Monday, January 31, 2011

ALCL and Breast Implants

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Last week, the U.S. Food and Drug Administration requested health care professionals to report confirmed cases of anaplastic large cell lymphoma (ALCL) in women with breast implants.
The FDA made this request as they continue to investigate a possible association between breast implants, both saline and silicone gel-filled, and ALCL.
The definition given of ALCL by the National Cancer Institute calls ALCL an aggressive type of non-Hodgkin lymphoma, but oncologist Elaine Schattner, M.D. concludes after studying the FDA’s assessment (bold emphasis is mine)
Most of the ALCL tumors were limited to the area of the implant cap­sules, and could – as best I can tell from the few reports – be treated by removal of the implants and affected, adjacent breast tissue. These don’t appear to be aggressive lym­phomas, as are some ALCL’s. I would go as far as to spec­ulate that these might indeed be antigen-driven tumors; in this light, it would make sense in prin­ciple and in practice to treat these by removal of the implants, at least as a first-line approach.
The FDA cites the Surveillance, Epidemiology, and End Results (SEER) Program of the NCI when noting ALCL is diagnosed in the United States in  approximately 1 in 500,000 women each year. ALCL in the breast is even more rare; approximately 3 in 100 million women per year in the United States are diagnosed with ALCL in the breast (Altekruse et al., 2010).
The FDA press release mentions an awareness of about 60 cases of ALCL in women with breast implants worldwide.   The same press release later notes “a review of scientific literature published between January 1997 and May 2010 and information from other international regulators, scientists, and breast implant manufacturers. The literature review identified 34 unique cases of ALCL in women with both saline and silicone breast implants.”
There are an estimated 5 million to 10 million women worldwide who have breast implants.
Among the 34 unique cases, the median age was 51 (28-87, with no age given in 8 cases); implant type (24 silicone, 7 saline, 3 unknown); implant texture (4 textured, 0 smooth, 30 unknown); median time from implant to diagnosis was 8 years (1-23, but not known in 11 cases); reason for implantation (11 reconstructive, 19 augmentation, 4 unknown).
The FDA notes (bold emphasis is mine):
ALCL is a very rare condition; when it occurs, it has been most often identified in patients undergoing implant revision operations for late onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.
The FDA is requesting health care professionals report all confirmed cases of ALCL in women with breast implants to Medwatch, the FDA’s safety information and adverse event reporting program. Report online or by calling 800-332-1088.
Women with implants should remember ALCL is extremely rare.  There is no need to change your routine medical care and follow-up.  For more information from the FDA:
Breast Implant Consumer Information
ALCL and Breast Implants Consumer Article

Other blog posts on topic:
An Oncologist Considers Rare Lymphomas in Women With Breast Implants; Medical Lessons Blog (January 28, 2011)
Breast implants and anaplastic large cell lymphoma (ALCL): Is there a link?; Science-Based Medicine Blog (January 31, 2011)

FDA Review Indicates Possible Association Between Breast Implants and a Rare Cancer; January 26, 2011
Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants: Preliminary FDA Findings and Analyses; FDA
Breast Implants and Lymphoma Risk: A Review of the Epidemiologic Evidence through 2008; Plastic & Reconstructive Surgery. 123(3):790-793, March 2009; Lipworth, Loren Sc.D.; Tarone, Robert E. Ph.D.; McLaughlin, Joseph K. Ph.D.
Anaplastic large-cell lymphoma in women with breast implants; JAMA. 2008;300:2030-2035; De Jong D, Vasmel WLE, de Boer JP, et al.

Friday, January 28, 2011

Kris’ Blue Quilt

I made this quilt for my nephew.  The center fabric was so lovely I didn’t want to cut it up so deliberately used it whole.  I wanted it to look like a pool of water.

I machine pieced the quilt, but had my friend Scottie Brooks hand quilt it.  It was finished July 10, 2004.  It measures 82.25 in square.

I used small squares to try to make it look like tiles around a pool.  The outer strip of blue/green is a lovely batik fabric.

My nephew took these photos for me.

Thursday, January 27, 2011

Determining Implant Size Preop

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

There is an interesting debate going on regarding bra stuffing for implant size at PRSonally Speaking.  In the interest of full disclosure, I use normal saline implant sizers which I place inside a thin sleep bra.  I then inflate with sizer (usually use two different sizes for comparison) with air.  I then have the woman place her shirt on and stand in front of the full length mirror.  It has worked well for me over the years.  And, yes, I know it is not perfect, but it allows the two (or three if a friend or spouse has come with her) to assess how she looks AND presents herself. (photo credit)
It has amazed me over the years how some women will decide on larger implants when I show them what a “C” cup for their body really is [the volume for a 34C is not the same as for a 38C] but also how some will decide they can’t go as large as they intended.  It has worked both ways.  Most of the time the decision is made in one office visit, occasionally two.  Rarely, do they come back wishing we’d made a different choice on size.
Back to the discussion at the PRSonally Speaking:  Letters to the Editor in Advance: Bra Stuffing for Implant Sizing? Satisfaction? Who, When, and Compared to What?
The discussion is in regards to an article in the PRS Journal’s June 2010 edition (full reference below)
A portion of Dr. John Tebbett’s comment
The authors characterize their bra stuffing implant sizing methodologies as “simple” and “accurate”. Simple? Up to three visits to the surgeon’s office to ruminate over shades of gray using a totally subjectively derived decision processes based on indefinable cup size parameters and patient’s visual perceptions? Accurate? 30% of sized respondents reported that the sizing methods were inaccurate.

Choosing breast implant size by bra stuffing has a repetitive, three decade track record of 15-25% reoperation rates (and a major percentage of reoperations for size change) …...

The authors’ implication that objective, scientifically validated, defined process implant selection methods preclude or minimize patient involvement in the decision making processes is misguided and incorrect
A portion of Dr. David Hidalgo replies
……..What is truly outdated is the model of the surgeon as an autocratic figure that dictates what is best while ignoring patient input beyond presenting anatomy. The trend today instead is towards personalized medicine. ……….
While FDA PMA studies may show a 15-25% reoperation rate preoperative sizing techniques are not specifically implicated as the source of the problem, as implied. In fact the vast majority of reoperations today are for capsular contracture, implant malposition, and saline implant deflations. ……
To be clear, preoperative sizing is not a precise method and is of course subjective. Improvements in the technique would be helpful and hopefully forthcoming. We do not believe that the ongoing advances in three dimensional patient photography with implant size simulation is the answer. There is no substitute for the patient trying on different sizes and visualizing the effect in clothing as well as experiencing the implant weight. The method is very instructive in revealing the patient’s aesthetic vision in a way that dictating a size based on tissue characteristics alone can never do. …….
Thoughts?  Add them here or over at PRSonally Speaking

Preoperative Sizing in Breast Augmentation; Hidalgo, David A.; Spector, Jason A.; Plastic & Reconstructive Surgery. 125(6):1781-1787, June 2010; doi: 10.1097/PRS.0b013e3181cb6530
Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes: The High Five Decision Support Process; Tebbetts, John B.; Adams, William P.; Plastic & Reconstructive Surgery. 118(7S):35S-45S, December 2006; doi: 10.1097/01.prs.0000191163.19379.63

Wednesday, January 26, 2011

USPSTF Breast Screening Guidelines Pushback

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

The question continues as to when breast screening should begin.  The current pushback comes from radiologists Dr. Mark Helvie of the University of Michigan Health System and colleague Dr. Edward Hendrick of the University of Colorado.
The two researchers have published an article (full reference below) in the February issue of the American Journal of Roentgenology questioning the U.S. advisory panel’s breast cancer screening guidelines and suggesting the panel ignored scientific evidence that more frequent mammograms save lives.
For the article, the two conducted a review of the risk models used by the U.S. Preventive Services Task Force (USPSTF) to issue controversial breast screening guidelines in 2009.  They used Cancer Intervention and Surveillance Modeling Network modeling to compare lives saved by different screening scenarios and the summary of evidence prepared for the USPSTF to estimate the frequency of harms of screening mammography by age.
As a reminder, the USPSTF 2009 breast screening guidelines recommend:
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.  (Grade: B recommendation)
  • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.  (Grade: C recommendation)
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (Grade: I Statement)
  • The USPSTF recommends against teaching breast self-examination (BSE). (Grade: D recommendation)
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.  (Grade: I Statement)
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. (Grade: I Statement)
Helvie and Hendrick analysis found that having annual mammograms from age 40 saved 64,889 more lives with the current 65% compliance rate.
They found that getting a yearly mammogram from age 40 cut a woman’s risk of fatal breast cancer by 71% versus the 23% reduction for women who followed the USPSTF recommendations.
The two researchers state, “The potential harms of a screening examination in women 40–49 years old, on average, consist of the risk of a recall for diagnostic workup every 12 years, a negative biopsy every 149 years, a missed breast cancer every 1,000 years, and a fatal radiation-induced breast cancer every 76,000–97,000 years.”
The two researchers feel the advantages of yearly mammograms starting at age 40 years outweighs the potential harms of screening.
I think perhaps they should read Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision
……..So, going back to the 10,000 women we are screening, of 9,900 who do NOT have cancer (remember that only 100 can have a true cancer), 10%, or 990 individuals, will still be diagnosed as having cancer. So, tallying up all of the positive mammograms, we are now faced with 1,070 women diagnosed with breast cancer. But of course, of these women only 80 actually have the cancer, so what's the deal?  ……….

Related posts:
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)

Hendrick, R. Edward, Helvie, Mark A.; United States Preventive Services Task Force Screening Mammography Recommendations: Science Ignored; Am. J. Roentgenol. 2011 196: W112-116

Doctors and Civics

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

Monday Diane Rehm had “A Conversation with Richard Dreyfuss” during which he discussed his initiative to encourage a civics curriculum in public schools.  It struck a cord with me as I faced my first meeting as a first-time trustee of the Arkansas Medical Society Board***.
I feel out of place.  There is language and protocol I don’t know.  I was asked (strong-armed) and said yes.  After listening to Dreyfuss, I am (almost) ashamed that I had to be strong-armed or even asked to be involved.  As a citizen of the United States, as a citizen of Arkansas, as a doctor and member of the society, perhaps it is as Dreyfuss believes – it is my duty to be involved.
The Dreyfuss Initiative is to teach our younger generation to be why civics is so important.
“To teach our kids how to run our country, before they are called upon to run our country….if we don’t, someone else will run the country.”  Richard Dreyfuss
Even though I wasn’t taught the importance of “civics” in the medical profession, it isn’t too late to learn.  So later today I will be attending the Arkansas Medical Society Day at the Capitol, the lunch and afternoon events.  I am forgoing the evening reception.
Is being involved only on the level of your local hospital enough?  Probably not, but it is a start.  Policy set in our local hospital or even in our offices are influenced by national and state policy.  It is important (as I am learning and admitting) to be involved on a state and national level.
I am not fond of politics, so this is not a natural fit for me.
Currently, I serve on the LRSC Medical Executive Committee (local surgery center) and the Pulaski County Medical Society Board of Directors.   In addition to being a member of my county and state medical societies, I am a member of the American Medical Association though I often don’t feel represented well by them.  Perhaps that is my fault.
How involved are you?  How involved do you think we should be?
***There is a question of whether I will be needed after all.  As with the US Congress, the number of trustees each county society gets is related to their membership/population.  It seems Pulaski County may have lost a trustee, so I may not be needed.
By the way, if any of my fellow Arkansas colleagues are reading this, the Arkansas Medical Society is having a membership drive.  Consider joining if you aren’t a member.

Tuesday, January 25, 2011

Shout Outs

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

Dr. Bryan Vartabedian, 33 charts, is the host for this week’s Grand Rounds! You can read this week’s edition here.
The reason I love grand rounds is that it offers me the opportunity to see stuff that I might normally overlook.
No themes here, per se.  Just some good stuff from around the web.  The response was great and all offered something unique.  I have chosen, however, to select some of the best material for your reading pleasure.  Rather than generate a massive dung heap of disconnected links that no one can practically manage, I have made the administrative decision to focus on some of the more compelling content.  I’ve also tried to place an emphasis on new, potentially understated blogs that might not otherwise see the light of day.
Buckle your seatbelt and keep your arms inside the vehicle.
. …………
Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 15)! You can find the schedule and the COS archives at Emergiblog. (photo credit)
Welcome to Change of Shift!
This is a miniature edition!
The quantity is tiny, the quality is superb!
Grab some coffee, kick back
Change of Shift is in da house!
Editor’s Pick: At the AJN Off the Charts blog, Juliana Paradisi pens a fantastic post on privacy, both personal and for patients, in Nurses, Hospitals and Social Media: It Depends What Business You’re In.  …..
Dr. Itzhak Brook, My Voice, shares an essay at KevinMD:  A laryngectomy shakes this physician to the core
As an infectious diseases physician with a special interest in head and neck infections, I had extensive experience in otolaryngological illnesses. However, when I was exposed to new, different, and challenging experiences as a neck cancer patient, I had to deal with these as a patient — not as a physician. I endured the consequences of radiation, repeated surgeries, and prolonged hospitalizations. I confronted medical errors in my care, discrimination following loss of my vocal cords, and the hardships of regaining my ability to speak.  ………….
Listening to NPR last week, I caught Tina Brown discussing her Must Read selections for the week.  The one that caught my attention was the story of the 'The Man Who Saw Too Much'.  It profiles Michael Ferrara who suffered PTSD as a first responder. 
The original article in the January 2011 issue of Outside Magazine is by Hampton Sides:  “The Man Who Saw Too Much”
LOOKING BACK over his nearly 30 years as a highly decorated first responder in Colorado's Roaring Fork Valley, Michael Ferrara has trouble pinpointing the exact moment when his life began to unravel. His ordeal arrived not all at once but in a long spool of assaults on his soul and psyche. A plausible starting point, though, might be March 29, 2001, and a nightmare that occurred at the airport in Aspen. ………
Starting in March, to boost the profile of his First Responder Recovery Project, Ferrara plans to ski across the state of Alaska.
Don’t forget to submit your nominations to MedGadget’s Medical Blog Awards -- 2010 Medical Weblog Awards!  This marks the 7th year of the competition. This year's competition is sponsored by Epocrates® and Lenovo. (photo credit)
While you’re at MedGadget’s, check out  how “handyscope Turns iPhone Into Professional Dermatoscope”
The handyscope is an optical attachment and an accompanying app that converts an iPhone into a practical dermatoscope. The attachment provides up to 20x magnification for the phone's camera and illuminates the skin with polarized light thanks to built-in LEDs and internal batteries. The iPhone app is used to store and examine encrypted images, as well as for sharing with other dermatologists for second opinions.
From LITFL comes a great post which takes you through the management of a toddler’s oral burn:   Hot Lips (photo credit)
You may want to check out my post on the same topic from September 28, 2007, Electric Burns to the Mouth
KevinMD has written a commentary, Old Doctors Who Continue to Practice, which was inspired by the NYTimes article, Worry Grows About Aging Doctors’ Fitness to Practice.  The NY Times article begins this way:
About eight years ago, at the age of 78, a vascular surgeon in California operated on a woman who then developed a pulmonary embolism. The surgeon did not respond to urgent calls from the nurses, and the woman died.
…., he continued to perform operations for four years until the board finally referred him for a competency assessment …..
“We did a neuropsychological exam, and it was very abnormal,” said Dr. William Norcross, director of the physician assessment program there, who did not identify the surgeon. “This surgeon had visual-spatial abnormalities, could not do fine motor movements, could not retain information, and his verbal I.Q. was much lower than you’d expect.”
Jessica, Endless Knots, has a nice post on “Taking verbatim notes.”  She describes how she does just that when conducting interviews in a step-by-step process:
……….Which brings me to my method for taking verbatim notes, which I'm guessing a lot of other writers/consultants use but just in case you don' goes. ……...
1. Open your fave word processing program and …..
2. In Tools>Autocorrect, enter abbreviations for the words you're most likely to hear your interviewees say. Example: current project is in healthcare. I enter "hc" for healthcare; dr for doctor; emr for electronic medical record; clbrt for collaborate, etc. The easiest way to create your own shorthand is by drpng vwls. Got it?
……………………………….. is hosting the Scrubinator Photo Contest.  The contest is open to everyone from students to seasoned professionals.  It launched January 19, 2011 and will run until April 20, 2011.
To enter the contest, participants must submit photos of themselves in their creative scrub apparel for a chance to win a $250 gift card to Scrubs and Beyond.
The official rules can be found here.  Each month, two winning pictures will be selected and announced on the official website and across the site’s social media profiles. 
Dr Anonymous’ guest this week will be KevinMD  who will be talking at the Texas Medical Association meeting on Jan 29, 2011.  Dr. Anonymous will also talk about the future of the Doctor Anonymous Show on BlogTalkRadio.  The show begins at 9 pm EST.
You may want to listen to the shows in his Archives. Here are some to get you started:
GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

Monday, January 24, 2011

Facing Monday

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

Last Monday was reported to be the saddest day of this year.   So to help you and I face Monday and the beginning of a new week, in case you missed these stories…..
Roger Ebert has written in his Chicago Sun Times blog of how he will once again be “Leading with my chin.” 
………..That was the beginning of a two-year process that has now resulted with my coming into possession of a silicone prosthesis. Dr. Reisberg brought in David Rotter, also from the University of Illinois, and he involved Julie Jordan Brown, a Milwaukee artist and anaplastologist. Working from molds, they created a prototype prosthesis and sculpted it carefully to more closely resemble what had been there before. This device would fit over my lower face and neck and, colored to match my skin, would pass muster at a certain distance……….
He will wear the facial prosthetic on his new show set to debuted Friday January 21, 2011:   Ebert Presents at the Movies.  He speaks using his voice through his laptop.
Last week, we heard the voice of a woman who is only the second person to receive a larynx transplant.   The 52 yo California woman’s surgery was done by a team of surgeons at UC Davis Medical Center.

From this article by Aaron Saenz: Woman Speaks With Her Own Voice After Larynx Transplant (video) comes the reminder that just last year a 10 year old boy had a new trachea made from his own stem cells.
So is this surgery simply a fluke? …... According to Paolo Macchiarini, one of the surgeons involved, “Not only is it highly relevant for future transplants, it offers us insights that may one day lead to using stem cells to repair the voicebox and surrounding areas in the throat.”
When it comes to stem cells and the throat, Macchiarini knows what he’s talking about. Last year he was the leader of a team that grew a new trachea in a 10 year old boy using the child’s own stem cells. As he stated in regards to the Jensen case, “Being able to restore nerves and reconnect blood vessels in and around the larynx and trachea, and have it all work, was a real test.” Perhaps this most recent operation will lead to further remarkable work from Macchiarini in the near future.
Related posts

Laryngeal Transplantation and 40-Month Follow-up; Marshall Strome, M.D., Jeannine Stein, M.D., Ramon Esclamado, M.D., Douglas Hicks, Ph.D., Robert R. Lorenz, M.D., William Braun, M.D., Randall Yetman, M.D., Isaac Eliachar, M.D., and James Mayes, M.D.; N Engl J Med 2001; 344:1676-1679

Friday, January 21, 2011

1790 Eagle Quilt -- WIP

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

A few months ago I was contacted by the person who bought my “War Eagle” quilt. She wanted me to take part in a project she is putting together which will feature an “eagle” quilt representing each decade. The decade I get is 1790-1800.
Before agreeing, I pulled out a couple of my quilt books to be sure I knew what quilts looked like during that time frame. I wanted to be sure I could deliver a quilt that looked like it came from 1790.
In Barbara Brackman’s Clues in the Calico (p 14-15)
In the mid-eighteenth century, ……Like the bed quilts, petticoats were of whole cloth, often of silk or glazed wool, quilted with designs such as feathers and flowers.
In Roderick Kiracofe’s The American Quilt --- 1750-1825 Preindustrial America chapter (p 46-48)
Many quilts from this period …. Those quilts tend to be of the “whole-cloth” style, made from a length of fabric that had not been pieced into a design, or of the broderie perse style, which involved the appliquéing of chintz motifs onto a base fabric.
So Sue and I decided it should be a whole cloth quilt. I purchased some white glazed cotton which I found on-line.
I then needed to design the quilting design with an eagle playing a prominent part of the design. What did eagles look like in quilting in 1790? None of my quilting books turned out to be of much help. Quilts with eagles in my books weren’t old enough.
My husband, however, had a perfect book: The Eagle on U.S. Firearms by John W. Jordan. Turns out the eagles during this time frame had downturned wings and a “turkey” neck.

I got lucky in my search. The Book of Patterns and Instructions for American Needlework had a beautiful example of such an eagle in a counterpane from the Henry Ford Museum. The pattern included was meant for embroidery, but I knew I could make it work as a quilting design. All I needed to do was redesign the wings so they went down and turn the oval into a circle.

So now the quilt is designed, I have begun hand quilting it. I am not a fast hand quilter, so it will be a while before I have the finished quilt to show you. I am happy with the design.

Thursday, January 20, 2011

Surgeons and Suicide Ideation

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

There is a new article on surgeons and the risk of suicide in the January issue of Archives of Surgery (full reference below).
The Kansas City Star’s new article on the study includes this from a colleague who was a plastic surgeon here in Little Rock when I went into practice.  He left his surgical practice a few years ago, retrained and is now in hospice care at the local VA. (photo credit)
Dr. Robert Lehmberg, 63, said it took prodding from close friends to finally get him to seek treatment for depression and suicidal thoughts several years ago. Though he feared losing his license and being stigmatized, neither happened, and he said medication and psychotherapy have greatly helped.
The article notes suicidal ideation (SI) among individuals 45 years and older is 1.5 to 3.0 times more common among surgeons than the general population (P < .02).
This study was commissioned by the American College of Surgeons (ACS) Committee on Physician Competency and Health.  It used an anonymous cross-sectional survey in June 2008. The survey included questions regarding suicidal ideation (SI) and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life.
There was a response rate of only 31.7% which resulted in 7905 participating surgeons.  Of these, 501 (6.3%) reported SI during the previous 12 months.
 Only 26% (130/501) of the surgeons with recent SI had sought psychiatric or psychologic help.  More than half [301 (60.1%)] reported the same reluctant to seek help due to concern that it could affect their medical license as Dr. Lehmberg mentions above. 
Burnout with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment), depression, and  report of a recent medical error were independently associated with SI even after controlling for personal and professional characteristics.
The authors conclude:
Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

Related posts:
Doctors with Depression (September 24, 2008)
Stress and Burnout Among Surgeons – an Article Review (April 22, 2009)
Doctors With Depression (September 24, 2009)

Special Report: Suicidal Ideation Among American Surgeons; Tait D. Shanafelt; Charles M. Balch; Lotte Dyrbye; Gerald Bechamps; Tom Russell; Daniel Satele; Teresa Rummans; Karen Swartz; Paul J. Novotny; Jeff Sloan; Michael R. Oreskovich; Arch Surg. 2011;146(1):54-62.

Wednesday, January 19, 2011

BDD Patients Can Get Better

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

The Science Daily article, Body dysmorphic disorder patients who loathe appearance often get better, but it could take years, discusses the The Journal of Nervous and Mental Disease (JNMD) article (full reference below, abstract available for free).  
The JNMD article reports the results of the longest-term study so far to track people with body dysmorphic disorder.  The study was conducted by researchers at Brown University and Rhode Island Hospital.
The good news:  the researcher “found high rates of recovery, although recovery can take more than five years.”
This is a small study with only 15 BDD patients who were followed over an eight-year span.
After statistical adjustments, the recovery rate for sufferers in the study over eight years was 76 percent and the recurrence rate was 14 percent. While a few sufferers recovered within two years, only about half had recovered after five years.
The subjects were a small group diagnosed with the disorder out of hundreds of people participating in the Harvard/Brown Anxiety Research Project (HARP). Study co-author Martin Keller, professor of psychiatry and human behavior and principal investigator of the HARP research program which has been ongoing for more than 20 years, said that because the BDD sufferers were identified through this broader anxiety study, rather than being recruited specifically because they had been diagnosed with BDD, they generally had more subtle cases of the disorder than people in other BDD studies. In comparing the HARP study with the prior longitudinal study of BDD, it is possible that the high recovery rate in the HARP study is due to participants having less severe BDD on average.

Body Dysmorphic Disorder
  • In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
  • This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
  • When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.
Related posts
Suitability (January 3, 2008)
The Barbie Syndrome  (March 25, 2010)

The Clinical Course of Body Dysmorphic Disorder in the Harvard/Brown Anxiety Research Project (HARP); Andri S. Bjornsson, Ingrid Dyck, Ethan Moitra, Robert L. Stout, Risa B. Weisberg, Martin B. Keller, Katharine A. Phillips;  The Journal of Nervous and Mental Disease, 2011; 199 (1): 55 DOI: 10.1097/NMD.0b013e31820448f7
Body Dysmorphic Disorder; eMedicine Article, September 3, 2010; Iqbal Ahmed, MBBS and Lawrence Genen, MD, MBA

Tuesday, January 18, 2011

Shout Outs

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

Enabling Healthy Decisions is the host for this week’s Grand Rounds! You can read this week’s edition here.
The concept of “engagement” in healthcare is a difficult one. Traditionally, we’ve had a build it and they will come approach that didn’t encourage preventative care. It also didn’t openly acknowledge the challenges that consumers have in dealing with medication adherence and even understanding the system or their physician’s instructions.
In this week’s edition of Grand Rounds, I looked at submissions and recent posts from several angles on this issue.
One of the most engaging was from the healthAGEnda blog where Amy tells her personal story about being diagnosed with Stage IV inflammatory breast cancer and trying to work though the system. Her focus on patient-centered care and support for the Campaign for Better Care make you want to jump out of your seat and shake the physician she talks about.
. …………
A beautiful post from Dr. Bruce Campbell, Reflections in a Head Mirror: Non-Frail
……….Finally, the big question emerged. The daughter took a breath. “Do you really think he could survive a big surgery, Doctor? After all, Dad is 90.”
Their eyes swung toward me. Here was a man who looked a lot younger than the calendar would predict. He still gets outside and walks every day and is fully engaged with his world. But, true enough, he has lived a very long time. …………….
As I opened the door to leave, he stopped me. “Doctor, I realize that I can have the surgery. Thanks for that. I trust you. But, Doctor,” he paused, “should I have the surgery? I am 90-years-old, after all!”
It’s time for MedGadget’s Medical Blog Awards -- 2010 Medical Weblog Awards!
This marks the 7th year of the competition. This year's competition is sponsored by Epocrates® and Lenovo. (photo credit)
The categories for this year's awards are:
  • Best Medical Weblog
  • Best New Medical Weblog (established in 2010)
  • Best Literary Medical Weblog
  • Best Clinical Sciences Weblog
  • Best Health Policies/Ethics Weblog
  • Best Medical Technologies/Informatics Weblog
  • Best Patient's Blog

  • Nominations are now accepted in the comments section of this post. When nominating, please indicate the blog's name and URL, nominating category, as well as your thoughts why this particular blog deserves recognition.
    Via tweeter: RT @EvidenceMatters: rt @MishaAngrist Sugar on the floor NY Historical Society's exhibit on the discovery of insulin.
    Yesterday I went to the New York Historical Society’s exhibit Breakthrough: The Dramatic Story of the Discovery of Insulin (through January 31; $12 for adult non-members). I know–the title is breathless and leads the witness. But forgive the curators. The “drama” was certainly real, but that’s not what I found most compelling. I was struck by ………
    (photo credit NY Historic Society online from Eli Lilly and Company Archives)
    Another via tweeter, this one from @krupali: Cyberspace When You’re Dead -
    Suppose that just after you finish reading this article, you keel over, dead. Perhaps you’re ready for such an eventuality, in that you have prepared a will or made some sort of arrangement for the fate of the worldly goods you leave behind ………..
    This has inspired a variety of entrepreneurs to place bets that, eventually, people will want control over the afterlife of their digital selves. ……. Legacy Locker claims “around 10,000” people have signed up for its digital-estate-management service. Its rivals include DataInherit, a service of DSwiss, “the Swiss bank for information assets” (you can even update your digital-legacy data via its iPhone app), and Entrustet, of Madison, Wis. Last May these three firms sponsored Digital Death Day, an event tacked on to an annual online-identity conference near San Francisco. ……………
    From Wachter’s World: The New Home Team: The Remarkable Rise of the Hyphenated Hospitalist
    I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful. We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalized patients. These were heady times.
    I experienced déjà vu last week …... Representing the “traditional” hospitalist field (I never thought I’d say that) were …., and me. …. But the real stars were six leading physicians in new subspecialty hospitalist fields: a neurohospitalist (Dave Likosky), two surgical hospitalists (John Maa and Leon Owens), two ob-gyn hospitalists (Rob Olson and Ken Jacobs), and even an ENT hospitalist, Matt Russell. Here’s what I learned: …….
    Via @Doctor_V who tweeted “The End of Internal Medicine as we Know It - hard look at ACOs”
    Physicians have doubtless been issuing jeremiads since before Jeremiah. We are overworked, underpaid, and underappreciated.
    But today, general internists have a real problem. And it is our leaders who do this to us. As summarized in the Annals of Internal Medicine: ……..
    In the future envisioned by the health policy community, including the leadership of the American College of Physicians and the American Medical Association, patients who want a personal physician, someone they know and trust, who understands and cares about them as individuals will have to pay extra for “concierge” care. Everyone else will migrate to team care from large “Accountable Care Oranizations” (accountable to whom, one may ask—certainly not the patients) …………..
    From twitter: @matthewbrowning: RT @DaphneLeigh: Beautiful images of DNA. Must watch this one, via @HealthIsSocial.

    The Folk Art Museum in New York has two quilt related exhibit currently on display. Many of the quilts can been seen online (just follow the links).
    “Quilts: Masterworks from the American Folk Art Museum” can be seen through April 24, 2011.
    “Quilts: Super Stars from the American Folk Art Museum” can be seen through September 25, 2011 at the Lincoln Square branch.
    Coming May 25-30, 2011 is an exhibit of more than 650 red and white American quilts, all of which are on loan from one private New York City collection -- Infinite Variety: Three Centuries of Red and White Quilts.
    From Erin Gilday's Patchwork Underground comes a wonderful tutorial: Vintage in Detail: Cutwork (photo credit)
    Cutwork is one of the sexiest vintage details out there. It’s also the brainchild of nuns. Go figure. ……..
    Though it looks really tricky, cutwork isn’t all that difficult to do. Though you can use a satin stitch on your zigzag machine to complete the outlines or even go nuts with your computerized embroidery machine, the directions below are for doing it the old-fashioned way – by hand! ……….

    Monday, January 17, 2011

    Factitious Disorder?

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

    Have you ever seen a case of factitious disorder?  Ever had a patient who’s wound just wouldn’t heal in spite of all the good care you gave them, all the blood work you checked (ie nutrition, infection, etc)?  Ever wondered if perhaps this nice patient was doing something to themselves?
    This recent case report in the December issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery prompted me to look up the diagnosis of “factitious disorder.”  Here is the abstract summary (full reference below):
    This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.
    I don’t have access to the full article, but what I found when I looked up factitious disorder makes me wonder
    The Cleveland Clinic has a nice overview of factitious disorder aka Ganser Syndrome aka Munchausen Syndrome (bold emphasis is mine).
    Factitious disorders are mental disorders in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created his or her symptoms. (The name factitious comes from the Latin word for "artificial.")
    People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways.
    The Cleveland Clinic website list the possible warning signs of factitious disorders include the following:
    • Dramatic but inconsistent medical history
    • Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
    • Predictable relapses following improvement in the condition
    • Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
    • Presence of many surgical scars
    • Appearance of new or additional symptoms following negative test results
    • Presence of symptoms only when the patient is alone or not being observed
    • Willingness or eagerness to have medical tests, operations, or other procedures
    • History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
    • Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care provider

    I’ll pick on myself here.  In fact that is exactly why a small area in my left eyebrow has failed to heal as quickly as it should.  I keep picking at it, picking off the scab before it’s ready to fall off.  I don’t do it to create or exaggerate the problem.  It’s a nervous tick.  I’ve always been a scab picker (and, yes, I tell my patients not to pick at theirs).  It’s a trait that comes in handy as a surgeon who gets to debride wounds.
    Don’t forget that some patients are simply like me.  Don’t forget that some may have a issue like this (Trigeminal Trophic Syndrome).  All these other possibilities must be ruled out before giving the patient the diagnosis of factitious disorder.

    Factitious Disorder as a differential diagnosis for recurrent skin graft failure; D.M. Seoighe, M. Dempsey, C. Lawlor, A.M. O’Dwyer;  
    Journal of Plastic, Reconstructive & Aesthetic Surgery - 27 December 2010 (10.1016/j.bjps.2010.11.004)
    Factitious Disorder; eMedicine Article, October 22, 2009; Todd S Elwyn, MD and Iqbal Ahmed, MBBS

    Sunday, January 16, 2011

    Black Linen Voyager Bag

    Last fall I bought a new bag pattern from Ghee’s, the Voyager Bag (#761).  I made the medium using some black linen in my stash.  As it was a light-weight linen, I underlined it to make it more durable.  I, also, fully lined the bag sections so there are no raw seams anywhere.
    The finished bag, folded over, measures 8 in X 9 in.  There are a total of 8 compartments/pockets.  I had a beautiful piece of 3 in wide trim that I wrapped around 1.5 in cotton strapping to make the bag’s strap. 

    Here is the back.  Note the pocket which could hold tickets when traveling.

    Here is the inside.

    Here you can see the antique buttons I used for the closure.  I found these years ago at an estate sale.

    Friday, January 14, 2011

    You Melt My Heart

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

    This quilt was made from the cut-out fabric from the EKG of my “Winter” quilt. You can see what I mean in this photo.
    This small wall hanging quilt is 16 in square. It is machine and hand appliqued. It is machine quilted. The icicles in the heart are quilted with metallic thread.
    Here you can see the deep red thread used to quilt the “frame” and the metallic used in the middle.
    Here is a photo of the center of the back of the quilt before the sleeve and label were added.

    I have listed it for sale on Etsy.  Never sold, so donated August 2012 to UAMS for silent auction at my 30th medical school reunion.

    Thursday, January 13, 2011

    Prophylactic Antibiotics in Aesthetic Surgery

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

    There is a very nice review of this topic in the Nov/Dec 2010 issue of the Aesthetic Surgery Journal (full reference below).
    While we want to prevent surgical site infections (SSIs), we don’t want to over utilize antibiotics.   Consequences of which include:   Clostridium difficile infections [CDI] and development of resistant organisms.
    The authors note that currently no national guidelines for antibiotic prophylaxis in aesthetic surgery although they do for cardiac, colorectal, neurosurgical, and orthopedic procedures.  “In fact, studies examining the impact of prophylactic antibiotics have produced contradictory results.”
    So what should we do:
    Until randomized controlled trials examining the efficacy of prophylactic antibiotics in aesthetic surgery are performed, we recommend giving prophylactic antibiotics in accordance with SIP project guidelines.
    The ideal antibiotic for surgical prophylaxis should (1) cause minimal toxicity or side effects, (2) be effective against the most likely organisms that will cause an SSI but have a narrow spectrum, (3) achieve adequate tissue concentrations at the surgical site for the duration of the procedure, and (4) be administered for the shortest effective period.
    For most patients undergoing aesthetic procedures, the preferred antimicrobial agent is a first-generation cephalosporin such as cefazolin (1 gm IV).  Increase the dose if the patient weighs more than 160 pounds (approximately 80 kg) --  the dose of cefazolin may be increased to 2 g IV.
    A second dose of antibiotics should be given IF the surgical procedure lasts more than three to five hours or if the patient has lost a significant amount of blood (greater than or equal to 1500 mL).
    Patients with a beta-lactam allergy may receive clindamycin or vancomycin.  If used, remember their longer half-lives if redosing is necessary (clindamycin every four to six hours; vancomycin every six to 12 hours).
    Vancomycin may be given for surgical prophylaxis in facilities with a high incidence of methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant coagulase-negative staphylococci. Guidelines recommend against the routine administration of vancomycin for antibiotic prophylaxis.
    The authors not strategies to prevent MRSA SSI are controversial, but current guidelines from the CDC and the Society for Healthcare Epidemiology of America recommend against routine universal screening for MRSA.
    The authors suggest that until more data are available to support routine active surveillance and decolonization among patients undergoing plastic and reconstructive surgery, these interventions should be reserved for patients who are colonized with MRSA or are known to have had an MRSA infection in the past.
    As I posted last week, when decolonization is deemed appropriate:
    • Nasal decolonization with mupirocin twice daily for 5–10 days.
    • Nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.)
    Antibiotic prophylaxis should be given prior to surgery to achieve tissue and serum concentrations that will produce bactericidal levels at the time surgical incision is made.  Most antibiotics should be administered within 60 minutes before incision. If fluoroquinolones or vancomycin is indicated, the infusion should begin 120 minutes before incision. If a proximal tourniquet is required for the surgery, the entire antibiotic dose should be administered before the tourniquet is inflated.
    The authors point out that prolonged courses of antibiotics given for prophylaxis have not shown benefit as compared to a single dose of prophylactic antibiotics.  The SIP project endorses cessation of antibiotics within 24 hours of the end of surgery.
    What about if a drain(s) is placed?  I, like many surgeons were trained to continue antibiotics for as long as the surgical drains are in place.  The authors point out:  “there is a lack of evidence to support this practice in aesthetic surgery.” 
    The SIP project guidelines recommend against continuing antibiotic prophylaxis for the duration of surgical drain placement for orthopedic and cardiothoracic procedures.   It should be noted that antibiotic therapy is appropriate when the surgical drain is placed for therapeutic drainage of an infected space or abscess.

    Prophylactic Antibiotics in Aesthetic Surgery; Lane, Michael A., Young, V.Leroy, Camins, Bernard C.; Aesthetic Surgery Journal November/December 2010 30: 859-871
    Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project; Bratzler DW, Houck PM; Clin Infect Dis 2004;38:1706-1715.
    Management of multidrug-resistant organisms in health care settings, 2006; Siegel JD, Rhinehart E, Jackson M, Chiarello L;  Am J Infect Control 2007;35(suppl 2):S165-S193.

    Wednesday, January 12, 2011

    Propranolol Treatment for Infantile Hemangiomas

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

    The Plastic and Reconstructive Surgery Journal article from 2009 (second reference below) spurred Will J. M. Holmes, M.R.C.S and colleagues to write a letter to the journal noting their experience with propranolol in the treatment of infantile hemangiomas.
    Holmes cited two articles (references 3 and 4 below) which report the efficacy of of β-blockers in the treatment of hemangioma.
    As part of a larger study, we have used propranolol in a total of 15 patients. So far, we have observed signs of rapid involution of hemangioma within the first week of treatment in all patients. The response rate is faster than those we have seen when corticosteroids are used. In addition to stopping the proliferation of hemangiomas, propranolol also causes rapid involution within a short period.
    We now offer propranolol as a first-line treatment to all rapidly proliferating hemangiomas with functional deficit and/or disfigurement. We have developed a treatment protocol in conjunction with the cardiologist that involves pretreatment cardiac workup and an in-hospital titration of propranolol up to 1 mg/kg three times per day. So far, we have not needed to increase the dosage to more than 1 mg/kg three times per day.
    Their treatment protocol is referenced to the 5th article below.
    Related post:  Propranolol for Hemagiomas?  (March 4, 2009)

    1.  Propranolol as First-Line Treatment for Infantile Hemangiomas (Letter); Holmes, Will J. M. M.R.C.S.; Mishra, Anuj M.R.C.S.; Gorst, Cath R.G.N., R.S.C.N.; Liew, Se-Hwang F.R.C.S.; Plast & Reconstr Surgery: January 2010 - Volume 125 - Issue 1 - pp 420-421; doi: 10.1097/PRS.0b013e3181c2a731
    2.     Classification of Vascular Anomalies and the Comprehensive Treatment of Hemangiomas;  Burns AJ, Navarro JA, Cooner RD.; Plast Reconstr Surg. 2009;124(1 Suppl.):69e–81e.
    3.    Propranolol for severe hemangiomas of infancy; Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, et al.;  N Engl J Med. 2008;358:2649–2651. (pdf)
    4.      Beta-blocking Agent for Treatment of Infantile Hemangioma; Bigorre M, Van Kien AK, Valette H. . Plast Reconstr Surg. 2009;123:195e–196e.
    5.      More on Propranolol for Hemangioma of Infancy; Siegfried EC, Keenan WJ, Al-Jureidini S. . N Engl J Med. 2008;359:2846–2847.
    6.       Ulcerated Hemangiomas of Infancy: Risk Factors and Management Strategies; eLiterature Review (John Hopkins Medicine) , Oct 2007, Vol 1, No 4; Bernard A. Cohen, MD, Susan Matra Rabizadeh, MD, MBA, Mark Lebwohl, MD, and Elizabeth Sloand, PhD, CRNP

    Tuesday, January 11, 2011

    Shout Outs

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

    FDAzilla blog is the host for this week’s Grand Rounds!   You can read this week’s edition here.
    When when I read the posts from this week’s grand rounds, I am astounded at how advanced, how intense, how personal, how vast, and also how amazingly complicated health care here in America is.  It’s so complicated that probably only the most astute health care observers will even understand every post below.
    As you read through the best posts from the medical blogosphere for the week, just think about how amazing all of this is -  health care leads to all kinds of misconceptions, frustrations, discoveries, inspiration, opportunities, tragedy, and humor. …………
    Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 5, No 14)! You can find the schedule and the COS archives at Emergiblog. (photo credit)
    Happy New Year!
    Welcome to the first 2011 edition of Change of Shift, the bi-weekly nursing blog carnival!
    Let’s get started!
    This is so the Editor’s Pick of the new year! The Muse, RN reminds us that there is …No “I” in “Team”, and believe me, it’s not what you think!!!  …..
    Need any good reading material?  Here are some suggestions from fellow bloggers:
    Dr. Marya Zilberberg, Heathcare, etc:  Radium, dopamine and innovation: Name your poison
    Reading Deborah Blum's "The Poisoner's Handbook" is an intellectual treat. Although non-fiction, it paints in understated sepia tones the crevices of New York City at the dawn of the Industrial Revolution, where bootlegged booze and poisons were fare of the day, homicides went unpunished and the corrupt coroner system basked in the glow of its own willful ignorance and political approval. ……..
    Fizzy, Mothers in Medicine:  Doctor chick lit?
    …….  I'm mildly embarrassed to admit it, but I LOVE chick lit. I don't know why, because I hate fashion and flowers and jewelry and everything else girly. But I love these books….. .
    ……..I recently discovered a list of the ultimate top 100 chick lit novels and noting that I've already read and enjoyed 7 of the top 10, I've decided to make it my mission for 2011 to work my way through the list. Come on, who's with me?
    Gizabeth Shyder, Methodical Madness:  Absence Makes the Heart Grow Fonder
    ……Yup, absence really does make the heart grow fonder. I missed the hell out of my kids last week and was glad to have four books (I recommend Little Bee by Chris Cleave, Inherent Vice by Thomas Pynchon, and Homer and Langley by E.L. Doctorow - and I won't mention the other because if you don't have anything nice to say don't say it, right???) to read at night and lots of work to keep me busy all week and weekend. ……
    A couple of funny posts of kids making up new words ---
    From Dino Doc:  Word of the Day
    From TBTAM:  The “B” Word
    A friend of mine was teaching her 4 year old daughter the nuances of feminine hygiene the other day. Here’s how it went down …….  
    I’ve received a few thank you notes from patients, but never as cool as this one Impacted ED Nurse received:  setting a new standard in thank you cards
    Via tweeter:  fnyc @precordialthump via @antidoped Cool way to practice or teach intraosseous cannulation
    Via tweeter @MedicalNews Down the Hatch and Straight Into Medical History
    …… But Dr. Chevalier Jackson went much further than most.
    A laryngologist who worked in the late 19th and early 20th centuries, he preserved more than 2,000 objects that people had swallowed or inhaled: nails and bolts, miniature binoculars, a radiator key, a child’s perfect-attendance pin, a medallion that says “Carry me for good luck.”
    Jackson retrieved these objects from people’s upper torsos, generally with little or no anesthesia. He was so intent on assembling his collection that he once refused to return a swallowed quarter, …….
    Threads has a nice tutorial article:  Weave a Celtic Knot (photo credit)
    One day while browsing in a fabric store, I came across an appealing piece of English trim made from charmeuse bias tubes laid out in a design reminiscent of interlaced Celtic patterns. I decided to use this technique to make embellishment pieces for cuffs, collars, and pockets starting with Celtic designs from clip art. It’s not that complicated, as long as you get your work mapped out initially. I will show you how.  …….

    Monday, January 10, 2011

    Surgical Safety Checklists

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

    Last week I received the December 2010 issue (pdf, pp 9 - 20) of the Arkansas BCBS Provider’s News. The item that caught my eye was: Blue Surgical Safety Checklist Implementation.
    If your hospital or surgery center is looking to implement the use of a surgical safety checklist, then this will be quite helpful.
    If you have missed it, the background of surgical safety checklist:
    In January of 2007 WHO began a program aimed at improving the safety of surgical care globally. The initiative, Safe Surgery Saves Lives, aims to identify minimum standards of surgical care that can be universally applied across countries and settings.
    …. Through a two-year process involving international input from surgeons, anesthesiologists, nurses, infectious disease specialists, epidemiologists,
    biomedical engineers, and quality improvement experts, as well as patients and patient safety groups, WHO created a surgical safety checklist that encompasses a simple set of safety standards that can be used in any surgical setting.
    ….. the checklist, which was officially launched on June 25, 2008, in Washington, D.C. Surgical safety is
    now a priority for health care safety and quality improvement.

    Recently, Stephen Colbert hosted Dr. Atul Gawande who attempted to explained how checklists make flying, surgery and Van Halen shows safer.
    From WHO:
    Integrated Management for Emergency and Essential Surgical Care (IMEESC) tool kit
    WHO Surgical Safety Checklist

    Friday, January 7, 2011


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

    This small art quilt was inspired by Movin Meat’s post:  Fearful Symmetry.  I took the EKG (photo credit), printed it out, enlarged a small segment and used it for the quilt. 
    The quilt was made as part of the ALQS5.  It is meant to be an art quilt.  The spikes of the EKG made me think of stalactites and stalagmites, of winter and cold.  I had a fat quarter of a gray blue fabric with trees which I used for the background.  I used a blue batik for the foreground. 
    It is machine appliqued and quilted using a multicolor metallic thread.  It is 8.5 in X 10.5 in.
    Here is a view of the back before I sewed on the label and sleeve.

    Thursday, January 6, 2011

    New MRSA Treatment Guidelines

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

    I learned of this thanks to a tweet from @OFPC:
    New #MRSA guidelines for the treatment of staph infections #medicine
    MRSA (methicillin-resistant staphylococcus aureus) infections continue to be a growing public health issue, both hospital-acquired and community-acquired.  These guidelines come from the Infectious Diseases Society of America (IDSA). 
    The article is a 38 page document (pdf file, full reference below); the last 10 pages are supporting references.
    The major performance measures are:
    1. The management of all MRSA infections should include identification, elimination and/or debridement of the primary source and other sites of infection when possible (eg, drainage of abscesses, removal of central venous catheters, and debridement
    of osteomyelitis).
    2. In patients with MRSA bacteremia, follow-up blood
    cultures 2–4 days after initial positive cultures and as needed thereafter are recommended to document clearance of bacteremia.
    3. To optimize serum trough concentrations in adult
    patients, vancomycin should be dosed according to actual body weight (15–20 mg/kg/dose every 8–12 h), not to exceed 2 g per dose. Trough monitoring is recommended to achieve target concentrations of 15–20 lg/mL in patients with serious MRSA infections and to ensure target concentrations in those who are morbidly obese, have renal dysfunction, or have
    fluctuating volumes of distribution. The efficacy and safety of targeting higher trough concentrations in children requires additional study but should be considered in those with severe sepsis or persistent bacteremia.
    4. When an alternative to vancomycin is being considered for use, in vitro susceptibility should be confirmed and documented in the medical record.
    5. For MSSA infections, a b-lactam antibiotic is the drug of choice in the absence of allergy.
    Their recommended management of skin and soft-tissue infections
    For a cutaneous abscess incision and drainage is the primary treatment.
    • For simple abscesses or boils, incision and drainage alone is likely to be adequate.  Simple boils most likely DON’T need antibiotics.
    Antibiotic therapy is recommended for abscesses associated with the following conditions:
    • severe or extensive disease (eg, involving multiple sites of infection)
    • rapid progression in presence of associated cellulitis
    • signs and symptoms of systemic illness
    • associated comorbidities or immunosuppression
    • extremes of age
    • abscess in an area difficult to drain (eg, face, hand, and genitalia)
    • associated septic phlebitis
    • lack of response to incision and drainage alone
    Antibiotic therapy for outpatients
    All antibiotic therapy should be individualized based on the patient’s clinical response.
    Patients with purulent cellulitis:  empirical therapy for CA-MRSA is recommended pending culture results.  Five to 10 days of therapy is recommended.
    Patients with nonpurulent cellulitis:  empirical therapy for infection due to b-hemolytic streptococci is recommended.  Empirical coverage for CA-MRSA is recommended in patients who do not respond to b-lactam therapy and may be considered in those with systemic toxicity. Five to 10 days of therapy is recommended.
    For empirical coverage of CA-MRSA in outpatients with SSTI, oral antibiotic options include the following:
    • clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX),
      a tetracycline (doxycycline or minocycline), and linezolid.
    If coverage for both b-hemolytic streptococci and CA-MRSA is desired, options include the following:
    • clindamycin alone or TMP-SMX or a tetracycline in combination with a b-lactam (eg, amoxicillin) or linezolid alone.
    Antibiotic therapy for hospitalized patients with complicated SSTI (cSSTI)  -- defined as patients with deeper soft-tissue infections, surgical/traumatic wound infection, major abscesses, cellulitis, and infected ulcers and burns).
    In addition to surgical debridement and broad-spectrum antibiotics, empirical therapy for MRSA should be considered pending culture data.  As with outpatients, all antibiotic therapy should be individualized based on the patient’s clinical response.
    Options include the following:
    • intravenous (IV) vancomycin, oral (PO) or IV linezolid 600 mg twice daily, daptomycin 4 mg/kg/dose IV once daily, telavancin 10 mg/kg/dose IV once daily, and clindamycin 600 mg IV or PO 3 times a day.
    • A b-lactam antibiotic (eg, cefazolin) may be considered in hospitalized patients with nonpurulent cellulitis with modification to MRSA-active therapy if there is no clinical response. Seven to 14 days of therapy is recommended.
    Pediatric considerations
    Children with minor skin infections (such as impetigo) and secondarily infected skin lesions (such as eczema, ulcers, or lacerations), mupirocin 2% topical ointment can be used.
    Patient education is the “heart” of preventing recurrence.
    Management of recurrent MRSA SSTIs
    Preventive educational messages on personal hygiene and appropriate wound care are recommended for all patients with SSTI.
    Instructions should be provided to:
    Keep draining wounds covered with clean, dry bandages.
    Maintain good personal hygiene with regular bathing and cleaning of hands with soap and water or an alcohol-based hand gel, particularly after touching infected skin or an item that has directly contacted a draining wound.
    Avoid reusing or sharing personal items (eg, disposable razors, linens, and towels) that have contacted infected skin.
    Environmental hygiene measures should be considered in patients with recurrent SSTI in the household or community
    Focus cleaning efforts on high-touch surfaces (ie, surfaces that come into frequent contact with people’s bare skin each day, such as counters, door knobs, bath tubs, and toilet seats) that may contact bare skin or uncovered infections.
    Commercially available cleaners or detergents appropriate for the surface being cleaned should be used according to label instructions for routine cleaning of surfaces.
    When decolonization is deemed appropriate (ie prior to elective surgery):
    Nasal decolonization with mupirocin twice daily for 5–10 days.
    Nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.)
    Screening cultures prior to decolonization are not
    routinely recommended if at least 1 of the prior infections was documented as due to MRSA.
    Surveillance cultures following a decolonization regimen are not routinely recommended in the absence of an active infection.
    Oral antimicrobial therapy is recommended for the treatment of active infection only and is not routinely recommended for decolonization.
    There is much more in the guidelines.  I have focused only on the skin and soft-tissue areas.
    Related posts:
    CAMRSA: Dx and Tx Update for Plastic Surgeons – an Article Review  (January 8, 2009)
    Revisit of Community Acquired MRSA--Prevention Tips (October 17, 2007)
    Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children; Catherine Liu, Arnold Bayer, Sara E. Cosgrove, Robert S. Daum, Scott K. Fridkin, Rachel J. Gorwitz, Sheldon L. Kaplan, Adolf W. Karchmer, Donald P. Levine, Barbara E. Murray, Michael J. Rybak, David A. Talan, and Henry F. Chambers; Clin Infect Dis. (2011) doi: 10.1093/cid/ciq146 First published online: January 4, 2011

    Wednesday, January 5, 2011

    Florida Liposuction Death?

    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 was going to wait until the autopsy came back to comment on this news article, but there are points to be made even now.
    First, it isn’t known if the death was due to liposuction. 
    This December 30th Palm Beach Post article gives the basics and that is all:   South Florida woman, 35, dies getting plastic surgery (bold highlights are mine).
    Lidvian Zelaya's New Year's resolution for 2011 was to "look good," so she went to Strax Rejuvenation Center in Lauderhill on Monday to have fat liposuctioned from her waist and added to her buttocks, her husband, Osvaldo Vargas, said.
    Three hours later, Vargas said, his wife was rushed to emergency facilities at a nearby medical center. When he arrived there, he was told she had died. She was 35. 
    Vargas and his attorney, Spencer Aronfeld of Coral Gables, said they were not sure what doctor performed the procedure nor whether the procedure had started when the medical problems began.
    It troubles me that the husband isn’t sure who performed the procedure.  It wasn’t a training hospital, but a private clinic (Strax Rejuvenation Center).  Perhaps it is reports like this one  and this one which has caused a loss of trust in physician integrity.
    It troubles me that the husband wasn’t sure the procedure had even started when the medical problems began.  As difficult as it would have been, didn’t Lidvian’s surgeon (reported elsewhere to have seen Dr. Roger L. Gordon in consultation)  sit down and talk with the family?
    He may not have done anything wrong.  It may turn out she had an allergic reaction to a medication or malignant hyperthermia or ….
    Or perhaps Dr. Gordon did talk to the family, but the grief stricken husband didn’t hear or process it.

    This also troubles me, as I know it will Dino Doc who has written on clearing patients for surgery.
    From the ABC News article on January 3, 2011:  Did Florida Woman's New Year's Resolution Costs Her Life?  Cosmetic Surgery Gone Wrong Has Family Wondering What Happened 
    According to the family, Zelaya was in perfect medical condition, and the clinic cleared her through a pre-operative screening. Now, the family is urging anyone considering cosmetic surgery to undergo a second, pre-surgical health evaluation by an independent primary care physician.
    "I think it's an inherent conflict of interest if you are getting screened by the surgeon who wants to do the procedure," said Aronfeld.
    Dino Doc that says a lot about why you are increasing asked to do pre-surgery clearances.

    Related posts:
    Know Your Surgeon (November 3, 2010)
    Liposuction – Shaping not Weight-loss  (February 8, 2010)
    Liposuction Overview  (October 6, 2010)
    Major and Lethal Complications of Liposuction -- An Article Review  (July 16, 2008)

    Tuesday, January 4, 2011

    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.

    Pizaazz is the host for this week’s Grand Rounds!   You can read this week’s edition here.
    Several key health care bowl games will be played in 2011. Their outcomes will affect the health and well-being of a hundred million Americans and help determine the timing of the nation’s inevitable economic double-dip. They’ll also help health insurance CEOs decide whether to re-decorate their offices with fur or linoleum, and who knows? They may even help Mrs. Farquhar find a PCP.  …………
    My first thought when I read Dr Rich’s title was in regards to HIPAA and privacy violations.   What about you?  Fugitive Busted By His Pacemaker (And His Doctor)
    In Durango, Florida the week before Christmas, the FBI arrested fugitives Roger Gamlin, 62, and his wife Peggy, 54 at Mercy Regional Medical Center after a doctor determined their real identities through Roger’s pacemaker.
    Wanted by the feds for 2 1/2 years on suspicion of embezzling millions of dollars from their south Florida title company, Roger and Peggy had been living quiet and unassuming lives as Ron and Nancy Jenner in Durango.  ….
    Via twitter and @kevinmd: Great read! NYTimes: The Doctor vs. the Computer
    Electronic medical records promise efficiency, safety and productivity in the switch from paper to computer. But there are glitches, as a patient of mine recently brought to light.  …….
    Estimating my patient’s surgical risk and planning for his operative care is not a straightforward process. After our physical exam, I sit down to write a detailed evaluation, because I want the surgeons and anesthesiologists to fully understand the complexity of his situation.
    As I type away, I feel like I’m doing the right thing, explicating my clinical reasoning rather than just plugging numbers into a formula. I’m midway into a sentence about kidney function when the computer abruptly halts……….
    The other side comes from db’s Medical Rants:  Resistance to change & electronic records
    The growing literature on electronic records seems dominated by those who resist change, that is the majority of people!  Most human beings dislike change.  We prefer our comfort zones, doing things like we have always done them.  …………..
    So I offer my first postulate – our current non-electronic medical records SUCK!!  ……………….
    My academic colleague, Dr. Danielle Ofri (NYU), wrote this piece for the NY Times – The Doctor vs. the Computer
    In it she tries to make the point that the new ways are not better.  Sorry, Danielle, but I disagree.  I remember trying to decipher other physician's handwriting.  …….
    I happen to think she was making the point that EMRs aren’t perfect and have limitations.  Those limitations need to be addressed.
    I endorse reading DB’s Rants post:  Change marijuana laws – even Pat Robertson agrees.
    I have written many times about this topic.  The rationale for criminal penalties for marijuana do not pass several tests.  First, this drug is much less harmful than alcohol.  …..  These laws are costing society dearly in financial terms and in general respect for the law.
    Pat Robertson understands – Pat Robertson's Christmas Present to Marijuana Legalizers – and he states the issue clearly ……….
    I love this article which @burndoc tweeted:  How music can heal: A burn unit in Cleveland uses music to manage pain.   I often tell patients to sing if I notice they are starting to hyperventilate.  It helps regulate their breathing and calms them down.  I think there is definitely something to this.
    A burn unit in Cleveland uses music to manage pain.
    This story was originally covered by PRI's Studio360. For more, listen to the audio above.
    After suffering extreme burns from a barbeque accident, Clifton Dobbs was taken to Cleveland MetroHealth Trauma Center for treatment. The burn unit at the center, run by Dr. Richard Fratianne, has been experimenting with music therapy to mitigate pain.   ………
    A feel good video:  Miracle Reunites Soldier and His Dog which notes the use of companion dogs as therapy for PTSD in returning soldiers.  The soldier refers to his dog as “Prozac with paws.”
    These photographs are amazing!  Via twitter and @Mtnmd “RT @hrana Pictures: "Vietnam's Mammoth Cavern" by National Geographic Magazine”
    What do you think of this -- Wall Street Bull Crocheted?  I actually like it, but can’t say the same for all of Olek’s work.
    NYC’s Crocheted Olek (a.k.a. Polish-born Agata Olek) hit up the Wall Street Bull and encapsulated it inside crocheted neon.