Yellow Flower

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active.

This small art quilt was inspired by a photo of a multinodular goiter in a JAMA article (photo credit), the upper right image here.

I took the photo and enlarged it more than 400% to create this template on freezer paper.  I applied light-weight fusible web to the back of my black fabric and the freezer paper to the front.  Then using an #11 blade I cut out the design.

The black fabric was then fused to the background fabrics.  First the yellow print and then the gray print.  The raw edges were then machine appliqued.   The border consists of two thin strips (an inner black and then the print) and a larger black.

I machine quilted the piece.  Here is a  close view of the yellow flower which was fussy cut from a wonderful Batik.

Here is the back before I sewed on the label but after sewing on the sleeve for hanging.  The quilt measures 17.5 in X 19.5 in.

The quilt is for sale on Etsy.

Screening Prior to Cosmetic Breast Surgery – an article review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

How are we plastic surgeons with screening prior to cosmetic breast surgery?  This article from November 2009 (full reference below)  reviews this topic.  Note this survey was done prior to the release of the new USPSTF guideline recommendations for screening mammograms the same month.   I wonder if a new survey would have different outcomes.

The article reports on a study which looked at breast cancer screening practices of American plastic surgeons (self-reported) and the degree to which those practices adhere to the American Cancer Society guidelines.

The study was conducted using an online survey of the members of the American Society of Plastic Surgeons over a 5 month period (January 2008 to May 2008). The 20 multiple-choice questions were designed to assess physician practice composition and familiarity with American Cancer Society guidelines, and to ascertain specific practices for preoperative evaluation and breast cancer screening in patients seeking aesthetic breast surgery. The survey comprised four components: general practice information, breast cancer screening practice, criteria for obtaining breast cancer screening, and criteria for further evaluation of breast cancer risk.

There were 1094 respondents (out of 4520 society members), so only a 24% response rate.   Twenty-eight responses were excluded because these surgeons responded that they do not do breast surgery, do not operate, are pediatric surgeons, are retired, or work with cancer patients only on an initial screening question.

Of the 1066 included respondents, 82% were male and 73% were in private practice.  The participants were roughly evenly distributed with respect to total years in practice, and a majority of surgeons performed augmentation mammoplasty, reduction mammoplasty, and mastopexy (96%).

In total, only 47% appeared to follow the American Cancer Society guidelines.  Only 64% claimed familiarity.

Not all responders always reviewed risk factors preoperatively in their aesthetic breast surgery patients (only 89%), nor did all responders always perform a clinical breast examination preoperatively (86%).

• 89% of respondents claimed that they obtain mammographic screening based on age
• 57% claimed to do so based on positive family history, regardless of age
• 61% stated they followed the ACS screening guidelines, 61 percent stated that they did follow the guidelines
• 24% stated that they did not know the guidelines

Seventy-five percent (n = 799) of plastic surgeons considered a mammogram within 1 year to be valid, whereas 15% (n = 166) stated that this was age dependent.

The authors concluded:

Breast cancer is a major public health problem, for which screening is at least part of the solution. Plastic surgeons are in a unique position to screen women who may not otherwise receive screening. Knowledge of the American Cancer Society guidelines is an essential component of effective cancer screening, but unfortunately only somewhat more than half of plastic surgeon respondents who perform breast surgery have knowledge of these guidelines. Being male predicted more accurate knowledge of the guidelines, but being female resulted in more aggressive screening, and possibly more diagnoses. Familiarity with the American Cancer Society screening guidelines also resulted in a greater number of perioperative diagnoses. As plastic surgeons, we have an obligation to actively participate in the health and well-being of our patients, and this involves understanding and applying good breast cancer screening practices.

Related posts:
New Breast Cancer Screening Guidelines  (November 17, 2009)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Screening Mammogram Recommendations (January 7, 2010)
USPSTF Breast Screening Guidelines Pushback  (January 26, 2011)



REFERENCE

Breast Cancer Screening Prior to Cosmetic Breast Surgery: ASPS Members' Adherence to American Cancer Society Guidelines; Selber, Jesse C.; Nelson, Jonas A.; Ashana, Adedayo O.; Bergey, Meredith R.; Bristol, Mirar N.; Sonnad, Seema S.; Serletti, Joseph M.; Wu, Liza C.; Plastic & Reconstructive Surgery. 124(5):1375-1385, November 2009; doi: 10.1097/PRS.0b013e3181b988c4

Advances in Nipple-Sparing Mastectomy – an article review

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

There is a very nice review article of the advances in nipple-sparing mastectomy surgery in the March 2011 issue of the Aesthetic Surgery Journal (full reference below).

Dr. Patrick Maxwell and colleagues includes some history of nipple-sparing mastectomy (NSM):

NSM was attempted in the 1980s but never gained popularity owing to the controversies surrounding oncological safety. Now, better technologies for preoperative staging and assessment of lesion distance from the NAC, along with an increased understanding of the anatomy of the breast ducts with relation to the nipple, are encouraging a return to the concept. One of the key publications that renewed and increased enthusiasm for this technique was the multicenter publication of 192 patients undergoing NSM with only four recurrences, all of which occurred distant from the NAC. Recurrences were seen in the upper outer quadrant, where nearly all recurrences are found with simple mastectomies, at the junction of the tail of the breast and axillary tissue.

In recent years, there has been a sudden increase in reports of NSM for prophylaxis and cancer treatment. Of the approximately 1868 NSM procedures performed for breast cancer treatment and published in recent literature, only three local recurrences within the NAC have been reported, representing 0.16% of local events attributed to patients with NAC preservation. Note, however, that most of these studies have short follow-up periods, thus rendering definitive conclusions premature.

While NSM is not an option in all cases, it is an option that when available is worth using.  No surgeon can create a nipple as lovely as the one that would be removed by the mastectomy, so if it can be used it greatly adds to the finished results.

Exclusion criteria included tumors larger than 3 cm, clinical invasion of the NAC, tumors within 2 cm from the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, and nodal disease, excluding isolated immunohistochemistry positivity.

The article does a quick review of some of the techniques for NSM (photo credit, 1st reference article):


The article is worth your time to read.



REFERENCES

1.  Advances in Nipple-Sparing Mastectomy: Oncological Safety and Incision Selection;  Maxwell G.P., Storm-Dickerson T, P Whitworth P, Rubano C, and Gabriel A; Aesthetic Surgery Journal March 2011 31: 310-319, doi:10.1177/1090820X11398111

2.  Nipple-Sparing Mastectomy for Breast Cancer and Risk Reduction:  Oncologic or Technical Problem?; Sacchini V, Pinotti JA, Barros AC, et al; J Am Coll Surg 2006;203:704-714

Shout Outs

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

Dispatches from Second Base is the host for this week’s issue of Grand Rounds! You can read this week’s edition here.

Welcome to Grand Rounds! First, a quick shout-out to Nick Genes, an emergency medicine physician who blogs at blogborygmi (possibly the best blog name ever) and is one of the founders of Grand Rounds. I had no plans to host GR a second time until I saw Nick’s APB for April hosts. I had forgotten how much fun this was until the posts started coming in. So thanks, Nick.

The theme this time is what gives your life or work meaning. One of the loveliest, most contemplative posts I’ve seen on this topic is Nourishing Healthy Seeds from Deb Thomas, who blogs at Debbie’s Cancer Blog. ………..

……………………………

Last night a tornado all but wiped out the small town of Vilonia, AR.  I went to school there from the 4th through 12th grades.  I played basketball.  The town and school are much larger than when I went to school there (didn’t live in the town limits or postal zip code).  I have learned of at least one friend who lost her home in the storm, but all the family members are okay.

I know this is nothing compared to Japan’s disaster, but it is my hometown.  KATV has made it easy to donate to the Arkansas Red Cross (as well as the Japan Tsunami relief) here.

……………………………….

NPR reminds us the Sitting All Day: Worse For You Than You Might Think  (photo credit), so get up and move. 

Yes, exercise is good for you. This we know. Heaps of evidence point to the countless benefits of regular physical activity. Federal health officials recommend at least 30 minutes of moderate exercise, like brisk walking, every day. ….

But now, researchers are beginning to suspect that even if you engage in regular exercise daily, it may not be enough to counteract the effects of too much sitting during the rest of the day.  ……

…………………………….

Another great interview by NPR.  This one by Terry Gross (Fresh Air) of Dr. Emery Brown on 'What Happens In Your Brain During Anesthesia' :

If you've gone in for surgery, it's likely that your anesthesiologist has told you to count backwards from 100 — and that you'll wake up after a nice deep sleep.

But that's not exactly true.

"Sleep is not the state you're going in, nor would it be the state in which someone could perform an operation on you," explains Emery Brown. "What we need to do in order to be able to operate on you — to perform a procedure which, is indeed, very invasive — is to put you in a state which is effectively a coma which we can readily reverse."  ……..

……………………………………….

NPR had a very interesting segment yesterday on interviewing Amy Stewart, the author of the book Wicked Bugs:  Where To Find The World's Most 'Wicked Bugs' (photo credit)

Japan is home to the world's largest — and most painful — hornet. With a wingspan of up to three inches, the Asian giant hornet can look more like a tiny flying bird.

And if you're a bird — or a bee — watch out.

The Asian giant hornet can inject "a deadly neurotoxin, [which] actually can be fatal," says science writer Amy Stewart. "In Asia, they call it a yak-killer because it has such a potent neurotoxin."  …..

…………………………………….

NPR’s Science Friday is a wonderful site. This past Friday they highlighted three space science videos. One uses candy corn to demonstrate how soap works and the last shows what happens to water balloons in space when you pop them (or how large would rain drops be with no gravity).  Here’s the one that answers the question of how a yo-yo works in space.

………………………………………..

More on Link Between Breast Implants and ALCL

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

I have written about this previously. 
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)

A quick review:  In January, the Food and Drug Administration (FDA) released a safety alert warning of the possible association of acute large cell lymphoma (ALCL) with breast implants.

After the Plastic Surgery Societies got through being defensive (http://www.theplasticsurgerychannel.com/fda-issues-safety-signal-on-alcl-breast-implants/), they did the right thing  reviewed the literature (4th reference below) and the Plastic Surgery Foundation and the Aesthetic Surgery Education and Research Foundation commissioned RAND to conduct an exhaustive review of the medical literature and organize a panel of medical experts to evaluate the evidence for a potential link and its implications.

The results of this RAND review confirmed breast implants do indeed appear to be associated with the rare form of lymphoma ALCL.  The report notes there is not yet evidence to show that the cancer is caused by implants or to suggest an underlying mechanism for how the disease might develop.

The study, published online (3rd reference below) by the journal Plastic and Reconstructive Surgery, also finds that the disease takes a slow course and can be controlled by surgical removal of the implant and surrounding capsule.

The conclusions are based on an exhaustive review of the medical literature regarding breast implants and anaplastic large cell lymphoma or ALCL, a type of immune system cancer that was first linked to breast implants more than a decade ago, and input from a multidisciplinary expert panel.

"Much more research is still needed to explore the link between breast implants and ALCL and the clinical significance of this rare disease, but our findings provide useful information for both patients and physicians in the near term," said Dr. Soeren Mattke, the study's senior author and a senior scientist at RAND, a nonprofit research organization.

The panel concluded that the evidence suggests an association between breast implants and anaplastic large cell lymphoma, but cannot definitely prove that implants cause the disease nor explain how the implants might trigger ALCL.

The experts recommended that the appearance of a fluid-filled sac near a breast implant six or more months after surgery should lead to a thorough diagnostic evaluation for anaplastic large cell lymphoma. They also concluded that the diagnosis of anaplastic large cell lymphoma should result in a complete evaluation to rule out spread of the disease outside of the breast capsule (the lining that forms around the implant), followed by removal of the implant and capsule.

Experts did not believe that disease confined to the implant capsule warrants radiation treatment or chemotherapy after surgery and expressed the belief that the risk of recurrence or development of systemic disease following surgical removal was low, but that close clinical follow-up was necessary.

The U.S. Food and Drug Administration and the American Society of Plastic Surgeons recently announced an effort to create a registry that will collect information on women with breast implants who have been diagnosed with anaplastic large cell lymphoma in order to gather information that will help increase understanding of the disease.

Health care professionals are requested to 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 at http://www.fda.gov/Safety/MedWatch/default.htm or
by calling 800-332-1088.


REFERENCES
1.  RAND Corporation;  Press Release April 19, 2011
2.  FDA safety alert; January 2011

3.  Anaplastic Large Cell Lymphoma and Breast Implants: Results From a Structured Expert Consultation Process; Kim, Benjamin; Roth, Carol; Young, V. Leroy; Chung, Kevin C.; van Busum, Kristin; Schnyer, Christopher; Mattke, Soeren; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 April 2011; doi: 10.1097/PRS.0b013e31821f9f23

4.  Anaplastic Large Cell Lymphoma and Breast Implants: A Systematic Review; Kim, Benjamin; Roth, Carol; Chung, Kevin C.; Young, V. Leroy; van Busum, Kristin; Schnyer, Christopher; Mattke, Soeren; Plastic & Reconstr Surgery., POST ACCEPTANCE, 25 February 2011; doi: 10.1097/PRS.0b013e3182172418

What They Hear….

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

This past week the comic strip Baby Blues has been doing a “When you say…..They must hear” series.  It has made me think this phenomenon in medical practice.

…..
Here’s one:
When a plastic surgeon says “Your scar will fade over time.”
Patients often hear “Your scar will disappear over time.”

Fracture II or Roses

A couple of years ago I made my first quilt using this technique called fracturing.  This time I started with four of these pieces of fabric I then cut into the pieces as described (see this post).

I mis-cut one of the four so ended up with a gap in the layout.
To correct this (as I didn’t have a fifth piece so I could just re-cut it), I inserted red squares so it would look like a ribbon woven in.
Here is the finished quilt.  It is machine pieced and quilted.  It measures approximately 29 in square.
I quilted it with gold metallic thread on the front using beige cotton thread in the bobbin.
Here is the back before I sewed on the sleeve and label.

More on Hand and Face Transplantation

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

There was a lovely news article on the first California hand transplant patient in the LA Times earlier this week:  Hand transplant patient speaks (bold emphasis is mine)

Emily Fennell, 26, last month became the first person in California to have the revolutionary surgery. Six weeks and many hours of therapy later, she has no regrets. …..

On March 5, Fennell became the first person to undergo a hand transplant in California and the 13th nationwide to have the revolutionary surgery. . ….

"It's crazy how good it looks," she said at her occupational therapy session one morning last week at UCLA, where she spends about eight hours a day working on learning how to move her new hand and fingers. "I knew the match wouldn't be perfect, but if you didn't know what happened, you'd think I just had some kind of orthopedic surgery."  ….

Doctors told her that the biggest risk from the surgery comes from the side effects of lifelong use of strong immunosuppressant medications, which can cause high blood pressure, kidney or liver damage, elevated cancer risks and lower resistance to infections. …..

"I decided the benefits were worth those risks," Fennel said. She has adjusted well to the medications.  ….

She has no sensation yet in the transplanted hand. The nerves grow about one millimeter a day from the connections the surgeons made to her arm, and it will be several more months before sensations develop.

"The hand is connected to me. It's mine," Fennell said. "But until I have feeling in it, it's not going to feel like mine."  ……….

Her therapists encourage her to say "my hand" instead of "the donor hand." It's a psychological adjustment that runs parallel to the physical challenges she deals with.  ……..

This news article coincides with my reading of the journal article on issues related to face transplantation (full reference below).  Both hand and face transplantation have similar issues to other solid organ transplantation.  One of the big issues with hand transplantation is whether the risks are worth it as a hand transplant is not a live-saving procedure as a heart or liver transplant is.

From the article

Two of the world's first four face transplant recipients acquired cytomegalovirus viral infection by means of their donated facial organs. Also, the French experience, and our own, has been challenged by cytomegalovirus reactivation and graft rejection, therefore necessitating a critical evaluation. The authors have also learned, from their own experience, that facial composite tissue allografts containing mucosa and paranasal sinuses present a distinct challenge with regard to their accompanying flora.

Conclusions: Although the risk of donor-derived cytomegalovirus is acceptable in life-saving solid organ transplantation, for face transplantation patients, the scenario is different. When the authors' team performed the first nearly total face/maxilla transplantation (December of 2008), there was little known regarding the consequences of cytomegalovirus-related donor transmission in face transplantation. Therefore, the authors now recommend that all candidates be fully informed as to the risks of cytomegalovirus/infectious transmission and that aggressive viral, bacterial, and fungal prophylaxis be instituted.

As with the young women who would give a year of life for a perfect body, it is a question for the individual (I am coming to believe) to decide.  But for them to decide, we surgeons/doctors must do a better than good job at educating them as to what the risks are AND as to the reality of the limitations that will remain.  The new hand will never work as well as the non-injured one did. 

Read Wolf’s comment on my blog post regarding the Florida student who had a hand transplant.

REFERENCE

Cytomegalovirus and Other Infectious Issues Related to Face Transplantation: Specific Considerations, Lessons Learned, and Future Recommendations; Gordon, C R; Avery, R K; Abouhassan, W; Siemionow, M; Plastic & Reconstructive Surgery. 127(4):1515-1523, April 2011; doi: 10.1097/PRS.0b013e318208d03c

Spring’s Poison Ivy Warning

Updated 3/2017-- photos and all links removed as many no longer active. 

This past weekend I helped my husband and his mother clean up some debris from the storms which had come through Thursday night/Friday morning.  Here are before and after photos.

Around the periphery of her yard and growing up her trees is poison ivy.

If you have read my blog over the past few years, you may recall that poison ivy and I don’t mix well.  I seem to have managed to not accidently grab any of it when picking up limbs and debris.   I am very thankful.

Still, it’s time to remind myself and you to watch out for poison ivy as you get outside to walk and play.

……

Here is a “updated” version of my post from May 23, 2008

I love to walk in the woods with my dog. I am lucky to have a neighbor who has a trail through her woods around her pond that she encourages us to use. This time of year I have to watch out for poison ivy. In the picture here you can see the poison ivy (leaves of three) intermingled with some Virginia Creeper (five leaves). I find both very pretty.

However, to the poison ivy I tend to react like this (photo credit):

Dr. Paul Auerbach wrote a review of the product Zanfel in 2008.  In the comment section White Coat left this helpful suggestion

One of the other things that helps to some degree is "Ivy Block" - it allegedly keeps the urushiol from binding to the skin.  http://www.ivyblock.com/ivyblock.php
Also, TechNu is reported to work as well as Zanfel, but is significantly less expensive.  http://www.teclabsinc.com/products.cfm?id=1F5604C8-9D05-4675-56129F6D83DF2417§ion=1

Also, check out the post he did “Poison Ivy – Son of an Itch”

REFERENCE
Leaves of Three, Let Them Be: If Only It Were That Easy; Medscape Article, May 28, 2004; Patricia L Jackson Allen, MS, RN, PNP, FAAN

Shout Outs

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

Bedside Manner is the host for this week’s issue of Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to Get Better Health’s Grand Rounds, Volume 7, Number 30.  This week’s theme borrows from Patriot’s Day which commemorates the anniversary of the Battles of Lexington and Concord, Massachusetts, the first battles of the American Revolutionary War, on April, 19, 1775.    …….…..

……………………………

Emily, @crzegrl15, who used to blog at crzegrl, flight nurse has come back to blogging with a new blog name:  FlightEMS.com.  She tells her blogging story in her post, After Seven and a half years, crzegrl.net becomes FlightEMS.com

Seven and a half years is a long time. My very first post on crzegrl was on 12 November 2011, a fitting date for me as so many major events have happened on that day for me.

I swore into the Army.
I closed on my first home.
My friend Danny died.
My blog was born.

I remember purchasing my first domain in 1999 (homesickangel.net) and struggling to create what was, then, an online journal, on software that didn’t easily support the idea. Who would have predicted that I would be considered an old timer in the blogging world. ……

……………………………….

H/T to @drval, Better Health,  for putting together her #HealthyRT : Join The HealthyRT Experiment: Let’s Use Twitter To Drown Out Health Misinformation

A few days ago I published a blog post about Dr. Mehmet Oz NOT being a trustworthy source of health information. It set off a firestorm of blog comments, tweets, and Facebook sharing – all because people (like me) had developed sincere concerns about the safety of viewers who might take his advice to heart. The outpouring of commentary, and the rapidity of the response made me wonder: can we harness this power for future good? Could we counter Dr. Oz’s (and others like him) misinformation with peer-reviewed content that’s easily accessible by Twitter and Facebook? ……….

…………………………………….

Check out the guest post on KevinMD  by Roy Benaroch, MD:  Should the HPV vaccine be given to boys?

Beth wrote, “I plan on having my daughter vaccinated against HPV when she’s the right age (which is what by the way?). Recently, some friends were saying they were planning to have their sons receive the vaccine as well because although males obviously don’t get cervical cancer, they can spread HPV and put their future partners at risk. Is this true?”

Yes, men can catch HPV infections, and spread them to women. But that might not be reason enough to have your son vaccinated.

………………………………………..

The current edition of the American Quilter magazine has an article: Children Speak Through Quilting – which features Ramona Lindsey’s project which began when she was a teacher at Woodlawn Community School.  Because a subscription is required to view the online article (p 30-32), I went searching for a free article to show you the work:  Check Out the Stop the Violence Traveling Quilts Exhibit (photo credit)

Mrs. Ramona Lindsey’s Fourth graders, in partnership with Woodlawn Community School, are taking their feelings about the high level of violence in Chicago through the Stop the Violence Traveling Quilts Exhibit.  Drawings are used to share how they really feel.  While some pictures spoke louder than others, the messages were all the same – STOP THE VIOLENCE!

Topical Treatment of Hypertensive Leg Ulcers – an Article Review

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

An interesting little article in the April issue of the Archives of Dermatology (full reference below) by Senet and colleagues on the treatment of hypertensive leg ulcers with platelet-derived growth factor-BB.  Interesting, in that, it reported a negative outcome or lack of superiority for one treatment over another.

First, what is a hypertensive leg ulcer (HLR)?

According to the Graves and colleagues (second article referenced below), Martorell, a Spanish cardiologist (1906-1984) first noticed the relationship between hypertension and alterations in arterioles and leg ulcers in 1945.  Martorell called these ulcers hypertonic or hypertensive ulcers of the legs and published the first 4 cases. 

Originally, Martorell described the following diagnostic criteria:

a) Ulcer located anterolaterally on the lower legs,

b) arterial diastolic hypertension of the lower legs,

c) hyperpulsatility of the arteries of the lower legs,

d) absence of arterial calcification,

e) absence of CVI (chronic venous insufficiency),

f) symmetric lesions (either ulceration at the same time or as a result of previous ulceration of the opposite leg),

g) increased pain in horizontal position, and

h) female sex.

Graves also noted that soon after Martorell reported his 4 cases, 11 other cases were published by Hines and Farber confirming the existence of these ulcers -- thus, the ulcer is also called the "hypertensive ulcer of Hines-Farber."

Senet and colleagues note, “Hypertensive leg ulcers (HLUs), first described in the 1940s, were renamed Martorell HLUs or necrotic angiodermatitis by American and European dermatologists.”

So HLU’s are also known as “hypertensive ulcer of Hines-Farber” and as necrotic angiodermatititis.

……

Whatever it is called, HLR’s are extremely painful, superficial, rapidly spreading, necrotic wounds on the dorsolateral part of the leg which have red purpuric margins.  The pathophysiologic characteristics of HLUs include dermal and subdermal vessel arteriosclerosis, inappropriate local vasoconstriction, but no significant involvement of the large deeper vessels.

Senet and colleagues note the medical management of HLU is currently symptomatic: controlling hypertension and diabetes, wound debridement, and application of the usual dressings.  Surgical management is often skin grafts.

Senet and colleagues conduced a multicenter, randomized controlled trial from March 2004 to June 2009 to determine the effect of topical becaplermin gel on HLU healing.

Eligible participants (n=59) were randomly assigned to receive either topical becaplermin gel-BB, 0.01% (Regranex gel) or hydrogel (Duoderm Hydrogel).

For both groups, treatment began 1 week after randomization, during the second visit (week 0), and all patients received the same daily local care: wound irrigation with normal saline, application of a continuous thin layer of gel on the wound, covering with a moist saline gauze and a bandage.

Each reference wound surface was estimated on treatment day 1 by measuring wound length and width to determine the appropriate becaplermin gel or hydrogel volume to apply that was maintained throughout the study [a single 15-g tube is enough to treat a 5-cm² wound for 6 weeks (1 cm of gel/cm²/d)].

The patient or his/her caregiver was instructed on proper wound care, gel application, and wound dressing, which was continued until complete healing or for a maximum of 8 weeks.   All patients were observed through week 12.

Topical becaplermin, compared with hydrogel dressing, did not improve the complete wound closure rate (primary outcome measure) after treatment week 8 and had no significant effect on quality of life, pain, or median wound area.

Complete wound closure rates for becaplermin and hydrogel, respectively, were 18% (5 of 28 patients) and 10% (3 of 31 patients), respectively, at week 8 (an 8 percentage-point difference; 95% confidence interval [CI], –10.3 to 26.0) and 36% (10 of 28 patients) and 26% (8 of 31 patients) at week 12 (10 percentage-point difference; 95% CI, –13.6 to 33.4).

REFERENCES

1.  Topical Treatment of Hypertensive Leg Ulcers With Platelet-Derived Growth Factor-BB: A Randomized Controlled Trial; Patricia Senet; Eric Vicaut; Nathalie Beneton; Clelia Debure; Catherine Lok; Olivier Chosidow; Arch Dermatol. 2011;0(2011):archdermatol.2011.84. 

2.  Martorell Hypertensive Leg Ulcer:  Case Report and Concise Review of the Literature; Graves JW, Morris JC, Sheps SG. J Human Hypertension. 2001;15:279-283. (pdf file)

3.  Las ulcers supramalleolares por arteriolitis de las grandes hipertensas; Martorell F.;  Actas del Instituto Policlinico de Barcelona. 1945;1:6-9. (not read by me)

4.  Ulcer of the leg due to arteriosclerosis and ischemia occurring in the presence of hypertensive disease; Hines EA Jr, Farber EM.; Mayo Clin Proc. 1946;21:337-346.  (not read by me)

Stairway to Heaven Baby Quilt

This baby quilt was made back in 1996 for my friend Marla who left her surgery residency after the fourth year to pursue her love of languages.  She now does medical translation work for John Hopkins.

The center area of the quilt is composed of courthouse step blocks.  I machine pieced the quilt but had Scottie Brooks do the hand quilting for me.  The quilt measures 38.5 in X 61.5 in.

The young man holding the quilt is the “baby” it was made for all those years ago.  Thank you Marla for the photos.

Another view with it oriented upright.
A close up to show the lovely fabrics.