Dressings for Acute and Chronic Wounds

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

A strong consensus was reached for use of the following combinations: for chronic wounds, (1) debridement stage, hydrogels; (2) granulation stage, foam and low-adherence dressings; and (3) epithelialization stage, hydrocolloid and low-adherence dressings; and for the epithelialization stage of acute wounds, low-adherence dressings," the review authors write. "For specific situations, the following dressings were favored: for fragile skin, low-adherence dressings; for hemorrhagic wounds, alginates; and for malodorous wounds, activated charcoal."

Chronic wounds were defined as those expected to take more than 4 to 6 weeks to heal because of 1 or more factors delaying healing, including venous leg ulcers, pressure ulcers, diabetic foot ulcers, extended burns, and amputation wounds. Acute wounds were defined as those expected to heal in the expected time frame, with no local or general factor delaying healing. These included burns, split-skin donor grafts, skin graft donor site, sacrococcygeal cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration. Summary from the MedScape article by Dr. Laurie Barclay. 

So what are these dressings? What is a hydrogel? or an alginate?

HYDROGELS

Hydrogel dressings are composed mainly of water in a complex network that keep the cross-linked polymer gels intact. The water is released to provide and maintain a moist wound environment. By increasing moisture content, hydrogels have the ability to help cleanse and debride necrotic tissue. Hydrogels are non-adherent and can be removed without trauma to the wound. Hydrogel dressings are not very absorptive, and therefore are not the appropriate choice for moderate to highly exudating wounds. Hydrogel dressings often require secondary dressings for this reason. Hydrogel dressings can be shaped into gauze, sheets, or filler material.

• Tegaderm Hydrogel Wound Filler (3M)
• Intrasite Gel (Smith & Nephew)
• VIGILON Primary Wound Dressing (Bard Medical)
• FlexiGel Strands Absorbent Wound Dressing (Smith and Nephew)--photo credit

SYNTHETIC FOAM DRESSINGS

These dressings were designed to absorb large amounts of exudates and to maintain a moist wound environment. They are not as useful as alginates or hydrocolloids for debridement. They should not be used on low or non-exudating wounds as they will cause dryness and scabbing.

• Allevyn (Smith & Nephew) (photo)
• Lyofoam (Convatec)
• Tegaderm Foam Dressing (3M)

HYDROCOLLOID DRESSINGS

Hydrocolloids are sterile wound dressings, which consist of a hypoallergenic, hydrocolloid adhesive with an outer clear adhesive cover film impermeable to liquids, bacteria and viruses. The inner layer of hydrocolloid adhesive rapidly absorbs exudate. The breathable outer film layer provides for a high rate of moisture vapor transmission. Together, these features ensure an optimal moist wound environment, minimize the chance for damage to healthy skin surrounding the wound and provide extended wear for up to seven days. (photo credit)

• DuoDERM (Convatec)
• Tegaderm Hydrocolloid Dressing (3M), regular and thin

LOW ADHERENCE DRESSINGS

The use of low or non-adherence dressing materials will minimize disruption of healthy granulation tissue and re-epithelialized surfaces.

• Jelonet Paraffin Gauze Dressing (Smith & Nephew) is a low-adherent tulle dressing that allows the wound to drain freely into an absorbent secondary dressing.
• Tegaderm Non-Adherent Contact Layer is a woven nylon fabric with sealed edges that is a lint-free, non-adherent, non-toxic, non-irritating, and hypoallergenic material. It can be left on the wound for up to 7 days. This contact layer can be used under gauze or other absorbent dressings. It will allow exudates to pass through to an absorbent outer barrier. The non-adherence of this material will minimize disruption of healthy granulation tissue and re-epithelialized surfaces. (photo credit)
• Paranet "Vernaid" Sterile Paraffin Gauze Dressing BP

ALGINATE DRESSINGS

These dressings are sterile, highly conformable, and absorbent primary wound dressings for use on moderately to heavily exudating wounds. They are composed of calcium alginate which is a seaweed component. When the dressing is in contact with wound, the calcium in the dressing is exchanged with sodium from the wound fluid and this turns dressing into a gel that maintains a moist wound environment. It is a good dressing for exudating wounds and helps in debridement of sloughing wounds. It should not be used on low exudating wounds as this will cause dryness and scabbing. This dressing should be changed daily. (photo credit)

• Kaltostat (Convatec)
• Sorbasan (Bertek Pharm)
• Tegaderm Alginate High Integrity Dressings (3M)
• Tegaderm High Gelling Alginate Dressing (3M)

The activated charcoal products are for stoma bags to decrease or elimate the odor from the collected urine or feces. The article at DermNet NZ on skin problems from stomas is very well written.

References
Dressings for Acute and Chronic Wounds--A Systematic Review; Arch Dermatol. 2007;143:1297-1304; Olivier Chosidow, MD & others (can access online if AMA member)
Consensus Statement Describes Dressings for Acute and Chronic Wound Management--MedScape article by Laurie Barclay, MD
Wound Dressings--Family Practice Notebook
Synthetic wound dressings at DermNet NZ
Skin problems from stomas at DermNet NZ

SurgeXperience 107--call for submissions

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

Vitum Medicinus is hosting SurgeXperiences 107 on October 28, 2007. Submissions will be accepted via a Blog Carnival. Click here to submit your blog post. Please submit your surgery related posts (surgeon, nurse, patient, etc viewpoints welcome). It is meant for learning and sharing. (photo credit) SurgeXperience home can be found here.

More Quilts--QOV and Baby

This past week I mailed off two more QOV quilt tops to someone who will do the actual quilting. The first one pictured is a square-in-a-square pattern. The quilt top size is 50" X 70".

A close up of some of the squares showing the fish.

This next QOV quilt top is a churn dash or shoo fly pattern.
It is also 50" X 70".

A close up of some of the blocks.

This next quilt top is what I worked on today. I had a left over "shoo fly" block, so I used it in a medallion type setting. To me it almost has an Amish feel. This top is 38" X 38" and will be quilted by me and given to someone for a baby (or grandbaby).

Focal Dystonia of the Hand

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

Earlier this week I read an article in Reader's Digest (November 2007 Issue) on Leon Fleisher and his focal dystonia of his right hand. The article is written by Oliver Sacks, MD and is a exert from his book "Musicophilia: Tales of Music and the Brain". I wanted to review what I knew about focal dystonia and ended up learning much. I would like to try to share this with you. Enjoy this "Ravel Piano Concerto for the Left Hand 1/2" played by Leon Fleisher (video).

The term dystonia collectively refers to a heterogeneous group of movement disorders characterized by sustained involuntary muscle contractions that result from co-contracting antagonistic muscles and overflow into extraneous muscles. Focal dystonias are adult-onset forms that affect a specific area of the body, ie hand, neck, vocal cords. Most focal dystonias are primary. By primary it is meant that the dystonia is the only neurological symptom. 

Focal hand and limb dystonia usually begins as a painless loss of muscular control in highly practiced movements. A genetic predisposition is thought to occur in less than 5% of all cases of focal dystonia. There are many professions that require repeated and intricate hand movements. However, focal hand dystonia is more common in musicians than any other group of professionals, including dentists, surgeons, and writers. This disorder is often referred to in medical literature as occupational cramps (ie, “violinist’s cramp”, “pianist’s cramp”, "writer's cramp"). (photo credit)

Cause
There is no one isolated cause of hand and limb dystonia. A variety of pathological conditions may lead to similar symptoms. As a child develops, he/she learns many different movements (such as walking, writing, or playing an instrument) that are stored in the brain as motor programs. Instances of hand dystonia that are highly task-specific have been described as a “computer virus” or “hard drive crash” in the sensory motor programs that are essential for playing music. However, additional factors, such as a genetic predisposition, are likely to play a significant role in the development of such a sensory-motor dysfunction. Why this “computer virus” cannot be easily overcome by establishing a new and improved sensory-movement pattern remains an important question for researchers. 

Symptoms
Most affected persons describe symptoms in terms of their occupation terms. A musician may notice

• Subtle loss of control in fast passages
• Lack of precision
• Curling of fingers
• Fingers “sticking” to keys
• Involuntary flexion of bowing thumb in strings

A writer may notice:

• Deterioration in neatness or speed of writing or just clumsiness
• A cramp or aching in the hand on writing
• May report that the hand freezes up on attempting to write
• Difficulty in moving the pen across the page

A tremor may or may not be associated with the spasms. In most cases, the dystonia is present only in the context of specific tasks (and may be very specific to one instrument--a clarinet but not a saxophone). The dystonia may appear extremely sensitive to sensory input: a pianist may experience symptoms while playing on ivory keys but not while playing on plastic keys. Sometimes the modification of posture and even facial expressions may affect dystonic spasms in the hand. 

Physical Exam

Inspection

No special examinations are described for focal dystonia other than inspect the patient performing his task.

• The pen commonly is held very tightly, with an exaggeration of the normal semiflexed posture of thumb, index and other fingers, and with hyperextension of the distal interphalangeal joint of the index finger. Occasionally, the hand suddenly stops and the paper is perforated, or it might dart across the page with a sudden jerk. The script produced is usually abnormal. Tremor is a common finding in all forms of writer’s cramp but it is usually not severe. (photo credit)
• Examination of the musician while playing reveals non-physiologic posture and gestures in most of the patients. Sometimes it is possible to identify involuntary dysfunction such as flexion, curling in one or two fingers, or involuntary extension of the “sticking fingers”. These may be difficult to detect, even with slow motion video.

The remainder of physical examination is often normal, but subtle findings can be noted in some patients: dystonic postures of the affected limb when the patients sit or walk, or loss of arm swing of the affected side during the gait. 

 

Palpation

There is minimal unilateral increase in muscle tone in some patients. There are no other abnormal findings. 

Quantification

The Fahn-Marsden scale was designed to quantify generalized or focal dystonia and can be found here. 

Electromyography

Electromyography studies show prolonged duration of muscle bursts with superimposed shorter, repeated bursts of activity. The pattern is of complete lack of selectivity for individual muscles with overflow of contraction to muscles not normally activated by the task being performed. Electromyography may also useful as a guide to botulinum toxin injections. 

X-rays

Radiographs are not useful in the assessment of focal dystonia. Occasionally, in an appropriate setting, magnetic resonance image of the brain can be useful to rule out a cerebrovascular disease. 

Treatment
There is no cure for dystonia at this time, and although treatment of the disorder may be challenging, there are several available options. The different causes of hand dystonia may warrant different treatments. Don't give up--see Leon Fleisher's story.

Oral medications: There are a number of therapeutic agents with clear beneficial effects to writer’s cramp, including anticholinergics, clonazepam and benzodiazepines. High dosage of anticholinergic drugs is firstly recommended for the treatment of dystonia.

• Doses recommended of biperiden are 2 mg per oral two or three times a day and titration to 16 mg a day.
• Diazepam is another choice. However, it is rarely adequate when used as sole agent. Doses are 10mg per oral two or three times a day.
• Clonazepam can be useful for improvement of phasic symptoms in cases with myoclonus and/or tremor. Doses are 0.25 mg per oral twice a day, increasing to 0.125 to 0.25 mg every three days up to a dose of 4 mg/day.

Botulinum toxin injections has been used for the treatment of writer’s cramp with good results. Its application requires careful and precise technique. The selection of the muscle should be based on careful physical examination while the patient writes or plays in order to trigger the dystonic movements. The injection should be carried out under EMG guidance with a hollow recording needle and the botulinum toxin is injected through the same needle. Small volume injections into multiple sites are preferred to a single large injection. Dose per muscle varies from 2.5-25 units. Initially, only few muscles are injected. The dose per muscle and number of muscles injected are optimized (based on response) for subsequent injections. 

Splints

Some patients find that finger-splinting device made individually according to their symptoms help improve their ability to write or to play a musical instrument. Limb immobilization for four weeks and a half is a simple and sometimes effective treatment for this condition. (photo credit) 

"Therapeutic approaches involving the practice of movements are likely to remain unsuccessful unless their design includes a framework that, in principle, aims at interrupting this vicious circle. Indeed, a recently developed behavioural therapy, termed sensory motor retuning, holds great promise (Candia et al., 2002). Musicians with focal hand dystonia performed repetitive movements with fingers of their dystonic hand while one or more fingers except the dystonic ones were immobilized. After therapy, movements of the dystonic fingers were substantially better controlled, with some musicians reaching near-normal performance levels. Along with improvement of motor behaviour, the topography of the somatosensory representation of the fingers became normalized." from Brain article (see references below). 

For an interesting list of people who have struggled with this problem, check here. 

References and Resources

Mark Hallett, MD

NIH clinical study "A Training Protocol for the use of Botulinum Toxin in the Treatment of Neurological Disorders", reference No. 85-N-0195

Focal Dystonia of the Hand by Marcos Sanmartin

Focal hand dystonia – a disorder of neuroplasticity?; Brain, Vol. 126, No. 12, 2571-2572, December 2003; Joseph Classen

Upper Limb Disorders in Musicians by Raoul Tubiana, MD

Tubiana R. Musician’s focal dystonia. Hand Clin 19: 303-308, 2003.

Dystonia Fact Sheet--National Institute of Neurological Disorders and Stroke

Dystonia--pianomap

Focal Dystonia from a Guitarist's Perspective by Jarrod Smerk

A Tale of Two Hands--Charlie Rose talks to pianist Leon Fleisher

Muscians with Dystonia Foundation

What is Plastic Surgery?

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

Recently I read an editorial in the Plastic and Reconstructive Surgery (PRS) Journal by Dr. Thomas R Stevenson regarding the question of "What is Plastic Surgery and Who Decides?" It is a very thoughtful article. With his and Lippincott Williams & Wilkins permission, I am re-printing it here. 

"What is Plastic Surgery and Who Decides?"

We are finishing a face lift consultation and my nurse puts away our mirror. Amy, rearranging her hair, asks a familiar question, “Why do they call it plastic surgery?” I fumble through an explanation of Carl von Graefe’s use of “plastic,” meaning “to mold,” and add something about having “nothing to do with a class of chemical compounds, but is a discipline that includes reconstructive and aesthetic surgery.” Amy’s eyes glaze over. Obviously confused but satisfied there is an answer, she walks into my manager’s office for a price quote. I am left with her question and my own interpretation of it. Amy really wants to know, “What is plastic surgery?” The answer depends on whom you ask. 

Quiz a U.S. citizen about our specialty and chances are you’ll receive a response referencing movie stars and breast augmentation. A crude colloquial noun often will substitute for “breast.” You might get a script outline from last week’s plastic surgery reality television show. Press a little further and you may hear a reference to nose jobs and face lifts— occasionally cleft lip repairs or breast reconstructions. If you mention pressure sore closure or limb salvage, digital replantation, or hand surgery, the reply might be, “That’s plastic surgery?” Such is our specialty’s public perception. 

Insurers have a clearer idea of surgery’s scope but limited concerns regarding plastic surgery’s future. Give them an ICD-9 and CPT code, and they will tell you if it is covered and what they will pay. Reimbursement is based on a negotiated fee-for-service scale. A plastic surgeon in private practice can decide if payment is sufficient, accepting only those insurance plans that pay enough and rejecting others. Plastic surgeons in large multispecialty groups or academic practice may not be allowed to turn down patients whose plans reimburse poorly. Thus, most private practitioners are pushed toward performing lucrative cosmetic procedures while other plastic surgeons are threatened with insolvency. Most of us do some cosmetic surgery. That part of our practice requires expertise, involves few emergency calls, and pays the bills. But who among us entered residency simply hoping to be a successful cosmetic surgeon? Unfortunately, if whittled down to a financially viable “chip,” plastic surgery would be one knife stroke away from disappearing. No, third-party payers and financial considerations should not circumscribe our specialty. 

Plastic surgery’s accrediting and credentialing organizations are the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. Each group has a slightly different view of what constitutes our specialty. The Plastic Surgery Residency Review Committee precisely delineates the variety and number of procedures each plastic surgery resident must perform in order for his or her program to stay accredited. Provide inadequate case volume and a training program risks loss of accreditation. Through written and oral examination processes, American Board of Plastic Surgery certification is granted only to those candidates who are familiar with a broad range of problems faced by plastic surgeons. The Residency Review Committee and American Board of Plastic Surgery determine what information a plastic surgery residency must impart and what a graduating resident must know to be board certified. These two organizations declare what a plastic surgeon starts out being, not what that surgeon will be doing in a mature practice. 

Plastic surgeons are encouraged by the board to maintain certification. Board certification is time-limited. If a plastic surgeon wishes to maintain certification, that surgeon must regularly assess his or her patient management abilities, identify deficiencies, and objectively demonstrate an effort to improve. However, this Maintenance of Certification process will not force a plastic surgeon to master the same breadth of skills that surgeon possessed when he or she was initially certified. Plastic surgery’s scope cannot be defined by accrediting or certifying bodies.

Plastic surgery training programs develop curricula based on comprehensive didactic and clinical outlines. Program directors are required to educate residents across a wide spectrum. Still, no two programs are identical. Some programs are strong in microsurgery, others in aesthetic procedures. Newly graduated residents are as different as snowflakes. Those differences grow over years of practice. Principles of problem analysis and treatment planning, developed as a resident, should be retained and used to refine patient care techniques. However, specific procedures taught to a resident are supplanted by the discovery of superior ones or are shown to be ineffective, even dangerous. Who among us is still injecting liquid silicone? When a resident finishes training, his or her perspective interprets plastic surgery as that body of knowledge personally amassed to date—but there will be so much more. 

Plastic surgery is defined by public opinion, reimbursement agencies, accreditation and certification bodies, training program curricula, and practice patterns. Is that the entire answer? 

Back to Amy’s question, “What is plastic surgery?” She may never know, but we should. I believe plastic surgery is what plastic surgeons do. It is what we do collectively, and what this aggregate body does is what each of us individually entered plastic surgery to do. Yes, it is constrained by finances, limited by local availability of cases, and confined to its practitioners’ skills and training. Our scope may be narrowed by competing specialties, and certainly our practice will change. Still, we as a group fix clefts, treat pressure sore patients, reconstruct burn victims, repair mangled hands, and care for patients overseas.

As applicants to plastic surgery programs, we were picked because we were capable and promising in our program directors’ eyes. We were young surgeons who looked at things differently. Each of us vowed to be an innovator. We wanted to figure out a new and better way of doing something. Preserving that ideal and providing the chance for enthusiastic, creative young surgeons to flourish is plastic surgery’s essence. Each of us retains a portion of that spirit. Private practitioners, academicians, and researchers in plastic surgery must continue their commitment to variety and innovation. We must encourage the American Board of Plastic Surgery and Plastic Surgery Residency Review Committee to maintain breadth in plastic surgery training. Our membership organizations must be stimulated to provide varied educational offerings. We are obligated to ensure that those opportunities we enjoyed persist and are passed on to the next generation of plastic surgeons.

Thomas R. Stevenson, M.D.
Division of Plastic Surgery
University of California, Davis
Sacramento, Calif. 95817
What Is Plastic Surgery and Who Decides?; Plastic & Reconstr Surgery, 120(4):1079-1080, September 15, 2007; Stevenson, Thomas R. M.D.

Revisit of Community Acquired MRSA--Prevention Tips

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

With the recent death of the Bedford County, Virginia student and today's closing of the schools there for cleaning, I thought it would be prudent to revisit MRSA.  This was first posted on July 30, 2007.

Staphylococcus aureus, or “staph” as it is sometimes called, is a common bacterium found on the skin or in the nose of ~25-30% of humans. Staph aureus is usually harmless, but in certain instances it may cause moderate to severe skin infections. Less commonly, it causes more serious systemic infections: bloodstream, surgical wound and pneumonia requiring hospitalization. One group of staph known as MRSA (methicillin-resistant Staphylococcus aureus) was first identified in the 1960’s. It is now prevalent in most hospitals. The organisms are resistant to multiple antibiotics (specifically, all antibiotics known as beta lactams, as well as other antibiotic families), and are therefore cause for considerable concern. Photo credit

A newer form of staph infection, known as CA-MRSA (for community-acquired, or community-associated Staphylococcus aureus) has appeared with increasing frequency and is now epidemic within certain community populations. Whereas hospital MRSA is almost always found in persons with established risk factors associated with prior medical treatment, these are not present in CA-MRSA. Today, in the U.S. a little more than 10% of all MRSA infections are CA-MRSA. This form causes serious skin and soft tissue infections in otherwise healthy persons who have not been recently hospitalized or undergone invasive medical procedures. Hospitalization is required in approximately one out of five cases.

CA-MRSA has been identified most frequently among specific populations, including prisoners, athletes, children, men who have sex with men, military recruits, Pacific Islanders, Alaskan Natives and Native Americans.

Rather than getting into treatment, I want to highlight was that can help PREVENT getting or spreading CA-MRSA.

1. Clean your hands frequently with soap and warm water or an alcohol-based hand rub.
2. Keep your linens and clothes clean. Wash sports clothing and washable athletic gear with laundry detergent after each use (not after a week or two of use).
3. Do not share personal care items. At home this includes washcloths, towels, and razors. At the gym or school this includes sports towels, sports equipment (helmets, gym mats), uniforms/clothing. Equipment that can't be washed should be cleaned with an antibacterial solution after each use.
4. Take care of skin cuts or abrasions before they get infected. Wash them with soap and water, then cover with a dry, sterile bandage daily. Promptly throw away the old bandage. Wash your hands before and after changing the bandages.

If you are given antibiotics for an infection, it is important to take ALL of the doses. Don't quit "when you feel better" or the skin "looks better". Finish all the doses. The bacteria that don't get killed by the missed doses can morph into tomorrow's superbugs.

Staph Infections--e-Medicine article by Robert W Tolan Jr, MD

Community-Associated MRSA Information for the Public --Centers for Disease Control

Staphylococcus aureus Section--Minnesota Department of Health

APUA Newsletter on CA-MRSA--2003

Digital Photos of CA-MRSA Infections

Pumpkin Carving--Prevent the Injuries

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

Carved pumpkins can be works of art, but carving one incorrectly can leave you with cut fingers. Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. Then keep the wound clean and dry while it heals. However, if the bleeding continues after 15 minutes or if you lose the ability to move the finger properly (very likely a tendon injury), then seek medical attention at a hospital emergency department. (photo credit--Headless Horseman)

Let's prevent the injuries. Here are some tips:

• Carve in a clean, dry, well-lit area.
  If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.
• Always have adult supervision (without alcohol use)
  Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.
• The right way to cut.
  You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.
• Use a pumpkin carving kit.
  Special pumpkin carving kits are available for purchase and include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits. (photo credit)

Here is a link for instructions and patterns for pumpkin carving at Spook Master. And here are just some fun photos I found:

George Bush at Jack of All Blogs

Happy Halloween (Jim Hendricks, bbc.co.uk)
Ping the Pug (photo credit)

Once carved, it is important to remember to KEEP dogs and cats away from Jack o'Lanterns or lighted candles as they could knock them over and start a fire.
Have a safe Halloween season!

Spit for the Cure

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

The local Susan G Komen Race for the Cure is this Saturday in Little Rock, AR. The University of Arkansas Medical Sciences (UAMS) is using the event to collect saliva samples from thousands of women. The samples will be used to used to create a DNA database for future studies related to breast cancer risk and treatment. Participants in "Spit for the Cure" will be asked to answer a short questionaire. All information is to be kept confidential and the samples are to be labeled by number not name. The leading researchers are Susan Kadlubar, PhD, assistant professor of environmental and occupational health in the UAMS College of Public Health, V. Suzanne Klimberg, M.D., director of the breast cancer program at the UAMS Winthrop P. Rockefeller Cancer Institute (formerly the Arkansas Cancer Research Center), and Kristy Bondurant, Ph.D., postdoctoral fellow. (photo credit)

“It has become clear that an individual’s inherited profile and environmental exposures will decide, to a large degree, that individual’s risk of developing breast cancer. We are working to obtain DNA samples from a representative group of Arkansas women that will be used to advance breast cancer research in a variety of areas.” Suzanne Klimberg, MD

A rare chance to spit in public and it be sociable acceptable.
Trail Manners by Wendy Bumgardner
Manners and Etiquette in the Antebellum South

SurgExperiences 106

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

SurgeXperience 106 is up over at IntraopOrate. Though she bemoans "Due to time constraints (and perhaps a lack of imagination!) the format of this edition is more practical than clever." I think she did a wonderful job! Check it out. I think you'll find many posts that you enjoy reading.

The Great Arkansas Quilt Show II

Last night was the awards presentation for the Great Arkansas Quilt Show II hosted by the Historic Arkansas Museum. I had entered two quilts, Flowers in a Vase (seen in the upper left corner of the blog page) and Will the Circle Be Unbroken (below, center quilt of the first photo). I did not expect to win any awards, but did. Will the Circle won "Best Hand Quilting".

Will the Circle Be Unbroken (center)
center of Flowers for Mattie by Irma Gail Hatcher

Peach Sherbert, an absolutely beautiful quilt

I need to get better at taking notes for my pictures.

This one has 50 different blocks, all in red and white. Very lovely.

A lovely quilt using the lone star pattern.

An applique of nursey rhymes

Flowers and Cats

I really like this one. It feels like Christmas.

A stunning appliqued quilt!

Another pretty red and green pieced quilt.

I wish you could see this in person. My photo does not do it justice!

Another lovely applique of flowers much prettier than my photo shows.

Beautiful blue and white pieced quilt!

Flying Birds

Generic Drugs

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

I was on my way to the office this morning when I heard this NPR story "Study: Generic Anti-Depressant Ineffective by Joanne Silberner." It is extremely rare that I don't mark the box --allow generic substitute -- on the prescriptions I write. When I am the patient, I ask for generics. So this news report gave me pause. According to the FDA, the definition of a generic drug is:

"A generic drug is identical, or bioequivalent to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically sold at substantial discounts from the branded price."

The same FDA page goes on to reassure:

"Health professionals and consumers can be assured that FDA approved generic drugs have met the same rigid standards as the innovator drug. To gain FDA approval, a generic drug must:

• contain the same active ingredients as the innovator drug(inactive ingredients may vary)
• be identical in strength, dosage form, and route of administration
• have the same use indications
• be bioequivalent
• meet the same batch requirements for identity, strength, purity, and quality
• be manufactured under the same strict standards of FDA's good manufacturing practice regulations required for innovator products"

I am like "Cheryl" in the NPR story, I am a fan of generics. Still if you (and your doctor) do not feel that you are getting the benefits expected from your prescription, you may want to try the "name" brand.

Toradol

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

Okay, so here's the deal. Ten years or so ago, I used toradol in most patients. That included breast implant patients. It really cut down on how much postoperative analgesic use. Then one of the older plastic surgeons in town mentioned that if I had a postoperative hematoma in one of my breast augmentation patients that I would have a difficult time defending myself in a law suit. I quit using toradol in all implant patients, but still used it in reduction patients, etc. Recently, I have had repeated discussions with a CRNA regarding the use of toradol in breast augmentation patients. I don't like my reason for not using it in these patients. So I went back to the literature to either remove my reason or bolster it. The literature was not much help. There doesn't seem to be any really great studies out there for either side. Here is what I found. Anyone have any other information to help me out? (photo credit)

Toradol (ketorolac tromethamine) causes significant inhibition of platelet aggregation by inhibiting cyclo-oxygenase and decreasing thromboxane A1 production. Ketorolac also inhibits platelet aggregation in response to collagen and arachidonic acid. Platelet aggregation is decreased by 25% three hours after a dose of ketorolac. Unlike the prolonged effects from aspirin, the inhibition of platelet function by ketorolac disappears within 24 to 48 hours after the drug is discontinued. This inhibition of platelet aggregation results in a significant prolongation of bleeding time. Healthy volunteers demonstrated prolonged bleeding times (from 4.9 to 7.8 minutes) after five days of parenteral ketorolac. Ketorolac significantly prolonged skin bleeding time from a baseline of 222 to 299 seconds one hour after an intramuscular dose in 50 surgical patients. Ketorolac does not affect platelet count, prothrombin time (PT) or partial thromboplastin time (PTT). Postoperative hematomas, operative site bleeding and other signs of would bleeding have occurred rarely with perioperative use of ketorolac. In controlled clinical studies, the incidence of clinically significant post-operative bleeding was 5/1170 (0.4%) compared to 1/570 (0.2%) in the control groups receiving opiates. Therefore, caution should be exercised where strict hemostasis is critical.

Dosage and Administration

Ketorolac tromethamine must not be used in children under 16 years of age. In adults, the loading dose is 30 to 60 mg IM/IV followed by a maintenance Dose --15 to 30 mg IM/IV every 6 hours or 10 mg po every 8-12 hours. Maximum Dose --150 mg on first day, then 120 mg per day, not to exceed 5 days.

Dosing Adjustments --A 30 mg loading dose and maintenance dose of 15 mg IM/IV q6h should be used for patients weighing 50 kg (110 lbs), patients over 65 years of age, or patients with decreased renal function (CrCl between 30 to 50 ml/min), and use should be discouraged in patients with CrCl less than 30 ml/min.

Ketorolac injection is indicated for the short-term management of pain, up to 5 days only. It is recommended to convert to oral NSAID therapy when the patient can tolerate oral medications. Concomitant use of anticoagulants (e.g., heparin, enoxaparin, warfarin) increases the risk of bleeding complications. Concomitant use of other NSAID therapy, including aspirin, may produce additive adverse effects.

The lowest effective dose should be given. A total daily dose of 90 mg for the non-elderly and 60 mg for the elderly should not be exceeded. (inserted article from the 5th reference below)

References

• The Rational Use of Parenteral Ketorolac; Nancy E. Sloan, Pharm.D.; P&T News: May 1994, Vol. 14, No. 11
• Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction; SHARMA Sanjay, CHANG David W., KOUTZ Cindy, EVANS Gregory R. D., ROBB Geoffrey L., LANGSTEIN Howard N., KROLL Stephen S.; Plastic and Reconstructive Surgery Journal, Vol 107, No 2, pp 352-355, 2001 (abstract here)
• Facial plastic meeting yields surgical pearls; Source: Dermatology Times, Originally published: June 1, 2002
• POSTOPERATIVE HEMATOMAS ASSOCIATED WITH TORADOL; Plastic & Reconstructive Surgery. 88(5):919, November 1991; Garcha, Iqbal S.; Bostwick, John M.D.
• PERSONAL EXPERIENCES WITH TORADOL; Plastic & Reconstructive Surgery. 89(6):1183, June 1992; Dowbak, Gregory M.D.
• The Effect of Ketorolac on Microvascular Thrombosis in an Experimental Rabbit Model; Plastic & Reconstructive Surgery. 98(1):140-145, July 1996.; Shufflebarger, John V. M.D.; Doyle, James Ph.D.; Roth, Tim M.S.; Maguire, Kevin M.D.; Rothkopf, Douglas M. M.D.