Sutureless Blood Vessel Repair

Updated 3/2017-- photos and all links removed (except to my own posts) removed as many no longer active. 

If this works in humans as it has in rats, then it will be a huge advance in microvascular repair.  The full article is referenced below (I did not read in it’s entirety due to pay wall).   (photo credit)

We have developed a new method of sutureless and atraumatic vascular anastomosis that uses US Food and Drug Administration (FDA)-approved thermoreversible tri-block polymers to temporarily maintain an open lumen for precise approximation with commercially available glues. We performed end-to-end anastomoses five times more rapidly than we performed hand-sewn controls, and vessels that were too small (<1.0 mm) to sew were successfully reconstructed with this sutureless approach. Imaging of reconstructed rat aorta confirmed equivalent patency, flow and burst strength, and histological analysis demonstrated decreased inflammation and fibrosis at up to 2 years after the procedure. This new technology has potential for improving efficiency and outcomes in the surgical treatment of cardiovascular disease.

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Currently, vascular microanastomosis (photo credit) is done by suturing.  Arteries 1 mm in diameter usually require 5 to 8 stitches, and veins require 7 to 10 stitches.  There is a risk of thrombosis even with the most meticulous repair -- total thrombosis rate 8%, with  no significant patency difference noted between the continuous suture technique and the interrupted suture technique in any vessel category.

REFERENCE

1.  Vascular anastomosis using controlled phase transitions in poloxamer gels; Edward I Chang, Michael G Galvez, Jason P Glotzbach, Cynthia D Hamou, Samyra El-ftesi, C Travis Rappleye, Kristin-Maria Sommer, Jayakumar Rajadas, Oscar J Abilez, Gerald G Fuller, Michael T Longaker, Geoffrey C Gurtner;  Nature Medicine, 2011; DOI: 10.1038/nm.2424

2.  Sutureless Method for Joining Blood Vessels Invented; ScienceDaily (Aug. 28, 2011)

3.  Technique for Microanastomosis; Wheeless Textbook of Orthopaedics, June 28, 2011

4.  Vascular Skills Lab Two (pdf)

Shout Outs

 Updated 3/2017--photos and all links removed (except to my own posts) removed as many no longer active.

Health 3.0 Blog  is the host for this week’s Grand Rounds. You can read this week’s edition here.

Welcome to this week’s edition of Grand Rounds. You can find the medical blogosphere’s best next week at Covert Rationing.

We’ve taken a different approach this week to organizing Grand Rounds. You can find all the submissions below in this post. But, we’ve also selected quotes from each blog and highlighted those on the main page. Consistent with our themes, we’ve also tagged all the posts related to health, happiness, design or innovation. You can search for these tags to see how each theme plays out. We’ve also added bits of commentary to some of the individual quotes and summaries - especially when we’ve read something recently that relates to the general topic or idea………

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I was aware of this new children’s book "Maggie Goes on a Diet" (I haven’t gotten to read it, but title makes me feel focus is wrong. Should be focused on eating healthy diet.), but @LindaP_MD’s tweet alerted me to a nice interview @drclaire did with @BridgetBlythe on @NECN about the book:  Talking to kids about weight, obesity

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Did you see the interview Albert Schweitzer (@SchweitzerASF) did with @docgurley?  --“The Addictive Power of Spending One’s Days Doing Something Worthwhile”: Five Questions for a Fellow with Jan Gurley, MD

Since 1979, ASF’s Lambaréné Schweitzer Fellows Program has selected senior U.S. medical students to serve clinical rotations as junior physicians at the iconic Schweitzer Hospital in Lambaréné, Gabon, Africa—the region’s primary source of health care since Dr. Albert Schweitzer founded it in 1913.

Jan Gurley, MD is one of those Fellows. ……….

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Check out the interview of @drkt at OnSurg.com:  Featured Surgeon, late summer 2011

First-year surgery resident Dr Katie has been sharing her educational experience online since undergraduate school. OnSurg is grateful for her participation in our Q & A:

What’s your story?

I first knew I wanted to be a doctor my senior year of high school (was going to go into Forensics from 7th-12th), and was told I’d never make it and that I’d change my mind. I knew what I wanted and wanted to prove people wrong at the same time. It wasn’t until the summer after my junior year that I actually had the chance to be in the hospital. When that time came, I knew that medicine was right for me.  ………….

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H/T to @DrSnit tweeting this:  “Monsters in the Dark by @chemo_babe bit.ly/reZDOi Parenting through cancer. "I don’t want to be the little boy whose mommy died.”   I hope you will go read the entire post.

…………….He grew earnest.
“But your heart will stop beating when you die. You can’t have love without a heart.”
“Love doesn’t just live in my heart. My love for you will continue on in your heart.”
Then he burst into tears and threw his arms around my neck.
“Mommy, I don’t want to be the little boy whose mommy died.”
I embraced him, stunned into silence. I looked for words of comfort. …………….

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H/T to @sandnsurf for finding and posting these “highly inappropriate adverts”:  High quality adverts (photo credit) 

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H/T to @BiteTheDust  for the link to this news article:   13 yr old designs breakthrough solar array based on Fibonacci sequence.

Plenty of us head into the woods to find inspiration. Aidan Dwyer, 13, went to the woods and had a eureka moment that could be a major breakthrough in solar panel design. ………

You can read Aidan’s award-winning essay here, which walks you through his experiment design and his results. But the short story is that his tree design generated much more electricity — especially during the winter solstice, when the sun is at its lowest point in the sky. At that point, the tree design generated 50 percent more power, without any adjustments to its declination angle. …………..

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The International Quilt Festival Summer 2011 Newsletter has a very nice tutorial for making a Patchwork/Purse Tote (pdf).  (photo credit)

Record Transfer Requests

Requests for transfer of records are coming in response to the closing practice letters.

These bring dueling emotions: pleasure in the knowledge the individual is planning for continued care AND the sting of rejection.

Intellectually, I know the second makes no sense. I am the one who is leaving them and the practice.

Still....

Razorback Blanket with Quilted Border

My nephew is headed to my old alma mater, University of Arkansas, this fall.  He is starting law school.  His birthday is in early September.   These two facts and then finding the fleece fabric in the “remnants bind” at Hobby Lobby inspired me to make this.

The fleece piece was not large enough for a guy my nephew’s size (well over 6 ft tall), but I had some left over Arkansas Razorback cotton I had used for a surgeon’s cap.

The border is reversible.  I machine pieced the 4-patches of red and white to the larger black patches.  The end borders (front and back) were sewn to the fleece first.  The fusible batting (good use for leftovers) was carefully placed in-between.  Then the two longer side borders (front and back) were done in the same fashion.

I then machine quilted the border.

Rather than make a label, I used the letter/number feature on my machine to sew one.

Pressure Treatment of Auricular Keloids

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

I have written of keloid treatment (general, not site specific) previously.  I have always tried to include pressure treatment as part of the plan when treating keloids of the ear lobe.   This pressure treatment came in the form of pressure earrings  -- clip-on, disc-shaped. 

The recent article (full reference below) in the Archives of Facial Plastic Surgery journal introduces a new pressure device which looks like it will work better than what has been available (photo credit) 

and as can be seen in this photo the upper ear can be treated with pressure which has not been possible with the clip earrings. (photo credit)

These devices were custom made which makes them more expensive than off-the-shelve pressure earrings and may make them difficult to get if no one is available in your area to make them.

From the article:

Pressure therapy was popularized in the 1970s after clinicians noticed that pressure stockings used over lower extremity burns caused scars to mature faster with decreased erythema and thickness.  Pressure causes localized hypoxia, resulting in fibroblast degeneration and disintegration owing to decreased intercollagenous cohesion and increased collagenase activity.

Furthermore, pressure has been shown to shorten scar formation time, reorient collagen fibers within the scar to become parallel to skin surface, increase hyaluronic acid levels, and decrease chondroitin sulfate levels, all of which help to flatten the initially elevated scar tissue and reduce recurrence rates.

According to various reviews and guidelines, pressure therapy is a long-standing therapeutic option for keloids, producing thinning and pliability. Although the precise biomolecular mechanism of compression is not understood, success rates of at least a partial reduction of derailed scars, from 60% to 85%, have been reported from a monotherapeutic regimen of pressure therapy. The combination of surgery with postoperative pressure treatment showed good response rates of about 90% to 100%, especially after excision of auricular keloids. ………

Overnight use of the new pressure device seems to be an effective extension of established auricular keloid therapy, with additional potential for prophylaxis of recurrence. Preliminary work was presented and intended to produce a demonstration of an optimized treatment modality. Analysis of this therapeutic regimen based on a larger sample size, and long-term follow-up will be the substance of a future report.

REFERENCE

Auricular Keloids: Combined Therapy With a New Pressure Device; Gregor M. Bran, Jörn Brom, Karl Hörmann, Boris A. Stuck; Arch Facial Plast Surg. 2011;Published online August 15, 2011. doi:10.1001/archfacial.2011.57

Frontline's Football High

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

With high school football season upon us, Frontline reran their show “Football High.”  It features two Arkansas football players who suffered heat stroke last year (one survived, one did not).  There is also a good discussion of other injuries, particularly concussions, among high school football athletes.  Here is a preview but it can be watched in it’s entirety here. 

There is more info here on Frontline’s website.

Grand Rounds Volume 7 Number 48

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

Thank you for coming to Grand Rounds 7:48, the weekly collection of the some of the best in online medical writing from all (doctors, nurses, patients, healthcare professionals).  Next week’s will be hosted by Health 3.0 Blog.

Along with the excellent posts, I’ve included pictures of the changes cameras have gone through over the years – from the pin-hole camera to digital phone cameras.  Enjoy!

Dr. Charles hasn’t had much time lately, but I was able to scribble down this pediatric poem:  A Beating.  As one commenter figured out, Dr. Charles is a new father.  Congratulations! and thanks for the poem.     (camera obscura – photo credit)

Jordan, In My Humble Opinion, writes about the covenant of being a doctor:

I mean it is kind of lonely....being your doctor. I picture it as sort of a covenant. Between you and I.

On one side you. And your family. And friends. Your house and your dogs. Your communities and lives.

On the other side me. Alone.

Skeptical Scalpel has written a post,  Do Surgeons Suffer From "Decision Fatigue"?, in response to a NY Times Magazine article.

……..Query: Has anyone seen studies linking surgical error rate to the time of day?”

The answer is, “Yes.”

But if the question had been, “Anyone seen any good studies linking surgical error rate to time of day?” the answer would have been, “No.” ………….

Dr. Schattner, MedicalLessons, talks about what she has learned from the offbeat and in some ways disturbing story of a young woman who's made a business of having had a rare form of cancer, epithe­lioid heman­gioen­dothelioma:   Notes on Crazy Sexy Cancer             (daguerreotype camera – photo credit)

Dr. Val, Better Health, asks Should Pharmacies Limit Teen Access To Protein Supplements?

A strange thing happened to me at a CVS pharmacy two days ago. I was attempting to purchase a protein drink when the girl at the counter asked me to show her my I.D. card. I assumed she meant my CVS savings card and was sincerely confused when she rejected it, saying, “No, your picture I.D.”

I dug through my purse to find my driver’s license while the girl explained,

“You have to be 18 years old to buy this product. I need to type in your date of birth into the computer.”  ……

Carolyn is a heart attack survivor who blogs at  HEART SISTERS.  In her post,    "How to be a good patient" , she shares her experiences and expertise she has gained in having a chronic illness.

Beth, Calling the Shots, discusses the controversial use of “war” terminology to describe cancer in her post:  Young Adults With Cancer: Why 'War' Analogies Work But 'Warrior' Analogies Do Not.

Many, many people don't like war analogies when it comes to cancer,  especially those of us who've been afflicted by it. We often hear that a comrade has lost or won his or her battle with cancer. Or about society declaring war on cancer. Or about someone fighting bravely against the disease.

Sure, this language of war is cliche, giving us a picture of the brave warrior fighting to the death against cancer.  ………….

Dr. Pullen

shared in his submission email his thoughts of using his own name as the name of his blog:  “I've thought a long time about why on earth I chose to use just my name as my blog name.  Thinking back it was probably not one that is going to draw much interest except from maybe the few who know me.  Maybe it was my interest in eponymous diseases.  This prompted me to have some fun with a word that is not on the tip of many tongues.”  Enjoy his post:  Eponymous Blog on Eponymous Diseases.         (Brownie   --- photo credit)

DrRich explains why direct-pay medical practices, contrary to official opinions, are not only ethical, but also may be the only remaining way for doctors to practice medicine in accordance with traditional medical ethics:  An Epiphany on Direct Pay Practices.

HealthBlawg takes a look at an unusual acquisition: a large health care system acquiring a Medicaid HMO.  What does it mean?  Check out their post:  Partners Health Care acquiring Neighborhood Health Plan: The 800-Pound Gorilla and the Fig Leaf?      (Canon F1 – photo credit)

Over at InsureBlog, Henry Stern reports on new breast cancer coverage for women only, and why that's not necessarily such a good thing:  Keeping Abreast of Cancer: Double-Standard edition

Laika,  Laika's MedLibLog, in her post -- RIP Statistician Paul Meier. Proponent not Father of the RCT – tells us  Paul Meier who recently died really had a great influence as a statistician in promoting the RCT (& he "invented" the survival curve).  Her post, however, focuses on the wrong headline in Boing Boing (the first headline she saw about the death of Paul Meijer), claiming that Paul is the father of the RCT.  In her post she tried to find out the real origin of the RCT.

Rick Pescatore, a medical student and EMT who blogs at Little White Coats  submitted a post --Help I've Fallen and I can't get up!  -- which details his experiences with senior falls as an EMT and provides a resource for seniors in his area (Philadelphia and Southern New Jersey area) to receive free medical alert devices from the PCOM Emergency Medicine Club.    (Poloraid  -- photo credit)

Amy, DiabetesMine, wants us to know about the upcoming summit on noncommunicable diseases at the UN next month:  Diabetes Battles for Obama’s / World’s Attention

Anybody heard about the first-ever upcoming United Nations (UN) High-Level Summit Meeting on Non-Communicable Diseases (NCDs), in which heads of state from around the world will meet in New York City on Sept. 19 and 20?  Um, we’re not sure President Obama has either, and that’s very bad news for diabetes, according to the International Diabetes Federation (IDF). ……….

Ryan,  ACP Internist blog, looks at the recent trends in healthy lifestyle choices by adapting two recent studies (and adding a touch of humor):   Smoking in front of the television must be really bad

ACP Hospitalist blog  feels doctors may already have all the skills they need to make the right diagnosis:  History and physical the best way to diagnose patients   (iPhone which includes camera  -- photo credit)

Geeners, Code blog: Tales of a Nurse, gives us a view of what it’s like to be a school nurse:  Interview - School Nurse

Well, what better time to post my interview with Erin at Tales of a School Zoned Nurse than now, when everyone’s headed back to the classroom? ……

Steven J. Seay, Ph.D. presents us with a timely post as school is back in session:   School Refusal & Parental Stigma: Am I a Bad Parent?

Like any other behavior, school refusal does not have a singular cause. This is pretty self-evident, but in the heat of the moment when your child is having a tantrum, this fact is quickly forgotten. It is simply too easy to conclude that you have raised a “bad child.” Sadly, much of society might wrongly agree with you. ……..

Louise, Colorado Health Insurance Insider, discusses the PPACA and changes made over the year since it was signed into law in her post:   Seeking Certainty

…. It's been over a year since the PPACA was signed into law.  Many Americans are eagerly awaiting 2014 when their health conditions will no longer limit them to high risk pools and when their health insurance premiums will be subsidized.  Health insurance carriers have already made numerous changes to comply with the law, with many more planned for the next few years.  A lot of states are working hard to come up with health insurance exchanges that will best serve their residents' particular needs.  Many other states have mounted costly legal battles against the individual mandate.  Some states - like Colorado - have done both.  In a nutshell, an awful lot of money and time is being expended on a law that still has a very uncertain legal future……….

Pathologist Gizabeth, Metodical Madness, sends us a poem, Monarch Butterfly and well wishes. 

REFERENCES
History of Photography by Mary Bellis
The Development of the Camera over the Years by Mandi
Canon Camera Story
History of the Digital Camera by Mary Bellis

Time for New Journal Subscription Model

I like open access, but I’m realistic.  The big journals (NEJM, JAMA, society journals, etc) aren’t likely to go that route anytime soon though more of them are making select articles available in full for limited time periods.

I have been thinking of the current subscription model more and more as my print journals stack up in my office and I read the articles online.  It has really been in my thoughts as I am closing my practice and have had to decide what to do with all the journal volumes accumulated over the past years.

Currently, subscription to a journal (ie my PRS journal) gives me both a print copy and the online access.  The online access allows me to search all years of the journal, even those prior to my subscription.  I love this.  I no longer go to the print indexes to search for a topic or article.  I lose this access if I cancel the subscription.

What I propose is a subscription model that would allow the subscriber to chose online access only without receiving the print version.   I would like this subscription model to allow the subscriber long term online access to the years (ie 1990 to 2015) of active subscription.

I believe it is possible to create a database of subscribers and years of full subscription so that this would be possible.   I also think the publishers savings from the mailings and print could be put towards keeping up this database.

Note, I am not asking for continued full access to all the old and any new journal volumes.  Just the ones I would have access to if I kept all the print volumes, but with this new model I would not have a storage problem of 20 plus years of not just one journal but several.

Anyone else have any thoughts on this model? 

…..

By the way, I’ve decided to just recycle the print copies of the journals I have.  I don’t have room at home and don’t want to end up being an episode of Hoarders.  I will continue my subscriptions as a way to keep current as I will continue to need CMEs.

More Fabric Postcards

This summer I seem to have been on a fabric postcard making spree.  Here are several more I have made.

This one I call “Girl with Basket of Pinwheel.”  It is 4.5 in X 5.5 in.

This one I simply call “Flowers.”  It is 3.5 in X 5 in.
This one I can’t decide on a name.  I want to call it either “Don’t Look Back” or “Are You Coming?”   It is 5 in X 7 in.

This one I call “Home Sweet Home.”  I mailed it to a friend who recently moved cross country to a new home.  I hand embroidered flowers on the fabric scene.  It is 5 in X 7 in.
This one I call “Let’s Ride.”  It is 5 in X 7 in.
This one I call “Leap Frog.”  I mailed it to @geeners who indicated that she loved my postcards.  It is 5 in X 7 in.
Here is the back of “Leap Frog.”  Most are just a simple plain back.
This one I simply call “Friends.”  It is 5 in X 7 in.
This one I call “Make a Wish.”  I hand sewed beads/sequins onto the cupcake and flame.  It is 5 in X 7 in.
This one is a simple fabric background with a ruched rose hand sewn onto to it.  I call it “Single Rose” and mailed it as a birthday card to a teacher from high school, Mrs. Bronnie Rose.

Role Playing to Learn Communication

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

I was alerted to this Archives of Surgery article (full reference below) by MedPage Today:  Role Playing Boosts Surgical Residents' Bedside Manner.

I find it intriguing.  Role playing gives you a chance for a “do-over” when you make a social or communication faux pas. 

So much of medicine is communication.  Those of us who have been at it for years, deliver bad news differently (learned the hard way) now than we did previously.  You choose your words more carefully (though I still occasionally screw up).  Some words are more emotionally charged than others.  Some patients want more information than others. 

The University of Connecticut Health Center conducted a prospective study  of a pilot projected designed to  teach surgical residents patient-centered communication skills.

The study offered 44 general surgery residents the opportunity to participate in the three-part patient communication curriculum: A pre-test, training, and a post-test.  Only 30 completed all three parts.

The pre-test assessed general communication skills awareness of the resident while he/she delivered a new diagnosis of either breast or rectal cancer to a patient. The evaluation was done by a standardized patient instructor.

The training portion required residents to attend a 90-minute workshop that involved a lecture from a professor of surgery and formal instruction from the director of the center's clinical skills program, followed by a 30-minute role-playing session.

The post-test assessment re-evaluated the residents by the standardized patient in a crossover fashion (those who previously participated in a breast cancer diagnosis now participated in a rectal cancer diagnosis and vice versa).

The study authors concluded:

Residents' assessment of their patient communication skills indicates that there is an immediate need for a formal educational curriculum. Our results show that case-specific improvements seem more amenable to measurable improvement than general communications skills, at least with the limited short-term training that we used. Such skills can be assessed over a longer period, perhaps by incorporating this model and assessments from year to year.

Surgical and nonsurgical residency programs will benefit by helping residents incorporate patient needs and opinions into the care team's decision-making process. Principles such as emotional support, transition and continuity of care, provision of information and education, involvement of family and friends, and respect for patient values and preferences will form the basis of our educational series.

REFERENCE

Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills; Rajiv Y. Chandawarkar; Kimberly A. Ruscher; Aleksandra Krajewski; Manish Garg; Carol Pfeiffer; Rekha Singh; Walter E. Longo; Robert A. Kozol; Beth Lesnikoski; Prakash Nadkarni; Arch Surg. 2011;146(8):916-921.

Changes

Due to many things, I will be closing my practice over the next few months and going to work for the Arkansas Disability Determination Services (DDS).  I only recently made the final interview and signed the contract.  My first day there will be October 3rd.  I don’t want to discuss the reasons, but I want you to know how difficult a decision this has been for me.

I have not hinted to patients that I might leave until recently.  I didn’t want them to leave me prematurely, so I now worry that I may not have given them enough heads up.  Such a blurry line between taking care of yourself/family and abandoning patients. 

I don’t think I have abandoned any of them, but I wonder if they might feel that way.  I have managed to “leave the door open” to see current patients on Fridays and Saturdays (if need be) over the next few months. 

Yesterday, I got the letters to patients, organizations (ie AMA, Arkansas State Medical Board, AMS, PCMS, etc), and hospitals in the mail. 

There are many things left to do, but I am fortunate to have a young colleague who is willing to allow me to transfer the charts to him.

I have begun making the phone calls regarding cancelling malpractice insurance, office overhead insurance, etc.   I will have to figure out a new voicemail message and when to change it.

I have been caught mid-contract with several leases (ie Pitney Bowes, credit card processor, and the actual office), but so it goes.  I have yet to talk with the building management.  I am hoping they will be able to sublease it for me.

I hope to continue to blog.  I have to maintain my medical license and do CMEs and blogging has become a way of learning for me.  Not sure what to do with the title as I will no longer be “suturing” for a living, but for now it will stay the same.  I will update the header at some point.

Suture for a Living to Host Grand Rounds

I’ll be your host next Tuesday, August 23rd, for Grand Rounds Volume 7 Number 48.   It will be my fifth time as host of this the weekly compilation of the best of the medical bloggers.  I have no specific theme in mind, but if you need a “spark of a suggestion” think of  changes:  schools are back in session, football season will soon begin, and there is just a hint of fall with no more triple digit weather here in the south.   Now apply that to medicine/surgery.

Submissions should be recent.  Please, only submit one (your best) post per blog.  Submissions are welcome until noon (CST) Monday August 22. 

Send an email to me ---  rlbatesmd(at)gmail(dot)com  ---   with Grand Rounds in the subject line.  Please help me out by including your site name, site url, your post  title, post url, your name and a sentence or two about why you think your submission is great. 

 

In the meantime check out my previous four editions:

Grand Rounds 4:33 (May 6, 2008)

Grand Rounds Vol. 5 No. 52 (September 15, 2009)

Grand Rounds Vol 6, No 26 (March 23, 2010)

Grand Rounds Vol 7 No 20 (February 8, 2011)