Xiaflex Is A True Breakthrough for Hand Disorders

By Dr. Elizabeth McLarney

In the coming months you may hear about a new drug for treating cellulite, called Xiaflex. The pharmaceutical manufacturer that makes it just began clinical trials of its effects in January. I am not recommending Xiaflex for treatment of cellulite because I’m not a cosmetic surgeon. I am familiar with Xiaflex, however, because it was originally developed to treat a hand disorder called Dupytren’s contracture. Normally, I hesitate to use words like “revolutionary” when describing medical advancements; few things truly change the way we do something. The arthroscope was revolutionary; it completely changed the way people have surgery, and ultimately not just in orthopedics. But Xiaflex really belongs in that revolutionary category because it has helped us treat Dupuytren’s patients in a much less invasive way.

Dupuytren’s contracture is a disease that causes a person’s fingers to curl down toward their palms. It can also affect the feet but it’s far more prevalent in the hands. There’s a layer of tissue just below the skin called fascia, which gives your skin the flexibility to move and grab things without disrupting or damaging the tendons, nerves, arteries and muscles underneath. Dupuytren’s turns fascia from being soft and pliable into hardened scar tissue that adheres to the skin, tendons, nerves and arteries. It feels like thick cords or nodules under your skin. The fingers can curl all the way down to the palm if it goes untreated, causing a person to completely lose function in the affected digits. You can’t grip anything. You can’t even get your hand in your pocket. It can be a very debilitating disease. In fact, one of the recommendations if the small finger becomes flexed all the way down is amputation.

Elizabeth A. McLarney, MD

The surgical treatments for Dupuytren’s are pretty extreme. In the early 1960s, a Scottish physician named McCash introduced a technique that removed all skin from the palm. The operation restored partial functionality to the fingers. But can you imagine what rehab must be like when you’re waiting for the skin to grow back on your hands so you can use them again? The more traditional surgery has been to make a series of zigzag incisions running from palm to finger, and then remove the cords and nodules. This procedure is fraught with risks of stiffness and nerve or artery damage, however, and the recovery time can be as long as a year.

I started reading about Xiaflex and hearing about it in professional development meetings sometime in 2009. It was being used with good success in Australia, New Zealand and Europe, and I was advising some of my patients to hold on until it was approved by the Food and Drug Administration. When that finally happened in 2010, I went through the training to do the injections. A lot of injections in orthopedic surgeries are made into spaces. Xiaflex is injected directly into the tissue and it essentially eats away at the cord or nodule in that spot. After waiting anywhere from 24 to 48 hours, you numb the hand and manipulate it until you hear a pop. I still jump every time I hear that pop because it’s so loud. But after the pop you can generally straighten the finger all the way out, though it depends on how severe the contracture was to begin with. There is physical therapy afterward to strengthen the hand, and you might wear a splint at night. But it really surprised me how quickly it resolves compared to surgery. You can be using your hand normally within a month.

The other thing that surprised me was the amount of swelling and bruising the injections cause. It looks like somebody has taken a sledgehammer to your hand, and in some people the bruises track all the way up the arm. The swelling subsides as you recover. Risks include the chance of rupturing the flexor tendons in your fingers. There have not been many reports of this happening fortunately, and it is occurring mostly in the pinky finger. Longer term studies may eventually show that there is more risk than benefit to using Xiaflex in smaller finger joints due to the potential for a ruptured tendon. Other risks include incomplete release, need for further injections, skin tears, nerve or blood vessel injuries, or even fracture of the finger. It should be stressed that all Dupytren’s disease, no matter how it is treated, will recur.

We do see a fair amount of Dupytren’s here in southern Vermont. It’s a genetic disease that happens most frequently in males of northern European descent. The condition can also be brought on by excessive alcohol use or certain types of seizure medication; but by and large, it’s a condition passed down from generation to generation. The trouble is most people aren’t diagnosed. They think they’ve sustained an injury to their hand and don’t get it looked at soon enough, which means the disease progresses and makes treating it much harder. We talk about it with primary care physicians when we do presentations on orthopedic issues to make them aware of it.

It’s very easy for an individual to determine whether they need treatment for Dupuytren’s. Try putting your palm flat down on the table. If you can’t do that then you need to get medical attention. The key is not to wait and let it get worse.

Xiaflex is not a cure for Dupytren’s. It could always return in a person who is genetically disposed. But unlike the surgeries, Xiaflex can restore a person’s quality of life faster and with far less risk. Think about a carpenter grabbing a hammer, an office worker typing on a keyboard, or any of the hundreds of other things we do with our hands each day and it’s really exciting that we have this kind of cutting edge treatment available in our community.

Elizabeth McLarney, MD, is a board-certified orthopedic surgeon with Southern Vermont Orthopaedic & Sports Medicine, which also includes Dr. Jonathan Thatcher, Dr. William Vranos and Robert Feinberg, P.A. She can be reached at 802-254-6211.

Daffodil Days are approaching – a wonderful sign of Spring and a way to promote hope for cancer patients. Daffodil Days is a fund raising effort to help raise money for different programs here at Brattleboro Memorial Hospital (BMH) as well as money for the American Cancer Society’s mission to save lives by eliminating cancer. The two major programs here at BMH that we offer our patients are the “Look Good, Feel Better” program and “Road to Recovery”. These programs are funded through Daffodil Days donations. The American Cancer Society provides rides to and from treatments for our patients here at BMH, helps to provide wigs and other products to help patients cope with the changes they endure while be treated. We are very blessed to offer these supportive programs to our cancer patients.

We will be asking for donations through the Daffodil Days promotion through March 2, 2012. Orders must be submitted with payment by March 2. Flowers will be delivered on March 21, 2012.

If you would like to participate in our drive this year, we are offering the following donation choices:

• Bouquets of 10 fresh-cut daffodils – $10 each
• Bear and a Bunch – $25 each (includes Shar N.Hope, a collectible 10″ special edition Boyds Bear and 10 daffodils)
• Potted daffodil bulbs – $15 each (3 multi-stem bulbs in a pot)
• Gifts of Hope – Start at $25 (Gift of Hope donations support the lifesaving research and programs of the American Cancer Society, and allow us to deliver daffodil bouquets to cancer patients in treatment centers.)
• Bear Hugs for Hope – $25 each (Your donation will help fund our programs and allow us to provide bears to children impacted by cancer.)

CLICK HERE TO PRINT ORDER FORM

Orders can be made by cash, check (payable to American Cancer Society) or credit card. Order forms available in the BMH mailroom, at the information (lobby) desks throughout BMH and through the Oncology Department. Once you have made your choices, please forward your order to the Oncology Department along with your method of payment. You will be given/sent a receipt that can be used for tax purposes. Any questions please contact the Oncology Department at 802-257-8221.

Aimee Creelman, Kristin Anderson, and Debbie Kitzmiller from the Brattleboro Memorial Hospital Birthing Center will be traveling to Nicaragua in March on a volunteer mission to raise awareness about lactation and other issues related to labor, delivery and newborn care.

Debbie Kitzmiller, Aimee Creelman, Kristin Anderson

The group will spend one week in Leon, Nicaragua’s second largest city, at the request of Hospital Escuela. According to BMH Birthing Center Nurse Manager Debbie Partrick, the hospital has been seeking volunteer assistance in strengthening their current lactation support services. The group will also bring much needed medical equipment and educational supplies to provide safe care for their obstetric and newborn patients.

In addition to promoting and supporting lactation, the group will collaborate with Nicaraguan nurses in the care of mothers and newborns in labor, delivery, and post partum care. Partrick says one volunteer is an International Board Certified Lactation Consultant, while other members of the group hold specialty certifications in fetal monitoring and neonatal resuscitation. All the volunteers have extensive experience in public health, speak Spanish and have traveled to Latin America previously.

“Breastfeeding has been shown to improve infant and maternal health, especially in developing countries where lack of clean water is linked to diarrhea illnesses, a leading cause of infant mortality in Nicaragua.” says Partrick.

To donate, you can either mail a check made out to Aimee Creelman to:
Aimee Creelman c/o Brattleboro-Nurses-Nicaragua
P.O. Box 6424 Brattleboro, VT 05302

For more information, contact Debbie Partrick at 802-257-8228,  or visit the Brattleboro Nurses in Nicaragua Facebook page.

Programs of Brattleboro Memorial Hospital’s New Moms Network in March start with a session called “Starting Solids” on Wednesday, March 7th. This is presented by Chris Ellis, RD with the Brattleboro Food Co-op.

The program on Wednesday, March 14th will feature “Ouch! What You Need to Know about Immunizations Now”. This is presented by Rebecca Olmstead, RN of the Vermont Department of Health.

On Wednesday, March 21st, new moms will discuss “Birth: What I Learned” This discussion will be lead by Dawn Kersula, RN, is a perinatal specialist in the BMH Birthing Center.

And finally on March 28th, new moms will have a day called “Wearing Your Baby: A Guide to all those Wraps and Things!” Come wrap with Michelle Stephens, a mother and wrap extraordinaire.

This free BMH program is a chance for new moms (dads are also welcome) to network and learn tips from each other. Babies are warmly welcomed, of course, and need not to have been born at BMH to attend. New Moms Network is a free service of the BMH Birthing Center.

Moms meet on Wednesdays from 9:30 to 11:00 AM in the BMH Exercise Room on the lower level of the main hospital.

For more information about any of these programs, you can call 802-257-8278 to talk to Dawn Kersula. For more complete information online for any of these BMH programs, check the monthly listings on the events calendar.

A New Baby is Coming to Your House

A new baby is coming to your house? Congratulations! As an oldest child myself, anticipating a new baby made me feel happy and sad all at the same time – how would this change my precious daughter’s life?

Here are some suggestions that helped guide our transitions from only child to big sister. Worked again when our third child was born! As with any advice, remember to read, discuss, listen – and then choose things that will work best for your family. Every big brother and big sister is unique; each situation is a “special situation”. It’s not always easy to integrate a new child into a family – but it’s not always hard either! Use your own style, expertise and flair to welcome these changes, and your new baby.

Think first about some of the good things about having another child.

Older siblings will benefit from the opportunity to be a teacher (and sometimes a boss!). It may be one of the reasons oldest child so often show leadership abilities – even more than the only child. Your “big kid” will learn how to share, enjoy expanded social opportunities, and have a friend who will always be very special.

The new baby gets the benefit of a larger cheering squad, extra stimulation, the love of an extra person in the family (the sibling), and extra wisdom (from the parent, who probably learned a thing or two about parenting from that first child!).

Emphasize reality

…versus “aren’t you looking forward to having a baby brother to play with?”. Babies really aren’t much fun at first, and mom may be pretty busy. But it won’t be all bad. Visit with a new baby, if at all possible. You might want to watch a baby care DVD together. (One big sister, after watching the section on cord care, remarked, “I was pretty worried about that black thing. But now it’s okay.”)

We placed our kids in charge of teaching the baby to smile. They spent a lot of time in en face position with the baby, and we have great pictures of big sisters with funny faces. The day when the baby first responds with a smile is priceless for everyone. And do you know how a baby let you know it loves you? Put your finger carefully on the baby’s palm. If s/he loves you, the baby will hold your hand. (Hey, we know it’s the plantar reflex. That doesn’t change the magic!)

Birth stories are helpful and fun (but many mothers say that is NOT true of the ones on TV). Instead of watching your daily dose of “an emergency cesarean right after this message” think back to the wonderful parts of your first child’s birth. Tailor the story for age and interest, and embellish with the details. (“The doctor said, What’s her name?” and Daddy shouted, “Blythe Hope!” and there you were!) Get out those baby books and photo albums too. You’ll enjoy it as much as your child.

Details, details

Begin to make arrangements for all the details that need to be taken care of. Can you believe how much your family – and you responsibilities – have grown since you first became a mom? Next week we’ll have a checklist that you can use to get yourself ready. Some of those tips are great for developing your child’s problem solving skills. But What If also helps to calm your child’s very natural fears about the future.

Start packing away baby things that will be handed down. You may want to enlist your child’s help in choosing baby toys to put away – or you may want them to just disappear! Give careful thought to the crib – most experts suggest it’s easier on the older child if they have about three months in a new bed before the crib becomes the new baby’s bed. If you are sharing a family bed, it’s a good time to discuss night time arrangements with your partner. The age and developmental stage of your older child, along with your feelings, can help you decide what’s best. (Our first child invited our second child to share her bed when we were facing this decision during our third pregnancy. We were all delighted!)

Fill the tank

Ross Campbell, in his excellent book How to Really Love Your Child, suggests you “fill your child’s emotional gas tank” by making sure s/he gets plenty of eye contact, physical attention, and focused attention. When a child is “full” of these three things, s/he will be better able to deal with stressful situations. (Works for me, too!) And just like the car seems to run out of gas when the tank is low – well, you get the picture.

Should your child attend the birth? You will hear many forceful arguments from both sides. Again – you are the expert on you and your child. If you decide to have your child with you, preparation should begin now. Have a special friend available to attend to your child’s needs during labor and birth.

By the way, we had a baby who never came to live with us, as I had a miscarriage just after we had told our three children about the pregnancy. I wish I’d had Marilyn Grite’s book, No New Baby, to help us with all our questions.

Finally, remember: Love doesn’t divide. Love multiplies! Here at the Birthing Center we had a lovely big family with a new baby. The five year old looked pretty down at the mouth. The mom called him close. “Do you remember when we went to Disney World? When someone new came, the hotel opened up a new room. My heart is just like that hotel. There is always room in my heart for you. Now that the new baby is here, I just opened a room for him too.”

The amount of love you have available will expand to take care of your baby’s needs, without taking anything away from the love you have for the children you love so very much today. Happy parenting!

Join us next week for our Getting Ready checklist.

Farro, Radicchio, and Roasted Beet Salad

Farro, an ancient variety of wheat, has a hearty texture and a nutty flavor. Here, the whole grain is tossed with bitter radicchio and earthy beets for a pretty, delicious, and healthful salad.

Farro is said to have sustained the Romans as they conquered the world 7,000 years ago. Legend had it that Julius Caesar himself brought it to Italy after invading Egypt in 30 B.C. Known as the Pharoah’s wheat because it was the only wheat cultivated in pharoanic times, this nutritious, high-energy grain was a staple in Roman society.

Also known as emmer wheat, farro (triticum dicoccon) is the Italian name for this hulled ancient mother grain that gave rise to modern wheat. Often confused with spelt they are two distinct, though closely related grains. Armed with more than twice the protein and fiber of modern wheat, each grain of farro packs a nutritious punch. Not only is it rich in magnesium, niacin, zinc and iron, it also provides a complete protein source when combined with legumes. Farro has a low gluten content with more fragile gluten molecules than those of modern wheat, making it easier to digest, and sometimes tolerable for many gluten-intolerant individuals. An excellent source of whole grains and complex carbohydrates, farro can play a significant role in maintaining healthy body weight, and reducing diabetes, heart disease, and cardiovascular disease risk, as well as helping to prevent certain forms of cancer.

Notable Nutrients

Per one-half cup:

• Calories: 170
• Carbohydrate: 34 grams
• Dietary Fiber: 5 grams
• Protein: 6 grams
• Iron: 2 milligrams

 Ingredients

•  8 1- to 1 1/2-inch-diameter beets, tops trimmed to 1 inch
• Vegetable oil
• 1 1/2 cups semi-pearled farro or wheat berries
• 4 tablespoons extra-virgin olive oil, divided
• 4 tablespoons red wine vinegar, divided
• 1 garlic clove, pressed
• 2 cups (packed) thinly sliced quartered radicchio (from about 1 medium head) or you may use fresh escarole (less bitter)
• 1/2 cup finely chopped red onion
• 1/3 cup chopped fresh Italian parsley
• 1 cup crumbled feta cheese (about 4 ounces)

Directions

1. Preheat oven to 350°F. Arrange beets in single layer in 8 x 8 x 2-inch baking dish. Drizzle with vegetable oil. Cover with foil and roast until beets are tender, about 45 minutes. Cool. Trim beets; peel. DO AHEAD: Can be made 1 day ahead. Cover; chill.
2. Cook farro in large saucepan of boiling salted water until tender, stirring occasionally, about 20 minutes. Drain. Transfer to large bowl. Stir 2 tablespoons olive oil, 1 tablespoon vinegar, and garlic into hot farro. Cool to room temperature.
3. Cut each beet into 6 to 8 wedges. Add beets, radicchio, onion, and parsley to farro; toss to incorporate evenly. DO AHEAD: Can be made 1 day ahead. Cover and chill.
4. Whisk 2 tablespoons olive oil and 3 tablespoons vinegar in small bowl. Drizzle over salad. Add feta cheese; toss to coat.

Test-kitchen tip:

Any type of beet (red, golden, red-and-white-striped Chioggia) would be great in this salad. To avoid stained hands, wear plastic gloves when peeling dark-colored beets.

Things to Consider Before Orthopaedic Surgery

By Robert Feinberg, Physician Assistant

In last week’s Health Matters column, my colleague Dr. William Vranos referenced some studies that indicated a significant rise in total joint replacement surgeries being carried out. Indeed, one study by the Agency for Healthcare Research and Quality projects a 670 percent increase in knee replacement surgeries alone by 2030.

But the good news is that a lot of people seeking orthopedic care aren’t in need of immediate surgery. In fact, some patients may not need surgery at all to treat their conditions. One of the main roles of physician assistants who practice in orthopaedic surgery, like myself, is to help make that determination.

Robert Feinberg, PA

Physicians have been utilizing physician assistants for about 40 years now. A PA’s training is a condensed medical school training. We do similar coursework but over a shorter time; most of our experience comes on the job. Instead of four years of medical school, we do one and a half years of didactic, followed by a year of clinicals and then it’s all on-the-job training. PAs can specialize in any specialty with orthopaedic surgery one of the most common.

PAs who specialize in orthopaedic surgery see a lot of non-surgical, musculoskeletal injuries and complaints which are orthopedic in nature but may not require surgery to fix: anyone who strains or sprains their knee, people who twist or trip, people who have meniscal injuries and those with cartilage or other soft tissue injuries. Often, these injuries are not severe enough to require surgery. Many knee problems, for example, can respond well to rest and physical therapy as well as injections of cortisone. In addition, synvisc (lubricating injections) are beneficial in many cases of degenerative arthritis. So, working with Drs. McLarney, Thatcher and Vranos, I may try some of those methods first and see what kind of results we get. If the results are less than optimal then I can work with the team of physicians to coordinate further evaluation and surgical interventions as needed.

I ask every patient this one question: How much does this injury affect you every day?

The ones who say it limits their everyday activities are the ones I refer on to surgery. In addition, some patients need to be put on a pre-surgery treatment plan to reduce inflammation and strengthen the affected area prior to an operation. A patient who follows a pre-surgery plan can recover more strength more quickly when doing rehab afterwards.

If it comes to surgery, a PA can assist the surgeon in all phases of the planned surgery. We assist in the pre-operative, inter-operative and post-op phases. Every state has different laws and different doctors have their own preferences. I’ve worked very closely with the surgeons on learning incisions and closures, fracture reduction, and assisting with total hip and knee replacements. With their guidance I can be a useful addition to the surgical team, which will enhance your surgical experience.

At most orthopedic practices in the United States there’s generally a 2-3 month waiting period to see somebody. Having a PA opens a practice to a lot of patients who couldn’t get in here before, especially for non-surgery complaints. Since I joined Southern Vermont Orthopaedics and Sports Medicine last fall, we’ve been able to schedule appointments within a couple of days and sometimes even the same day. There are people who are exclusively my patients. If there’s no surgery involved I treat them until they’re better. New patients will see me first and if they’re a candidate for surgery they will be assigned to whichever surgeon is here with me that particular day. However, if a patient already has an established relationship with a particular surgeon we try to keep it. So I learn the routines and preferences of Drs. McLarney, Thatcher and Vranos for approaching a patient. Each has their own area of expertise and their own preferences when determining when the time is right for surgery.

Part of my job is to facilitate pre-surgical planning. I will work closely with each patient and the surgical team as we map out a treatment plan. So when we are considering whether a patient is a candidate for surgery, I have to take into account not only the surgery but the recovery period, lifestyle, age and other medical issues. I will order x-rays, MRIs and lab work to make sure there are no other health-related risks, such as cardiac problems. We look at every individual patient’s case and determine the cost benefit of doing the surgery versus not doing the surgery and what it’s going to be like for her or him. I then work closely with the patient and surgeon to determine the best timing and course of treatment for each individual patient. This way BMH can provide optimal care for your orthopaedic needs.

Robert Feinberg, PA, is a physician’s assistant in the Southern Vermont Orthopaedic and Sports Medicine practice. He can be reached at 802-254-6211.

Brattleboro Memorial Hospital will offer a free, 10-week writing workshop for individuals living with cancer and an accompanying loved one, starting Tuesday, March 6 at 6:00 PM in the Richards Building.

“Spirit of the Written Word” provides cancer survivors the opportunity to promote their own healing and experience the therapeutic benefits of group writing. No writing experience is required and all sharing is voluntary. The program meets every Tuesday through May 8. Refreshments will be provided.

The workshop facilitator is Pam Roberts, program director for Forest Moon, a nonprofit organization dedicated to improving the quality of life for cancer survivors and their families through interactive learning and therapeutic activities. Roberts is a writer, artist, yoga instructor and energy healer. She is a graduate of the IM School of Healing Arts in New York City and leads ongoing writing and yoga workshops for people touched by cancer in Vermont and Massachusetts.

To register, contact Pam Roberts  at 413-625-2402. Spirit of the Written Word is sponsored by the Brattleboro Memorial Comprehensive Breast Care Program, VT/NH Komen for the Cure, and Forest Moon.

Belinda Sargent, RT (R, M)

Belinda Sargent, RT (R, M) of Brattleboro Memorial Hospital has earned certification in Bone Densitometry from the American Registry of Radiologic Technologists. She will add the “BD” designation to her list of credentials.

Bone Densitometry, better known as DEXA, is a type of x-ray imaging test performed to measure bone mineral density at a specific anatomical site, usually the spine, hip or forearm or to calculate total body mineral content, determining if a person has osteoporosis. Osteoporosis is a condition where bones become weak and break more easily. Physicians use the results of this exam to estimate the amount of bone loss, to track the rate of bone loss over a specific period of time and to estimate the risk of fracture.

“We are very pleased to have such a dedicated, qualified technologist such as Belinda here at Brattleboro Memorial Hospital,” said Marcy Rushford, Director of Imaging & Cardiology. “She and the other technologists she works with have set a high bar for themselves to ensure excellent quality in imaging can be obtained for every patient during every visit. Their commitment to exceptional patient care makes BMH a world class diagnostic imaging center.”

Bone density testing is currently offered at Brattleboro Memorial Hospital on Wednesdays and Thursdays. Appointments can be made, with a physician’s order, by calling 802-251-8451.

Brattleboro Memorial Hospital’s Diagnostic Imaging Department performs more than 40,000 procedures annually, and provides Breast Imaging, CT, Ultrasound & Echocardiography, Nuclear Medicine & Nuclear Cardiology, MRI and X-Ray imaging, in addition to Bone Density testing.

The National Osteoporosis Foundation estimates that over 10 million people nationwide have osteoporosis and 34 million more have low bone mineral content, putting them at risk for osteoporosis. The disease occurs to people of all ages and in both men and women. In 2005, osteoporosis related fractures were responsible for over $19 million dollars in costs to healthcare—that number is expected to grow to 25 billion by the year 2025.

Seared Scallops in Garlic Butter

Makes: 4 servings

Start to Finish: 20 mins

Ingredients

• 1 pound fresh or frozen sea scallops
• 2 tablespoons butter or margarine
• 3 cloves garlic, minced
• 2 tablespoons dry white wine
• 1 tablespoon snipped fresh chives or parsley
• 1/8teaspoon salt

Directions

1. Thaw scallops, if frozen. Rinse scallops; pat dry with paper towels.
2. In a 12-inch skillet cook garlic in 1 tablespoon of the butter over medium-high heat for 30 seconds. Add the scallops. Cook, stirring frequently, for 2 to 3 minutes or until scallops turn opaque. Remove from skillet and transfer to a serving platter. Add remaining 1 tablespoon butter and wine to the skillet. Cook and stir to loosen any browned bits. Pour over scallops; sprinkle with chives and salt.
3. Makes 4 servings

From the Test Kitchen

Variation Seared Shrimp in Garlic Butter: Prepare as above, except substitute 1-1/2 pounds fresh or frozen medium shrimp in shells for the scallops. Thaw shrimp, if frozen. Peel and devein shrimp, leaving tails intact. Rinse shrimp; pat dry with paper towels. Cook shrimp in the butter and garlic for 1 to 3 minutes or until shrimp turn opaque. Continue as above.