Friday, December 31, 2010

Ruched Roses Quilt – Finished

More than three years ago, I began this quilt.  I reached a point where I wasn’t happy with it.  I simply put it aside and worked on other projects.  That act of putting it aside and coming back to it later gave me a different prospective.  I pulled it back out earlier this year and actually undid much of the work, redid the border, and finished the quilt.

The quilt has ruched roses made by hand and appliqued onto the quilt by hand.  The center rose is appliqued by hand and has extra batting just beneath it (trapunto technique) to give it extra dimension.  The stems and leaves are machine appliqued.

The wall hanging measures 56 in square.  It is machine quilted.  Here is a close up of one of the corner ruched roses.
Here is the center rose.
The yellow ruched rose along with tulips.
A detail of the double-folded ribbon border which is machine pieced.
Here are two photos of the back before the sleeve and label were sewn on to show the quilting.
Here you can see the trapunto effect beneath the center rose better than from the front.

Happy New Year to you all!

Thursday, December 30, 2010

Top Content for 2010

Looking back at my blog for the year, I started with google analytics.  I naively thought at least one of the current year’s post would be in the top ten visited for the year.  Not so for my blog.
The home page is the most visited, followed by these six:
Inverted Nipples (November 5, 2007)
Glomus Tumor (October 29, 2007)
Flexor Tendon Repair (July 10, 2008)
Le Fort Fractures (January 17, 2008)
The others referenced in the top ten analytics were simple archive searches, not specific posts:
January 1, 2008 archives
October 1, 2007 archives
August 1, 2007 archives
I enjoyed the ones I did with 55 words or less.  I hope to do more of them in the coming year.
Her Scar’s Story
Picture Worth a Thousand Words
Not Here to Judge

Wednesday, December 29, 2010

Surgical Treatments for Breast Cancer-Related Lymphedema

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Upper extremity lymphedema for breast cancer survivors can be a major source of morbidity. Historically, the reported incidence in breast cancer survivors after axillary lymph node dissection has ranged from 9 to 41%. Even with sentinel node biopsy, the reported incidence of upper limb lymphedema remains at 4 to 10%.
Lymphedema after surgery may occur immediately but most often appears after a latent period of weeks or months. Common lymphedema symptoms are increased volume and weight of the limb and increased skin tension.
Conservative therapy (complex decongestive treatment) should be the initial treatment when lymphedema is suspected or present. This includes skin care, compression garments, exercise therapy, and manual lymph drainage.
An article in the December issue of the Plastic and Reconstructive Surgery Journal reviews the surgical treatments.
Charles published the first reported surgical procedure of lymphedema of the scrotum in 1912 and described its application to lower limb lymphedema briefly in the same article. Since then, a variety of surgical techniques have been attempted as cures for lymphedema.
These operative strategies can be classified into two categories: ablative operations and physiologic operations in which new channels are created to increase the capacity to transport lymph fluid.
The article goes through a review of the surgical procedures for lymphedema (in general) beginning with the Charles’ operation for elephantiasis. It was an aggressive operation which resected the overlying skin and soft tissue above the deep fascia in the lymphedematous area. The raw surface was covered by a skin graft harvested from the opposite thigh or the resected specimen.
The article presents the authors preliminary experience using lymphaticovenular bypass, an approach to upper limb lymphedema in which healthy lymphatic vessels from the medial thigh area are used as a composite graft.
The senior author (D.W.C.) evaluated 20 consecutive patients with stage 2 or 3 upper extremity lymphedema (clinical staging of lymphedema by Campisi et al) secondary to treatment of breast cancer who underwent lymphaticovenular bypasses ranging from 0.3 to 0.8 mm. Mean operative time was 3.3 hours (range, 2 to 5 hours). Hospital stay was less than 24 hours in all patients.
Of 20 patients, 19 reported significant clinical improvement following the procedure. Mean volume reduction at 1 month was 29 percent; at 3 months, it was 36 percent; at 6 months, it was 39 percent; and at 1 year, it was 35 percent. There were no postoperative complications or exacerbation of lymphedema.
This youtube video from one of the article’s authors, Dr. David Chang ( MDAnderson) explains the procedure:

Resources for more information on lymphedema: – Arm Lymphedema (last updated Dec 2009) – Lymphedema (general info, not breast cancer specific)
National Lymphedema Network

Overview of Surgical Treatments for Breast Cancer–Related Lymphedema; Suami, Hiroo; Chang, David W.; Plastic & Reconstructive Surgery. 126(6):1853-1863, December 2010; doi: 10.1097/PRS.0b013e3181f44658

Tuesday, December 28, 2010

Shout Outs

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

Grand Rounds is taking a week off. Next week it will be hosted by Pizaazz. So I’d like to point you to Dr. Wes’ post from yesterday, Time in a Bottle
This is a short video honoring some of the scientists who developed the lifesaving combination of breaths and chest compressions now known as CPR. 

MedGadget is has announced the winner of their contest: Imagine Medicine Contest: Please Meet the Winner!

When we announced the Imagine Medicine contest last month, we hoped to see a showcase of photography that imagines medicine from as many angles as possible. …….. So after reviewing all the photos, we are proud to announce that the winner of this year's Imagine Medicine Contest is Inge Vugs for his photograph Beelitz Heilstätten; The former surgery room of the abandoned hospital in Beelitz Heilstätten. ……..
Do take a look at all the submissions below, and we want to thanks all of you who have contributed to this exciting competition. …….
Go take a look at the others and see the winning photo full size.
Cervical cancer is in the forefront of my consciousness these days. A young friend, Sarah, had surgery back in early summer, radical hysterectomy and pelvic lymph node dissection. Hers was Stage IIA. She is doing well. UAMS is taking care of her. She recently shared with me the fact that she has a blog: Cargo. I encouraged her to update it. I hope she will.
Sarah also told me of a friend of hers who has inoperable uterine cancer. This young woman also has a blog: Gray Skies Are Going to Clear Up. I think from what Sarah tells me, this young woman’s is Stage IV.
As Sarah says at the end of one post in her letter to anyone and everyone:
…….I am angry that this happened to me and I am only 29. Cancer sucks.
I am totally grateful. My Cancer could be worse. I have two beautiful healthy kiddos. I learned of the first abnormal pap smear after my 6 week check up after having Margo. …….
There is a song, Bring The Rain, by Mercy Me. I love it.
Ladies, please go to your GYN regularly and take them seriously when they say you need to have something done. I know those tests are no fun but this is seriously not going to be fun. Take care of yourselves because putting it off or skipping a year or two can be devastating.
Doctors and other healthcare providers are not immune to drug and alcohol abuse. This article by Joel Hood is a couple of weeks old, but if you missed it is about a fellow doctor who battled drug addiction now counsels others to kick theirs.
Richard Ready had been a drinker most of his life, but by the time he became chief resident of neurosurgery at a prominent Chicago-area hospital, it was drugs, not alcohol, that kept him going,
Ready took stimulants to keep alert through his daily rounds. He took heavy pain relievers to numb his emotions after his mother's death. He wrote himself a prescription for the sedative Tranxene to calm his nerves before an important seminar. …….
NPR’s series The Long View featured Madhur Jaffrey's Indian Kitchen yesterday. At the end of the interview, she shared her recipe for 'Red Pepper Soup With Ginger And Fennel'
With dozens of cookbooks published and her own cooking shows in the U.S. and Britain, you'd think Madhur Jaffrey had planned all along for a life in the kitchen. But the Indian chef began her career as a classically trained actress. ……….
Jaffrey's cooking career, however, began well before her film days when, at 19, she left her family's comfortable home in Delhi to study at England's Royal Academy of Dramatic Art. Jaffrey, a scholarship student with little money, was expected to eat at the local canteen. But when it came to British college grub, the chef tells NPR's Renee Montagne that she didn't like what she found. ………
Via twitter and @drjvpoblete: Eyebrows are the frame for your face, here's tricks to maintain them:
…..eyes are the widows to you soul, but your eyebrows are the frame for your face. ….., having sloppy or non-existent eyebrows may completely ruin your look. Below are some of the top eyebrow tips out there so you can be sure that your brows are in tip-top shape ……

The Alliance for American Quilts is hosting another quilt contest. This is the 5th annual contest. I entered the past two years. You can see my finished quilts here and here.
This year's theme, "Alliances: People, Patterns, Passion," is as open-ended as the last and celebrates cooperative relationships that work towards a common goal.
Important: This year's deadline is much earlier: March 7, 2011. The reason: all entries will be exhibited at the American Quilter's Society show in Paducah, April 27-30. Our grand prize winner this year will have their choice of any Handi Quilter quilting machine!! Visit the "Alliances" homepage for full details and the downloadable entry form.

Monday, December 27, 2010

Janet Cater and Women’s Work

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

I am a proud University of Arkansas alumni.  The current issue of the alumni magazine has a short segment on Janet Cater and her work with female wounded warriors.  Her research on military women amputees earned her a doctoral degree in rehabilitation counseling. 
I did a google search and was happy to find she has a blog:  Female Wounded Warriors posterous.    There were only four entries but they allow an understanding of her research project.
The first one, Institutional Review Board Information (November 10, 2009), lays out the goal:
I am seeking to understand the psychosocial adjustment issues experienced by women veterans who have had a traumatic amputation. I am interested in your life experience.  ………
The second one, Volunteer to help future Wounded Women Warriors....., presented the goal and method again:
My study seeks to understand the adjustment issues faced by American women warriors who experience a traumatic amputation.   ….
At the present time there is no published research.  As the number of women warriors returning with physical disabilities increases, it is vital that medical and mental health support staff understand the unique challenges these women face.  ….
Over 220,000 female soldiers have been deployed to Iraq and Afghanistan for one or more tours of duty.  As of August 2009, a total of 121 women warriors have died, and it is estimated over 620 have received serious injuries.  …..
This study will use internet interviews using Skype to understand this life experience. Each woman will be invited to tell her story of how she adjusted to life as an amputee with the assurance of confidentiality.  ….
The third entry, Executive Summary, presented the data.  It’s all laid out there for anyone to read.
……..Six Army/Army National Guard women were interviewed in this study: three enlisted and three officers. At the time of the study, their ages ranged from 24 to 42; three were married and three were single; the lowest rank was Specialist and the highest was Major; five were injured in combat and one completed a tour of duty in Iraq on a prosthetic leg. Their injuries ranged from the loss of a lower limb, to the loss of one to two arms, or the loss of both legs.
Each participant was asked three questions; (1) Please describe your experience in combat as a woman. (2) In what ways, if any, has being injured changed your life? (3) If you were to visit a woman in the hospital with your same injuries who was just beginning her journey to recover, what would you tell her?  All of the women in this study had a positive experience in the Army and felt that in their unit they were treated the same as the male soldiers. After losing one or more limbs they had to cope with both physical and psychosocial adjustments. ………

The fourth entry, Learning more..., indicates just that – she is learning more.
I have been interviewing one of the occupational therapists who worked with some of my women while they were adjusting to their new life as an amputee. ….
Very interesting reading.  Very interesting work.

Her dissertation reference:
A phenomenological study of female military servicemembers' adjustment to traumatic amputation; Cater, Janet K., Ph.D., University of Arkansas, 2010, 238 pages; AAT 3421074

Saturday, December 25, 2010

Christmas Knitting

I’m blaming all the knitted gifts for Christmas this year on Dr Smak, @DrCris, and  @Geek2Nurse  who have encouraged my knitting.  The other reason is there are so many nieces and nephews who range from 6 months of age to 35 years of age. 
This small hat is for the 6 mo baby girl, Emmy. It was made using the pattern Koolhaas by Jared Flood.
This hat and fingerless gloves were given to my 14 yo niece who loves to text.  The hat is made using the pattern Mondo Cable Cap by Bonne Marie Burns and Bernat Alpaca Natural Blends yarn.  The gloves are made using the pattern Fishtail wristwarmers by Alexandra Brinck and Lion Brand Sock-Ease yarn.

I made three of these hats (different yarns) for three nieces all under the age of 5.  The pattern is Foliage by Emilee Mooney.

I made two of these hats, one red and one blue, for two brothers.  The pattern is Herdwick Dell Scarf and Hat by Lion Brand Yarn.  It is written to be done flat and seamed.  I did it in the round so I didn’t have a seam.

I made six of these hats in different colors and sizes for several nephews (ages 6 to 24).  It uses the pattern Cross Skull Cap by Kimberly Nicdao Reynolds.  I used  Lion Brand Vanna's Choice Solids & Heathers.

This hat was given to a young friend and a brown cross-skull cap to her brother.  This hat uses the pattern Odessa by Grumperina.

Merry Christmas to you all! 

Friday, December 24, 2010

Sample Quilt of Biblical Blocks

As with Bart and Amy’s quilt, I’m not sure I have all the names correct for the blocks used in this quilt for their son Dallas.  It was done in Christmas fabrics.  I finished it in November 1994 and gave it to him for Christmas that year.
The quilt is machine pieced and quilted.  It measures 63 in X 71 in.

Upper row from left to right:  Unsure, maybe King David’s Crown / Robbing Peter to Pay Paul (Arizona) / Christmas Star
Middle row:  David and Goliath (from The New Quilting & Patchwork Dictionary which is different from the link) / don’t know / don’t know
Bottom row:  ?Joseph’s Coat variation / Crown of Thorns  / Jacob’s Ladder
Here is the back which is pieced to use up left over Christmas fabrics.

Merry Christmas to you all!

Thursday, December 23, 2010


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

Dimples are often considered attractive, but would you have surgery to create one?
A natural dimple is usually formed when there is a small defect in the cheek musculature (most often the buccinator muscle). The skin overlying this small defect is stuck down to the underlying connective tissue and creates a dimple in the skin with facial animation (smiling, smirking, etc). (photo credit)
Back in June, British plastic surgeons reported an increase in requests for dimples just like the singer Cheryl Cole's.
There’s an article in recent Aesthetic Surgery Journal (full reference below) which discusses the surgical technique. The goal is to create a scar (basically) or adhesion between the skin and the underlying muscle in the cheek area agreed upon by the patient and surgeon. Ideally, the dimple is not noted in repose (or with the face neutral and not smiling).
The procedure is most often done using local anesthesia. Post-procedure care involves good oral hygiene. It is recommended not to overly animate the face (ie smiling to broadly trying to check out the new dimples) for a few weeks so the suture placed can create the adhesion desired.
As with every surgery patients (and their surgeons) should remember there are possible complications. Risks include infection, poor dimple location, dimple visible at rest, may not be able to reverse the effect.
Cost ranges I found suggest the procedure to create dimples costs anywhere from $2,000 to $5,000.
Improved Surgical Access for Facial Dimple Creation; Thomas, M., Menon, H., and D’Silva, J.; Aesthetic Surgery Journal November/December 2010 30: 798-801
Barry Eppley, M.D.: Cheek Dimple Creation Surgery
Gal Aharonov, M.D.: Dimple Surgery or Dimple Creation Surgery Photos

Wednesday, December 22, 2010

the Eve procedure

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

Earlier this week I stumbled across the news of a 12 yo boy with a bone tumor involving his mandible.  Pediatric plastic surgeon Rohit Khosla, MD, Lucile Packard Children's Hospital, and his team performed a new procedure believed to be the first of its kind in the United States.
The procedure originally described by a team in Belgium has been nicknamed "the Eve procedure."   The procedure involves transplanting a rib along with its blood vessels and attach this circulation to an artery and vein in the neck.
It is hoped that as the young boy continues to grow, the transplanted bone will do so also.
The boy’s tumor was a chondromyxoid fibroma,  a non-malignant bone tumor that usually occurs in the limbs and feet.  In this case, it occurred in the boy’s mandible.  Removal involved  about a third of the patient's jaw bone, the section extending forward from the temporomandibular joint near his right ear.
Since the family wanted the boy’s identity protected, there are no photos to be found to show you.  I wish him well as he heals and grows into a young man.
The "Eve" Procedure: The Transfer of Vascularized Seventh Rib, Fascia, Cartilage, and Serratus Muscle to Reconstruct Difficult Defects; Guelinckx, P. J.; Sinsel, N. K.; Plastic & Reconstructive Surgery. 97(3):527-535, March 1996.

Tuesday, December 21, 2010

Shout Outs

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

Chronic Babe blog is the host for this week’s Grand Rounds! You can read this week’s edition here.
It's the end of the year, and while most folks are resolving to lose a few pounds or see their nieces more in the new year, our bloggers are trying to make sure their patients are healthier...that we learn to use robots to teach patients to manage pain...that health care legislation works well for millions...we are an ambitious crew. Editrix Jenni Prokopy is proud to present Vol. 7, No. 13 of Grand Rounds, the last edition of 2010, chock full of fun and compelling new year's health care resolutions. Enjoy!……….
Dr. Marya Zilberberg, Healthcare,etc., does a fantastic job of explaining “Why medical testing is never a simple decision.”
………..The case illustrates the pitfalls of getting a seemingly innocuous test for what appears to be a humanistic reason -- patient reassurance. Yet, look at the tsunami of harm that followed this one decision. But what is done is done. The big question is, can cases like this be prevented in the future? And if so, how? I will submit to you that Bayesian approaches to testing can and should reduce such complications. Here is how.
First, what is Bayesian thinking? ……….
I am an advocate of organ donation, but when using living donors everything must be done to do it safely. It is not a good thing for a healthy person to end up unhealthy, disabled, or dead when donating to help a friend or loved one. We are reminded of this in the news article by Elizabeth Cohen: When liver donations go wrong
…….Four living liver donors have died in the United States since 1999, according to the United Network for Organ Sharing, including Arnold and another patient who died earlier this year at the Lahey Clinic in Massachusetts. About 38% of liver donors have some kind of complication, according to the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, a project to disseminate information about living donor liver transplants. Some experts think some of these deaths and complications could have been prevented if there was a change the way hospitals exchanged information about complications with organ donations. ……….
Via Kerri, Six Until Me: What NOT to Say to the Parent of a Kid with Diabetes.
From twitter:  RT @tbtam RT @THCBstaff Using An App to Confront Your Metastatic Melanoma
The Health Care Blog post,  Using An App to Confront Your Metastatic Melanoma, is written by George D. Lundberg, MD.
If you or anyone else you know has had a malignant melanoma, you and that other person, and your respective physicians, should click to access the Targeted Therapy Finder--Melanoma (ttf-melanoma). It is free and does not require registration.  …..
The app is based upon the science of the original Melanoma Molecular Disease Model (MMDM) in Cancer Commons built by David Fisher and Keith Flaherty of Harvard Medical School and Smruti Vidwans and colleagues on our staff.   …….
The Alliance for American Quilts is hosting another quilt contest. This is the 5th annual contest. I entered the past two years. You can see my finished quilts here and here.
This year's theme, "Alliances: People, Patterns, Passion," is as open-ended as the last and celebrates cooperative relationships that work towards a common goal.
Important: This year's deadline is much earlier: March 7, 2011. The reason: all entries will be exhibited at the American Quilter's Society show in Paducah, April 27-30. Our grand prize winner this year will have their choice of any Handi Quilter quilting machine!! Visit the "Alliances" homepage for full details and the downloadable entry form.

Monday, December 20, 2010

Weight Lifting, Breast Cancer, and Lymphedema

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

Last August, Kathryn Schmitz, PhD, MPH and colleagues published the results of their study Weight Lifting in Women with Breast-Cancer–Related Lymphedema in the New England Journal of Medicine.  They have now published a similar study in the Archives of Internal Medicine (see full reference below).
While the NEJM article focused on breast cancer survivors with lymphedema, the Archives article focuses on breast cancer survivors without lymphedema.
The new study adds weight for the need to change historic dogma which cautions breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.
As noted by Schmitz, etc (bold emphasis is mine):
Breast cancer survivors at risk for lymphedema alter activity, limit activity, or both from fear and uncertainty about their personal risk level, and upon guidance advising them to avoid lifting children, heavy bags, or other objects with the at-risk arm.
Such guidance is often interpreted in a manner that deconditions the arm, increasing the potential for injury, overuse, and, ironically, lymphedema onset.
Adherence to these precautions may limit physical …. Furthermore, activity avoidance may deter survivors from performing regular exercise, which may prevent cancer recurrence and improve survival.
The randomized controlled equivalence trial (Physical Activity and Lymphedema trial) enrolled 154 breast cancer survivors (only 134 completed the study)  1 to 5 years post-unilateral breast cancer with at least 2 lymph nodes removed and without clinical signs of lymphedema.  Recruitment took place between October 1, 2005, and February 2007, with data collection ending in August 2008.
Participants in the weight lifting intervention group (n = 72)received a 1-year membership to a community fitness center near their homes. For the first 13 weeks, women were instructed twice weekly during 90 minute sessions on safe performance of exercises in groups of 2 to 6 survivors.
Upper body exercises (seated row, supine dumbbell press, lateral or front raises, bicep curls, and triceps pushdowns) were performed with dumbbells or variable resistance machines. Lower body exercises (leg press, back extension, leg extension, and leg curl) were performed with variable resistance machines. Three sets of each exercise were performed at each session, 10 repetitions per set.
After 13 weeks, participants continued twice weekly unsupervised exercise to 1 year. Weight was increased for each exercise by the smallest possible increment after 2 sessions of completing 3 sets of 10 repetitions with no change in arm symptoms.
Participants in the control group (n = 75) were asked to not change baseline level of exercise during study participation and were offered a 1-year fitness center membership with 13 weeks of supervised instruction following study completion.
Fewer women experienced incident BCRL onset in the weight lifting intervention group (11%, 8 of 72) compared to the control group (17%, 13 of 75).
The difference was even greater among women with 5 or more lymph nodes removed:  7% (3 of 45) in the weight lifting intervention group and 22% (11 of 49) in the control group.
Once again, this is a small group, but I lean more and more towards allowing motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.
Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.
Weight Lifting for Women at Risk for Breast Cancer–Related Lymphedema: A Randomized Trial; Kathryn H. Schmitz, Rehana L. Ahmed, Andrea B. Troxel, Andrea Cheville, Lorita Lewis-Grant, Rebecca Smith, Cathy J. Bryan, Catherine T. Williams-Smith, Jesse Chittams; JAMA. Published online December 8, 2010. doi:10.1001/jama.2010.1837
Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene
Related Posts
Lymphedema (December 5, 2007)
ARM Technique (October 15, 2008)

Sunday, December 19, 2010

Restoring Hope

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

Yesterday at a family Christmas gathering I learned of my family’s connection to this military effort to prevent suicide.  I posted on my second cousin-in-law Josh Farmer’s suicide back in September 2009.  His wife Stephanie and her mother Gail Gunter (my first cousin) pushed for an investigation, pushed for more to be done in the future for other families.  It resulted in a law named after Josh.  Gail needed to tell us of the video and the law.  I want to pass it on to all of you.

Friday, December 17, 2010

Jaymie's Baby Quilt

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

I don’t know if there is a name for this quilt pattern.  I was inspired by this one (link removed) from Paint Creek Quilt.  The quilt is for my second cousin who is having her first baby (a girl).  It is machine pieced and quilted.  It measures 36 in square.
These next few photos are so you can see the characters in the featured fabric.
Also, so you can appreciate the multiple orange fabrics used.
The quilting is a simple cross-hatching.

Thursday, December 16, 2010

Some Resources for Fit in 10

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

The University of Arkansas Division of Agriculture Cooperative Extension Service has produced a series of workout DVD’s, handouts, and postures. LaVona S. Traywick, professor of gerontology, is largely responsible for the information. Even though these are aimed at those of us over 50, I feel they include good information for all ages.
It is important to continue your normal exercise program during the holiday season. It will not only help keep your from gaining weight during this time, it will help with the stress that often comes with the season.
Increasing Physical Activity as We Age: Exercise Recommendations (FSFCS30 pdf)
The hardest part of exercising for many is getting started, but when you think about fitness goals in 10-minute segments, it doesn’t seem as daunting.
Increasing Physical Activity as We Age: Fit in Ten (volunteer leader training guide, pdf)
Fact Sheets Handouts (many with diagrams of the exercises):
Increasing Physical Activity as We Age: Balance (FSFCS31 pdf)
Increasing Physical Activity as We Age: Endurance (FSFCS32 pdf)
Increasing Physical Activity as We Age: Strength Training (FSFCS33 pdf)
Increasing Physical Activity as We Age: Stretching (FSFCS34 pdf)
Increasing Physical Activity as We Age: Strength Training with Stretch Tubes (FSFCS36 pdf)

Poster Stretch it Out: Strength Training with Stretch Tubes (pdf)

Theses must be ordered, not available for free:
Hit the Floor: Strength Training on an Exercise Mat (poster, MP493, $3)
Get on the Ball: Strength Training with a Stability Ball (poster MP494, $3)
Fit in 10 DVD Video (DVDFCS10, $10)

Wednesday, December 15, 2010

Breast Augmentation: A Geographical Comparison

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

This article (full reference below, free access) came to my attention via MDLinx.  It was interesting to read.  The conclusion verified my expectations rather than surprised me.
The authors conducted a retrospective review of patient demographics and implant information from three university settings:  Kelowna (British Columbia, Canada), Loma Linda (California, USA), and Temple (Texas, USA).  Each cohort included 100 consecutive breast augmentation cases.
Characteristic analyzed included age, height, weight, BME, parity, and average implant volume. 
When considering the 300 as one cohort, the average age was 34 years with a height of 163 cm (5’4”), weight of 58.1 (127.8 lb) and parity of 1.7 .  The average implant size was 370 ml.
When considered separately, the three group medians were significantly different for weight, BMI and implant volume, but not for age.
Kelowna’s average patient was 33 years of age, had a BMI of 20.8 kg/m2 and an implant volume of 389 mL.
Loma Linda’s average patient was 32 years of age, had a BMI of 21.6 kg/m2 and an implant volume of 385 mL.
Temple’s average patient was 36 years of age, had a BMI of 22.6 kg/m2 and an implant volume of 335 mL.
Without going back through all my cases, I can say it the average size of implants used has increased over the years.  It was rare to use more than 300 cc when I was in training (1987-89), now it is rare to use one smaller than 300 cc.

Breast augmentation: A geographical comparison;   JL Maher, DC Bennett, P Grothaus, RC Mahabir; Canadian Journal of Plastic Surgery, 12/07/2010 (pdf file)

Tuesday, December 14, 2010

Shout Outs

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

John Mandrola, M.D., Dr John M, is the host for this week’s Grand Rounds! You can read this week’s edition here.
Hey all.
Welcome to another edition of Grand Rounds, a collection of writings from medical bloggers, the world-wide.
Here are this week's posts, collated into four chapters, with just a little commentary and a few selected images. ……….
A really nice piece at EP Monthly by Dr. Greg Henry:  The ED as Political Safe Zone 
………..Now if you believe that the ED is that bastion of neutrality, free of all political bias, I have a bridge in lower Manhattan that heads to Brooklyn that I’d like to sell you. The reality is that politics are everywhere. The question is, how do we rein them in so that we can give out reasonably competent care without letting our innate prejudices control us? ………….
As Movin Meat said in his post: An Anticipated Relaunch
One of my favorite writers has returned to the blogosphere!  Intueri has relaunched as In White Ink -- The Unwritten Details!  The early posts are promising, as one would expect of a long-time medblogger, and the site design is lovely, as one would expect from the beautiful, minimalist design of the old site.
…….I've added it to my feed reader, and I'd recommend you do as well.
Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 12)! You can find the schedule and the COS archives at Emergiblog. (photo credit)
Welcome to Change of Shift!
…….Now, let’s get started!
Editors Pick of the Week and Dedicated to Raise Blood Pressure Post: A story of a frequent flyer who needs the flights, presented by NPs Save Lives at The Nurse Practitioner’s Place: He’s Gotta Ticket To Ride and The NP Says It’s Okay posted at The Nurse Practitioner’s Place.
From twitter comes a link to a very nice article
@Mtnmd RT @apjonas Sedentary Physiology Part 1 – Not Just The Lack of Physical Activity VERY interesting
The article is written by Travis Saunders who is a PhD student researching the relationship between sedentary time and chronic disease risk in children and youth.  It begins:
Welcome to our 5-part series delving into the fascinating research being performed in the emerging field of sedentary physiology.  Today, we’ll start with an introduction.  For Part 2 in our series, click here.
……., I’d like to give a bit of background.
What is sedentary behaviour?
Sedentary behaviours are those characterized by very low energy expenditure – typically those requiring 1.5 METs or less.
Here are links to all 5 parts:
Sedentary Physiology Part 1 – Not Just The Lack of Physical Activity
Sedentary Physiology Part 2 – Can Sitting Too Much Kill You?
Sedentary Physiology Part 3 – The Importance of Interruptions in Sedentary Time
Sedentary Physiology Part 4 – How Does Sitting Increase Health Risk?
Sedentary Physiology Part 5 – Future Directions
Medical advances can be amazing!  This NPR story by Richard Knox is exemplary of just such an advance in the field of congenital heart malformations:   Stitch In Time: Fixing A Heart Defect Before Birth
About 17,000 U.S. babies are born every year with a serious heart defect. Nobody knows how many might benefit from the kind of fetal surgery Wells had. ……
The root cause of HLHS, much of the time, is a partially blocked valve that regulates blood flow from the heart's main pumping chamber, the left ventricle, to the aorta, which carries blood to the entire body. …
The goal of fetal heart surgery is "to open the aortic valve at a point when the left ventricle is not quite beyond irreparable damage," says Dr. Wayne Tworetzky, a cardiologist at Children's Hospital in Boston.  ….
NPR story by Susan Stamberg: In Paris, A Display From Hockney's Pixelated Period.   All the drawings are done on either an iPhone or iPad.  Beautiful!  (photo source)


Monday, December 13, 2010

New Technology May Help Prevent Rejection in Hand Transplant Patients

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

Previously I posted on rejection in hand transplant patients when it was reported double hand transplant on patient Rich Edwards of Oklahoma might “lose the fingertips on his right thumb and pinkie because his body started to reject the new limbs.”
Jewish Hospital Hand Care Center and the Christine M Kleinert Institute have released news on a new medical device which may allow detection of rejection at an earlier stage.  Early detection could then improve treatment and perhaps prevent limb loss as with the team’s 4th patient Dave Armstrong who had his transplanted hand amputated in April 2009 due to rejection.
I first read about this new device, an ultrasound biomicroscopy device, in’s December 6, 2010 article: New technology helping keep transplanted hands attached.  Today I found the December 9, 2010 press release from the team (bold highlight is mine).
Despite recent setbacks, Dr. Richard “Rich” Edwards, the nation’s third double hand transplant recipient, continues to progress under the care of Kleinert Kutz and Associates hand surgeons at Jewish Hospital in Louisville, Ky.
Dr. Edwards experienced complications in mid-November when signs of rejection caused him to be hospitalized for several days.  Michael Marvin, M.D., chief of transplantation, Jewish Hospital/University of Louisville, and Rosemary Ouseph, MD, director of kidney transplantation at University of Louisville, who have overseen Edwards’ post-surgical immunosuppressant drug regimen, added steroid shots to Dr. Edwards’ routine to counteract the rejection.
The complication, which resulted in a loss of blood flow has caused the tip of Dr. Edwards  right pinkie to turn black. He had already had the tip of the thumb turn black due to a loss of blood flow shortly after the transplant. Unfortunately, those fingertips may eventually need to be removed.
Dr. Warren Breidenbach, partner at Kleinert Kutz  and Associates and assistant clinical professor of surgery at the University of Louisville said, “ The left hand is doing great and has good function. I call the right hand the “miracle hand” because of blood flow issues early on. The good news about the right hand is it has re-established blood flow and his hand function has almost caught up with the left hand.  The bad news is the right hand does not have the same volume of blood flow as the left, but it does have enough to survive.  The right hand remains a problem hand with an unknown future.  We are in uncharted waters with the right hand.”
Breidenbach added, “All hand transplant patients have the risk of loosing a hand at any time. In addition, all patients go through a rejection episode in the first six months. Dr. Edwards was around three months out from the transplant.  He had swelling which compromised the blood flow in mid November.“
Dr. Edwards remains closely monitored by the team at the Christine M. Kleinert Institute for Hand and Microsurgery (CMKI), including Christina Kaufman, PhD., executive director of CMKI and assistant professor at the University of Louisville.  Dr. Kaufman uses ultrasound biomicroscopy (UBM), a new technology that utilizes very high frequency ultrasound (20-70 MHz) to noninvasively monitor blood flow, vessels, arteries and artery intima, or thickness, which is where signs of potential rejection often first appear.
The device, which has not yet been approved for clinical use, was purchased with funds from the Department of Defense in January 2010.  Each of the previous hand transplant patients are also being monitored using UBM. Currently, Dr. Edwards is being tested every two weeks.
“Using this new technology we have done a great deal of investigation,” said Kaufman.  “There is a push to reduce the immunosuppressant medications, but we do not want to risk the loss of the hand.  With this machine, we are hoping to be able to reduce the drug regimen with maximum safety.  We are making advances and we’re getting better. That’s what research is about.”
Dr. Edwards continues therapy on his hands five-days-a-week with the therapists at the Christine M. Kleinert for four-hours-a-day. His wife, Cindy Edwards, assists him with additional therapy on his own several times each day, seven-days-a-week. His hands have already helped him regain independence in his daily activities.  He can brush his teeth, comb his hair, take his shirt on and off and feed himself throughout an entire meal – all activities that he was unable to do unaided before the transplant.  He hopes to be able to return to his home in Edmond, Oklahoma for the holidays.
“Every one to two days, I can see a change in my hands,” said Dr. Edwards.  “They are the best Christmas gift that I have ever been given.”
“These are minute changes, but when you work with his hands all day every day, those changes are encouraging,” said Cindy Edwards.  “He’s come a long way in less than four months.”
Dr. Edwards worked as a chiropractor before losing both hands when his truck caught fire on February 11, 2006.  Unable to escape the burning vehicle, he was severely burned on his face, back, arms and hands, leaving very little tissue in both hands.
Dr. Breidenbach led the team of surgeons from Kleinert Kutz, Christine M. Kleinert Institute and the University of Louisville who performed the initial 17 ½ hour surgical procedure August 24-25, 2010, at the Jewish Hospital Hand Care Center.  He continues to manage Dr. Edwards’ follow-up care.
The Composite Tissue Allotransplantation program is a partnership of physicians, researchers and healthcare providers at the Jewish Hospital Hand Care Center, Kleinert Kutz and Associates, the Christine M. Kleinert Institute and the University of Louisville. The group developed the pioneering hand transplant procedure and has performed five other hand transplants since 1999.  Kentucky Organ Donor Affiliates coordinated the hand donation for the team’s hand transplant procedures.
The hand transplant is sponsored by the Department of Defense, Office of Naval Research and Office of Army Research to further research in the composite tissue allotransplantation program.
Patient and physician information, photography and video are available at and 

Drug Abuse in Plastic Surgery Patients

The article (full reference below) is a reminder of drug abuse in our patients.  Many of which can create issue peri-operatively.  The article begins:

In 1957, Dr. George Crikelair detailed the impact of drug abuse on the practice of plastic and reconstructive surgery.   Five decades later, the subject remains salient: surveys administered by the White House Office of National Drug Control Policy (ONDCP) state that 41.7% of the U.S. population older than 12 has taken an illicit drug in their lifetime.  12.6% reported illicit drug use in the past year. 

….. This article seeks to impart clinical savvy regarding verbal and non-verbal cues of the seven most commonly abused drugs by detailing their pharmacology, clinical manifestations, screening and management, thus enabling plastic surgeons to provide prompt and appropriate treatment when encountering complications related to these

I would recommend this article be read by more than just plastic surgeons.  It will either educate you or simply be a good review.  I’m not as good at picking drug abuse up as say Gruntdoc or Movin Meat or White Coat, so I found it worth my time.

To begin:

The typical urine drug screen (UDS) is based upon federal guidelines established by the Substance Abuse and Mental health Services Administration, or SAMHSA. This drug screen is referred to as the “SAMHSA-5” (and previously as the “NIDA-5”) because it detects only the five drugs required by federal workplace testing. These include cocaine, opiates, amphetamines, cannabinoids, and phencyclidine (PCP).

Synthetic opioids, such as oxycontin and hydrocodone, will not be noted on these routine screens.

The seven drugs the article reviews are:

Cocaine -- Common names: coke, blow, crack, snow, nose candy

Marijuana  -- Common names: pot, weed, grass, mary jane

Benzodiazepines  -- Common names: benzos, bars, tranks, normies, sleepers and xanies

Opioids  --  Common names: Heroin (H, smack, horse, brown/black tar), Prescription pain medication (oxy, roxy, vike, patches)

Amphetamines -- Common names: speed, uppers, dexies for amphetamine, and meth, crank, crystal, ice for methamphetamine

Gamma hydroxybutyrate --Common names: GHB, liguid Ex, G

Ecstasy  -- Common names: E, Adam, XTC, X, love drug


Each drug review includes pharmacology, clinical manifestations, screening, and management sections.   If you don’t have access to the journal, get your medical library to get it for you and READ the article.



Drug Abuse in Plastic Surgery Patients: Optimizing Detection and Minimizing Complications; Cone, J.D., Harrington, M.A., Kelley, S.S., Prince, M.D., Payne, W.G., Smith, D.J.; Plast & Reconstr Surgery: POST ACCEPTANCE, 23 September 2010; doi: 10.1097/PRS.0b013e3181fad5ac

Saturday, December 11, 2010

Arkansas Women Bloggers Meetup

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

The first ever Arkansas Women Bloggers Meetup Scheduled! (photo credit) was held today at the Museum of Discovery. 
I attended it with Methodical Madness, @gastromom (we’ll get her to actually blog and not just tweet someday), and @ksboulden.  
I met several of the approximately 40 attendees.  Lunch was provided by Petite Jean Meats.  Elaine provided cupcakes for dessert.  Elaine blogs at Cupcake Crazy Arkansas.
Two of the attendees gave short presentations.  La Tonya (40 Tude) gave one on finding your voice.  Kyran (Planting Dandelions) talked about how to measure your blog’s influence in more ways than just numbers (or stats from your sitemeter).
There were door prizes!  I won (or rather my dog Rusty did) this one, homemade dog bonz from Mac the Labradoodle.  Mac, Rusty definitely approves!
Others I met include Nikki (NikkMo PaperCrafts), Christie (Fancy Pants Foodie),Desmond (Arkansas Research), and Kat (Tie Dye Travels).
It was a good meetup!  I made sure Christie (Fancy Pants Foodie) and @gastromom met. 

Friday, December 10, 2010

Madison's Bouquet Quilt

This quilt was made for my niece Madi using Christmas colors and fabric. Once again, I used the nutcracker fabric. This pattern is a nosegay block. I machine pieced it and had my friend Scottie Brooks hand quilt it for me. The quilt is 67 in X 80 in. It was finished in April 2005.My sister took these photos for me (thank you Kiddo). I hope you can see the block well enough.

Thursday, December 9, 2010

Repost: Focal Dystonia of the Hand

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

Earlier this week I caught bits and pieced of Diane Rehms interview of pianist Leon Fleisher. She was interviewing him about his many musical careers and his memoir: My Nine Lives: A Memoir of Many Careers in Music.
So I thought I would repost my blog post from October 2007 on Focal Dystonia of the Hand.
Earlier this week I read an article in Reader's Digest (November 2007 Issue) on Leon Fleisher and his focal dystonia of his right hand. The article is written by Oliver Sacks, MD and is a exert from his book "Musicophilia: Tales of Music and the Brain". I wanted to review what I knew about focal dystonia and ended up learning much. I would like to try to share this with you. Enjoy this "Ravel Piano Concerto for the Left Hand 1/2" played by Leon Fleisher.

The term dystonia collectively refers to a heterogeneous group of movement disorders characterized by sustained involuntary muscle contractions that result from co-contracting antagonistic muscles and overflow into extraneous muscles. Focal dystonias are adult-onset forms that affect a specific area of the body, ie hand, neck, vocal cords. Most focal dystonias are primary. By primary it is meant that the dystonia is the only neurological symptom.
Focal hand and limb dystonia usually begins as a painless loss of muscular control in highly practiced movements. A genetic predisposition is thought to occur in less than 5% of all cases of focal dystonia. There are many professions that require repeated and intricate hand movements. However, focal hand dystonia is more common in musicians than any other group of professionals, including dentists, surgeons, and writers. This disorder is often referred to in medical literature as occupational cramps (ie, “violinist’s cramp”, “pianist’s cramp”, "writer's cramp"). (photo credit)
There is no one isolated cause of hand and limb dystonia. A variety of pathological conditions may lead to similar symptoms. As a child develops, he/she learns many different movements (such as walking, writing, or playing an instrument) that are stored in the brain as motor programs. Instances of hand dystonia that are highly task-specific have been described as a “computer virus” or “hard drive crash” in the sensory motor programs that are essential for playing music. However, additional factors, such as a genetic predisposition, are likely to play a significant role in the development of such a sensory-motor dysfunction. Why this “computer virus” cannot be easily overcome by establishing a new and improved sensory-movement pattern remains an important question for researchers.
Most affected persons describe symptoms in terms of their occupation terms. A musician may notice
  • Subtle loss of control in fast passages
  • Lack of precision
  • Curling of fingers
  • Fingers “sticking” to keys
  • Involuntary flexion of bowing thumb in strings
A writer may notice:
  • Deterioration in neatness or speed of writing or just clumsiness
  • A cramp or aching in the hand on writing
  • May report that the hand freezes up on attempting to write
  • Difficulty in moving the pen across the page
A tremor may or may not be associated with the spasms. In most cases, the dystonia is present only in the context of specific tasks (and may be very specific to one instrument--a clarinet but not a saxophone). The dystonia may appear extremely sensitive to sensory input: a pianist may experience symptoms while playing on ivory keys but not while playing on plastic keys. Sometimes the modification of posture and even facial expressions may affect dystonic spasms in the hand.
Physical Exam
No special examinations are described for focal dystonia other than inspect the patient performing his task.
  • The pen commonly is held very tightly, with an exaggeration of the normal semiflexed posture of thumb, index and other fingers, and with hyperextension of the distal interphalangeal joint of the index finger. Occasionally, the hand suddenly stops and the paper is perforated, or it might dart across the page with a sudden jerk. The script produced is usually abnormal. Tremor is a common finding in all forms of writer’s cramp but it is usually not severe. (photo credit)
  • Examination of the musician while playing reveals non-physiologic posture and gestures in most of the patients. Sometimes it is possible to identify involuntary dysfunction such as flexion, curling in one or two fingers, or involuntary extension of the “sticking fingers”. These may be difficult to detect, even with slow motion video.
The remainder of physical examination is often normal, but subtle findings can be noted in some patients: dystonic postures of the affected limb when the patients sit or walk, or loss of arm swing of the affected side during the gait.
There is minimal unilateral increase in muscle tone in some patients. There are no other abnormal findings.
The Fahn-Marsden scale was designed to quantify generalized or focal dystonia and can be found here.
Electromyography studies show prolonged duration of muscle bursts with superimposed shorter, repeated bursts of activity. The pattern is of complete lack of selectivity for individual muscles with overflow of contraction to muscles not normally activated by the task being performed. Electromyography may also useful as a guide to botulinum toxin injections.
Radiographs are not useful in the assessment of focal dystonia. Occasionally, in an appropriate setting, magnetic resonance image of the brain can be useful to rule out a cerebrovascular disease.
There is no cure for dystonia at this time, and although treatment of the disorder may be challenging, there are several available options. The different causes of hand dystonia may warrant different treatments. Don't give up--see Leon Fleisher's story.
Oral medications: There are a number of therapeutic agents with clear beneficial effects to writer’s cramp, including anticholinergics, clonazepam and benzodiazepines. High dosage of anticholinergic drugs is firstly recommended for the treatment of dystonia.
  • Doses recommended of biperiden are 2 mg per oral two or three times a day and titration to 16 mg a day.
  • Diazepam is another choice. However, it is rarely adequate when used as sole agent. Doses are 10mg per oral two or three times a day.
  • Clonazepam can be useful for improvement of phasic symptoms in cases with myoclonus and/or tremor. Doses are 0.25 mg per oral twice a day, increasing to 0.125 to 0.25 mg every three days up to a dose of 4 mg/day.
Botulinum toxin injections has been used for the treatment of writer’s cramp with good results. Its application requires careful and precise technique. The selection of the muscle should be based on careful physical examination while the patient writes or plays in order to trigger the dystonic movements. The injection should be carried out under EMG guidance with a hollow recording needle and the botulinum toxin is injected through the same needle. Small volume injections into multiple sites are preferred to a single large injection. Dose per muscle varies from 2.5-25 units. Initially, only few muscles are injected. The dose per muscle and number of muscles injected are optimized (based on response) for subsequent injections.
Some patients find that finger-splinting device made individually according to their symptoms help improve their ability to write or to play a musical instrument. Limb immobilization for four weeks and a half is a simple and sometimes effective treatment for this condition. (photo credit)
"Therapeutic approaches involving the practice of movements are likely to remain unsuccessful unless their design includes a framework that, in principle, aims at interrupting this vicious circle. Indeed, a recently developed behavioural therapy, termed sensory motor retuning, holds great promise (Candia et al., 2002Go). Musicians with focal hand dystonia performed repetitive movements with fingers of their dystonic hand while one or more fingers except the dystonic ones were immobilized. After therapy, movements of the dystonic fingers were substantially better controlled, with some musicians reaching near-normal performance levels. Along with improvement of motor behaviour, the topography of the somatosensory representation of the fingers became normalized." from Brain article (see references below).
For an interesting list of people who have struggled with this problem, check here.
References and Resources
Mark Hallett, MD
NIH clinical study "A Training Protocol for the use of Botulinum Toxin in the Treatment of Neurological Disorders", reference No. 85-N-0195
Focal Dystonia of the Hand by Marcos Sanmartin
Focal hand dystonia – a disorder of neuroplasticity?; Brain, Vol. 126, No. 12, 2571-2572, December 2003; Joseph Classen
Upper Limb Disorders in Musicians by Raoul Tubiana, MD
Tubiana R. Musician’s focal dystonia. Hand Clin 19: 303-308, 2003.
Dystonia Fact Sheet--National Institute of Neurological Disorders and Stroke
Focal Dystonia from a Guitarist's Perspective by Jarrod Smerk
A Tale of Two Hands--Charlie Rose talks to pianist Leon Fleisher
Muscians with Dystonia Foundation

Wednesday, December 8, 2010

Gynecomastia: Is Pathologic Examination Justified?

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

Most medical centers routinely perform or require that breast tissue be sent to pathology for histologic examination.  The authors of the article (referenced below) question whether this is useful when the breast tissue excised comes from an adolescent male with gynecomastia considering the benign nature of the condition.
Furthermore, the authors point out male breast cancer is rare and when it does occur it is most often in older males, not adolescent males.
In 2009, there were an estimated 1,910 new cases and 440 deaths related to male breast cancer, accounting for just 0.25% and 0.15% of all new cases of cancer and cancer deaths for males in the entire United States, respectively, with historical cohorts demonstrating that the peak incidence of male breast cancer occurs at approximately 71 years of age.  More significantly, breast cancer becomes increasingly uncommon among younger age groups.
To look at the issue, the authors did a retrospective chart review  of their patients younger than 21 years of age who had undergone subcutaneous mastectomy for gynecomastia between 1999 and 2010.  A review of the literature was done, as was an informal survey of major children's hospitals regarding their practice of histologic examination for adolescent gynecomastia.
The authors had  81 patients during the time period.  All cases were negative for malignancy, with only one case of cellular atypia.
The literature review found only 36 articles which discussed cases of adolescent gynecomastia and the associated pathologic results, resulting in data for 615 individuals.  Of these 615 individuals, there have been six cases of cancer and five cases of ADH.  The average age of patients involved was 17.4 years (range 16-20 years) and 43% of cases presented with unilateral gynecomastia. 
Of twenty-two survey respondents, all either routinely performed or required histologic examination of breast tissue excised for gynecomastia. The out-of-pocket costs for self-pay patients to perform pathologic exam has been quoted at $1,268 for bilateral cases.
The authors conclude:
The incidence of malignancy or abnormal pathology associated with gynecomastia tissue in the adolescent male is extremely low, and given the costs associated, the histologic examination of breast tissue excised for gynecomastia in individuals 21 years of age or younger should be neither routinely performed nor required, but should be performed only when desired by either the patient, patient's family, or managing physician.

Breast Cancer Incidence in Adolescent Males Undergoing Subcutaneous Mastectomy for Gynecomastia: Is Pathologic Examination Justified? A Retrospective and Literature Review; Koshy, J. C.; Goldberg, J. S.; Wolfswinkel, E.; Ge, Y.; Heller, L.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 23 September 2010; doi: 10.1097/PRS.0b013e3181f9581c

Tuesday, December 7, 2010

Shout Outs

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

Highlight Health is the host for this week’s Grand Rounds! You can read this week’s edition here.
Welcome to Grand Rounds: the Impact of Healthcare Reform.   For this edition of Grand Rounds, Vol. 7 No. 11, we’re focusing on the impact of healthcare reform: what are the changes to healthcare delivery, utilization, quality, costs (either as a provider or a patient) and outcomes. After all, these changes affect everyone, whether you’re a patient, a healthcare provider or a biomedical researcher.……..
A beautiful love poem via twitter by  @otorhinolarydoc: An Otorhinolaryngological Love Poem -
My ossicles shiver at the sound of your name
My cochlea swirls at the sound of your voice
I get symptomatic labyrynthitis when I see your beauty
And my world becomes vertiginous when you enter it
That’s the first verse, go read the rest.
Wall Street Journal has an interesting article by Sue Shellenbarger:  Women Doctors Flock to Surprising Specialty.
People often assume women gravitate to certain professional fields because they have an innate liking for the work. Women become pediatricians because they love babies, for example, or they become veterinarians because they love animals.
So why are women flocking to colon and rectal surgery as an occupation of choice?  ………….
From Shrink Rap comes a nice post by Dinah:  News Flash: Preauthorization Impacts Care
The American Medical Association had a press release on November 22nd and announced findings from their survey on the impact of insurance company preauthorization policies. Surprisingly, they discovered that these policies use physician time and delay treatment. It's funny, because preauthorization policies were designed to save money. And I imagine they do, for the insurer, but they cost money for everyone else. ………..
Check out this nice video designed to teach basic suturing techniques to medical students:

Wow, these are lovely but I don’t think my relatives would like to have their food served on them.  H/T Street Anatomy.  (photo credit). 

A.Word.A.Day is having a contest.  Deadline for submissions is this Friday, December 10th. 
Have you come across a pleonasm somewhere? How about making up your own examples of pleonasm? Send us your pleonasms, whether homegrown or captured in the wild (include a picture, if possible). The best entry will receive a copy of the word game WildWords (courtesy WildWords Game Company) and a runner-up will receive a copy of the word game One Up! (courtesy Uppityshirts).

Would love to hear your examples of pleonasm with a medical twist or link.

Isn’t this bag wonderful!  The pattern for this Noriko Handbag  is free from Lazy Girl  as her  “year-end gift to you.”   (photo credit)

I’m hoping to attend with a couple of friends -- Arkansas Women Bloggers Meetup Scheduled! (photo credit)

When: December 11, 2010 11am-1pm
Where: Museum of Discovery @ 500 President Clinton Avenue
Why: Meet other bloggers and help decide future activities/goals for AWB
We will keep you updated with event details as we pull them together.
To RSVP, you can leave a comment on this post. If you're on Facebook, you can RSVP and invite friends at the event page. You can also RSVP by emailing us at

Monday, December 6, 2010

Dorsal Hand Coverage Refinements

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

Injuries to the dorsal hand, wrist, and distal forearm are relatively common. Degloving and crush injuries can result in exposed tendons and bone. These are not simple wounds which can be repaired by primary closure but often require early debridement of devitalized tissue and soft-tissue coverage involving local or regional flaps (reverse radial/ulnar forearm or posterior interosseus flaps), distant pedicle flaps, or free flaps.
The skin of dorsal hand and wrist is very thin, mobile, and supple and very visible in day to day activities. We present our hand in greeting for a hand shake. Our hands are visible when keyboarding or talking on the phone. We hold hands with our loved ones. We want our hands to both work/function and be aesthetically pleasing.
Function must come first with a severe injury, but the authors of the first article referenced below correctly note “with high success rates, flap survival should no longer be the sole criterion in judging success in dorsal hand and wrist reconstruction.”
In an attempt to determine the best flap for dorsal hand coverage in terms of aesthetic appearance, donor-site morbidity, and minimization of revision surgery, the authors conducted a retrospective review of all free flaps for dorsal hand and wrist coverage from 2002 to 2008 was performed. Flaps were divided into four groups: muscle, fasciocutaneous, fascial, and venous flaps. Outcomes assessed included need for debulking, blinded grading of aesthetic outcomes, and flap and donor-site complications.
The problem with this article and it’s outcomes is the fact that it is a retrospective review. This “confounding factor” is expounded upon in the discussion article (second reference below).
Keeping that in mind, here are a few “findings”
Fasciocutaneous flaps scored the lowest in all aesthetic categories. The bulkiness of these flaps can make contouring difficult and often require future debulking. Color match is also an aesthetic issue.
Fasciocutaneous flap donor-sites often require skin grafting. When primary closure is done, the authors found a higher rate of breakdown than with the other flaps.
Due to these disadvantages, fasciocutaneous flaps have become our secondary choice for dorsal hand reconstruction.
There are two advantages of fasciocutaneous flaps. First, flap re-elevation is easier than with muscle flaps.
Second, flap tissue can be rearranged and divided with less concern for blood supply as would be needed in a muscle flap; a few months after flap transfer, fasciocutaneous flaps appear to be less reliant on the primary pedicle. In addition, if patients will require secondary reconstructions, then debulking can be done at this time.
The authors found muscle flaps covered with split-thickness skin grafts had significantly better overall aesthetic, contour, and color match results than fasciocutaneous flaps. They also required less debulking most likely due to atrophy of the muscle.
We have been increasingly using partial muscle flaps for dorsal hand and wrist coverage in which the flap size harvested is tailored to the defect size. These are harvested as a partial superior latissimus muscle or as a partial medial rectus muscle flap, leaving the majority of the donor muscle and its motor nerve intact. These are small, custom-designed flaps.
………Despite the teaching that fascia is needed for tendon glide, we have noted no difference in tendon functional results when covered with muscle versus fascia. This conceptually makes sense, as normally tendons and muscle bellies constantly glide past each other in the forearm.
Fascial flaps with split-thickness skin graft are thin and pliable. These scored high in all aesthetic categories and rarely needed debulking. Donor-site morbidity is minimal, as no muscle is harvested and the donor site is closed primarily without need for grafting.
For these reasons, fascial flaps are a first-line treatment for moderate-sized to large dorsal hand wounds, allowing a single-staged procedure with minimal need for revision surgery. Their aesthetic appearance is better than that of fasciocutaneous flaps, and they require less debulking than muscle flaps.
Final aesthetic results are dependent on skin graft take and any graft failure results in poorer texture and color match results. Nonmeshed grafts have better aesthetic results than meshed grafts for the dorsal hand.
Venous flaps required no debulking in this study and had the best overall aesthetic results with excellent color, contour, and texture match. These flaps are often harvested from the volar forearm in the suprafascial plane, allowing them to be very thin and pliable, matching the surrounding dorsal hand skin. They are limited to use for small to moderate-sized defects.
Refining Outcomes in Dorsal Hand Coverage: Consideration of Aesthetics and Donor-Site Morbidity; Parrett, Brian M.; Bou-Merhi, Joseph S.; Buntic, R. F.; Safa, B.; Buncke, G. M.; Brooks, D.; Plastic & Reconstructive Surgery. 126(5):1630-1638, November 2010; doi: 10.1097/PRS.0b013e3181ef8ea3
Discussion: Refining Outcomes in Dorsal Hand Coverage: Consideration of Aesthetics and Donor-Site Morbidity; Fang, F.; Song, J. W.; Chung, K. C.; Plastic & Reconstructive Surgery. 126(5):1639-1641, Nov 2010; doi: 10.1097/PRS.0b013e3181f1cf42

Saturday, December 4, 2010

Macramé Covered Clothes Hanger

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Almost two weeks ago my friend Jabulani tweeted a photo of a covered hanger project she was working on. I tweeted a photo of a macramé covered hanger I had made a few years ago. As there was interest in how to do mine and as I could find no instructions online to direct folks to, I decided to try to do a show-and-tell.
The supplies you will need are a wire coat hanger, twine, two rubber bands, tape, and fabric glue. Cut approximately 6-7 yards of twine twice. [I used 10 yds and had just under 5 left on each.] To make them easier to handle and to avoid tangling, coil and secure with a rubber band.
Now that all your supplies are gathered, let’s begin.
Tape the loose ends of each twine coil to the end of the hanger hook. The ends of the twine should point towards the upsweep of the hook and will be covered with the knots. Begin tying your square knots. Note that one twine length always goes behind the wire and one in front.
This photo is meant only to show you how the knots will cover the taped ends.
In these next two photos I hope to show you how the square knot is formed, but you may find the instructions here helpful (link removed 3/2017).
The “pink” cord on the left is brought over the front of the wire. The “green” cord on the right is then brought over the “pink” cord, taken behind the wire and then come up and over the “pink” cord.
The “pink” cord is now on the right.  It is brought over the front of the wire and under the “green” cord.  The “green” cord then wraps behind the wire and up over the “pink” cord.

Those two steps are repeated until the entire wire is covered.  When you first come to the juncture of the hook and hanger body continue along either limb.  You will eventually come back to that juncture which is where you end.
When you have finished covering the entire wire with square knots, cut your twine.  Snug the twine into the juncture and using the fabric glue secure it here.  Cut off the extra twine.

You now have a nicely covered wire hanger.