Saturday, July 31, 2010

Eye Words Quilt -- Work in Progress

My first word quilt was the “Hope quilt” I did for Intueri to make a quilt to help her raise money for Multiple Sclerosis Society.  I ventured into word quilts after finding Lazy Gal Quilting blog.  Earlier this summer, I began playing around with piecing words that have to do with the eye.  I would twitter photos as I made the word blocks.  Turned out to be fortuitous as I somehow (even being careful to check myself) misspelled ophthalmology.

MaryMillsRN caught the mistake and was kind enough to let me know.  It would have been horrible to have completed the quilt and then discovered the misspelling.

@rlbates Do you want me to tell you that ophthalmology is misspelled?

It is machine pieced and measures 50.5 in X 68 in.  I have basted it and am machine quilting it.

Here is a close view to see some of the fabrics and words.
Here is one of my 20/20 (vision).  I am happy with how it is turning out.

Friday, July 30, 2010

Ashley's Scottie Dogs Quilt

This small wall hanging was made in 1995 for my sister-in-law Ashley who has Scotties.  I used an appliqué pattern from a magazine (have forgotten which one).  Each dog is from a different black fabric which is fused to the white background and then machine zigzag stitched in place.  
The quilt is machine pieced and quilted.  I outline quilted each Scottie, then stitched along the sashing.   It measures 21.5 in X 27.5 in. 

Here are some sources for Scottie Dog quilt patterns:
Patterns From the Mid 1900s for Doll & Baby Scottie Dog Quilts
Patchwork Scottie Dog by Denyse Schmidt (pdf file)
Scottie Dog

Thursday, July 29, 2010

Fitness to Fly

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

I noticed this tweet from @doc2doc
In Flight Emergencies
Enclosed in the link article was the pdf file link for the paper by the working group of the British Medical Cardiovascular Society:   Fitness to fly for passengers with cardiovascular disease.
The portion of the paper I found most interesting was the advise to patients regarding travel, DVT risk, and recent surgery:
Advice to long-distance (air) travelers (>6 h)
1. Low risk
< No history of DVT/VTE.
< No recent surgery (4 weeks).
< No other known risk factor.
It is common sense, given the foregoing, that encouragement be given to keep mobile in so far as is possible, adopt regular flexion and extension exercises of the lower limbs and extremities with the avoidance of dehydration.
The passenger should be well hydrated the day before as well as on the day of the flight. 
Smoking (now generally banned on aircraft) should be avoided.  Also to be avoided are alcohol and/or caffeine, which contribute to dehydration, and hypnotics, particularly in a cramped environment.

2. Moderate risk
< Previous history of DVT/VTE.
< Recent surgery lasting >30 min in the past 2 months but not in the last 4 weeks.
< Known thrombophilia.
< Pregnancy.
< Obesity (BMI >30 kg/m2).
The guidance for low risk should be adopted with the addition of compression stockings which have been shown to reduce risk, although their use has given rise to adverse comment.

3. High risk
< Recent (within 4 weeks) surgery under general anesthesia lasting >30 min.
< Previous DVT with known additional risk factor(s) including known cancer.
The guidance for low and moderate risk should be adopted and low molecular weight heparin considered (ie, subcutaneous enoxoparin 40 mg on the morning of the flight and on the following day).  Although rare compared with unfractionated
heparin, complications including bleeding and thrombocytopenia can occur so it is only recommended in those at high risk.
Co-existent treatment with warfarin is protective and should be continued. Advice should be sought for patients with a plaster cast and consideration given towards a split cast to relieve limb compression.
Similarly, advice is needed following recent (<2 weeks) DVT/VTE. Aspirin had no effect in one study of the prevention of DVT during air travel and its use was associated with gastrointestinal symptoms in 13% of those who used it. It is not currently recommended in this context for DVT/VTE prophylaxis.

I often ask patients of if they have any travel plans when scheduling elective surgery, especially when the surgery is one that is longer than 1 hour.  This has become a routine part of my DVT assessment risk.

Wednesday, July 28, 2010

Hidradenitis Suppurativa

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

The July issue of the journal Advances in Skin & Wound Care has a CME review article on the chronic, relapsing skin condition known as hidradenitis suppurativa (HS).  I have given the full article reference below.
When I see patients with this condition, it is because they have already progressed past the first clinical stage into either the second or third stage.  It is due to their family doctor or internist deciding perhaps they are in need of surgery.
HS is not a skin condition anyone wants to have.  Robin in her 365 Project:  365 Days with Cushing’s Disease has discussed living with the condition:
Hidradenitis suppurativa....
I'm lucky.  Mine is "mild" compared to most.  Nonetheless, it's no fun.  In 1985, I saw a doctor because of it.  She told me to use white Dial soap and to lose weight. At that time, I hadn't gained very much weight.   Yes, 25 years ago.  And I'd had other symptoms of Cushing's, also, long before then. 
Hidradenitis suppurativa (hi-drad-uh-NI-tis sup-u-ra-TI-va) is a condition marked by chronic skin inflammation,  occurring in areas that contain apocrine sweat glands, usually the axilla and groin.   The exact cause of hidradenitis suppurativa remains unclear.  According to the article:
HS symptoms were first described in 1839 by Velpeau when a patient presented with superficial abscesses in the axillary, breast, and perianal regions. In 1854, Verneuil associated the condition with the apocrine glands, and the condition was given its current name, although for many years, the process was referred to as Verneuil disease.
Genetics, hormones, endocrine factors, and cigarette smoking have all been reported to play a part in the development of hidradenitis suppurativa (HS).  
The prevalence of HS is approximately 1% to 2% of the general population.  Women are affected by HS three times as often as men.   HS affects all races; but the most severe cases are often seen in people with black skin.
HS can present anytime between puberty and post menopause.  The onset of HS peaks between ages 11 and 50 years.
The extent and severity of the disorder varies widely between individuals. Initially a firm pea-sized nodule (0.5-1.5 cm diameter) resembling acne may appear on one site. These lesions may resolve spontaneously or within hours to days rupture and ooze a pus-like discharge. These may heal without treatment but at a later time new lesions recur in the adjacent area. If uncontrolled, this leads to development of larger lesions (golf ball size), sinus tract formation, and involvement of multiple sites.
Three distinct clinical stages have been defined for the condition.
  • Stage 1 – solitary or multiple, isolated abscess formation without scarring or sinus tracts
  • Stage 2 – recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation
  • Stage 3 – diffuse or broad involvement, with multiple interconnected sinus tracts and abscesses.

Areas that may be affected by HS lesions are the axilla, areola of the breast, submammary fold, periumbilical region, groin, scalp, zygomatic areas of the face, nape of the neck, external auditory meatus, and shoulders.
Treatment, or more accurately management, of HS is difficult. The aim is to catch the disease in its early stages.  Weight loss in obese patients and smoking cessation are recommended.   Other measures include:
  • Good hygiene with ordinary soap. 
  • Wear loose fitting clothing to avoid friction.
  • Topical or oral antibiotics similar to those used for treatment of acne  in higher doses.
Surgical management may include:
  • Incision and drainage of abscesses – at the very painful pointing stage.
  • Persistent hidradenitis lumps may be excised after several months of conservative treatment (i.e. waiting and/or antibiotics).
  • Radical excisional surgery is reserved for very severe cases of hidradenitis suppurativa.
  • Carbon dioxide laser ablation has been proposed as a better alternative to removal of glandular and scar tissue.  The wound is left open to heal by secondary intention. 

Hidradenitis Suppurativa: A Clinician's Tool for Early Diagnosis and Treatment; Beshara, Monica A.; Advances in Skin & Wound Care. 23(7):328-332, July 2010; doi: 10.1097/01.ASW.0000363559.53350.84
Hidradenitis suppurativa – Mayo Clinic
Hidradenitis suppurativa – DermNet NZ  (has photos as well as text information)

Tuesday, July 27, 2010

Shout Outs

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

Inside Surgery is the host for this week’s Grand Rounds.  You can read this week’s edition here.
Favorite Post of the Week
Dr. Toni Brayer has a guest post at ACPInternist about how insurance companies are killing primary care. I would like every Grand Rounds Reader to take a look at this and think very hard about what they will support in terms of insurance industry oversight. This post was first published on Dr. Brayer’s blog
From the Surgeons – hey, what can I say, I am a homer
Bongi is a surgeon working in South Africa – he shares part of his day. …….
Don’t forget LITFL is hosting next week.  They are looking for your “killer posts".” 
Trawl your archive, dive deep into the soul of your writing and send us your best; most inspirational; clever; witty; well-researched; head-turning; gut-wrenching; magnificent; glorious requiem of a post…A post that is pathognomic of your writing. A post that is empathic and understanding. A post that is idiosyncratically and inimitably…YOU
Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 2) which is in its 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)
Welcome to the latest edition of Change of Shift!
The nursing blogosphere came through in a big way this week, many thanks to those who have submitted.
I’m excited to showcase these colleague contributions!
So, without further ado,
I present…..Change of Shift!……..
Dr Charles is hosting the first annual 2010 Charles Prize for Poetry.
Open to everyone (patients, doctors, nurses, students, etc.). Limit 1 or 2 entries per person.
Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter……
Contest closes August 31st.
There is a nice article in the New Yorker by Atul Gawande on hospice care:  Letting Go -- What should medicine do when it can’t save your life?
People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives. ……………
This tweet from @Doctor_V

RT @Ed: Hundreds of people have asked about my long-time Twitter background. Here's the story
led to the story in the Armenian Weekly:   Armenian Orphan Rug Lives up to Its Name about a rug
Not just any rug, but one created by 400 Armenian orphans from 1924-25 in a town called Ghazir, about 40 miles north of Beirut.
This colorful piece of tapestry, which measures 18 feet by 12 feet, lives up to its name: It has remained an “orphan” rug since it passed through the hands of President Calvin Coolidge in 1926.
The intricacy is woven with a passion unlike others of its kind, containing some 4 million knots made to characterize the biblical Garden of Eden with its collection of animals and other symbolic features…….
I actually learned of this program, Spokes for Little Folks, from an article in the Arkansas Democrat-Gazette but they don’t have an open policy – you have to have a subscription to read their articles online.  I found this Daily Record article which tells the same story:  
On a recent sweltering Saturday morning, Realtors from North Little Rock rallied together to clean, fix and organize bike parts. Their time was donated on behalf of Spokes for Little Folks. …..
Working with Ron King, who refurbishes donated bikes and donates them to kids who are in need of them, Martin decided to get the NPBOR to join in on the effort. ……..
Anyone can donate any type of bike, working or not, to Spokes for Little Folks.   For additional information or questions, contact Janene Inzer at 501-834-0710 or Bruce Martin at 501-425-5042.

Dr Anonymous’ BTR show will be  4th year Student Kevin Bernstein and 3rd year FamMed Resident Gerry Tolbert  giving a report on the 2010 AAFP Resident and Student Conference.   Show time this Thursday is 8 pm ET.

Upcoming shows (9pm ET)
8/5: Pre-Med Student Erin Breedlove
8/12: Pre-Med Student @InsaneMo
8/19: 4th Year Med Student @DrJonathan
8/26: Dr. A Show 3rd Anniversary

Monday, July 26, 2010

Asclera Now FDA Approved

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

The FDA recently (March 2010) approved Asclera (poliocanol) injection for the treatment of small spider veins (tiny varicose veins less than 1 millimeter in diameter) and reticular veins (those that are 1 to 3 millimeters in diameter).
Asclera is a detergent sclerosant and produces endothelial damage through interference with the cell's surface lipids.and acts by damaging the cell lining of blood vessels. This causes the blood vessel to close, and it is eventually replaced by other types of tissue.
Common adverse reactions to Asclera include leakage and collection of blood from damaged blood vessels at the injection site (hematoma), bruising, irritation, discoloration, and pain at the injection site.
Although they usually occur in the legs, varicose veins also can form in other parts of the body. Factors such as genetics, age, female gender, pregnancy, obesity, and prolonged periods of standing may increase the risk for varicose veins.
Asclera is distributed by BioForm Medical Inc. of Franksville, Wis., and manufactured by Chemische Fabrik Kreussler & Co. of Wiesbaden, Germany.
Check out my old post on Spider Veins.
Food and Drug Administration Newsroom
Aclera Prescribing Information (PDF)

Sunday, July 25, 2010

Medicine and Music

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

Thanks to the PSP Blog which linked to the Culture Map article by By Douglas Newman --  Medical jams: From plastic surgery to cancer to sex changes, it's been rocked about.
Newman has put together the following list with audio links included in his article.  I hope you will pop over and give them a listen.  Do you have any to add to the list? 
"Heart Doctor" by Lee "Scratch" Perry
This late period track by the legendary (and legendarily kooky) Lee "Scratch" Perry finds the reggae/dub artist and producer doling out "advice" to his patients. ….
"A Nurse's Life is Full of Woe" by Billy Bragg
An unreleased track taken from the sessions of Talking With the Taxman About Poetry, "A Nurse's Life is Full of Woe" finds Bragg taking on the plight of the working class,…...

"Plastic Surgery" by Maps of Africa
You can't have a medical themed songlist without a nod to the vain, and there's no better ode to plastic surgery than this psychedelic thumper by Maps of Africa. Granted, it seems as if things have gone horribly wrong for this patient: "I used to be a person/but I've turned into a version/of my plastic surgery."

"Still Ill" by The Smiths
If you know anything about Morrissey you know that the illness in question is undoubtedly an ailment of the heart. And by heart, I don't mean clogged arteries. As is true with almost any song by The Smiths, there are multiple interpretations of "Still Ill."………..Depression? Knowing Morrissey I would say that's a safe bet.

"Call the Doctor" by J.J. Cale
Such a smooth groove, this track from J.J. Cale's 1971 debut finds the laid back bluesman ravaged after a particularly rough night of loving: "A shady lady took all my bread/Ravished my body, lord, and messed with my head/I don't know but I've had my fill/Call the doctor and tell him I'm ill/"

"I Tried to Stay Healthy For You" by Palace Brothers
Like the rest of the Palace Brother's mysterious debut, "I Tried to Stay Healthy For You" sounds like it was recorded in Appalachia during the early part of the 20th century. ……….
The lyrics, seemingly written from the point of view of an aging coalminer are equally ancient and haunting, "Sing to them all and I'll stand by/Though jealousy it threatens/Smoke's around my blackened lungs/It is my only weapon."

"Cure for Pain" by Morphine

"Sick Bed Blues" by Skip James
…… "Oh Lordy, Lord, Lord, Lord/I been so badly misused/An treated just like a dog."
"Cancer" by Joe Jackson
Jackson laments that everything give you cancer and that's no cure and there's no answer. ….

"Acute Schizophrenia Paranoia Blues" by The Kinks

"Hospital" by The Lemonheads

"Lady Godiva's Operation" by The Velvet Underground
"Lady Godiva's Operation" is a terrifying account of a sex-change operation …...
"Love Sick" by Bob Dylan

A few I can think of might include
“Doctor My Eyes” –  Jackson Brown
Bad Case Of Loving You (Doctor, Doctor Give Me The news) – Robert Palmer
Addicted to Love – Robert Palmer
Bad Medicine – Bon Jovi
Disease – Matchbox Twenty
Fever – Elvis Presley

Friday, July 23, 2010

Scrappy Flying Squares Quilt

Earlier this year I made another scrappy flying squares quilt using using leftover 2.5 in fabric squares.  This one uses leftover 3 in fabric squares.  It is 40 in X 50 in, machine pieced and quilted.

I have donated it to the Alzheimer’s Study Quilt Program as I did this one.Here is a photo to show some of the fabrics used.
And another to show the same.  The quilting is simply cross-hatching.

Thursday, July 22, 2010

Recent Breast Cancer News Articles

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

Interesting news recently related to breast cancer.  Original journal articles are listed in the references below.
First topic --
'Cancer risk' for house-proud women – Associated Press
Houseproud women who like to keep their homes clean and fragrant may be at greater risk of breast cancer, research has suggested.
Household cleaners may double risk of breast cancer –
Women who regularly use household cleaners and air fresheners are at double the risk of developing breast cancer than those who never use the products.

If you take the time to look at the study done by Dr Julia Brody, from the Silent Spring Institute, and colleagues which was published in the July issue of the Journal of Environmental Health you do find it suggests there is a link.
However, it is a study using data collected by telephone interviews of 1,508 women (787 who were diagnosed with breast cancer between 1988 and 1995; 721 who did not) about their cleaning regimes.  The authors even noted a bias among women who believed pollutants contribute “a lot” to breast cancer.  The study's authors acknowledge that "recall bias" may have skewered the results.
So while there may turn out to be a true link between household cleaning products and the development of breast cancer, this is a very weak study.  There needs to be a prospective study done with all possible recall bias filtered out.

Next topic:
New Arsenic Nanoparticle Blocks Aggressive Breast Cancer –
…….Prior to the new research, arsenic hadn't been effective in solid tumors. After the drug was injected into the bloodstream, it was excreted too rapidly to work. The concentration of arsenic couldn't be increased, because it was then too toxic.
A new arsenic nanoparticle -- designed to slip undetected through the bloodstream until it arrives at the tumor and delivers its poisonous cargo -- solved all that. The nanoparticle, called a nanobin, was injected into mice with triple negative breast tumors. Nanobins loaded with arsenic reduced tumor growth in mice, while the non-encapsulated arsenic had no effect on tumor growth. The arsenic nanobins blocked tumor growth by causing the cancer cells to die by a process known as apoptosis. ………
Looking ahead, the challenge now is to refine and improve the technology. "How do we make it more toxic to cancer cells and less toxic to healthy cells?" asked Cryns, also the director of SUCCEED, a Northwestern Medicine program to improve the quality of life for breast cancer survivors. ……….
Arsenic Trioxide Nanoparticle Can Target Triple Negative Breast Cancer  -- Breast Cancer Blog
…………In a study on mice with breast cancer, this arsenic trioxide nanoparticle made tumors shrink!  Dr Cryns and Richard Ahn published their research on arsenic trioxide nanobins in Clinical Cancer Research on July 15, 2010. 
Nothing negative to say here.   To me it’s obvious that this is all preliminary – still in the mice research stage.    I find it interesting.

Third topic:
Fish Oil May Help Reduce the Risk of Breast Cancer --
Fish oil reduces risk of breast cancer by a third –
The new study, just published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research, was conducted by a research team at the Fred Hutchinson Cancer Research Center in Seattle, Washington. They investigated 35,016 postmenopausal women between the ages of 50 and 76 with no history of breast cancer who were participating in the Vitamins and Lifestyle cohort study (dubbed VITAL, short). The woman was asked to complete a 24 page questionnaire about their use of supplements other than vitamins and/or minerals.
After six years of follow-up, 880 of these women had been diagnosed with breast cancer. However, those women who reported regularly taking fish oil supplements, which contain high levels of the omega-3 fatty acids EPA and DHA, were found to have a 32 percent reduced risk of invasive ductal breast cancer -- the most common type of breast cancer. The use of other specialty supplements, such as the herbs black cohosh and dong quai which are often taken by women to relieve symptoms of menopause, was not associated with raising or lowering breast cancer risk.

Yes, fish oil is important to heart health, and the original article did find an association in lowering the risk of ductal breast cancer, but the above news articles over state it.  The authors state their results as (bold highlight is mine):
Current use of fish oil was associated with reduced risk of breast cancer (HR, 0.68; 95% CI, 0.50-0.92). Ten-year average use was suggestive of reduced risk (P trend = 0.09). These results held for ductal but not lobular cancers. The remaining specialty supplements were not associated with breast cancer risk: Specifically, use of supplements sometimes taken for menopausal symptoms (black cohosh, dong quai, soy, or St. John's wort) was not associated with risk.

Self-reported chemicals exposure, beliefs about disease causation, and risk of breast cancer in the Cape Cod Breast Cancer and Environment Study: a case-control study; Ami R. Zota, Ann Aschengrau, Ruthann A. Rudel, Julia Green Brody; Environmental Health 2010, 9:40 (20 July 2010)
A Novel Nanoparticulate Formulation of Arsenic Trioxide with Enhanced Therapeutic Efficacy in a Murine Model of Breast Cancer; Richard W. Ahn, Feng Chen, Haimei Chen, Stephan T. Stern, Jeffrey D. Clogston, Anil K. Patri, Meera R. Raja, Elden P. Swindell, Vamsi Parimi, Vincent L. Cryns, and Thomas V. O'Halloran; Clin Cancer Res July 15, 2010 16:3607-3617; Published OnlineFirst June 2, 2010; doi:10.1158/1078-0432.CCR-10-0068
Specialty Supplements and Breast Cancer Risk in the VITamins And Lifestyle (VITAL) Cohort; Theodore M. Brasky, Johanna W. Lampe, John D. Potter, Ruth E. Patterson, and Emily White; Cancer Epidemiol Biomarkers Prev July 2010 19:1696-1708; doi:10.1158/1055-9965.EPI-10-0318

Wednesday, July 21, 2010

7 Links for Bloggers Challenge

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

I can’t say I was prompted by a recent post on Problogger to do their challenge.  Truth is I found the challenge due to posts from T,  Notes of an Anesthesioboist, and Mike Cadogan, Life in the Fast Lane, who both took up the challenge.    Read their posts here and here.
After reading their posts, I thought it would be fun to try and complete the 7 links for Bloggers challenge!   And as Mike said, “I am hoping that more medical bloggers will take up this challenge.”

Your first post – my first post was back on May 16, 2007 -- First Cut (I mean draft).

A post you enjoyed writing the most –   Recently, the one I have enjoyed doing the most was the tongue in check one “Adding to My Vocabulary”  but I find this hard to answer.  I have enjoyed doing many of the series (facial fractures, tendon transfers, etc).

A post which had a great discussion –  I’m not sure many of posts have ever created much discussion, but the one with the most comments is my post glomus tumor from October 2007.  It continues to get comments almost as if the comment section has become a forum.

A post on someone else’s blog that you wish you’d written –  My writing tends to be “text-bookish.”   I wish I could write like our storytelling surgeon Bongi or like T or like Sid did when he wrote Surgeon’s Blog or Dr Bruce Campbell. 
For the contrast between my writing and other medical writers just see the comparison I did here.
An example of one such post would be Bongi’s recent post“Silence“ or Bruce’s post “The Odor.”

A post with a title that you are proud of – I liked the title, Tailoring, as it for me brought in my sewing skills with my surgical skills.

A post that you wish more people had read – All of them (smiling here), but perhaps my post Tips for Surgery Patients from March 2008.

Your most visited post ever – According to Google Analytics, my most visited post is the one I did on Inverted Nipples back in November 2007.

Tuesday, July 20, 2010

Shout Outs

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

Captain Atopic is the host for this week’s Grand Rounds.  It’s a musical edition, “With a Little Help From My Friends.”  You can read this week’s edition here.
Welcome to another edition of Grand Rounds! This week, Grand Rounds 6:43 pays tribute to our friends, with a little help from Messrs Lennon and McCartney (with Ringo on vocals...)
What would you think if I sang out of tune,
Would you stand up and walk out on me.
Lend me your ears and I'll sing you a song,
And I'll try not to sing out of key.
Thanks to @gastromom for the heads up on this NYTimes article:  Guns in Frail Hands
She is a 90-year-old widow with mild Alzheimer’s disease, and her son is begging her, for safety’s sake, to give up something she considers essential to her independence and sense of control.
“You can’t take it away from me,” she told him recently. “It’s all I’ve got.”
This may sound like a classic confrontation with an elderly mother who won’t give up her car. But it’s in fact about a loaded .38 caliber handgun that she keeps wrapped in a scarf in her top dresser drawer in a Southern California retirement community…..
Like cars, guns symbolize independence and individualism to many Americans. In states where gun ownership is a way of life, the elderly population is as likely as anyone to be armed and, in the view of many family members and professionals who care for them, possibly dangerous. ……………..
Fellow med-blogger Sterile Eye has one of his photos in this Legions Magazine article by Sharon Adams:   Then And Now – Medical
From Carbolic Acid to Antibiotics
Today, nobody expects anyone to die of a broken leg, having a baby or from suffering a minor wound. But 150 years ago, these could be death sentences. Broken legs and wounded arms were often amputated, and nearly half of all amputees died. Childbed fever was the second most likely cause of death of women of childbearing age.
Infection was a major killer until Louis Pasteur discovered the connection between bacteria and disease in the mid-1800s. Some physicians like England’s Joseph Lister (yes, the mouthwash was named for him), embraced the idea of keeping patients’ environment—and their doctors and the equipment they use—clean in order to prevent transmission of germs. In 1865, Lister began spraying wounds, tools and the patient with carbolic acid to kill germs……….
A tweet from @DrJenGunter:  “Study at UCSF looking to recruit moms carrying babies with spina bifida -”
….. Recently, some doctors have started operating to close the defect during pregnancy, in hopes that protecting the spinal cord as early as possibly will minimize injury. However, it is really not known if it is better to operate on a baby with spina bifida during pregnancy or immediately after birth. The National Institutes of Health is currently enrolling pregnant mothers carrying a baby with spina bifida in a study called MOMS (management of myelomeningocele study) to answer that very question……
ABC News’ Person of the Week this past week: Surgery on Sunday-- Doctors Give Free Health Care to the Uninsured
It's Sunday and Dr. Andrew Moore isn't taking a day off in his Lexington, Kentucky, neighborhood. Instead, he scrubs in and spends his day tending to a carpenter's torn ligament and removing another man's hernia. Moore does all of this for free.
Person of the Week Stan Brock has provided free health care for 25 years………..
Moore founded Surgery on Sunday in 2005. It's a nonprofit organization where doctors and nurses volunteer their services for free the third Sunday of every month, working in donated surgical space at Lexington Surgery Center.
Together, they are this week's "World News" person of the week……………
TBTAM has been interviewed by Womens
I was privileged to be the featured interview this month at the Spotlight on Women's Health series at, the website of the Office of Women's Health. Thanks to the editors for their thoughtful questions and  for the opportunity to speak to women about HPV, healthy living and, of course, cooking!

I started another blog devoted only to my handwork:  Ramona’s Handwork.  I don’t want to loose my non-medical friends from this blog, but neither do I want to “frighten” them with images from some of my medical posts.  So if you only want to see my handwork, then please bookmark my new blog

Dr Anonymous’ BTR show will be on summer break until late August.

Upcoming shows (9pm ET)
7/29: Reports from 4th year Student Kevin Bernstein and 3rd year FamMed Resident Gerry Tolbert at 2010 AAFP Resident and Student Conference
8/5: Pre-Med Student Erin Breedlove
8/12: Pre-Med Student @InsaneMo
8/19: 4th Year Med Student @DrJonathan
8/26: Dr. A Show 3rd Anniversary

Monday, July 19, 2010

Vampire Facelift?!

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

I first saw mention of the “vampire facelift” almost two weeks ago as a news article listed in the July 9th issue of the Plastic Surgery SmartBrief:  "Vampire face-lift" uses patient's platelets and fibrin in dermal filler.
The article begins:
Instead of a traditional facelift, patients are being offered another option to get rid of wrinkles. It's called Selphyl or the "vampire face-lift," and it uses a person's own blood to sculpt the face.
Selphyl according to the companies website
The patented SELPHYL® System enables the safe and rapid preparation of an activated Platelet-rich Fibrin Matrix (PRFM).  A small volume of the patient’s blood is collected and the platelets and fibrin are concentrated during a simple centrifuge process.  The resulting product (liquid, gel or membrane) can be applied to a treatment area of the face or body to stimulate natural, new tissue growth.  SELPHYL® prepared PRFM has been shown to increase skin volume and rejuvenation.
SELPHYL® ensures a preparation of fibrin and platelets, with virtually no red or white blood cells. Studies have shown these platelets to be viable and intact.  Platelets will release proteins, which have been reported to trigger cell migration, proliferation and differentiation over time.
With over 45,000 procedures performed world-wide, this technology has been extensively used for soft tissue regeneration in plastic surgery, orthopedics and maxillofacial surgery.
So how does Sephyl create any face-lifting effect?  Back to the news article, as explained by a non-physician owner of a medical day spa, Kathleen Stegman of Midwest Medical Aesthetics:
The Selphyl process is done in the office. A tube, filled with the patient's blood, is put in a centrifuge machine, where platelets and fibrin are separated and the blood is prepared for application as a dermal filler.
Oh, it is used as a dermal filler, but that’s not a face lift!   What nonsense!
It is my opinion that this news article and day spa are simply “cashing” in on the current vampire craze with increase vampire novels and movies.
I searched the Journal of Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, and PubMed for articles on Selphyl.  Here are the ones I found:
Platelet-rich fibrin matrix for improvement of deep nasolabial folds.; Sclafani AP; J Cosmet Dermatol. 2010 Mar;9(1):66-71.PMID: 20367676 [PubMed - in process]Related citations
Applications of platelet-rich fibrin matrix in facial plastic surgery., Sclafani AP., Facial Plast Surg. 2009 Nov;25(4):270-6. Epub 2009 Nov 18.PMID: 19924600 [PubMed - indexed for MEDLINE]Related citations

Sunday, July 18, 2010

Adding to My Vocabulary

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

This past week I learned several new words and phrases.  Allow me to share a few with you.
Speed sag – I learned of this phrase from a tweet from @BAAPSMedia
Have just seen a cosmetic surgery press release about so-called "Speedo Sag"....Ew
My first thought was the same as my OR crew whom I polled.  We all thought it had to have something to do with the parts of the male anatomy which should be covered by the speedo such as perhaps the scrotum.  It doesn’t. 
I googled it to find out. It has to do with the male’s abdominal skin and fat which falls over the top of the speedo.   Apparently, they are looking for a male abdominoplasty.
Many of the men that want to get the Tummy Tuck, aka “Speedo sag” surgery, have lost weight or started a fitness plan and are looking for a surgery that can remove pockets of fat or loose flaps of skin from their stomach.
I would have called this the “spare tire” or the “dunlop” but not “speedo sag.” 
The above phrase gave us some risible moments in the OR.
1. Laughable; ludicrous.
2. Disposed to laugh.
3. Relating to laughter.
From Latin risus, past participle of ridere (to laugh). Other words that share the same root are ridiculous, deride, rident, and riant.
It hit me as I was writing this that the facial muscle – risorius – who’s function is to retract the angle of the mouth to produce a smile has the same etymology.
And now I hope you will forgive me for the above  folderol as I wish you many risible moments today.
1. Nonsense; foolishness.
2. A trifle; gewgaw.
From a nonsense refrain in some old songs. The word is also spelled as falderal.

Friday, July 16, 2010

Kristen's Baby Quilt

I made this baby quilt for our niece Kristen.  It was made in a “quilt-as-you-go” manner.  I literally sewed each strip with the batting and backing as the base.  Somehow the center ended up “puffing” up so it doesn’t lay flat.  I think I must have “stretched” the long strips as I sewed them.  For a baby quilt, it didn’t end up mattering.  Still. 

The quilt is 39 in X 50 in.  It was made in 1996.

Here is a close photo to show some of the interesting fabrics.  Here is a photo of the back which is also pieced.
Here is the label.

Thursday, July 15, 2010

The Asian Dermatologic Patient: Article Review

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

I ran across this article on Medscape (full reference below):  The Asian Dermatologic Patient: Review of Common Pigmentary Disorders and Cutaneous Diseases.  It is originally from the American Journal of Clinical Dermatology.
The vast majority of my patients are Caucasian and African American, but over the years there has been an increase in Asian and Latino.  So when I see an article like this, I read it, even though it is not in depth as it adds to my knowledge.
The Asian patient ….., photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color.
The article notes that over half the world's population is Asian.  At the time of the 2000 US Census, 4.2% of the US population was reported to be of Asian origin.  This group is projected to double in size by 2050. 
The term Asian refers to people having origins from the Far East, southeast Asia, or the Indian subcontinent.  They are a diverse group with various skin phototypes ranging from Fitzpatrick type III to V in the Chinese and Japanese to type IV and V in Indians and Pakistanis.
The most important issues of Asian skin from my standpoint are the issues of photoaging, problems with pigmentation, tendency to form hypertrophic or keloid scars, and the need to remember they too can develop skin cancers.

Here are some key points from the article:
Photoaging in Asians
  • Significant photodamage in the form of epidermal atypia and atrophy, dermal collagen and elastin damage, and pigmentary disorders can occur in skin of color.
  • Both pigmentary changes and wrinkling can be major features of photoaging in Asians. However, moderate-to-severe wrinkling becomes apparent only at about 50 years of age, which is a decade or two later than in age-matched Caucasians.
  • Other cutaneous manifestations of aging ethnic skin include the development of benign cutaneous growths such as dermatosis papulosa nigra, seborrheic keratoses, and the development of solar lentigines.
Disorders of Pigmentation
Post-inflammatory hyperpigmentation (PIH) is a common pigmentary disorder in Asian skin.     The severity of PIH is related to the degree of inflammation and extent of disruption of the epidermo-dermal junction. It may be caused by endogenous inflammatory skin disorders or iatrogenic sources such as lasers. 
Melasma is an acquired symmetric hypermelanosis involving sun-exposed areas commonly seen in Asian middle-aged women. Genetics, UV radiation, pregnancy, hormonal therapies, and other phototoxic drugs are all thought to be contributing etiologic factors and melasma remains a difficult condition to treat.  (photo credit)
Combinations of hydroquinone with topical corticosteroids and tretinoin can be effective first-line treatment of melasma.  Glycolic acid, salicylic acid, and trichloroacetic acid peels are also useful adjuncts to topical treatments in the management of melasma in Asians.
Use of bleaching agents and sunscreens for at least 6 weeks, and preferably for 3 months, prior to any laser or light therapy can help suppress the function of hyperactive melanocytes and reduce the risk of PIH. 
Freckles and lentigines are common benign pigmented lesions seen in Asians.
Nevus of Ota is a dermal melanocytic hamartoma common in Asians, affecting about 0.6% of the population.  It presents as a bluish hyperpigmentation along the distribution of the trigeminal nerve. (photo credit)
Acquired bilateral nevus of Ota-like macules or Hori's macules is a condition that affects 0.8% of the Asian population, and are described as bluish-brown hyperpigmentation typically affecting the bilateral malar regions, forehead, and temples of middle-aged women.
Common Skin Diseases in Asians
Atopic dermatitis (eczema) is a common presenting complaint in all dermatology clinics.  Management of atopic dermatitis is similar in the different ethnic groups, and includes emollients, topical corticosteroids, topical tacrolimus, phototherapy, oral antihistamines, and immunosuppressants in resistant cases.
Acne:  The acne hyperpigmented macule is common in skin of color and persists for an average of 4 months or longer.  Ice-pick scarring or keloidal scarring may also occur.
Hypertrophic and keloid scars are more common in individuals of Asian descent than in their Caucasian counterparts.
Psoriasis was the seventh most common skin condition in a large Asian patient survey conducted in Singapore, but is more commonly seen in Caucasians than in Asians and Africans.  It is very rare in Native Americans and Hispanics.

Cutaneous Malignancies in Skin of Color
The incidence of melanoma has been reported to range between 0.2 and 2.2 per 100 000 in Asians.   In skin of color, the most common sites for the development of melanoma are non-sun-exposed areas, such as palmar, plantar, subungual, and mucosal surfaces.
Non-Melanoma Skin Cancer  Basal cell carcinoma (BCC), followed by squamous cell carcinoma (SCC), are the most common skin cancers in Chinese and Japanese individuals.
Mycosis fungoides or cutaneous T-cell lymphoma is the fourth most common skin cancer amongst the Japanese.
Hypopigmented mycosis fungoides, with ill-defined, often pruritic, hypopigmented macules and patches, tends to present in a younger patient population and only in skin of color.  The disorder can often be mistaken for vitiligo, pityriasis alba, tinea versicolor, or post-inflammatory hypopigmentation. Misdiagnosis can delay treatment. There is usually a good response to PUVA, UVB phototherapy, or topical mechlorethamine (chlormethine), but recurrences are common. The overall prognosis is good

The Asian Dermatologic Patient: Review of Common Pigmentary Disorders and Cutaneous Diseases; Am J Clin Dermatol. 2009;10(3):153-168; Stephanie G.Y. Ho; Henry H.L. Chan
Dermatosis Papulosa Nigra; eMedicine Article, Feb 19, 2009; Mehran Nowfar-Rad, MD, Frederick Fish, MD
Nevi of Ota and Ito; eMedicine Article, July 14, 2008; Harvey Lui, MD, Youwen Zhou, MD
Melasma; eMedicine Article, May 28, 2010; Andrew D Montemarano, DO, Hugh Lyford
Keloid and Hypertrophic Scar; eMedicine Article, May 14, 2010; Brian Berman, MD, PhD, Whitney Valins, Sadegh Amini, MD, Martha H Viera, MD

Wednesday, July 14, 2010

Using Botox in Combination with Other Treatments

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

Recently I read and completed a nice CME article on Medscape (first reference below).  It focused on the consensus panel’s (second reference, from first article and not read by me) recommendations. 
As Botox and Dysport are used more often, it is becoming more common for them to be used in combination with other treatments (ie Laser resurfacing, fillers, and surgery).  It was nice to see a consensus regarding how to approach multimodal treatment with BoNTA. 
Treatment Recommendations
Botox+ Injectable fillers
BoNTA and injectable fillers can be administered the same day or separate days. However, it may be preferable to inject the first agent, wait until effects are clinically evident, and then follow up with second agent as needed.
Upper face: Typical to inject BoNTA first.
Mid and lower face: Typical to inject filler first.
Botox + Ablative laser resurfacing
Inject BoNTA several days prior to the ablative procedure and wait until BoNTA effects are clinically evident.
Botox + Nonablative lasers/chemical peels
Nonablative procedure first. Inject BoNTA 10-15 minutes after nonablative procedure.
Botox + Surgery
Avoid injecting BoNTA on day of surgery. Follow-up BoNTA injections can continue beginning 3 months after surgery.

Aesthetic Treatment With Neurotoxins: Options and Individualized Treatment: Practical Use of Botulinum NeurotoxinA in Aesthetic Practice; Medscape article,   06/18/2010;  Michael A.C. Kane, MD
Kane M, Donofrio L, Ascher B, et al. Expanding the use of neurotoxins in facial aesthetics: a consensus panel's assessment and recommendations. J Drugs Dermatol. 2010;9;7-22.

Tuesday, July 13, 2010

Shout Outs

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

Bongi, other things amanzi, is the host for this week’s Grand Rounds.  You can read this week’s edition here.
it's not just the soccer world cup that is on south african shores but the great grand rounds, something that some would say is far more important than the world cup (ok only one guy would actually say that and he is in a psychiatric institution in outer mongolia) is also presently hosted in south africa!!! proudly south african!!!
but time to see what the bloggers have dished up for us this week.
Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 1) which marks the beginning of the 5th year!   You can find the schedule and the COS archives at Emergiblog. (photo credit)
Welcome to the Change of Shift anniversary edition!
Today marks the beginning of Change of Shift’s fifth year.
Thanks to everyone who responded with suggestions for our carnival! I’ll be compiling those thoughts into a future post (let’s just say link lists are out…).
Many thanks to those who contributed! This week, I’ve added a few new-to-me nursing blogs I’ve discovered along with favorite CoS regulars………
NPR has a wonderful series called StoryCorps were family members interview one another.  In this one, two young children interview their father about his bionic hand:  For Kids, Dad's Bionic Hand Recalls 'Star Wars'
In 2007, Eric Jones survived a bout with cancer, but complications from his treatment led doctors to amputate his right hand. He then became one of the first Americans to receive a bionic hand. He recently spoke with his son Alex, 7, and daughter, Lanie, 10, about his recovery.
"How did you get your bionic hand, Dad?" Lanie asks.
"On the Internet," her father says.
"Did you just go to Google and look up, um ... 'bionic hand?' " she asks…..
Interesting article on lack of remuneration to organ donations via a tweet by @txmed -- “The organ donor—alone among all the participants in the world of transplantation—receives no benefit”:  Our Deeply Unethical National Organ Policy (bold emphasis is mine)
………Everyone involved in the organ transplantation process benefits handsomely, except the donor. Organ transplantation provides a wonderful example of life-saving science and technology deployed in serving mankind. It is also a thriving industry. The entire transplant team, including the surgeons, nurses, technicians, pharmacists, nephrologists, and other specialists are well-paid for their respective roles in providing organ transplant service. The medical centers at which transplants are performed are also handsomely compensated. The procedure feeds revenue into virtually every facet of the hospital. It occupies rooms, keeps labs busy, requires numerous expensive tests, and staff at all levels benefit. The pharmaceutical industry certainly benefits, as transplant patients remain on various expensive drugs to protect their new organ for the rest of their lives. Then, of course, there is the recipient who is, perhaps, compensated best of all. He or she gets his or her life back. Only the donor, who gives the most and without whom the entire process would grind to an abrupt halt, is required to forego any material recompense for his or her service.………………..
TBTAM has been interviewed by Womens
I was privileged to be the featured interview this month at the Spotlight on Women's Health series at, the website of the Office of Women's Health. Thanks to the editors for their thoughtful questions and  for the opportunity to speak to women about HPV, healthy living and, of course, cooking!

The Alliance for American Quilts received 115 quilts for it’s “New from Old Quilt Contest Contest.”  You can see all the quilts here.  My entry was “Label Me.”  The winner was this lovely quilt called “Metal Measures” by Jamie Fingal of California.

Measuring tape fabric, wool felt, old zippers, embroidery thread. Fabric was Mistyfused onto zippers and handsewn into place. Zigzag on domestic machine to felt.
The quintessential American design made into a modern day log cabin that is heavy on the metal.

Dr Anonymous’ BTR show will be on summer break until late August.

Upcoming shows (9pm ET)
Jul-Aug: Summer Break
8/26: Dr. A Show 3rd Anniversary

Monday, July 12, 2010

First Full Face Transplant Done!

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

French surgeons at the the Creteil Henri-Mondor Hospital in the Paris suburbs performed the first successful full face transplant which included the lacrimal system (eyelids and tear ducts) last month on June 26.
The team was lead by head surgeon Laurent Lantieri who has already performed four other partial or nearly-complete face transplants including the one two years ago on Pascal Coler, 24, who needed a new face after suffering from Von Recklinghausen's disease — known as the "Elephant Man" condition.
This landmark surgery was done on a patient who is identified only as “Jerome,” a 35 year old man a face-disfiguring genetic disorder.  No sources report which genetic disease Jerome has, but it is most likely neurofibromatosis.
Jerome is reported to be doing well.  Lantieri is reported to have said, "My patient is doing well. He is walking, eating, talking. His beard has started to grow back on his new face."
A face transplant involves the removal of the entire face from a corpse, including mouth and eyelids, and grafting it onto the patient. Nerves and blood vessels are connected under a microscope.  Like other transplant procedures, the patient remains at risk of rejecting the transplanted tissue.
Neurofibromatosis is an autosomal dominant disease, which  means that an individual has reached a 50% risk of transmission to their children.  It affects the brain, spinal cord, nerves, skin, and other systems in the body.
There are two types of neurofibromatosis, NF1 and NF2. NF1 is more common, occurring in 1 of every 4,000 births and affecting an estimated 100,000 Americans.  It is also known as von Recklinghausen disease.
NF2 is characterized by the presence of bilateral acoustic neurofibroma-like tumors and is rarer, seen in 1 in 50,000 births. People with NF2 usually develop benign tumors on the nerves in their ears, causing hearing loss, eventual deafness, and problems with balance.
Neurofibromatosis is defined by tumors, called neurofibromas, that grow along nerves in the body, or on or under the skin.  Neurofibromas often first appear in childhood, especially during puberty. Many neurofibromas can be removed.  Although usually benign (noncancerous), an estimated 3%-5% become cancerous.

Daily Telegraph
eMedicine:  Neurofibromatosis
National Institute of Neurological Disorders and Stroke

Saturday, July 10, 2010

Directory Assistance

Is this the Doctor’s Building?”

“No, Ma’am.  This is an office in the Doctor’s Building.  What doctor are you looking for?”

I don’t know.  I’m pregnant and was given this number when I called 411 looking for a doctor.”

Friday, July 9, 2010

Girl in Basket Quilt

I made this quilt last month using fabric scraps for the crazy-pieced basket.  It is machine pieced and quilted.  It measures 16 inches square.  It is available for sale on Etsy.

I marked the quilt with a chalk marker which appears to not have completely washed out.  All the quilting was done with white thread.
Here you can see the quilting of the triangle corners.
Here is the back before I sewed on the label and sleeve for hanging.

Thursday, July 8, 2010

Alopecia: the Patient’s Viewpoint

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

The New York Times has a series called Patient Voices which gives insights from the patients with the disease, physical and emotional changes in their lives, and accommodations made.  The most recent series is on patients with alopecia or hair loss.
The Voices of Alopecia by Tara Parker-Pope (July 6, 2010)
This week, Patient Voices explores alopecia, an autoimmune disease that leads to a few bald patches to the loss of every hair on a person’s body.
To hear what it’s like to live with alopecia, listen to the Patient Voices audio slide show that features adults, children and their parents who are coping with the condition.
Patient Voices: Alopecia  Listen to these seven people tell what it is like to live with alopecia?
Matt Kelly, 43, lost his hair at age 38 over a 6 week time span.
Jennifer DeFreece, 29, developed alopecia totalis as a child.
Margaret Staib, 42, an artist with three daughters.
Rafi Wasselman, 16, says his best medicine is his collection of caps.
Maureen McGettigan, 47, began losing her hair at age 16.
Annie Kazmi, 33, tells her daughter Noori’s story.  Then Noori tells her own.

A ‘Forest Fire of Hair Loss,’ and Its Scars written by Karen Barrow tells Matt Kelley’s story.
……….Mr. Kelley, now 43, has alopecia areata, an autoimmune disease that causes the body to attack its own hair follicles. Alopecia, which does not include normal male-pattern baldness, affects nearly 2 percent of the global population and has no universally effective treatment. Its progression is unpredictable and can range from a few bald patches to a completely hairless scalp to the loss of every hair on a person’s body — known as alopecia universalis. Sometimes the hair regrows, sometimes it does not, and sometimes it grows in only to fall out again years later.

The associated “Ask an Expert About Alopecia” gives NYT’s readers the opportunity to have their questions regarding alopecia answered by Dr. Maria Hordinsky, chair of the dermatology department at the University of Minnesota.

Wednesday, July 7, 2010

Adherence to Surgical Care Improvement Project Measures

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

An article in the June 23/30 issue of JAMA features an analysis of the reported adherence to Surgical Care Improvement Project measures (SCIPs) and the reduction of postoperative infections.
There are 9 publicly reported SCIP measures, 6 of which focus on postoperative infection prevention.
  • INF-1: patients who received prophylactic antibiotics within 1 hour prior to surgical incision (2 hours if receiving vancomycin).
  • INF-2: patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • INF-3: patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours for coronary artery bypass graft surgery or other cardiac surgery).
  • INF-4: cardiac surgery patients with controlled 6 AM postoperative blood glucose level (≤200 mg/dL [≤11.1 mmol/L]).
  • INF-6: surgery patients with appropriate surgical site hair removal with clippers or depilatory or those not requiring surgical site hair removal.
  • INF-7: colorectal surgery patients with immediate postoperative normothermia (first recorded temperature was ≥96.8°F within first 15 minutes after leaving the operating room).
The intention of CMS in collecting this data and publicly reporting it is "to assist patients in selecting centers of excellence" for receipt of their surgical care.  CMS also ties it to payment for services.
Hospital participation in these data collection efforts is voluntary. However, the Centers for Medicare & Medicaid Services (CMS) reduces hospital reimbursement by 2% if they fail to report their performance on these measures.    After validation and cleanup of the data, the results are reported on the Hospital Compare Web site (

The authors of the paper point out “Developers of the SCIP measurement process are hoping to demonstrate a 25% reduction in complication rates over 5 years; however, our findings are unable to suggest that the improvements in SCIP compliance have been associated with a reduction in infection rates. According to our estimates, increasing adherence to 100% would result in less than a 25% decrease in these rates.”
The results of their analysis:
There were 3996 documented postoperative infections (out of 405 720 patients).
The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95).
The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection.
None of the individual SCIP measures were significantly associated with a lower probability of infection.

For me, the point that stood out (even with the limitations of the study) is that NONE of the individual SCIP measures were associated with lower infection.  It took (takes) a combination of good practices to lower and or prevent infection.

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections; Jonah J. Stulberg, MD, PhD, MPH; Conor P. Delaney, MD, PhD; Duncan V. Neuhauser, PhD; David C. Aron, MD, MS; Pingfu Fu, PhD; Siran M. Koroukian, PhD; JAMA. 2010;303(24):2479-2485
The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery; Bratzler DW, Hunt DR.;  Clin Infect Dis. 2006;43(3):322-330.

Tuesday, July 6, 2010

Shout Outs

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

Dr. John Schumannis, Glass Hospital, the host for this week’s Grand Rounds.   You can read this week’s edition here.
Hope you had a wonderful holiday weekend.
GlassHospital is proud to host this week’s Grand Rounds, a compendium of medical-related writing and blogging from around the world. This week’s theme, in honor of the holiday, is CELEBRATION. Here at GH we’re pleased to be celebrating the six month anniversary of our debut.
We have 21 pieces to share with you, including one poem and one photo. This week’s submissions, all celebratory-themed, seemed to cluster into five main categories: Aging gracefully, history & literature, medical drama, health care policy, and good ol’ humor. So pull up a chair, maybe a nice iced coffee, and dig in………..
Here are a few of many injuries in the news due to fireworks.:
N.Y. man loses arm in fireworks blast
Man seriously injured in fireworks accident at Cross Lake
Colo. Springs man injured by homemade fireworks
Children injured by fireworks brought to hospital
Girl Hurt in Fireworks Accident in Platte City
3 Hurt In Blue Springs Fireworks Accident
I am not a fan of guns, but my husband is.  He doesn’t hunt, but collects antique guns (Civil War Era) and has a concealed carry permit.  It is with interest that I have been following the news story on gun rights vs public safety.  NPR has done a nice job of covering this:  High Court Ruling Fuels Chicago's Handgun Debate
Twice in two years, the U.S. Supreme Court has struck down handgun bans in major American cities.
More On Gun Rulings
Some D.C. Residents Say It's Too Hard To Get A Gun July 5, 2010
The first ruling two years ago overturned a gun law in Washington, D.C. The second high court decision, which came last week, involved a similar statute in Chicago.
The City Council quickly changed the law — and it is now legal to own a handgun in the Windy City.
Gun rights advocates say Chicago residents will be safer from violent crime. But those advocating gun control say the opposite: that guns in the home put more people at risk………….
As I have seen many injuries due to power saws, I paid close attention to this NPR story:  Sharp Edge: One Man's Quest To Improve Saw Safety
Table saws are by far the most dangerous tools used by woodworkers and do-it-yourself enthusiasts. Every year around the U.S., more than 3,000 people cut off their fingers or thumbs in table saw accidents, according to data from the Consumer Product Safety Commission. And 30,000 end up in emergency rooms with other injuries.
One entrepreneur has developed a safety device called SawStop that prevents those injuries. But the power tool industry has chosen not to adopt the technology. And because of that, power tool manufacturers now face a growing number of lawsuits………
Brendan Marracco’s story is told by Lizette Alvarez in the New York Times:  Spirit Intact, Soldier Reclaims His Life
……..In the nearly 15 months since, Specialist Marrocco has pushed past pain and exhaustion to learn to use his four prosthetics, though he can walk for only 15 minutes at a time. He has met sports stars like Jorge Posada and Tiger Woods — and become something of a star himself here at Walter Reed Army Medical Center, where his moxie and humor are an inspiration to hundreds of other wounded service members. He has also met, fallen in love with and proposed marriage to a young woman who sees what is there rather than what is missing, though Specialist Marrocco has lately been questioning the relationship……….

Dr Anonymous’ BTR show will be on summer break until late August.

Upcoming shows (9pm ET)
Jul-Aug: Summer Break
8/26: Dr. A Show 3rd Anniversary

Monday, July 5, 2010

Hereditary Coagulopathies – an Article Review

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

For any of us surgeons this is a topic with which we should be familiar.  The article (full reference below) in the May issue of the Journal of Plastic and Reconstructive Surgery is a nice review of the topic.  The article begins with the reminder of why this topic is important:
There are over 200,000 hospital admissions for pulmonary embolism annually in the United States, with an estimated mortality of 50,000 to 100,000.  Most thromboembolic complications related to surgery and immobilization occur within 30 days of surgery.  Underlying hypercoagulable states, or thrombophilias, are a common risk factor for venous thromboembolism.….
It has been recently reported that a hypercoagulable state is present in more than half of the patients who present with an “unprovoked venous thromboembolism.”  There is also a significant incidence in patients with presumably provoked venous thromboembolism, and it is a reasonable approach to perform a thrombosis workup on all patients who suffer venous thromboembolisms.
The article then goes on to review the types of thrombophilias, dividing them into two main subsets based on the mechanisms involved:  (1) abnormal function of naturally occurring coagulation factors and (2) deficiencies of naturally occurring coagulation factors.  The first subset is approximately five times more common among the Caucasian population than the second subset.

Subset I: Abnormal Function of Coagulation Factors
Activated Protein C Resistance and Factor V Leiden:
Factor V Leiden was first described in 1994 and is responsible for at least 90 percent of the activated protein C–resistant conditions. It is the most prevalent thrombophilic defect, occurring in 5 to 15 percent of the general population………
The relative risk for venous thromboembolism among heterozygotes is 3 to 10, but this risk significantly increases when an acquired hypercoagulability factor is added, such as oral contraceptives, which increases the relative risk to 30 to 40.   Homozygotes develop more significant thrombophilia, with a relative risk of 79 increasing to 100 with oral contraceptives.
Prothrombin Mutation G20210a
….is the second most prevalent form of inherited thrombophilia, found in 1 to 5 percent of the population and up to 9 percent of patients presenting with their first episode of venous thromboembolism.  …. The relative risk for venous thromboembolism is 2 to 5 in carriers and increases to 16 when combined with oral contraceptive use.
Elevated Levels of Coagulation Factors
Increased levels of factor VIII, factor IX, and factor XI and fibrinogen may also increase the risk of venous thromboembolism.  This is most strongly supported for factor VIII, with a 10 percent increase raising relative venous thromboembolism risk by 10 percent.
Similarly, elevated factor IX and factor XI may increase the risk of venous thromboembolism by 2.5-fold and 2-fold, respectively.
Finally, elevated fibrinogen levels (>500 mg/dl) are associated with a 4-fold increased risk of venous thromboembolism.

Subset II: Deficiency of Coagulation Factors 
Antithrombin III Deficiency
Antithrombin III deficiency is an autosomal dominant trait found in 0.02 percent of the general population and in 0.5 to 7.5 percent of patients who present with their first venous thromboembolism.
Protein C Deficiency
is a rare thrombophilia, with a general population prevalence of 0.2 percent found in approximately 2.5 to 6 percent of patients presenting with their first venous thromboembolism.
Protein S Deficiency
is another rare thrombophilia with a prevalence of 0.026 to 0.13 percent and is found in 1 to 2 percent of patients presenting with their first venous thromboembolism episode.

Recommended Screening
Surgeons should inquire about a patient's personal and family history of any venous thromboembolism events and anticoagulation treatment.   The article includes some suggested questions to help get the history.  Here are a few of them:
  • Have you or anyone in your family every had a blood clot?
  • Have you or anyone in your family ever been diagnosed with a blood clotting disorder?
  • Has anyone in your family had a disease called “purpura fulminans”? 
  • Have you ever been diagnosed with lupus or any other autoimmune disease?
  • For female patients:  Have you ever had a miscarriage?
Patients suspected to be at risk should be evaluated further. The plastic surgeon can initiate the workup by ordering the following lab work:  CBC, PT, PTT, Activated protein C resistance (factor V Leiden testing if abnormal), Prothrombin G20210A genotype (factor II mutation), Antithrombin III activity, Protein C activity, Protein S activity, and Antiphospholipid antibody testing (lupus anticoagulant, anticardiolipin, anti-Beta2-glycoprotein I).
Patients with a known diagnosis of a coagulopathy can be referred to a hematologist for specific recommendations on management so that the needed surgery can be safely done.

Hereditary Coagulopathies: Practical Diagnosis and Management for the Plastic Surgeon; Friedman, Tali; O'Brien Coon, Devin; Michaels V, Joseph; Bontempo, Franklin; Young, V. Leroy; Clavijo, Julio A.; Rubin, J. Peter; Plastic & Reconstructive Surgery 125(5):1544-1552, May 2010; doi: 10.1097/PRS.0b013e3181d51344

Saturday, July 3, 2010

Joan Benoit Samuelson and Me

I was once told that I looked like Joan Benoit. I’m not sure the person was serious, but I took it as a huge compliment. The thought that I could favor in any way (real or imagined) Joan Benoit was amazing to me. After all, this woman was a marathon runner!!! Not just any marathon runner, but the first woman to win the gold in the Olympics woman’s marathon when the event was introduced in 1984 in Los Angeles!!!
My running is more jogging or plodding but I have always enjoyed it. I don’t have speed, but when I train I can build up endurance. Over the past few years it has become more walking my dogs than running.
Joan Benoit Samuelson is the famous runner brought in this year to compete in the 34th Firecracker 5k held on the July 4th weekend.   The 5K takes  place today, July 3rd, at 7:30 am.

I got to meet her yesterday when I picked up my husband’s and my race packets at Easy Runner, the race host.  I was star-struck but managed to ask for a photo.  Was at a loss of where to take the conversation when she noticed the pedometer on my skirt’s waistband.  “How many steps do you do each day?”
“I try to get at least 10,000 steps each day.  When you work in an office, it’s easy to fool yourself into thinking you’re more active than you are.”
“Good for you,” she replied.  “If everyone in American did the same we wouldn’t have nearly the obesity problem we have.”