Suture for a Living

Topical Fluorouracil for Photoaging?

noreply@blogger.com (rlbates) — Thu, 18 Jun 2009 05:57:50 PDT

The authors of the article referenced below looked at the use of topical fluorouracil and it’s affects on improving photoaging in skin. Topical fluorouracil (5FU) has become a standard treatment of actinic keratoses (AKs). For treatment of AKs it is applied to the skin once or twice daily for 2-4 weeks. It produces significant and predictable irritation and inflammation. When the skin is healed there is always a decrease in the number of AKs. A “side benefit” of the AK treatment in many patients was improved skin (smoother, more even color, and a decrease in fine wrinkles). This improvement appears to come from the wound-healing response of the skin.

The authors end the article with this observation:

Evidence is accumulating that even minimal epidermal injury, such as that from nonablative laser resurfacing, microdermabrasion, and now topical fluorouracil, can lead to mild to moderate clinical improvement. It is likely that other topical agents such as diclofenac gelor imiquimod that have similar skin-injuring properties in photodamagedskin may have a similar restorative effect.

Although the standard course of therapy may last only 2 to 3 weeks, the ensuing reaction can persist for several more weeks. That reaction looks like this (photo credit):

The cost of topical 5FU is much less than ablative laser resurfacing. It is also unlikely to achieve (at least consistently) the same degree of improvement. For treatment of AKs, it is a great treatment with the side benefit of improved skin.

REFERENCE

Topical Fluorouracil for Actinic Keratoses and Photoaging: A Clinical and Molecular Analysis; Arch Dermatol. 2009;145(6):659-666; Dana L. Sachs, MD; Sewon Kang, MD; Craig Hammerberg, PhD; Yolanda Helfrich, MD; Darius Karimipour, MD; Jeffrey Orringer, MD; Timothy Johnson, MD; Ted A. Hamilton, MS; Gary Fisher, PhD; John J. Voorhees, MD

Sunshine and Shadow Baby Quilt

noreply@blogger.com (rlbates) — Fri, 19 Jun 2009 04:09:42 PDT

If you haven’t noticed by the number of times I use this quilt pattern, I love the “sunshine and shadow” quilt pattern. So once again, I have used it to make a baby quilt. This one is machine pieced and quilted. It measures 42 in square.

This photo shows the fabric colors better than the one above.

Here is a photo of the label on the back.

SurgeXperiences 226 – Call for Submissions

noreply@blogger.com (rlbates) — Sun, 21 Jun 2009 04:01:01 PDT

The host for SurgeXperience 226 (June 28th) will be Vijay (Scan Man’s Notes). It will be the 50th edition!

Suggested theme is surgical practices in different parts of the world.

The deadline for submissions is midnight on Friday, June 26th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. If you would like to be the host in the future, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Posture

noreply@blogger.com (rlbates) — Mon, 22 Jun 2009 04:01:26 PDT

I had a patient come in last week for her yearly breast/implant exam. I gently reminded her to watch her posture. She then told me that her fiancé who has come with her on previous visits and heard me give her the same reminder now will look at her, smile, and say “posture.” The story made me smile.

It is something I picked up from my mother (and last week was the one month anniversary of my mother’s death). When my sisters and I were young, Mom would have us walk around with a book on our head as a way to teach us to stand up straight. I can’t say I liked it then, but am grateful for it now.

The patient, the anniversary, and the recent post of JMB (Nobody Important) all came together at the right time to inspire this post. This photo she used in her post Shrinking Woman – Arrghhh is exactly why I want all the women around me to stand straight.

JMB’s post is focused on osteoporosis, her mother, and her loss of height.

My mother suffered severely from osteoporosis, being severely bent over for many years before her death at 85. ……….

How tall were you at your tallest? Five foot six inches, I replied. Mmm. Five foot four inches now. Normal, he said. What?????

Yes it is normal to lose two inches of height without necessarily having osteoporosis. The Baltimore Longitudinal Study of Aging found that the cumulative height loss from age 30 to 70 years averaged about 3 cm (1.18 inches) for men and 5 cm (1.97 inches) for women (Sorkin, Muller, & Andres, 1999)……….

Mine is on posture. Good posture can help you “appear” tall and thinner. My mother had great posture. She never developed the rolled back (dowager's hump). So I would encourage you all to watch your posture both in standing and at your computer or sewing machine, etc.

Here is a repost of my June 3, 2007 post “Good Posture for Sewing (or Blogging)”

For comfort and to decrease the risk of strain injury, it is important to pick a good chair and to set the sewing machine at a good height for your own body. Susan Delaney Mech, M.D answered this question as follows (photo credit):

The first step is to set the height of your sewing chair. The seat should be at a height that allows your feet to rest flat on the floor and your knees to make a perfect 90-degree angle. A secretarial chair makes a good, adjustable sewing chair.
The next step is to lower your sewing machine table until, with your elbows bent at a perfect 90-degree angle, your fingertips can rest on the feed dog of your machine. I am 5 feet 6 inches tall, and my sewing machine table is 22 inches off of the floor.
Proper chair and sewing machine height, combined with good posture of your back and neck, and hourly breaks, will go a long way toward preventing (or healing from) Repetitive Strain Injury.

Avoid slouching. Keep your neck and shoulders relaxed. Try to keep your elbow, hips, and knees at right angles (ninety degrees). Avoid pressure to the back of the knees. If your feet can't comfortably be flat on the floor, then consider a foot rest. You should also consider taking breaks every 30-60 minutes and do some stretching exercises for your wrists and hands and body. Sometimes, as in the OR, breaks can't be taken that often. Do the best you can with table/chair (computer monitor/OR table/etc) height and stretch when you are able. It will help keep the aches at bay and the joints a little more supple. That will allow you to enjoy your hobby (sewing, knitting, blogging) and maybe your work for many more years.

You may want to check out this OSHA sewing station design page. Another interesting source for prevention of injury while sewing/quilting is a PowerPoint presentation at Sport & Spine Physical Therapy website is "How to Quilt Forever"

Shout Outs

noreply@blogger.com (rlbates) — Tue, 23 Jun 2009 05:20:40 PDT

Barbara Olsen, Florence Dot Com, is this week's host of Grand Rounds. You can read it here (photo credit). Great edition!

Welcome to Grand Rounds! It's officially summertime, and Flo & Bo are taking you out to the ballgame! At Florence dot com, Bo, a seasoned nurse with an engineer's mind, channels Florence Nightingale, a systems thinker whose interest in public health and service gave rise to modern nursing. (Flo favors cricket, but this is Bo's gig.)

From Better Health comes “A Medical Transgender Primer” written by DrJonLaPook. Very nice article.

Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful……….

See DermDoc for the Proper Way to Pop a Pimple

As a dermatologist, I am obligated to tell you: “Do not attempt to pop your pimples.” But I know you are going to do it anyway, so here’s how to do it properly:

Pick only pimples that are ready to be popped………..

If you deal with head injury patients, you’ll find this list of resources by VP Medical useful

We here at VP Medical Consulting are currently working on a life care plan for a young lady with a traumatic brain injury. In developing the plan we consult many resources and thought I would share them here. If you have a resource I have missed, please let me know and I will be sure to add it…….

VP Medical has also put together a list of resources for care givers.

From @drval (on twitter): For those interested in what was discussed at the HC reform meeting at BIO today (June 17): check out the blog: http://tinyurl.com/nqowbm #hcrmtg

TBTAM brings to our attention “Folic Acid Supplementation – Too Much of a Good Thing?” I must admit, folic acid is one of those vitamins (water soluble) that I never thought of as ever having a problem of too much. I associate the water soluble ones which our bodies don’t store as having the problem of deficiency. I stand corrected. I hope you will read her entire post.

Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.
But too much folic acid may lead to an increased risk for colon cancer……………….

If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.

This week Dr Anonymous will be doing a “summer vacation” show. I hope you will join us. The show begins at 9 pm EST.

You can check out the archives of his Blog Talk Radio show. Here is the upcoming schedule:

July: Break
August: Two Year Anniversary of the Doctor Anonymous Show

Surgical Glove Perforation and the Risk of Surgical Site Infection – article review

noreply@blogger.com (rlbates) — Wed, 24 Jun 2009 04:01:08 PDT

H/T to ACP Internist for bringing this article to my attention (see full reference below).

It's best not to get holes in one's surgical gloves in the middle of a procedure, as this leads to a higher risk of infection for the patient, the Archives of Surgery reports in a study about the effect of ripped gloves. …… Which is, perhaps, why the surgeons put on the gloves in the first place?

For me, I found nothing new in this article. Yes, surgeons wear gloves to both protect the patient and him/herself. Gloves are part of the universal precautions.

It is well known that the risk of getting a hole in one’s glove increases with the length of the surgery (especially when over 2 hours) or when dealing with spiked bone fragments. The authors of the article felt they had a new angle --

The frequency of glove perforation during surgery has been studiedextensively and found to range from 8% to 50%. Theimpact of glove perforation on the risk of surgical site infection(SSI), however, is unknown. The present study was conductedto test the hypothesis that clinically visible surgical gloveperforation is associated with an increased SSI risk.

I think most surgeons change their gloves if the hole is visible. It is intuitive that the patients who are not on antimicrobial prophylaxis would be at the greatest risk of surgical site infection when a defective glove is involved. This holds true with the authors’ findings:

In the presence of surgical antimicrobial prophylaxis, the rateof SSI (6.9% vs 4.3%)was higher in procedures involving perforated gloves comparedwith procedures with maintained intraoperative asepsis. Afteradjusting for 6 confounders in multivariate logistic regressionanalysis, however, the odds of contracting SSI in the eventof glove puncture were not significantly higher when comparedwith procedures with intact gloves.

In the absence of surgical antimicrobial prophylaxis,glove leakage was associated with an SSI rate of 12.7%, as opposedto 2.9% when asepsis was not breached. This differenceproved to be statistically significant.

Double gloving may decrease the risk of transfer of germs (either direction: patient to surgeon or surgeon to patient), but it is not always the answer. I have tried all the combinations: both gloves the same size, the outer one a smaller size, the outer one a larger size. In all cases, my hands go numb. Numb hands is not a good thing in a surgeon.

Routine changing of one’s gloves might capture some of the “un-caught” glove perforations and therefore decrease the risk of SSI in patients. The authors even suggest doing so every two hours. It would be interesting to figure up the costs of all the glove changes compared to the SSI costs. Would it be cost effective?

The use of surgical microbial prophylaxis for all cases is still controversial. The risk of SSI with clean surgical procedures is considered too low to be worth the risk of “side effects” from the antibiotics or the possibility of contributing to “super bugs.” As pointed out in the article, indications for prophylacticantimicrobials approved by the CDC are clean operations involvingprosthetic material and any operation in which a potential SSIwould pose catastrophic risk (ie all cardiac operations,most neurosurgical and major vascular operations, and some operationson the breast).

REFERENCE

Surgical Glove Perforation and the Risk of Surgical Site Infection; Arch Surg. 2009;144(6):553-558; Heidi Misteli, MD; Walter P. Weber, MD; Stefan Reck, MD; Rachel Rosenthal, MD; Marcel Zwahlen, PhD; Philipp Fueglistaler, MD; Martin K. Bolli, MD; Daniel Oertli, MD; Andreas F. Widmer, MD; Walter R. Marti, MD

Needle Sticks (January 2008)

Healthcare Discussion

noreply@blogger.com (rlbates) — Wed, 24 Jun 2009 11:57:34 PDT

I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest Advance (CMPIA). In addition to him, Dr. Val Jones (Founder and CEO Better Health Network) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers. The focus was to be on the risks of government-run healthcare.

It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term. As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.

Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it's we the patients who are not at the policy table, and you can bet that it's the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

There were two links given by the CMPIA as sources for factual information on the healthcare discussion: publicplanfacts.org and biggovhealth.org.

I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link. First this one --

Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.

I won’t comment on that one, but will this next one:

Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.

This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements. I think this trend will only get worse. Check out Barbara Duck’s series at Medical Quack on desperate hospitals. Here’s an excerpt from the May 24, 2009 post:

In Chicago, Illinois

The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.

The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.

"We have been hit by a number of things," Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. "We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it."

In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion. Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs. We don’t need more rules like the Medicare’s 75% rule.

Saving money by providing an inferior “product” isn’t what any of us want. Is it?

How Poland’s Syndrome Was Named

noreply@blogger.com (rlbates) — Thu, 25 Jun 2009 04:01:02 PDT

Poland's syndrome is a congenital disorder. The classic ipsilateral features of Poland syndrome include the following: absence of sternal head of the pectoralis major, hypoplasia and/or aplasia of breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of rib cage, and upper extremity anomalies. These upper extremity anomalies include short upper arm, forearm, or fingers (brachysymphalangism). (photo credit)

Additional features of Poland syndrome include the following: hypoplasia or aplasia of serratus, external oblique, pectoralis minor, latissimus dorsi, infraspinatus, and supraspinatus muscles; total absence of anterolateral ribs and herniation of lung; and symphalangism with syndactyly and hypoplasia or aplasia of the middle phalanges. (photo credit)

The name of this condition pays homage to Dr. Alfred Poland of Guy's Hospital, who in 1841 described a case of these two deformities during the autopsy of a 27-year-old convict, but as this article points out he wasn’t the first to recognize the syndrome.

If you enjoy medical history, then you will enjoy this article. It explores the historical literature to reveal the progression of knowledge about this syndrome. Here is a quick summary of different investigators who contributed to the understanding of Poland's syndrome. The article goes into more detail of each.

1826	Lallemand is first to describe the absence of the pectoralis.
1835	Bell is the first to record the absence of the pectoralis
1839	Forlep is first to describe the paired absence of the pectoralis and ipsilateral syndactyly
1841	Poland is the second to describe the paired absence of the pectoralis and ipsilateral syndactyly
1895	Thomson is the first to document an understanding that the deformities accompanied one another
1900	Furst is the first to propose that the anomalies constituted a syndrome
1902	Bing is the first to present a case series of patients with the syndrome
1940	Brown and McDowell are the first to document a thorough review of the syndrome
1962	Clarkson is the first to propose the name “Poland’s Syndactyly” for the syndrome

As the authors conclude:

Honoring physicians for notable achievements in the form of eponyms can be viewed as a harmless way to bring a little bit of warmth to an otherwise cold world of facts. The least we can do, though, is to recognize the contributions of those who endeavored to shape our current understanding of disease.

Perhaps if history took another course, Poland's syndrome would instead be called Frolep's syndrome or Furst's syndrome. Or perhaps it might simply have been called pectoral-aplasia-dysdactylia syndrome

REFERENCES

Poland's Syndrome: Current Thoughts in the Setting of a Controversy; Plastic & Reconstructive Surgery. 123(3):949-953, March 2009; Ram, Ashwin N. B.S.; Chung, Kevin C. M.D., M.S. (subscription required)

Interlaced Ribbon Quilt

noreply@blogger.com (rlbates) — Fri, 26 Jun 2009 04:01:02 PDT

I made this quilt for a lawyer friend who helped my husband several years ago. He and his wife use it as a wall hanging rather than a bed quilt. It is 88.5 in X 99 in. Recently he went to visit them and I asked him to get some photos of it for me.

The quilt is machine pieced by me, but I paid Peggy Ries (Peg’s Quality Quilting, Epworth, Iowa) to do the machine quilting for me. She does excellent work.

Because of the size, my husband wasn’t able to get a true full view photo of the quilt.

Here is a detail photo that shows some of the fabrics.

Here is another detail photo that shows some of the fabrics.

SurgeXperiences 226 is Up!

noreply@blogger.com (rlbates) — Sun, 28 Jun 2009 04:36:54 PDT

The 50th edition of SurgeXperiences is hosted by Vijay, Scan Man’s Notes. You can read this edition here.

Welcome to the latest edition of SurgeXperiences, the fortnightly carnival of blog posts related to surgery.

This happens to be the 50th edition. Ironically the number 50 has acquired an altogether unwelcome significance this week due to the unfortunate and untimely death of Michael Jackson aged 50. Mr. Jackson may very well be the King of Pop to fans and music lovers, but to most of us in healthcare he is probably better known as the worst example of celebrity plastic surgery on demand or as a prominent plastic surgeon describes him, the most famous “nasal cripple.”

The host of the next edition (227), July 12th, will . The deadline for submissions is midnight on Friday, July 10th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Breast Implants and Lymphoma Risk

noreply@blogger.com (rlbates) — Mon, 29 Jun 2009 04:01:03 PDT

Yes, I’m behind in my journal reading. This article was published in the March issue of the Plastic and Reconstructive Surgery Journal. The article is the summary of a literature review using PubMed to review the evidence from all epidemiologic cohort studies of cancer incidence among women with cosmetic breast implants that include results on the incidence of non-Hodgkin's lymphoma, with specific attention to lymphomas arising in the breast.

The review was prompted by the article from The Netherlands (second reference below) which suggested an association of breast implants with anaplastic large T-cell lymphoma.

Primary breast lymphoma is a rare malignancy. Most of them are of B-cell origin. It is important for anecdotal reports not to alarm providers or patients. This review article found only five long-term cohort studies which had evaluated the incidence of non-Hodgkin's lymphoma following cosmetic breast augmentation surgery.

The authors looked at each study and came to the following conclusion:

The association between cosmetic silicone breast implants and non-Hodgkin's lymphoma has been examined in a number of long-term cohort and surveillance studies, based on large numbers of women with virtually complete follow-up substantially longer than the 17-year study period presented in the Dutch case-control study.

In the only cancer incidence study to include women followed for at least 25 years after implantation, including 3336 women followed for 15 years or more and 827 followed for at least 25 years, no significant excess of non-Hodgkin's lymphoma was observed overall and not one primary lymphoma of the breast was observed.

Moreover, the largest study to date, with cancer surveillance up to 24 years, actually reported a reduced incidence of total non-Hodgkin's lymphoma among almost 25,000 Canadian women with cosmetic breast implants.

Based on the epidemiologic studies published to date, there is no evidence of an excess of non-Hodgkin's lymphoma incidence overall among women with cosmetic silicone-filled breast implants.

REFERENCES

Breast Implants and Lymphoma Risk: A Review of the Epidemiologic Evidence through 2008; Plastic & Reconstructive Surgery. 123(3):790-793, March 2009; Lipworth, Loren Sc.D.; Tarone, Robert E. Ph.D.; McLaughlin, Joseph K. Ph.D. (subscription required)

Anaplastic large-cell lymphoma in women with breast implants; JAMA. 2008;300:2030-2035; De Jong D, Vasmel WLE, de Boer JP, et al. (subscription required)

Shout Outs

noreply@blogger.com (rlbates) — Tue, 30 Jun 2009 04:20:08 PDT

Dr Edwin Leap is this week's host of Grand Rounds. You can read it here. Great edition!

Today is June 30, 2009. Which means, if I’m correct, that tomorrow is July 1st. And July 1st is the day that, all across the country, recent medical school graduates begin residencies in their assorted specialties. An amazing time, indeed! I remember it well. Standing around in a suit, listening to lectures, trying to figure out who was really smart and who was more like me. None of us knowing, by a long-shot, what we were embarking upon.

The latest edition of Change of Shift (Vol 3, No 26) is hosted by ReHabRN! You can find the schedule and the COS archives at Emergiblog.

Welcome to the June 25, 2009 edition of Change of Shift. Many thanks to Kim at emergiblog for allowing me to host this edition.
'Tis the holiday season, so I thought I'd go for a holiday theme for this edition. So since I'm thinking holiday more in the sense of how our British friends and other folks around the world view holidays as Americans view vacation. Ah, relaxing and not being at work tops the list for me.

Dr Gwenn O’Keeffe, Pediatrics Now, has authored the American Academy of Pediatrics’ expert-driven "social media and sexting tips" for parents: Talking to Kids and Teens about Social Media and Sexting. The “tip sheet” is full of good information and advice. Here’s a small example:

“Sexting” refers to sending a text message with pictures of children or teens that are inappropriate, naked or engaged in sex acts. According to a recent survey, about 20 percent of teen boys and girls have sent such messages. The emotional pain it causes can be enormous for the child in the picture as well as the sender and receiver--often with legal implications. Parents must begin the difficult conversation about sexting before there is a problem and introduce the issue as soon as a child is old enough to have a cell phone. Here are some tips for how to begin these conversations with your children:

H/T to Lakshmi for this tweet which links to a wonder article:

RT @TheCuriousMind: Habitat: 15 Year Old Invents Algae-Powered Energy System http://tinyurl.com/lmsqlg; My hero

Nice story by NPR on the stigma nonsmokers with lung cancer experience.

Smoking is such a well-known cause of lung cancer that many don't realize thousands who never smoked get the diagnosis. The great majority are women. Recent research shows it's really a different disease than smoking-related lung cancer. But those with the diagnosis say they suffer the same stigma.

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

Infections After Face Lifts

noreply@blogger.com (rlbates) — Wed, 01 Jul 2009 04:01:01 PDT

When you read articles at sites like MedScape or MedPage Today, you are often referred to other articles of interest. That’s how I came across this one on the MedPage Today site. I went there to read the one on “Sinus Infections Cause Toxic Shock Syndrome in Children”. Both are interesting articles, but I want to discuss the article referenced below that was discussed on MedPage Today.

The topic is postoperative infections in face lift surgery. The stated objective of the article:

To determine the incidence of methicillin-resistantStaphylococcus aureus (MRSA)-positive surgical site infectionsafter face-lift surgery and to discuss the screening, prevention,and treatment of such infections.

MRSA infections are never a good thing, but as a postoperative face lift infection – really not a good thing.

The article mentions having done a literature review and finding only one published article (second reference below) on the incidence of postoperative surgicalsite infections (SSIs) after rhytidectomy. It was a retrospective studyperformed more than 10 years ago on 6166 consecutive face-lifts. In that study only 11 infections requiring hospitalization were found (0.18%) and none of the cultures were positive forMRSA.

This current article is also a retrospective study. Charts of 780 patients from January 2001 to January 2007 were reviewed. These patients all had a deep-plane rhytidectomy. Some had other procedures such as blepharoplasty, browpexy,rhinoplasty, autologous fat transfer, laser resurfacing, andchemical peel. All were done as outpatients.

The article highlights the techniques used for infection prevention:

Themorning of surgery, all patients showered and washed their hairwith chlorhexidine solution.

After the induction of anesthesiaand before incision, the patients' faces were scrubbed withchlorhexidine and povidone-iodine. Attention was placed alongthe areas of the face-lift incision, including the hair-bearingscalp 5 cm posterior to the hairline.

Sterile towels were thensecured around the patient's head to sterilely secure the surgicalsite.

Before incision, 1 g of intravenous cefazolin sodium (Ancef)was administered (clindamycin if the patient was allergic topenicillin).

After surgery, all patients were given a 7-dayprescription for oral cefadroxil (Duricef).

The patients werethen seen on postoperative days 1, 5, 8 (suture removal), 21,and 40. During each visit, they were examined for any signsof infection, such as erythema and fluid collection.

There were 4 patients (out of 780) who developed postoperative wound infections with cultures thatwere positive for MRSA. Another patient developed a woundinfection that yielded anaerobic skin flora. This gave an overall infection rate was 0.6%. As noted in the article 80% (4/5) of the infections were MRSA related.

The article highlights each of the five patients with individual case reviews. I want to highlight the outcomes in terms of scarring. With the exception of the first case, there is really not enough follow up on the scar evaluation.

Case 1: “Six monthsafter surgery, the scarring was barely perceptible.”

Case 2: “Four weeks after surgery, the patienthad healed completely. She had no scarring, and the area ofthe incision that was opened had healed well.”

Case 3: “and the patient healed uneventfully over thenext 7 days.”

Case 4: “The patient healedrapidly, and she had no evidence of infection or scarring after7 days of treatment.”

Case 5 (non-MRSA): “She improved rapidly and healedwell”

The article makes some nice points for setting up screening protocols. For the facelift patients, perhaps preoperative cultures of the nose and throat.

Thosecases with MRSA colonization and no clinical infection weretreated with mupirocin (Bactroban) nasal ointment 3 times dailyand 2% triclosan (Aquasept) washes twice daily for 5 days.

Povidone-iodine(Betadine) mouthwash was also used 2 to 3 times daily as garglefor 5 days. Chlorhexidine mouthwash was used in patients witha contraindication to iodine.

The article does a very nice job of point out the importance of postoperative surveillance, aggressive early treatment (incision and drainage, culture, antibiotics).

Once MRSA infection is diagnosed after a face-lift, aggressivetreatment is advised to prevent rapid progression of the infection.Prompt initiation of appropriate antibiotic therapy, along withincision and drainage, is essential. The cosmetic nature ofrhytidectomy may make facial plastic surgeons hesitant to openwounds that have an infected collection. However, openly drainingwounds that have collected MRSA-positive material is prudent.

…….

The facial plastic surgeon must be quick to culture any suspiciousfluid or discharge. The result of the sensitivity and resistanceprofile from these cultures will be the ultimate guide for theantibiotic regimen. Prompt culture cannot be stressed enough.The infection can spread rapidly along the surgical dissectionsite and become extensive in a very brief time frame. …….

REFERENCES
"Methicillin-resistant staphylococcus aureus-positive surgical site infections in face-lift surgery" Arch Facial Plast Surg 2008; 10: 116 – 123; Zoumalan RA, Rosenberg DB

Infections requiring hospital readmission following face lift surgery: incidence, treatment, and sequelae; Plast Reconstr Surg. 1994;93(3):533-536; LeRoy JL Jr, Rees TD, Nolan WB III.

Fireworks Safety

noreply@blogger.com (rlbates) — Thu, 02 Jul 2009 04:01:02 PDT

Time for a reminder of safe firework use. I hope you will all have a safe and happy July 4th. Be safe and stay out of the ER. photo credit

Please use the following tips:

Never allow children to play with or ignite fireworks.
Read and follow all warnings and instructions.
Fireworks should be unpacked from any paper packing out-of-doors and away from any open flames.
Be sure other people are out-of-range before lighting fireworks. Small children should be kept a safe distance from the fireworks; older children that use fireworks need to be carefully supervised.
Do not smoke when handling any type of "live" firecracker, rocket, or aerial display.
Keep all fireworks away from any flammable liquids, dry grassy areas, or open bonfires.
Keep a bucket of water or working garden hose nearby in case of a malfunction or fire.
Take note of any sudden wind change that could cause sparks or debris to fall on a car, house, or person.
Never attempt to pick up and relight a "fizzled" firework device that has failed to light or "go off"
Do not use any aluminum or metal soda/beer can or glass bottle to stage or hold fireworks before lighting.
Do not use any tightly closed container for these lighted devices to add to the exploding effect or to increase noise.
Never attempt to make your own exploding device from raw gunpowder or similar flammable substance. The results are too unpredictable.
Never use mail-order fireworks kits. These do-it-yourself kits are simply unsafe.

If you need more information on the injuries that can occur, check out these sites:

Indian Hand Center

Reflections by Dr. Bruce Campbell---5th of July

Fireworks Related Injuries by the CDC

Prevent Blindness America

Patriotic Sampler Quilt

noreply@blogger.com (rlbates) — Fri, 03 Jul 2009 04:01:00 PDT

One thing my blog has helped me do is better documentation of my quilts. My husband has been after me for years to take better pictures of them before giving them away. He wanted me to keep records of the each one. Unfortunately, I didn’t do a good job of that in the past. I found two Polaroid photos of this patriotic sampler quilt that I made after September 11, 2001. I quickly took the photos before mailing it in the spring of 2003 to Laura and George W Bush. Not sure if they received the quilt as I never got a note.

Anyway, I had the four churn dash blocks and the small pinwheel and pineapple blocks as my start. If my memory is correct the blocks are 12 in square. I think the sashing is 3 in wide. I think the borders are 5 inches wide. If my memory is correct, then the quilt measures 52 in X 67 in.

I’m not sure if I have the names of all the blocks correct, so feel free to correct me if not (Celeste). Starting at the top from left to right, then the second row from left to right, and so on:

1. Evening Star with Pinwheel in center

2. Churn Dash

3. Stepping Stones

4. Odd Fellow’s Cross

5. Grecian Cross (rotated 45 degrees)

6. Many Pointed Star

7. Churn Dash

8. Ribbons

9. Churn Dash

10. Eight-pointed Star with Pineapple Square in center

11. Churn Dash

12. Mosaic Star

I added several rosettes which you can see (though not well – I wish I’d taken better pictures.). The one with the gold base began as a strip of black & white striped ribbon folded into the rosette. The small black one on the “ribbons” block is a rushed rose.

The fabric on the left side border has frogs holding American Flags which I just loved but didn’t have enough of to do all four borders. It is on two borders. The other two have red fabric with roses.

Lou Gehrig's Speech 70 Years Later

noreply@blogger.com (rlbates) — Sat, 04 Jul 2009 04:01:00 PDT

This is the 70th anniversary of Lou Gehrig’s famous farewell speech. It is still very inspiring.

For more information on ALS (Amyotrophic Lateral Sclerosis):

Lou Gehrig: the Official Website

ALS Association

National Institute of Neurological Disorders and Stroke

SurgeXperience 301 – Call for Submissions

noreply@blogger.com (rlbates) — Sun, 05 Jul 2009 04:01:02 PDT

The host for SurgeXperience 301 (July 12th) will be Buckeye Surgeon. This is the beginning of the 3rd season!

The deadline for submissions is midnight on Friday, July 10th. Be sure to submit your post via this form.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Preventing and Treating Skin Tears

noreply@blogger.com (rlbates) — Mon, 06 Jul 2009 04:01:00 PDT

If you work with elderly patients, then you have probably seen “skin tears.” There is a nice basic article (see full reference below) on the topic that recently crossed my desk. I’d like to share some of the information with you. (photo credit)

In considering the mechanism of skin tears, I love the way Dr Salcido (2nd reference below) puts it. His paper explanation could be useful in explaining the problem to patients.

I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions: pathomechanical & pathophysiological.

The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears.

To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will.

Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.

The main article has a nice list of risk factors for “skin tears” that should be considered when dealing with patients:

Advanced age (>85 years of age)
Sex (female)
Race (white)
Immobility (chair or bed bound)
Inadequate nutritional intake
Long-term corticosteroid use
History of previous skin tears; presence of ecchymoses
Altered sensory status or cognitive impairment
Stiffness and spasticity
Using assistive devices; Visual impairment
Applying and removing stockings
History of vascular, cardiac, and/or pulmonary problems

Many of the prevention strategies shared are common sense and focus on fall prevention – ie adequate lighting, removing clutter from a pathway, avoiding scatter rugs, making the bathroom safe for bathing. Other strategies focus on removing sources of skin trauma – ie padding edges of furniture and equipment, avoiding adhesive products on frail skin, keeping fingernails and toenails cut short.

Lift patients, do not drag them across sheets or surfaces. Reduce moisture from incontinence or other sources.

Improved nutrition and hydration are important in prevention, as well as being gentle with the skin.

Once a skin tear has occurred, the same principles used to manage other wounds should be used. First, the wound has to be assessed. They suggest using the Payne-Martin classification of the skin tear. However, the STAR consensus does not

Once again, the STAR consensus was to simplify the parameters of assessment and

a category 1a or 1b skin tear is one ‘where the edges can be realigned to the normal anatomical position
(without undue stretching)’.

A category 2a or 2b skin tear presents ‘where the edges cannot be realigned to the normal anatomical position (without undue stretching)’.

Whichever classification you use, remember these are acute wounds and have the potential to close by primary intention.

Next, the wound has to be cleaned -- removing bacteria and necrotic tissue. When thinking about repair, it is usually best to avoid staples and sutures as the fragile tissue won’t hold. So go straight to the next step – the dressing.

Most skin tears tend to achieve wound closure within 7 to 10 days using the following treatment plan:

Category 1a or b skin tears can be treated with adhesive strips anchor or Dermabond to the re-approximated edges
Category 2a or b skin tears can be treated with soft silicone or low tact foam dressing.

All can be treated by using a transparent film dressing (ie POLYSKIN* II) if there is minimal moisture. The longer the dressing can be left unchanged, the better for the fragile skin. It will often need changed every 3-7 days, but if the wound looks fine underneath consider leaving it another day or so. If fluid develops under the transparent film dressing, then it will need to be changed promptly.

REFERENCES

Prevention and Management of Skin Tears; Advances in Skin & Wound Care, 22 (7): 325-332, July 2009; LeBlanc, Kim BScN, RN, ET, MN; Baranoski, Sharon MSN, RN, CWOCN, APN, DAPWCA, FAAN

Deconstructing Skin Tears; Advances in Skin & Wound Care, 22(7):294-295,July2009; Salcido, Richard MD

STAR: a consensus for skin tear classification; Primary Intention Vol. 15 N o. 1 FEBRUARY 2007; Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P

Don’t Forget HIPAA Privacy Rules

noreply@blogger.com (rlbates) — Tue, 07 Jul 2009 08:32:22 PDT

As we move towards EMR’s, the ability to know who has looked at the medical record may get more and more in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story shows the importance of this respect.

Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.

I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.

I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.

The hospital said in November that it fired up to six people for looking at Pressly's records after a routine patient-privacy audit showed that as many as eight people gained access to them.

It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.

With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….

If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.

My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressley case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.

We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.

Dr Holland had no malicious intent, just curiosity. Be careful.

Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter

3 charged with getting TV anchor's medical records by Jon Gambrell (no subscription required)

Macrodactyly

noreply@blogger.com (rlbates) — Wed, 08 Jul 2009 04:01:00 PDT

Macrodactyly is an uncommon anomaly of the extremities. It can affect both the fingers or toes which become abm=normally large due to overgrowth of the tissues composing the digit. All the tissues are involved: bone and soft tissue-particularly the nerves, fat and skin. (photo credit)

Other names used for macrodactyly include megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis.

Hands are more commonly involved than feet. Most of the time (~90%) patients present with unilateral (one side affected) macrodactyly. Often more than one digit is involved. The most frequently involved digits of the hand are the index finger, followed by the long finger, thumb, ring, and little fingers. Syndactyly may be present in 10% of patients. Men are more often affected than women.

It is not known why macrodactyly occurs. It does not appear to be an inherited anomaly, but there are some syndromes (ie Proteus Syndrome, Maffuci syndrome, and tuberous sclerosis) which may be associated with enlarged digits. There are some surgeons who believe that macrodactyly is a variant of neurofibromatosis.

Macrodactyly may be either static or progressive. The progressive type is more common than the static.

In static the enlarged digit (finger or toe) is present at birth and continues to grow at the same rate as the normal digits of the hand. The involved digits are generally about 1.5 times the normal length and width of the normal digits.
In progressive the affected digits begin to grow soon after birth and continue growing faster than the rest of the hand. The involved digit or digits can become enormous.

There is no medical treatment for this disorder. It is treated by surgery. In the hand, the indications for surgery can often be cosmetic in nature as the hand can functionally tolerate a digit with some increased width and length. In the foot, the enlarged digit can make shoe fitting/wearing difficult.

Surgical treatment of macrodactyly is complex as multiple tissue layers are involved. It typically will involve debulking, epiphyseal arrest, and shortening. Multiple surgeries are the norm.

Soft tissue debulking:

This is done to help correct the width of the digit. This is often done at the same time as the epiphyseal arrest. The affected fingers are approached volarly with Bruner-type incisions/flaps. The fat is removed from the skin and the tissues are debulked.
Care is taken to preserve the ulnar and radial digital neurovascular bundles. Sometimes the enlarged nerve branches will need to be sacrificed along with the enlarged subcutaneous tissues.
When a sufficient amount of tissue has been removed, the skin flaps are overlapped and excised, which allows for tension-free closure. It needed, skin grafts using healthy skin will be done.
Debulking is often need to be done in staged procedures.

Shortening procedures:

This is done to help correct the length of the digit. Shortening procedures usually involve either surgical excision (removal) of one of the phalanges of the finger or toe, or removal of a metacarpal (hand bone) or metatarsal (foot bone).
Barsky and Tsuge originally introduced the two most described methods. Barsky’s technique involves removing the distal portion of the middle phalanx and proximal portion of the distal phalanx, thereby reducing the length of the finger while preserving the nail. Tsuge’s technique also preserves the nail by overlapping the dorsal portion of the distal phalanx with the volar portion of the middle phalanx.

Ray resection:

This may be done in progressive macrodactyly. It involved the complete removal of the digit or digits. It is also an option if there is excessive widening of the forefoot, where digital shortening and debulking procedure may not be effective.

Epiphyseal Arrest:

The timing of the this surgery is critical. An attempt to “guess” the adult finger length is done by comparing the child’s digits with those of his/her parents. When growth of the affected digits matches those of the parent, epiphyseal arrest can be performed. This in effect will stop the bone growth of the digit.
The epiphyses of the proximal and distal phalanges are the ones treated by disruption or removal. The middle phalanx epiphyses is not treated to help preserve motion at the proximal interphalangeal joint.

Other surgical options include amputation and wedge osteotomies. Amputation is reserved for patients with nonfunctioning digits or digits that are extremely difficult to correct. Wedge osteotomies are performed in patients who have digits that are grossly deviated.

Complications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.

REFERENCES

Wood VE. Macrodactyly. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingston; 1998:533-544.

Treatment of macrodactyly; Plast Reconstr Surg. 1967; 39:590-599; Tsuge K.

Congenital anomalies of the hand; Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New York, NY: Little, Brown and Company; 1994; Upton J, Hergrueter C.

Macrodactyly; Boston Children’s Hospital website

Macrodactyly; Wheeless’ Textbook of Orthopaedics

Shout Outs

noreply@blogger.com (rlbates) — Wed, 08 Jul 2009 04:53:22 PDT

Pharmamotion is this week's host of Grand Rounds. You can read it here. It comes to us from Argentina! Check it out:

I’m starting this Grand Rounds with a confession: I completely suffered of lack of time for this Round’s preparation. Maybe you are wondering why, since this blog carnival is perfectly scheduled. Well, the thing is that here in Argentina winter has arrived and things are starting to get a bit more complicated than we thought. I think that most of you guessed what I am talking about. Yes! The current pandemic of Influenza A(H1N1) has settled in South America and I was hired to cover night shifts in a local hospital

#1 Dinosaur comes out of anonymity as she announces the publishing of her first book! Congratulations! (photo credit)

Question: What do anonymity and virginity have in common?

Answer: You can only lose them once, so make it count.

I am pleased, proud and thrilled to announce the upcoming release of my first book. From Kaplan Publishing, on August 4, 2009:

GrrlScientist is trying to win a trip to Antarctica! She needs your help. Here’s how:

I've posted a picture and written a 300 word essay (which I will no doubt revise over time) and my entry is now public. Voting ends on 30 September 2009, and the Official Quark Blogger will travel to Antarctica in February 2010 to blog about the experience, chronicling the action, the emotion, and the drama as their polar adventure unfolds.

My official essay where you can vote for me.

Dr Rob is now doing podcast as the “House Call Doctor” giving “quick and dirty tips” to help you take charge of your health. You can find the list of his podcasts here. Enjoy!

Addicted to Medblogs’ calendar continues. Dr June is … Whitecoat! I agree with the answer he gave on this question, but go read the rest of the interview. Oh, yeah, listen to his singing.

12. If you could be reincarnated, what would you like to come back as?
A dog with a really cool owner whose back porch backed up to a beach.

H/T to A Respository for Bottled Monsters

In one of those strange, how-did-I-get-here moments on the internet, I came across the abcnews website that shows some oddball x-rays. As they say, Viewer Discretion is Advised.

H/T to MedGadget for the link Theories of Mind Art Gallery... The work is absolutely amazing! It is from a Tel Aviv University physics professor named Eshel Ben Jacob. Here’s one used in the MedGadget post (photo credit).

The International Quilt Study Center & Museum shows off one of the amazing quilts from our collection each month in their “quilt of the month” section. This month the quilt (photo credit) is one created by Gail Belmont, Cathy Morris, and Marie Aquino for the Quilts of Valor Foundation.

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

Use of Zafirlukast for Capsular Contracture

noreply@blogger.com (rlbates) — Thu, 09 Jul 2009 04:01:00 PDT

I first read of the off-labeled use of zafirlukast back in 2002. I had one patient with a unilateral Baker’s Grade IV capsular contracture who wanted to avoid surgery (open capsulectomy). I told her it wasn’t proven (only 30 patients) but that half experienced softening of their capsules. I went over the possible side-effects of the drug with her. She wanted to give it a try. So I prescribed zafirlukast 20 mg twice daily for 3 months. She responded with softening of her capsule. After 3 months she asked for a refill to try to achieve more softening. She now had a Grade II-III capsular contracture. I agreed. It softened to a Grade II and she was happy.

I now have another patient who is in the same state. I have decided to try to review the literature and see if the early study has been confirmed. The first six articles referenced below are the ones I found. All were small in number, ranging from 20-120 human patients or 40 rats.

The last article cautions us to remember the adverse side effects which can sometimes be worse than the problem being treated. In this case – liver injury with zafirlukast. Dr James L. Baker, Jr in a commentary (7th article referenced below) gives this caution:

The effectiveness of Accolate and Singulair in treating
capsular contracture remains anecdotal. It is quite possible that while acting as an antagonist against the
leukotriene receptor, Accolate and Singulair may in reality work as a histamine receptor site antagonist and cause the relaxation of the myofibroblast, with improvement in capsular contracture in some patients. However, the increasing evidence of an association between treatment with Accolate and liver dysfunction in patients with asthma, as reported by Dr. Gryskiewicz, is a powerful argument against widespread off-label use of asthma medications to treat capsular contracture without further investigation. In addition to liver toxicity, Churg-Strauss syndrome (systemic eosinophilic vasculitis) has been reported with both drugs, more frequently with Singulair. This syndrome can have permanent ramifications, including limitation of lifestyle.

Surgeons treating patients for benign conditions with
medications carrying potentially lethal side effects should thoroughly advise patients of the off-label status and the serious risks. I discourage the use of Accolate and Singulair in the treatment of capsular contracture until such time as we can prove through laboratory research exactly how these drugs work on the myofibroblast and capsular tissue and better determine the risk-reward ratio of the therapy.

The six articles which looked at the effectiveness of zafirlukast for treating capsular contracture while noting the positive response in many of their patients also note that further studies need to be done.

Conclusions

Zafirlukast appears effective in treating early capsular contracture after primary submuscular breast augmentation using saline-filled, smooth-walled implants. Further prospective studies with control groups and long-term follow-up will be needed to address many unanswered questions, including whether leukotriene inhibitors have long-term effects on capsular contracture following breast augmentation.

If this patient and I decide to proceed with zafirlukast treatment, I will be sure she is aware of the potential side effects (minor and major) of the drug.

For photos of a removed capsule and implant check here.

REFERENCES

1. A new treatment for capsular contracture. (Letter to the editor); Aesthetic Surg. J. 2002; 21: 164-165; Schlesinger SL and Heck RT.

2. Zafirlukast (Accolate): A new treatment for capsular contracture; Aesthetic Surg. J. 2002; 22: 329-336; Sclesinger SL, Ellenbogen R, Desvigne MN, Svehlak S, and Heck R.

3. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: A pilot study; Aesthetic Surgery Journal, Volume 25, Issue 1, Pages 26-30 (January 2005); R.Reid, S.Greve, L.Casas

4. The Effects of Zafirlukast on Capsular Contracture: Preliminary Report; Aesthetic Plastic Surgery, Volume 30, Number 5, October 2006 , pp. 513-520(8); Scuderi, Nicolò; Mazzocchi, Marco; Fioramonti, Paolo; Bistoni, Giovanni

5. Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance; Int J Immunopathol Pharmacol 2007 Jul-Sep; 20(3):577-85; Scuderi N, Mazzocchi M, Rubino C

6. Reduction of Capsular Thickness around Silicone Breast Implants by Zafirlukast in Rats; Eur Surg Res 2008;41:8-14 (DOI: 10.1159/000121501); A. Spano, B. Palmieri, T. Palmizi Taidelli, M.B. Nava

7. Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns; Aesthet Surg J. 2003 Mar;23(2):98-101; Gryskiewicz JM

Quilt Top for Steve and Lori

noreply@blogger.com (rlbates) — Fri, 10 Jul 2009 04:01:00 PDT

This quilt is in progress. It is for my brother Steve and his wife Lori. I finished the top in mid-June. It measures 56 in X 76 in. I could quilt it, but would end up with major neck and should spasms as I use a simple sewing machine to do my machine quilting. I have contacted a friend with a long-arm quilting machine whom I will pay to do the quilting.

The block pattern is one I have used before – Alabama quilt block.

Here is a detailed photo of the fabrics. You can see the turquoise blue dots in the dark chocolate brown fabric here.

I’ll share the quilt with you once it is finished. My friend is backed up a month or two. I will need to do the binding once the quilting is done.

SurgeXperiences 301 is Up!

noreply@blogger.com (rlbates) — Sun, 12 Jul 2009 16:19:34 PDT

The 1st edition of SurgeXperiences’ third season is hosted by Buckeye Surgeon. You can read this edition here.

Welcome to another tardy edition of SurgeXperiences! It's been a killer week for me so this is probably going to be a little substandard. Apologies will be forthcoming. Operating three nights in a row after 2AM while your partner is out of town will do that to you. So excuse the spelling errors, the fractured syntax, the incoherence, the lack of any semblance of organization. Which seems to fit perfectly in the context of the former Alaskan governor's rambling resignation speech....So here it goes, just follow the damn links.

The host of the next edition (302), July 26th, will be . The deadline for submissions is midnight on Friday, July 24th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Over Diagnosis of Breast Cancers

noreply@blogger.com (rlbates) — Mon, 13 Jul 2009 04:01:00 PDT

Are breast cancers over-diagnosed? If so, how often? Those are the questions looked at by the systematic review of incidence reported data/articles done by Karsten Juhl Jørgensen & colleagues. Their results are published online in the June 9th issue of the British Medical Journal. Their review shows an estimated 52% over-diagnosis of breast cancer.

The researchers’ objective was to estimate the extent of over-diagnosis. Screening for breast cancer is meant to detect lethalcancers earlier. Unfortunately it also detects harmless ones that will not cause deathor symptoms. As it is not possible to distinguishbetween lethal and harmless cancers, all detected cancers aretreated. Over-diagnosis and overtreatment are therefore inevitable.

They begin their review of incidence reported data from 7 years before routine screening programs were implemented and 7 years after full screening was implemented. They included screened and non-screened age groups. Data was available from United Kingdom; Manitoba, Canada; New SouthWales, Australia; Sweden; and parts of Norway.

This data came from a PubMed search (May 2006) which yielded 2861 titles, 2546 of whichwere not relevant. That left 315articles which were evaluated. Four were included ascore articles and one was added when the search was updatedin April 2007, presenting data from the United Kingdom; Manitoba,Canada; New South Wales, Australia; Sweden; and parts of Norway. A meta analysis was done on the data.

Looking at the United Kingdom data, they found that the screening program began in 1988 for women aged 50-64. National coverage began by 1990. The screening was expanded to women aged 65-70in 2002. There was a 41% higher than expected rate of invasive cancer found in women aged 50-64 during the 1993-1999 period with no compensatory drop during the 7 yrs after full screening was implemented. This is interpreted as over diagnosis of breast cancer. This chart (photo credit) shows the incidence of invasive breast cancer per 100,000 women in UK.

This same trend was found in the data from the other countries. Combining the data, the researchers estimated 52% over diagnosis of breast cancer in a populations of women who are offered organized mammography screening. That amounts to one in three breast cancers being over diagnosed.

We need improved screening methods to decrease this number to less than 10% over-diagnosis. Each “un-necessary” surgery for one of the over-diagnosed cancers puts the patient at risk for complications. Not to mention the increased cost to the healthcare system of each country.

REFERENCE

Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends; BMJ 2009;339:b2587; Karsten Juhl Jørgensen, researcher, Peter C Gøtzsche, director

A Few Other Breast Cancer Related Posts

Breast Self Exam (BSE) (October 2008)

Mammograms (October 2008)

Breast Cancer Screen in Childhood Cancer Survivors – An Article Review (February 2009)

Indications for Breast MRI – an Article Review (March 2009)