widely, they wrote about their patients with a singular degree of material specificity, and they resisted surgeons' tendency to blur patients' individual characteristics. In their letters and diaries, they referred to patients by name, frequently mentioning hometowns, culinary tastes, or other distinguishing details. Often they quoted their conversations with soldiers, which surgeons who kept diaries rarely did. . . Surgeons' diaries do not show nearly the same individualization of suffering. They were more likely to refer to their patients in the abstract or to refer to the clinical details of a particular treatment without mentioning the soldier's name at all……….

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From Teen Imperium >> Teen Chat: 4 Steps To Have A Great Body Image

If we were to do a survey that asked how many of us feel happy with our bodies, what percentage do you think would answer, “I am happy with how my body looks?”
Research done about body image shows that women are much more critical of their appearance than men. They are much less likely to like what they see in the mirror. Eight out of ten women will be dissatisfied with their reflection, and more than half may see a distorted image.* Young women need more self-confidence and self-esteem in themselves…………

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In the same vein of helping teens with self-image, Dr Nancy Brown  discusses  Teen Girls And The “How I Look Journal” over at Better Health.

The How I Look Journal was designed for middle school girls in 2007 (revised in 2009), and has been used primarily in group settings, although girls can use it by themselves. Counselors and therapists tend to use the topics as a basis for discussions and teachers prefer using the journal in lesson formats. There is also a companion journal (2009) for mothers called “How I Look at my Daughter, Her World, and Her Future.”

Given I had the week off I decided to review the copies I was sent and am delighted to say that my teenage daughters and I thought the journals are a great idea. The journal prompts help girls identify and celebrate their inner strengths and attributes, manage stress, accept their bodies and dream!……….

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Dr Charles on how our skin care products can affect the environment:  Exfoliating Soap is Full of Plastic. Seriously. 

I’ve been buying, using, and recommending Dove Exfoliating Soap as an affordable and low maintenance facial cleanser. Doctor-recommended. In general my skin has liked the stuff. But a friend recently made me aware of the fact that most of these mass-produced exfoliating soaps contain “microbeads” of plastic. These tiny globules of polyethylene act as a gentle abrasive that exfoliates dead skin, but the synthetic grit then washes down our drains and into our watersheds and oceans where it accumulates, gets eaten by sea creatures, and damages our ecosystems. Plastic beads, made from petroleum products, in my soap. Really?…….

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H/T to @staticnrg who tweeted an announcement regarding her new blog, 365 days with Cushing’s Disease.  It will be interesting following and learning from her.

Inspired by other "365 days in pictures" bloggers, I thought I'd try it. I may fizzle out, but I started: http://bit.ly/8Gbu7Z  

Along the same lines:  100 Inspiring Blogs for People Affected by Chronic Illness

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The Dr Anonymous’ show  for this Thursday night has been canceled, but there will be one Saturday night at 9 pm ET.   

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

Clinical and Radiographic Poland Syndrome Classification: A Proposal – an Article Review

The authors of the recent Aesthetic Surgery Journal article (full reference below) have proposed a new classification of Poland Syndrome based on both clinical and radiographic presentation (CRPS). Using their CRPS classification, they present an algorithm for planning surgical treatment.

The article begins with a review of Poland Syndrome:

Classically, it consists of a combination of unilateral aplasia of the sternocostal portion of the pectoralis major muscle (PMM) and hypoplasia of the ipsilateral hand, with syndactyly and synbrachydactyly.

The reported incidence of Poland Syndrome (PS) is one in 30,000 live births. Male-to-female ratio is 3:1. The right side is affected twice as often as the left.

The etiology of PS is still unknown, but recently a vascular hypothesis suggests hypoplasia of the ipsilateral subclavian artery.

Using data obtained from 28 female patients, they classify PS patients as follows:

First Degree (Mild): The diagnosis of first-degree PS would be made in a patient with mammary asymmetry caused by hypomastia or amastia and areolar asymmetry, with or without a partial absence of the pectoralis major muscle (PMM). No other musculoskeletal alterations are observed; other congenital alterations may or may not be present.

Second Degree (Severe): Hypomastia or amastia, areolar asymmetry, total absence of the PMM, and alterations of the ipsilateral muscle group and/or bones of the chest results in a diagnosis of second-degree PS; ipsilateral superior limb alteration and other congenital alterations may or may not be present.

Third Degree (Very Severe): Third-degree PS would be diagnoses in patients with amastia; areolar asymmetry; major ipsilateral musculoskeletal chest alterations, such as total absence of the PMM, the pectoralis minor muscle, and /or the serratus anterior muscle; possible lung herniation; widened opening of the mediastinum; and ipsilateral superior limb alteration. Other congenital alterations may or may not be present.

Suggested surgical approach for each degree of presentation:

First Degree (mild) – Breast implantation or customized breast implantation and contralateral mammary reduction or augmentation when needed (symmetrization procedure).

Second Degree (severe) – Tissue expander placement when needed; regional local flap surgery; breast implantation or customized breast implantation; symmetrization procedure.

Third Degree (very severe) – Tissue expander placement; latissimus dorsi flap or other flap surgery, such as a free flap or transverse rectus abdominis myocutaneous (TRAM) flap; breast implantation or customized breast implantation as needed; other surgeries such as the Ravitch procedure and a contralateral symmetrization procedure.

REFERENCE

Clinical and Radiographic Poland Syndrome Classification: A Proposal; Aesthetic Surgery Journal, Volume 29, Issue 6, Pages 494-504 (November 2009); Ricardo Cavalcanti Ribeiro, Renato Saltz, M. Gabriela Moreira Mangles, Hilton Koch (subscription required)