Flowers in Hands

Recently I removed some beaded flowers from an old Liz Claiborne sweater.  When thinking of how to use them, I recalled Picasso’s Flowers in Hand.   I partially copied/ partially free-handed the flower position, stems, and hands.

I machine stitched the hands and stems, then added the blue fabric border.  I did the machine quilting next, hand sewing on the beaded flowers after I had the binding done.

The quilt measures 15.75 in X 18 in.

Here you can see the beaded flowers and stitching.
Here is the back.

More on Implant-Related ALCL of the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

Last week @prsjournal tweeted

Pre-print Article: Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the B... http://bit.ly/o9lQ1f

The title definitely caught my eye.  I have finally read it and re-read it.
Here’s the abstract:

Implant-related primary anaplastic large cell lymphoma (ALCL) of the breast is a rare clinical entity. With increasing attention being paid to this disease, most cases reported to date in the literature have demonstrated indolent clinical courses responsive to explantation, capsulectomy, chemotherapy and/or radiotherapy.

We describe a case of bilateral implant-related primary ALCL of the breast that proved refractory to both standard and aggressive interventions, ultimately resulting in patient death secondary to disease progression. We situate this case in the context of the current state of knowledge regarding implant-related primary ALCL of the breast and suggest that this entity is generally, but not universally, indolent in nature.

The story of implant-related ALCL is far from being completely written.  This article notes (as did the recent FDA report) most investigations performed to date suggest an association between breast implants and primary ALCL of the breast.  The specifics regarding this relationship remain poorly defined.

A review of all reported cases of implant-related primary ALCL of the breast demonstrates no obvious correlation with implant fill type (silicone vs. saline), surface morphology (smooth vs. textured), implant position (subpectoral vs. subglandular), or indication for implant placement (cosmetic vs. reconstructive).

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.

Related posts:

More on Link Between Breast Implants and ALCL (April 25, 2011)

ALCL and Breast Implants – an article review (March 9, 2011)
ALCL and Breast Implants (January 31, 2011)
Breast Implants and Lymphoma Risk (June 29, 2009)


REFERENCE

Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the Breast: A Case Report and Review of the Literature; Carty, Matthew J.; Pribaz, Julian J.; Antin, Joseph H.; Volpicelli, Elgida R.; Toomey, Christiana E.; Farkash, Evan A.; Hochberg, Ephraim P.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 19 July 2011; doi: 10.1097/PRS.0b013e318221db96

Modification of Square Face

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

Recently an article in the Archives of Facial Plastic Surgery (full reference below) led to a Reuters news by Genevra Pittman:  Face too square? There's a surgery for that

The journal article is from China where the surgical procedure to modify a square face to a more oval face is done much more commonly than in the United States.  The Reuters article includes quotes from two U.S. surgeons:  Dr. Jeffrey Spiegel, chief of facial plastic and reconstructive surgery at the Boston University School of Medicine, and Dr. Ross Clevens, a cosmetic surgeon in Melbourne, Florida.

Spiegel states he does the procedure described in the Archives article two to four times each week.  Clevens states “he doesn't treat many male patients who want a more "feminine" face shape.”

Xiaoping Chen, MD, International Plastic and Cosmetic Center, China, and colleagues reviewed the procedure done for nineteen men with a square face (aged 22-30 years).  The time span of the cases was not given (ie 2001 to 2010) in the article.

The procedure involves an ostectomy with resection of the mandibular angle, splitting of the lateral cortex around the mandibular angle, and reduction of the width of the chin by an intraoral approach. (photo credit)

It sometimes was necessary to resect part of a hypertrophic masseter muscle. In addition, partial buccal fat pad removal was performed in patients with prominent cheeks. When the operation was completed, the wound was irrigated; a suction tube to allow drainage was then placed and maintained for 48 to 72 hours. The patient's lower face was lightly compressed with a dressing. Antibiotics were administered for 3 to 5 days, and the sutures were removed 7 days postoperatively.

In this series of 19 patients, there were no complications.  Complications that can occur include:  microgenia, facial asymmetry, hematoma, infection, or permanent mental nerve injury.

All patients developed edema in their lower face  (tx’d with corticosteroid therapy, 10 mg/d for 3 days) and varied amounts of difficulty in opening their mouth for 1 to 2 weeks.

Results can be as dramatic as the procedure needed to achieve them  (photo credit)


The Reuters news article states, “The procedure typically takes an hour or two, and costs up to $10,000, surgeons said.”



REFERENCE

Modification of Square Face in Men; Xiaoping Chen, Jinde Lin, Jie Lin, Jian Shen, Yudan Zhou, Xuan Wu, Yanwu Xu; Arch Facial Plast Surg. 2011;13(4):244-246.doi:10.1001/archfacial.2011.47

Shout Outs

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

Center for Advancing Health (CFAH), Prepared Patient Forum, is the host for this week’s Grand Rounds. You can read this week’s virtual tour edition here (photo credit).

Welcome to Better Health’s Grand Rounds Volume 7, Number 44!

This is our second time hosting Grand Rounds and we’re excited about sharing the posts we received.  The theme of this week’s collection came from a recent Health Affairs blog post by CFAH president, Jessie Gruman, Patient Advocates: Flies In The Ointment Of Evidence-Based Care, which addresses a few of the many challenges of basing health care practices, policies, and decisions on evidence of effectiveness. ……….

……………………………

Check out @globalsurgeon paper in July Bulletin of @AmCollSurgeons: Beyond Volunteerism – Augmenting Surgical Care in Resource Limited Settings (pdf file)

Surgical care was recently characterized as “the neglected stepchild of public health.” Critical storages of health care workers throughout the developing world have led to “calls to action” and have reinforced the need for safer surgery. …………..

……………………………….

H/T to @angryorthopod who tweeted “I liked this reminder from @drpullen for physicians and patients "Don't Trust Dr. Google." http://ow.ly/5Mud6”

I jokingly tell my patients that I am consulting with Dr. Google when I go online in the exam room to find information, but in fact I rarely use the Google search engine to access health care information. …….

When my daughter was in an entrepreneurship program at the University of Portland (e-scholars) I told her of my frustrations with having easy one click access to the best free online medical information I use in the office every day. Together we put up a web site called Exam Room Favorites that is designed to be an easy to use home page for physicians. ………….

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Dr. Rob Lamberts (@doc_rob) was recently a presenter in the CDC Public Health Grand Rounds:   Electronic Health Records: What’s in it for Everyone? (text and video)

Electronic health records (EHRs) allow for the systematic collection and management of patient health information in a form that can be shared across multiple health care settings. …….

This session of Public Health Grand Rounds explored the issues of EHR implementation with particular attention to public and population health while addressing concerns of cost, patient confidentiality, and other challenges. .…….

……………………………………………….

This is worth reading/listening to if you missed it on NPR yesterday:  'Twelve Breaths': Lessons From The End Of Life (photo credit)

When life draws to an end, family, caregivers and medical professionals face a flurry of often heartbreaking decisions. Are there any last treatments to try? How much longer can a patient hold on? When is it time to turn off the ventilator — and who gets to decide?  ………….

Lee Gutkin's essay collection, Twelve Breaths a Minute, captures the experiences of doctors, caregivers, family members, 911 dispatchers and others who have learned valuable lessons from witnessing life's final moments.  …………..

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H/T to @MtnMD who tweeted the link to this Huffington Post article: Humpback Whale Puts On Show For Men Who Saved Her (VIDEO)

When Michael Fishbach set out for his day of boating around the beautiful waters of the Sea of Cortez, he probably didn't think that it would be the day he and his friends would become wildlife heroes. As luck would have it, that's exactly what happened…….

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BYU exhibit features African-American quilts (photo credit) (Deseret News article by Carma Wadley):

Quilting has been part of American landscape for centuries, but each culture has taken the art form and made it its own.

The quilts you see in "From Heart to Hand: African American Quilts from the Montgomery Museum of Fine Arts" at the Brigham Young University Museum of Art are "very different from the quilts that many Utahns make," says Paul L. Anderson, MOA curator for the show. Yet, they have a folk-art quality, a homespun charm that makes them appealing, he says. …..

Should Langer’s Lines be Used for Incisions?

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

An old PRS journal article came to my attention recently thanks to a tweet by @prsjournal: “Most Emailed Article Langer's Lines: To Use or Not to Use: Thirty-six differently named guidelines have develope... http://bit.ly/mPR6v1”
[I’m not sure the time frame involved in the “most emailed.” Not sure if it’s for the day, the week, etc.] –
The tweeted article (first full reference below) is a short one and I would recommend it to young plastic surgeons and students.

A state of tension exists naturally in skin. For instance, wounded skin will gape, becoming elliptical instead of round. The first to notice this skin property was Dupuytren. In 1834, he encountered a corpse of a man who had stabbed himself with a round-tipped awl. Dupuytren noticed these stab wounds were elliptical instead of round. Then in 1838, Malgaigne wrote about the direction of these ellipses being different in different areas of the body. These two men did not drive home their point; Karl Langer, however, exhaustively studied the direction of these ellipses by stabbing a round-tipped awl into hundreds of cadavers. …….. but he is best remembered for his lines. ……….

In 1897, Kocher recognized the surgical importance of Langer's tension lines. He advised that surgical incisions follow these lines. However, Langer, an anatomy professor, did not intend for his lines to be used as guides for incisions. Later, Borges pointed out that Langer's lines represent lines of cleavage in cadavers and not lines of relaxed tension……….

Langer's lines are quite different from the relaxed skin tension lines of the face. These lines were described by Borges in 1962,and they are probably the most-accepted guide for incisions of the face………..

Langer's lines are almost perpendicular to Borges's relaxed skin tension lines in the areas of the scalp, forehead, glabella, midcheek, and lateral eye…………….

Cornelius Kraissl maintained that scars were least conspicuous when placed in wrinkle lines. … Kraissl recognized that wrinkles occurred perpendicular to muscle action. From this, he developed a scheme for elective incisions. However, these incisions might not be inconspicuous in patients without wrinkles or with ill-defined wrinkles. Also, wrinkle lines do not always coincide with Borges's relaxed skin tension lines. Hence, Borges's lines are the best guide for elective incisions of the face. …………….

Developed from cadavers with extremities in extension, Langer's lines are longitudinal over joints. Blocker and Hendrix recognized that Langer's longitudinal lines predisposed patients to contractures when they were used over joints. Oriented perpendicular to muscle action, Kraissl's lines have a more transverse orientation than Langer's. Accordingly, Kraissl's transverse lines of the upper extremity do not predispose patients to contracture formation. ……….

Many other factors contribute to the camouflaging of scars, including wrinkle and contour lines. Learn how to assess the direction of least tension on the wound and orient the closure accordingly.

Borges's and Kraissl's lines are better guides for elective incisions in the face and body, respectively, than Langer’s lines. Remember, they are only guidelines. (photo scanned in from 2nd reference article)

REFERENCE

1. Langer's Lines: To Use or Not to Use; Wilhelmi, Bradon J.; Blackwell, Steven J.; Phillips, Linda G.; Plastic & Reconstructive Surgery. 104(1):208-214, July 1999

2. The Selection of Appropriate Lines for Elective Surgical Incisions; Kraissl, Cornelius J; Plastic & Reconstructive Surgery. 8(1):1-28, July 1951.

3. Relaxed Skin Tension Lines (RSTL) versus Other Skin Lines; Borges, Albert F.; Plastic & Reconstructive Surgery. 73(1):144-150, January 1984.

More Fabric Postcards

Last weekend I went on a fabric postcard making spree!  These have been sent to friends/family I think will appreciate them as birthday cards.

This first one is going to a friend who loves purple (background fabric) and loves to photograph feet (bare, in sandals, etc).   It is 5 in X 7 in.

This one is going to a friend whom I’ve known since grade school.  It is 3.5 in X 5 in.
and this is the back! 
This one is going to a nephew-in-law who is an artist (photography and painting).  The background fabric is black linen with “fussy-cut” Batik figures machine appliqued with gold metallic thread.  It is 5 in X 7 in.
Here is the black of it.
This one is for another friend whom I’ve known since elementary school.  She too is an artist (photography, graphic arts).  Not counting the quarter inch fringe, it is 5 in X 9 in.
Here is the back of it.

Comfort Tactile Quilt

This quilt is made of denim shirts and jeans, a cotton flannel shirt, and a silk flannel shirt.  There are seven working pockets on the quilt.  A couple of them from the jeans have the rivets.  The ones from the shirts still have their buttons.  These things add to the tactile feel of the quilt which is important as I made this quilt for a new friend/colleague who is blind due to retinitis pigmentosa.

The quilt is machine pieced and quilted.  It is 45 in X 55 in.

The next few photos show some of the pockets.


The back is a simple blue cotton.

Barbers of Civility

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

It seems to me this topic of surgeon and their lack of civility gets pulled out ever on a fairly regular basis.  This latest discussion in the news media is due to a short article in the current Archives of Surgery (full reference below).

Surgeons as a group have a reputation (which even nice ones have trouble overcoming) of arrogance and incivility. 

The authors, Klein and Forni, of this article state (bold emphasis is mine):

Uncivil behavior is so present in society at large that we should not be surprised to find it among health care workers. This article is meant to raise the awareness of the costs—both in dollars and in human misery—of incivility in the practice of medicine by looking in particular at the case of surgeons.

Uncivil behavior brings misery wherever it occurs.  If the individual tends to behave in an uncivil fashion prior to medical school and prior to residency, then that individual is likely to behave in an uncivil behavior in practice.  Medical school and residency aren’t “finishing schools” in that regard.

Medical schools seem to have become aware of this simple fact.  Recent news articles report some medical schools will begin interviewing for “people skills” in their applicants --  NY Times article by Gardiner Harris: New for Aspiring Doctors, the People Skills Test.

I applaud Klein and Forni for their suggestions that surgeons lead the civility imitative in health care: 

The surgical community has an incredible opportunity to lead a civility initiative in health care. The first step is to recognize the power that civility has to improve the surgical workplace, the patient outcomes, and the workers' quality of life. Organizations should commit to developing a universal code of conduct that is identical for surgeons, nurses, staff, administrators, and patients. This code must have clearly defined expectations as well as consequences for violations. More important, the code should be applied fairly and consistently, without modification or special allowances based on an individual's actual or perceived status in the group.  ………

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”   --Maya Angelou
……….
My past article on the topic
Behavior of Surgeons  (July 24, 2008)
A Surgeon's Outburst  (August 13, 2008)
Consultations  (May 24, 2010)
Tips on Dealing with Difficult Colleagues (May 9, 2011)



REFERENCE
Barbers of Civility; Andrew S. Klein; Pier M. Forni; Arch Surg. 2011;146(7):774-777; doi:10.1001/archsurg.2011.150

Recalling My Episode of Bell’s Palsy

Yesterday I received a call from one of my high school teachers who I remain in touch with.  She wanted to ask me about my Bell’s Palsy as she now has a friend who has been diagnosed with it. 

Nine years ago today I diagnosed my Bell’s Palsy.  I still recall that summer day well.  It was a Saturday.  A beautiful sunny summer day.

I was home alone with my dogs (Columbo, Girlfriend, and Ladybug) as my husband was working out of town.  I was on ER call.  I had had a horrible headache the past few days with severe pain in my right ear.

I can recall noticing my face in the bathroom mirror mid-morning and thinking my mouth didn’t look quite right.  I ignored it.  Later that day as the ascending paralysis of Bell’s Palsy progressed, I would not be able to ignore it.

As far as the world can see now, all my facial function returned.  There are some very minor things that still bug me – the teeth on the right side of my mouth are very sensitive (I use Senodyne toothpaste which helps but find I avoid professional cleaning on a regular basis).  Sometimes the right facial muscles feel tight so I will try to discretely massage them.  When I am really tired, my right eye gets an odd “itching” sensation.

One of these days I want to do a self-portrait quilt (ala Picasso) that reflects my face (or my perception of it) during the Bell’s Palsy episode.

I disliked speaking during the weeks when my mouth didn’t work.  I never drooled but  the poor control over the right side of my mouth made some words difficult to pronounce (plosive constant's need a good lip seal).  It seemed to me that people had more trouble understanding me over the phone than in person. 

My friend’s phone call brought it all back so very clearly.

Check out this essay:  HOW CRUEL TO CALL IT 'BELL'S PALSY!' By Graeme Garden

Shout Outs

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

Dr. Elaine Schattner, Medical Lessons, is the host for this week’s Grand Rounds. You can read this week’s virtual tour edition here (photo credit).

Live, from New York, it’s med-​​blog Grand Rounds, volume 7, number 43!

As I’m staying home for the summer, I’ve asked bloggers to share images of where they’re from, or where they go, so we could take a virtual tour together:

We’ll start with a post from the Wash­ington, DC-​​based Pre­pared Patient Forum, where Jessie Gruman clar­ifies that Engagement Does Not Mean Com­pliance. As Jessie says, “I am com­pliant if I do what my doctor tells me to do. I am engaged, on the other hand, when I actively par­tic­ipate in the process of solving my health problems.”  ……….

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Peggy, TBTAM, has a great post on How to Save Money on Birth Control (photo credit)

If you live in New Hampshire, or some other state that is withdrawing Planned Parenthood funding, you may need to find an alternate source of affordable birth control, at least until the states get their heads screwed back on straight. In the meantime, please, don’t stop your birth control because you think you can’t afford it - the costs of not using it are much, much higher…………

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H/T to @KaveyF for this tweet “Good god! RT @52Betty: Wow, this gallery of past tampon ads is fascinating...the one with the dangling fish....really?? http://is.gd/EHrNht?”

And, yes, I’m old enough to have used sanitary belts.  (photo credit)

………………………….

Robert W. West, Jr., PhD wrote an guest blog post for KevinMD:  Female physicians on Twitter

I delivered a keynote presentation a few weeks ago entitled “Personalized Medicine: Tailoring Healthcare in the Information Age” to a group of parents who had taken their kids to the Bristol-Myers Squibb Science Horizons summer science camp. ………….

That said, below is a list of female docs who are currently engaged in social media, at least via Twitter, and in many instances, through other social media channels, including blogs. In each case their respective Twitter handle is provided for easy reference (often, additional information, such as a blog link, can be obtained by visiting the respective Twitter page).  …...  The order shown provides no indication of either personal or professional qualification.…….

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H/T to @masseyeandear for the link to EyeWorld Mobi’s interview of Dr. Claes Dohlman by Dr. Bonnie An Henderson:  CATARACT -- Innovations and advice from Claes Dohlman, M.D. (photo credit)

This month's cover feature is on femtosecond laser refractive cataract surgery. This new technology has the potential of dramatically changing the manner in which cataract surgery is performed. How are such innovative ideas developed? Many ophthalmologists may have a new idea for an instrument but do not know how to pursue the idea. I interviewed Claes Dohlman, M.D., professor of ophthalmology, Harvard Medical School, and chair emeritus, Massachusetts Eye and Ear Infirmary, Boston, who pioneered numerous innovations in cataract and corneal surgery, including a well-functioning keratoprosthesis. He shared some advice on how to take an idea and develop it into a product. . …..

……………………………………….

An article in the July edition of Plastic Surgery Practice outlines the smart phone apps related to plastic surgery:  There Are a Lot of Apps for That (by Wendy Lewis)

Apps rule the world of smartphones, and the world of plastic surgery has certainly taken notice and jumped on this trend. ……

Most of the apps designed for consumers range from free to $1.99 to download to an iPhone, iPod Touch, or iPad, but some tools designed for surgeons may run into the hundreds of dollars.   ……….

This growing category of apps gives prospective aesthetic patients a lot of information. One might argue that some of these apps give patients too much information, such as the ability to digitally morph photos of their faces and bodies into a desired state of perfection that may not be physically possible even using a scalpel or syringe.

Now, in no particular order .…..

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Chimecco Kinetic Sculpture (photo credit)

Chimecco is an interactive instrument and kinetic sculpture by artist, architect, and designer Mark Nixon, which was recently exhibited at Sculpture by the Sea in Aarhus Denmark …..

2-Stage Ear Reconstruction – an Article Review

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

There is a nice article on a 2-stage ear reconstruction for microtia (full reference below) in the current issue (May/June 2011) of the Archives of Facial Plastic  Surgery journal.

I am in awe of the surgeons who can carve the 3-dimensional cartilage framework fabricated in the first stage.  This is not something I mastered but continue to read to learn (while referring this patients to others).

In the article, Yanyong Zhao, MD  and colleagues describe the 2-stage procedure they used to reconstruct the ears of 68 patients (ages ranged from 5 to 17 years).  The surgeries were done  between January 1, 2006, to December 31, 2008. Forty-eight patients were boys, and 20 were girls. Unilateral microtia was present in 66 patients and bilateral microtia was present in 2 patients.

The authors clearly describe the procedure and have added nice photos such as this one to make it even more clear (photo credit).

The first stage involves elevating the skin flap and retroauricular fascial flap in the mastoid area, then the cartilage framework is wrapped by the fascial flap from behind and covered by the skin flap from front.

In the second stage the crus, the tragus, and the conchal cavity are reconstructed. So almost all of the fine structures of ear are reconstructed.

Here is one of the photos which shows their results (photo credit)

The article is worth reading, especially for students and residents.  Even experienced surgeons may find it useful.

REFERENCE

Original Article A 2-Stage Ear Reconstruction for Microtia; Haiyue Jiang, Bo Pan, Yanyong Zhao, Lin Lin, Lei Liu, Hongxing Zhuang; Arch Facial Plast Surg. 2011;13(3):162-166; doi:10.1001/archfacial.2011.30

My WIP -- Learning About Color in Quilting

I bought a kit to make a color wheel years ago (1993), but never made it as I knew for me the tight points would be an issue.  I decided it was time to tackle it.  I did better with the points than I would have then, but still am not perfectly happy.  The problem is the seams are wider than the points which makes it difficult and then there is the problem of pressing said seams.

Anyway, here it is.  I have finished piecing it (machine and hand), but have not decided how I want to quilt it.

With some of the left-over fabric, I planned and pieced this which I call my Ohio Star color wheel.

Color wheels are used to help learn color theory.  My color wheel kit was designed by Susan McKelvy (author of Color for Quilters.
From the insert which came with my color wheel kit:
Color terms illustrated in the color wheel

Pure Colors:  The color wheel is made up of pure colors (the truest and brightest versions of each color).  This wheel is made up of twelve pure colors.

Light-Dark Contrast (Value):  There are many values of each color from light to dark.  Three are included in this wheel – a light value (tint), the pure color, and a dark value (shade).

Warm-Cool Contrast:  Colors have warmth.  On this wheel, the cool colors (greens and blues of the sky and sea) are on the left and the warm colors (the yellows, oranges, and reds of fire and the the sun) are on the right.

Analogous Colors:  Any colors next to each other on the wheel are analogous.

Complementary Contrast:  Every color has a complement – the color directly opposite it on the wheel.

Colors look different on different backgrounds.

…………….
The twelve colors in my color wheel are
The 3 primary colors:   Red, yellow and blue

In traditional color theory, these are the 3 pigment colors that can not be mixed or formed by any combination of other colors. All other colors are derived from these 3 hues

The 3 secondary colors:  Green (yellow and blue), orange (yellow and red) and purple (red and blue)

These are the colors formed by mixing the primary colors.

The 6 tertiary colors:  Yellow-orange, red-orange, red-purple, blue-purple, blue-green and yellow-green.

These are the colors formed by mixing a primary and a secondary color. That's why the hue is a two word name, such as blue-green, red-violet, and yellow-orange.

Guidelines for Injector in Aesthetic Medicine

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

There is a great article in the “throw-away” MedEsthetics magazine (July/August 2011 issue) written by Padriac B. Deighan, MBA, JD, PhD.  You can read the entire article here (pp 16-20; online issue).   If you employ any practice extenders in your office or run a medical day spa, you will find the article useful.

Deighan categorizes injectables in three ways:  botulinum toxins, dermal fillers, and sclerotherapy.

Botulinum toxins are prescription only drugs which are available to physician offices and via pharmacies, but not directly to non-physicians.  In other words, a registered nurse can inject neurotoxins under physician supervision, but cannot acquire them.

Botulinum toxin injection is considered a medical procedure which should only be provided in a medical setting by a trained and licensed provider (ie physician, registered nurse, nurse practitioner or physician assistant). 

Deighan notes that a medical spa is a medical setting ONLY if it is owned by a physician.  He recommends against Botox parties in patient’s homes, even though a physician can legally provide this service in that setting.

……

Injectable dermal fillers are not prescription drugs, but are medical devices

As such, they are delivered pursuant to the practice of medicine and all state and federal guidelines.  This is a distinction without difference because, although they are not prescriptive, medical devices – as categorized by the United States Food and Drug Administration (FDA) – can only be utilized in a medical facility and delivered to patients by an appropriate medical provider.

Non-medical day spas or even medical day spas without physician supervision should not be injecting dermal fillers.

……

Moving on to sclerotherapy used most commonly to treat leg veins but also other areas.  Sclerotherapy is the introduction of a foreign substance into the lumen of the vein to cause thrombosis and subsequent fibrosis.  The injected solution falls into three types:  Chemical Irritants (glycerin, polyiodinated Iodine), Hypertonic solutions (Hypertonic-saline 11.7%, Hypertonic-glucose), and Detergent sclerosants (Sodium morrhuate, Sodium tetradecyl sulfate, 0.25% -3%, Ethanolamine oleate, and Polidocanol foam, 0.5-5% ).

Deighan states that saline is not considered a medical device or product, but the others are and therefore are subject to medical practice guidelines for the particular state and must be delivered in a medical setting.

…….

Please go read the article for his take  on CMAs (certified medical assistants) and cosmetic medical procedures.  Here’s part of it:

Recently, many CMAs have wrongfully asserted that they are allowed to inject and, therefore, have been injecting botulinum toxins, dermal fillers and sclerosants.  CMAs are marginally trained, non-medical personnel………

It will also be a huge problem in any professional negligence claim, because there will be no coverage for such a loss.  An insurance carrier will not provide a defense or indemnity for any claim related to these procedures. …….

He extends this same stand to “certified” technicians. 

For example, some “certified laser technicians” and their employers incorrectly believe that the designation “certified” elevated their stature and allows them to perform medical services.  Certified Laser Technician, Certified Medical Esthetician, and Medical Esthetician are not categories of medical providers. ……..

Related posts:

Medical Spa Regulations (March 26, 2009)

Medical Lasers and the Law (March 25, 2009)

Sunscreen Graphics

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

Information is Beautiful has a superb post:  The Sunscreen Smokescreen meant to answer the question “How much sunscreen should you wear?”

The full graphic can be found here.  It begins by explaining UVA and UVB rays, goes on to explain SPF (UVA protection) and the star rating (UVB protection),  and protection times avoided by sunscreen.

I cropped out the middle section which is specific to the amount of sunscreen which should be used and how often it should be reapplied.  Not many (if any) of use use enough or reapply often enough.

The lower portion of the Information is Beautiful graph gives info on how cloud cover, reflective surfaces (snow, lakes, etc), and altitude affects the amount of  UVA/UVB radiation.  There is a section on skin cancers and one on the possible harmful effects of sunscreens.

Related posts:

Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)
Skin Cancer (March 24, 2010)
Safety of Sunscreens (June 14, 2010)
Dear 16-Year-Old Me (May 18, 2011)

New FDA Sunscreen Labeling  (June 15, 2011)

Shout Outs

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

Hank Stern, Insure Blog, is the host for this week’s Grand Rounds. You can read the “It’s Up to Us” edition here (photo credit).

Our theme this week is "Personal Responsibility" - only posts that address this issue have been included. I was quite impressed with the creativity that potential contributors brought to the table to make sure their posts fit the bill.

We like outside-the-bun thinkers.

The concept of personal responsibility (or accountability, if you prefer) has been a consistent meme here at IB since our earliest days some 6+ years ago. So it seemed appropriate to use that as the theme for this edition of the venerable Grand Rounds:  ……….

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It’s been very hot here in Arkansas lately.  Here is a great sheet put together and tweeted by the Arkansas Children’s Hosp (@archildrens): “This handy sheet on kids and heat illness is a good primer. Put it on the fridge or leave for a babysitter”

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A NY Times article by Andrew Revkin:  On Strokes and (Personal) Sustainability (photo credit)

I have a long list of backlogged posts but am taking a brief break from tracking global sustainability to check my personal operating systems.* A stroke will do that to you.

I summarized one moral of the story below in this Tweet:

Don’t stress your carotid arteries if you like your brain & the things it does for you.

There are other lessons here, one being that stroke is not restricted to what you might call “the usual suspects.” Here’s what happened. …..

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H/T to @EllenRichter for the link to the NY Times article by  @theresabrown:  When Nurses Make Mistakes 

This year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt’s death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child’s death days later. ….

This story makes me feel sick — sick for that dead baby and her parents, and sick for Kim, who must have felt so alone with her pain.

It’s a pain that I, and every nurse and doctor, can relate to on some level. We’ve all made mistakes, most of them small and inconsequential to the patient’s health, but sometimes the mistakes are serious……….

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H/T to @hrana for the link to the Columbia Journalism Review article by Trudy Lieberman: Keeping an Eye on Patient Safety, Part III

Slowly the public is coming to realize that hospitals are not always safe places. …. The series is archived here.

I have just returned from England, where as a Fulbright Senior Specialist I attended a conference of European health journos and participated in meetings with health care academics and government officials. …. At the NHS Institute for Innovation and Improvement I learned about some pretty cool stuff that has found its way into UK hospitals and improved care for patients. ….

One practice that intrigued me was a way to cut down on errors made by nurses when they give patients their meds. Taylor told me that medication errors are a problem in the UK as they are in the US. Any reporter who has spent time examining hospital or nursing home inspection reports knows how frequent they are. Taylor explained that nurses administering medications too often are interrupted, causing them to lose focus and increasing the chance for a deadly mistake. To solve this problem nurses started wearing red pinafores over their uniforms when they gave patients their medicines. That signaled to others not to bother them. “It’s so simple,” said Taylor…….

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H/T to @sterileeye who tweeted the link to this “beautiful photo project about aging”:  Timeless Memories (photo credit)

A personal journey to find the oldest person in the city of Barcelona.  After weeks of taking photos I thought the search was over after meeting Matilde who is 101. However, the next day I visited another retirement home and after taking a couple of photos I was ready to leave when one of the care takers told me ¨There is a person you should meet before you go, her name is Ana Maria, she is 108 years old and will be 109 in July¨…

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An interesting Star Tribune article (H/T @garyschwitzer)  by Michael Nesset: Masterpieces, but only if unmedicated

We could diagnose and heal the human frailties found in literature. But why?

Not long ago, members of my American lit survey class decided that the disturbing behaviors of Herman Melville's Bartleby the Scrivener -- staring out the window at a blank brick wall, preferring not to do pretty much whatever he's asked to do -- were symptoms of clinical depression.

Paxil or Prozac, along with some good counseling, maybe group therapy to help with his peer interactions, was what the poor fellow needed. …..

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Justine Abbitt, BurdaStyle blog, has written a nice article: Madeleine Vionnet and the Bias Cut  (photo credit)

Madeleine Vionnet was a revolutionary designer for her time; not as universally well known as Coco Chanel but just as influential to the world of fashion. She is credited with creating the bias cut, a technique of cutting on the diagonal grain of the fabric which creates a sinuous and slightly clingy silhouette. The designer regularly had fabric custom made for her as wide as 180 inches to cut her dresses from. …..

If you want to read more on Madeleine Vionnet and her influence in fashion, Betty Kirke wrote a wonderfully comprehensive article for Threads magazine which you can check out here.

Laser Treatment of Stretch Marks – an Article Review

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

Stretch marks (striae distensae) are common.  They represent linear dermal scars accompanied by epidermal atrophy.  Stretch marks aren’t a significant medical problem, but can be a source of significant emotional distress.

There are many treatments available, ranging from therapy applied to the skin, laser therapy, and even more invasive surgical methods. Unfortunately, stretch marks remain a tricky problem to target, in which no established treatment exists.

A recent article in the  May issue of the Aesthetic Surgery Journal (full reference below) discusses the use of fractional nonablative laser treatment for stretch marks.

Dr. Francesca de Angelis and colleagues conducted a clinical study involving 51 patients with striae, three male and 48 female,  who were treated between May 2007 to May 2008.  Several patients had striae on multiple areas of the body so a total of 79 striae locations were treated.  

Patient ages ranged from 13 to 56 years (mean, 33 years). Fitzpatrick skin type ranged from II to IV. The duration of striae ranged from one to 40 years, with an average duration of 12 years. The striae formed as a result of pubertal growth (41%, n = 21), pregnancy (31%, n = 16), weight change (20%, n = 10), muscular atrophy (2%, n = one ), or unknown causes (6%, n = three).

Anatomical locations for treatment included the hips, breasts, abdomen, flanks, knees, buttocks, arms, thighs, and shoulders, with the majority of treatments occurring on the first three sites.

The stated objective of this study was to determine whether the 1540-nm Er:Glass laser could safely and effectively improve the appearance of both striae rubra and alba while minimizing the risk of PIH.

The laser used in this study, the fractional nonablative 1540-nm erbium:glass (Er:Glass) laser (Lux1540; Palomar Medical Technologies, Inc., Burlington, Massachusetts), is currently the only fractional laser approved by the US Food and Drug Administration to treat striae.

Treatment parameters included two to three passes with the 1540-nm laser, with energy settings from 35 to 55 mJ/mb with the 10-mm optical tip or 12 to 14 mJ/mb with the 15-mm optical tip. Two to four total treatments were performed at four- to six-week intervals.

Patients were given a pretreatment regimen which consisted of applying a compound of 1% hydrocortisone, 4% hydroquinone cream, and 3% vitamin C to their striae for 30 days prior to treatment.

After treatment, patients were instructed to apply moisturizing cream multiple times per day to maintain hydration of the skin and to help reduce erythema. All patients were also instructed to apply the same pretreatment topical compound to their treated striae every day for three to six months after their final treatment.

Both nonblinded and blinded reviewers evaluated the percent improvement after treatment on a 0% to 100% quartile scale.

Skin reactions were assessed by the treating physician and recorded at multiple time points, and histology was conducted with hemotoxylin and eosin as well as Orcein-Giemsa staining.

The researchers report

H&E staining of pretreatment tissue samples revealed an atrophied epidermis and flattened rete ridges within the papillary dermis. No intact collagen fibers were identifiable in the striae before treatment, and the degenerated appearance of the fibers resulted in uneven staining as well as indistinct borders.

In contrast, following three 1540-nm treatments with the 10-mm tip at 40 mJ and 10-ms pulse width, significant neocollagenesis was observed. Elastic fibers in the reticular dermis appeared sparse and fragmented prior to the 1540-nm treatment.

One month after the third treatment, elastic fibers were uniformly increased in number throughout the reticular dermis.

My biggest problem with this study is how do the researchers know the laser was the source of improvement rather than their pre- and post-treatment topical skin care.  Why not do a comparison of areas treated with the topicals verse the topicals and laser? 

The photos included did show some improvement, but …. (photo source, the article)

 


REFERENCE

Fractional Nonablative 1540-nm Laser Treatment of Striae Distensae in Fitzpatrick Skin Types II to IV: Clinical and Histological Results;  F de Angelis, L Kolesnikova, F Renato, G Liguori; Aesthetic Surgery Journal May 2011 31: 411-419, doi:10.1177/1090820X11402493

Montage Baby Quilt

The inspiration for this baby quilt was a Facebook friend photo montage.  Different size photos were placed together in the montage.  I sketched out the measurements and then went through my fabrics.  This is the result.

The quilt is machine pieced and quilted.  It measures 39 in square.

These next few photos allow you to see the fabrics better.  Here the baby/child will be able to find dogs, a donkey, horses, zebras, and a tiger.
This section contains sunflowers, a turtle, a butterfly, more of the horse/zebra fabrics, and a peacock feather.
This section contains bees, a boy and his dog, a cow, and more zebras.

The baby is a lovely yellow and white cotton.  The label has a monkey.

 

It has been given to a friend and his wife.

Lawn Mower Safety

The power lawn mower is considered one of the most dangerous tools around the home. Each year, more than 74,000 small children, adolescents and adults are injured by rotary, hand and riding power mowers due to improper handling.

Lawn mower injuries include deep cuts, loss of fingers and toes, broken and dislocated bones, burns, and eye and other injuries. Some injuries are very serious. Both users of mowers and those who are nearby can be hurt.

The kinetic energy (motion) imparted by a standard rotary blade is comparable to the energy generated by dropping a 21-pound weight from a height of 100 feet or is equal to three times the muzzle energy of a .357 Magnum pistol. Blade speed can eject a piece of wire or an object at speeds up to 100 miles per hour.

The most commonly injured person is an adult 25-64 (those most often doing the mowing) or a child under age five. About a fourth of all lawnmower injuries (22%) involve the wrist, hand or finger. About 14% involve foot, ankle or toes. Of all the hand and foot injuries, about 25% will result in amputation.

Safety Tips

• As with other power tools and equipment, do not operate a lawn mower when consuming alcohol.
• Wear appropriate clothing: sturdy shoe, not sandal; eye and hearing protection.
• Children should be at least 12-years-old before they operate any lawn mower, and at least 16 years old for a ride-on mower.
• Children should never be passengers on ride-on mowers.
• Young children should be at a safe distance from the area you are mowing.
• Pick up stones, toys and debris from the lawn to prevent injuries from flying objects.
• Use a mower with a control that stops it from moving forward if the handle is released.
• Never pull backward or mow in reverse unless absolutely necessary - carefully look for others behind you when you do.
• Start and refuel mowers outdoors - not in a garage. Refuel with the motor turned off and cool.
• Blade settings should be set by an adult only.
• Wait for blades to stop completely before removing the grass catcher, unclogging the discharge chute, or crossing gravel roads. (As a safety feature, some newer models have a blade/brake clutch that stops the blade each time the operator releases the handle.)

To help educate the public and prevent injuries, the American Society for Reconstructive Microsurgery (ASRM), American Society of Plastic Surgeons (ASPS), and American Society of Maxillofacial Surgeons (ASMS) offer a video, “When Lawn Mowers Attack,” with tips on how to avoid injuries

 

 

REFERENCES

U.S. Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS) Online.

Lawn Mower Safety; American Academy of Pediatrics

Keep Your Hands Safe: Follow Lawnmower Safety Tips; American Society for Surgery of the Hand

Lawn mower-related injuries to children; J Trauma. 2005; 59(3):724-8; Abstract

Is Personalizing Mammogram Screening the Way to Go?

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

I read the LA Times article by Shari Roan, Study urges more individual mammogram guidelines, with interest.  As Roan notes, guidelines to date have mainly focused on a woman’s age and not her other risks factors.

The American Cancer Society recommends that healthy women undergo screening mammograms every one to two years beginning at age 40 regardless of risk factors. In 2009, the U.S. Preventive Services Task Force recommended a different schedule which urged the inclusion of an individual’s personal risks:  screening for women ages 40 to 49 should be based on individual risk factors and women ages 50 to 74 should be screened every two years.

Monday, a paper was published in the Annals of Internal Medicine (full reference below) which argues for a more personalized approach to screening mammograms.

The study by Dr. Steven R. Cummings, senior author and senior researcher at the California Pacific Medical Center Research Institute, and colleagues was based on a computer model comparing the lifetime costs and health benefits for women who got mammograms every year, every two years, every three to four years or never.

The researchers concluded that “Annual mammography was not cost-effective for any group, regardless of age or breast density.”

They also note that “Mammography is expensive if the disutility of false-positive mammography results and the costs of detecting nonprogressive and nonlethal invasive cancer are considered.”

I find it interesting that the major limitation of the paper noted by it’s authors is that the results are not applicable to carriers of BRCA1 or BRCA2 mutations.   This is a group of women who has a major risk factor for developing breast cancer, yet “personalization” of screening mammograms might not work for them.  Why not?  Might not personalization for this group involve more frequent rather than fewer mammograms?

I personally like the idea of individualizing the screening schedule, rather than one-size fits all.  It is why I have embraced the U.S. Preventive Services Task Force recommendations. 

Related posts:
New Breast Cancer Screening Guidelines (November 17, 2009)
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision (December 15, 2010)

REFERENCES

1.  Personalizing Mammography by Breast Density and Other Risk Factors for Breast Cancer: Analysis of Health Benefits and Cost-Effectiveness; John T. Schousboe, Karla Kerlikowske, Andrew Loh, and Steven R. Cummings; Ann Intern Med July 5, 2011 155:10-20

2.  To Screen or Not to Screen Women in Their 40s for Breast Cancer: Is Personalized Risk-Based Screening the Answer? (Editorial); Jeanne S. Mandelblatt, Natasha Stout, and Amy Trentham-Dietz; Ann Intern Med July 5, 2011 155:58-60

Shout Outs

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

Doctor Fizzy is the host for this week’s Grand Rounds. You can read this week’s edition here (photo credit).

I attended my very first grand rounds as a third year med student. The talk was given by my former pathology professor to a large auditorium packed with students, residents, fellows, and attendings. I don't remember the topic of the lecture, but I do remember this:
Midway through the lecture, the professor called on me. In an hour-long lecture, he called on one person out of 200 in the audience, and somehow that person was me. I almost choked on my cinnamon-raisin bagel.   ……..

All in all, not my favorite grand rounds.

But this week's grand rounds are going to be awesome. I'm dedicating it to all the medical trainees that got humilated during lectures, pimped during rounds, or tried to answer three beeping pagers at once.  ……….

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H/T to @medrants who twitted  “Practicing Medicine Can Be Grimm Work - http://nyti.ms/kveFkD -  a beautiful op-ed from one of our med students”  

The NY Times Op-Ed piece is by Valerie Gribben:  Practicing Medicine Can Be Grimm Work

TODAY, after four arduous years of examinations, graduating medical doctors will report to their residency programs. Armed with stethoscopes and scalpels, they’re preparing to lead the charge against disease in its ravaging, chimerical forms. They carry with them the classic tomes: Harrison’s Principles of Internal Medicine and Gray’s Anatomy. But I have an unlikely addition for their mental rucksacks: “Grimm’s Fairy Tales.”………….

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Robin Young, Here and Now/NPR, interviewed Francesco Pia last Wednesday: What You Don’t Know About Drowning

……Lifeguarding consultant Francesco Pia has some advice for the summer about drowning. He worked as a lifeguard in New York’s Orchard Beach, and he made a documentary called “The Reasons People Drown,” that challenged a lot of misconceptions about drowning. He found that:

1.) Drowning is often silent: …..

2.) Drowning happens very quickly: ….

3.) Drowning often happens when people are around others: ….

Remember Drowning Doesn’t Look Like Drowning

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Check out this great advice from the Better Health post:  The Right And Wrong Ways To Strengthen Your Core Muscles

What do slouching, back pain, and a middling forehand or weak shot off the tee have in common? Often it’s a weak core—the girdle of muscles, bones, and joints that links your upper and lower body. Your core gives you stability and helps power the moves you make every day……..

Core Exercises: 6 workouts to tighten your abs, strengthen your back, and improve balance is available from Harvard Health Publications. You can read an excerpt here from the report with tips on checking and improving your posture. ……..

Core Exerise #1: Plank

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I’ve always been concerned about the number of drugs some patients have to take. The risk of side effects and bad interactions increases with each addition. H/T to Dr. Elaine Schattner (@medicallessons) to the link to this Scientic America article by Laura Newman: Overprescribing the Healthy Elderly: Why Funding Research and Drug Safety is Paramount

My frail, 92-year-old mother was prescribed 80 mgs of the cholesterol-lowering drug, or statin, simvastatin for years. She fell four times in the last four years of her life: the last fall was the least forgiving. Doctors diagnosed her with rhabdomyolysis, a life-threatening condition, and acute kidney failure; she was dead within 8 weeks. …..

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Dr. Sanjay Gupta speaks with Paul Stanley (KISS) about microtia and how he has dealt with it himself.

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Sarah McFarland, Threads Magazine, has a piece announcing: “Show Your Support" and Embellish a Bra (photo credit)

The 2011 American Sewing Expo is coming right up - September 23-25 at the Suburban Collection Showplace in Novi, Michigan…..

A staple exhibit at ASE is the annual entries in the "Show Your Support Bra Challenge." Sponsored by Coats & Clark and BurdaStyle, the contest showcases some amazing lingerie decorated by the skills of sewers across the country…..

You can find the Show Your Support Bra Challenge full rules and the entry form online at the ASE site. Good luck, and good for you if you enter!

Happy 4th of July

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

I made cheesecake for the family cookout.  On the healthier side, I am also roasting corn-on-the-cob to contribute.
 

I would encourage you all to remember your sunscreen as you get up out of your chairs and head outside.   Watch out for the heat.  Be safe as you enjoy the fireworks.

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I wish you all could read this wonderful essay in its entirety:  Sleepless by Joshua Alley, MD in the June 22 issue of JAMA (full reference below).  It is an essay that speaks of how we treat our enemies

I thought about our enemies tonight, and why and how we physicians care for them.  ….

…, but the reason I went nearly sleepless that night is so that I can sleep all the other nights. It's essentially the same reason I take extra care with each patient at home. A common phrase in my operating room is “I do it this way so I can sleep at night.” I can go to bed knowing I cut no corners, I gave each patient the best possible chance at a good outcome. There are still bad outcomes, and I agonize over those, replaying each decision in my head afterward. But I did the best I could by each one.  ….

One mark of a civilized people is our response to wounded enemies. …… Yes, caring for our enemies consumes resources: helicopter flight time, ICU days, operating room hours, sleepless nights, expensive medications and equipment. Because we ought to. Because I’ll have to live with my actions. “Do good to those who hate you,” we read in Matthew's gospel. And tonight, I can sleep, because last night I didn’t.

 Happy 4th of July!  Thanks to all our military (active and retired) and their families.

REFERENCE

Sleepless; Joshua B. Alley; JAMA, 2011;305(24):2501-2502.doi:10.1001/jama.2011.863

Patriotic Pineapple Baby Quilt

I have not yet participated in the Block Lotto exchange, but I follow the blog for inspiration and patterns.   The pattern for May was the Pineapple Blossom block.  I chose to do it in red, white, and blue scarp fabric.

This small baby quilt is 36 in X 46 in.  It is machine pieced and quilted.

Here is a close up to show the blocks/fabric.
The back fabric is a lovely white on white with large polka dots.