Saturday, May 31, 2008

Memory Quilt from Shirts

I was asked by an extended family member to make several quilts from the shirts of a deceased loved one. The husband/father died two years ago in his mid-fifties of sepsis. He was a "good-old boy" in the best sense of the phase. Always had time for his family and friends. Loved cars -- watching NASCAR, restoring old cars, etc.

So with a few specifications (I would piece them. I would even quilt them if they were no larger than 50 in X 70 in. I would not agree to a deadline. I would keep receipts for the batting, thread, and backing used. I would not be paid for anything other than supplies.) I agreed to do the quilts. I was given a large container of shirts -- 42 of them. Here is a picture prior to cutting them up.

It took me a couple of weeks working in the evenings to cut off collars and cuffs, press the shirts, and then cut them into pieces. I decided to for the most part use 5 in squares (5.5 in prior to sewing) so that the shirt patterns wouldn't be lost. Of course, I had to make sure the pockets were used in at least one quilt -- this one.

I also cut some 2.5 in X 10.5 in strips from the yokes so the tags could be used.

Here is the first one. I used the pockets in this one. They all still are functioning pockets too. The quilt is 50 in X 70 in, machine pieced and quilted. The pockets are "tied" from the back so they can still be used.

He was also a ball cap wearer, usually a John Deere one. I cut the patch off of one and added it to the quilt.

One of the shirts had paint stains on it. I decided to make sure they were included. I am glad I did, as I found out recently that it represents the "car that didn't get finished". The paint stains are from working on a car restoration.

Friday, May 30, 2008

Chemical Peels

Chemical peels have been around for many years. Even with the continued improvement of lasers, there will most likely always be a place for chemical peels. If the right peel is used for the skin problem, the results can be spectacular. If not done properly, they can (like lasers) create new problems (scarring, hypopigmentation, etc).

Chemical peels are classified into three categories based on the depth of the burn created by the peel.

Superficial

  • includes Jessner's peels, salicylic acid peels, gylcolic acid peels, and light trichloroacetic acid (TCA) peels
  • uses include acne treatment, rosacea, and fine lines
  • minimal discomfort, no recovery time, may be repeated weekly
  • may have mild skin irritation (2 days), temporary flaking, redness or dryness (up to 5 days)
  • Use of cosmetics and moisturizers during the time of the peel generally is avoided if at all possible

Medium

  • includes 30-50% TCA peels, and Jessner's combined with TCA peels
  • used for melasma, pigment disorders of the skin such as lentigos, deeper wrinkles, and acne scars
  • there is mild to moderate discomfort with these peels
  • recovery time may be up to two weeks to heal completely
  • there is usually some crusting, swelling, and redness

Deep

  • includes phenol peels, 75% and higher TCA peels
  • used to reduce severe wrinkling, aging and scarring
  • severe pain should be expected
  • takes two weeks or more to heal
  • severe swelling (5-7 days), crusting, and redness (up to 6-8 weeks)

The risk of complication is greater with the deeper peels, but the benefits are increased also. Risks include infection (more so with the deep peel), scarring, pigmentation problems, unsatisfactory results (ie patient expected the results of the deep peel but only wanted to go the superficial or medium route), and possible unevenness (acid solution not applied evenly).

In patients prone to hyperpigmentation, pretreatment and posttreatment with a bleaching agent are necessary. Sun exposure after the procedure should (must) be avoided, especially in these individuals who are prone to hyperpigmentation. Hypopigmentation in white persons after a deep peel is almost universal and should be an accepted sequela of the procedure.

Pre-peel

Preconditioning the skin is a useful adjunct in order to improve results. Use of an exfoliative agent like transretinoic acid (Retin-A, Renova) is believed to facilitate uniform penetration of the peeling agent and promote more rapid re-epithelialization. The transretinoic acid should be applied nightly or every other night for several weeks prior to peeling, depending on the degree of skin irritation caused and patient tolerance.

Patients with a history of hyperpigmentation may also beneifit from pre-and post-treatment with hydroquinone.

Patients with a history of cold sores should receive acyclovir (400 mg PO bid), beginning 2 days prior to the peel and continuing 7 days after the peel.

Patients with a decreased number of epithelial appendages from prior radiation treatment or current isotretinoin (Accutane) use are poor candidates because healing will proceed more slowly and scarring is more likely. Recent use of Accutane is considered a contraindication to medium or deep peels. Wait at least 12 months after stopping Accutane to allow some regeneration of epithelial appendages prior to peeling.

Following the peel, it is important that the patient follow instructions given by the physician to prevent complications (especially with the medium to deep peels).

  • The patient should stay out of the sun. When unavoidable, the patient should apply a strong sunscreen (SPF 45 or greater) and wear a hat. An ointment, such as petroleum jelly or Aquaphor, should be applied to the involved skin.
  • Remind the patient that the skin will exfoliate and may look cosmetically unattractive for a period of time depending on the depth of the peel.
  • For superficial peels, a follow-up appointment can be scheduled at the time of the next peel. For deeper peels, patients should be seen 2-3 times the first week following the peel to provide for early intervention if problems (ie infection) develop.

REFERENCES

Skin Resurfacing, Chemical Peels; Gregory Caputy MD, PhD; eMedicine Article, March 28, 2008

Chemical Peels; Raymond T Kuwahara MD; eMedicine Article, Jan 19, 2007

Skin Resurfacing: Chemical Peels; Don R Revis Jr MD and Michael B Seagle MD; eMedicine Article, Oct 27, 2005

Thursday, May 29, 2008

Dr Bruce Campbell to be Dr. A's Guest

Join us tonight for The Doctor Anonymous Show at 8 pm CST. His guest will be Dr Bruce Campbell.  He is an Otolaryngologist (ENT) who works at the Medical College of Wisconsin.  His well written blog is Reflections in a Head Mirror.   His stories have also been published a few times in JAMA.

In addition to just listening to the show, there is a chat room that we "listeners" gather in. It is great fun! Hope you will join us.

For first time Blog Talk Radio listeners you may want to review these Tips from Dr A.

Wednesday, May 28, 2008

Grand Rounds 4.36 Up

Emeritus (Parallel Universes) is this weeks host for Grand Rounds. It is a great edition you can read here.

This is my 5th time to host (Thanks, Nick!) and I have not stopped enjoying the privilege of hosting this wonderful weekly anthology of the best posts of the medical blogosphere. Since FIVE is the lucky number for me today, I am opening this round with five of the best posts submitted to me this week...

If you don't read any posts, but one please read the one by Doc Gurley on NOMA and donate. Thanks.

Next week's host will be The Happy Hospitalist. You can submit posts to him at dequervains@yahoo.com

Tuesday, May 27, 2008

Abdominal Wall Reconstruction

Acquired abdominal wall defects can be challenging. These defects may result from trauma, tumor resection, or complications of previous abdominal surgery, such as hernias and mesh infections.

The abdominal wall functions to protect vital intra-abdominal organs, flex and extend the trunk (torso), and assist in supporting the lumbar spine. The abdominal muscles do not contribute to the function of normal breathing, but patients may recruit them in times of respiratory distress or during forced expiration and coughing.

The goals of abdominal reconstruction are 1) restoration of function and integrity of the musculofascial abdominal wall, 2) prevention of visceral eventration, and 3) provision of dynamic muscle support.

It is essential to understand the anatomy of the abdomen wall. So I will refer you to these on-line sources:

Dr Norman's site as he explains the basic Anatomy of the Abdominal Wall (great pictures)

Clinically Oriented Anatomy by Keith L Moore and Arthur F Dalley; 5th Edition, Google eBook (pp 196-230)

If you have access to Medline, then this article: Structural and functional anatomy of the abdominal wall. Clin Plast Surg. 2006; 33(2):169-79, v (ISSN: 0094-1298).

(photo credit)

Abdominal Wall Defects

Abdominal wall defects can be partial or complete. Partial defects involve either the skin or fascia. Complete defects involve deficiencies of the entire abdominal wall, including skin and fascia.

Preoperative considerations that influence the decision-making process and availability of certain reconstructive options include the depth of involvement (partial vs complete) as well as location, size, infection/contamination, timing, staging, and co-morbidity (ie nutritional state, diabetes, COPD, etc). Even with meticulous planning, operative technique, and postoperative care, complications of abdominal wall reconstruction are encountered. Abdominal reconstruction after previous surgery has a high rate of enterotomy, which converts a clean case into a clean-contaminated or contaminated case.

Immediate versus staged repair will depend on the clinical situation.

Immediate reconstruction is preferred.

  • It is more cost-effective and less time-consuming in the medically stable patient with a clean wound bed and reliable reconstructive options.
  • It may need to be aborted if significant abdominal distention or inflammation is present.

Delayed reconstruction is done when the patient is unstable, reconstructive options are limited or risky, the wound is contaminated, or further procedures are planned.

  • This is often done in the trauma patient with a loss of domain (for example when the intestines are too swollen to place back into the abdomen and then wound closed). The wounds of such patients are routinely closed with a temporary substance and subsequently reexplored. A skin graft may be applied as a temporary measure until reconstruction can be performed.
  • A split-tissue skin graft (STSG) will aid in contracture, decreasing the size of area. STSGs have a higher success rate than a full-thickness skin graft. The down-side is that a STSG will remain fairly fixed.
  • If abdominal reconstruction is delayed, surgery should be avoided for 6 months or until the previous abdominal scar has fully matured. This will decrease the number of adhesions and the density of the scar tissue.

Medically unstable patients with chronic fascial defects are managed nonsurgically with abdominal binders and light activity.

TREATMENT ALGORITHMS

The following is adapted from the algorithms found in the 4th reference below (Rohrich, et al).

Partial Skin Defect --

  • Primary Closure when 5 cm or less defect
  • Skin Graft
  • Flap: Random/local or Fasciocutaneous Flaps
  • Vacuum-assisted Closure -- Using this procedure, a sterile foam dressing is placed in the wound cavity and an evacuation tube exits the wound parallel to the skin surface. The surface of the wound is covered to create an airtight seal, and subatmospheric pressure is applied to the foam dressing.
  • Tissue Expander

Partial Musculofascial Defect --

Small -- defined as less than 10 cm if central; less than 5 cm if lateral in the upper third. Defined as less than 6 cm if central; less than 3 cm if lateral in the middle third. Defined as less than 20 cm if central; less than 10 cm if lateral in the lower third.

  • Primary Closure
  • Component Separation
  • Local Flaps -- for example: ext oblique, int oblique

Large -- defined as more than 10 cm if central; more than 5 cm if lateral in the upper third. Defined as more than 6 cm if central; more than 3 cm if lateral in the middle third. Defined as more than 20 cm if central; more than 10 cm if lateral in the lower third.

  • Distant Flaps -- ie Tensor Fascia Lata Flap, gracilis flap
  • Tissue Expansion
  • Free Tissue Transfer (FTT)

Complete Defect

Adequate Skin (less than 15 cm defect) with musculofascial defect --see above recommendations under Partial Defect

Inadequate Skin (more than 15 cm defect) -- Immediate Reconstruction

Local Flaps/Skin Grafts

  • Sup Rectus Abd or Ext Oblique [upper third defects]
  • Rectus Abd or ext Oblique [middle third defects]
  • Inf rectus abd or int oblique [lower third defects]

Distant Flaps

  • ext latissimus dorsi or ext TFL [upper third defects]
  • TFL or RF [both middle and lower third defects]
  • vastus lateralis or gracilis [lower third defects]

Prosthesis/flap

Tissue Expansion

Free Tissue Transfer

Delayed reconstruction with absorbable mesh and a split-tissue skin graft can be a temporizing solution.

The 2007 study (11th reference article) done by T. S.de Vries Reilingh & others was the first randomized controlled trial comparing two different techniques for repair of giant midline hernias. The series is small, but the results suggest that repair of giant abdominal wall defects with the component separation technique compares favorably with prosthetic repair,

because wound infection in patients in whom a prosthetic repair was performed had major consequences, resulting in removal of the prosthesis in 7, whereas wound infection in patients after CST had only minor consequences.

Disturbed wound healing frequently complicates repair of large abdominal wall hernias. Wound complications such as hematoma, seroma, skin necrosis, and infection are reported in 12%–67% of patients after CST and in 12%–27% after prosthetic repair. Wound complications are associated with the extensive dissection needed in both procedures, which are often performed after intra-abdominal catastrophes. The risk is further increased by the long duration of the operative procedure and the need to mobilize the skin in dividing the epigastric perforating arteries. This endangers the blood supply of the skin, because then it solely depends on the intercostal arteries, which may have been damaged during former operations by introduction of drains, or by stoma construction and other procedures needed in patients with intra-abdominal sepsis.

COMPONENTS SEPARATION TECHNIQUE

Operative technique of the “components separation technique.” (photo credit)

1 = rectus abdominis muscle; 2 = external oblique muscle;

3 = internal oblique muscle;

4 = transversus abdominis muscle;

5 = posterior rectal sheath.

A. Dissection of skin and subcutaneous fat.

B. Transaction of aponeurosis of external oblique muscle and separation of internal oblique muscle.

C. Mobilization of posterior rectal sheath and closure in the midline.

The technique as described by Ramirez (8th reference) is performed by separating the rectus muscle from the posterior rectus sheath. The external oblique muscle is separated from the internal oblique muscle. These separations are atraumatic because of the relatively avascular plane of dissection. The compound flap [the rectus muscle with the anterior rectus sheath and attached interanl oblique and transversus abdominis muscles] can be advanced medially once it is separated from the external oblique muscle. The advancement is in the range of 5 cm in the epigatrium, 10 cm at the waistline, and 3 cm in the suprapubic region for direct closure of abdominal wall defects. If the muscular components are separated bilaterally, these distances are doubled. This allows for closure of some very large mid-line defects as the one pictured below.

Giant Abdominal Hernia before and after repair (photo credit, 11th reference article)

REFERENCES

1. Abdominal Wall Reconstruction; eMedicine Article, Feb 26, 2003; Bradon Wilhelmi MD, Arian Mowlavi MD, Michael Neumeister MD, Elvin Zook MD

2. Basic Anatomy of the Abdominal Wall -- good explanation with great pictures (Wesley Norman, PhD, DSc)

3. Clinically Oriented Anatomy by Keith L Moore and Arthur F Dalley; 5th Edition, Google eBook (pp 196-230)

4. An Algorithm for Abdominal Wall Reconstruction; Plastic & Reconstructive Surgery. 105(1):202-216, January 2000; Rohrich, Rod J. M.D.; Lowe, James B. M.D.; Hackney, Fred L. M.D., D.D.S.; Bowman, Julie L. M.D.; Hobar, P. C. M.D.

5. Restoration of Abdominal Wall Integrity as a Salvage Procedure in Difficult Recurrent Abdominal Wall Hernias Using a Method of Wide Myofascial Release; Plastic & Reconstructive Surgery. 107(3):707-716, March 2001; Levine, Jamie P. M.D., and; Karp, Nolan S. M.D.

6. Abdominal Wall Reconstruction following Severe Loss of Domain: The R Adams Cowley Shock Trauma Center Algorithm; Plastic & Reconstructive Surgery. 120(3):669-680, September 1, 2007; Rodriguez, Eduardo D. D.D.S., M.D.; Bluebond-Langner, Rachel M.D.; Silverman, Ronald P. M.D.; Bochicchio, Grant M.D.; Yao, Alice B.A.; Manson, Paul N. M.D.; Scalea, Thomas M.D.

7. Vacuum-Assisted Closure for Defects of the Abdominal Wall; Plastic & Reconstructive Surgery. 121(3):832-839, March 2008; DeFranzo, Anthony J. M.D.; Pitzer, Keith M.D.; Molnar, Joseph A. M.D., Ph.D.; Marks, Malcolm W. M.D.; Chang, Michael C. M.D.; Miller, Preston R. M.D.; Letton, Robert W. M.D.; Argenta, Louis C. M.D.

8. "Components separation” method for closure of abdominal wall
defects: An anatomic and clinical study; Plast.Reconstr. Surg. 86: 519, 1990; Ramirez, O. M., Ruas, E., and Dellon, A. L.

9. Sliding myofascial flap of the rectus abdominis muscles for closure of recurrent ventral hernias; Plast. Reconstr. Surg. 98: 464, 1996; DiBello, J. N., Jr., and Moore, J. H.

10. Risks associated with “components separation” for closure of complex abdominal wall defects. Plast Reconstr Surg 2003;111:1276–1283; Lowe JB III, Lowe JB, Baty JD, et al.

11. Repair of Giant Midline Abdominal Wall Hernias: “Components Separation Technique” versus Prosthetic Repair; World J Surg. 2007 April; 31(4): 756–763; T. S.de Vries Reilingh, H. Goor, J. A. Charbon, C. Rosman, E. J. Hesselink, G. J. Wilt, and R. P. Bleichrodt

12. Method of Surgical Treatment of an Extensive Post-Burn Deformity of the Abdominal Wall and the Lumbosacral Region; Annal of Burns and Fire Disasters, Vol XVII, #1, March 2004; Moroz V., Adamskaya N., Sarygin P., Yudenich A.A.

Monday, May 26, 2008

Memorial Day 2008

May we all stop at 3 pm  today for a moment of silence as "one nation, one remembrance".  My thanks to all those who serve.

You may also wish to visit these blogs to see their Memorial Day posts:

Dr Wes --  Happy Memorial Day

Movin' Meat -- very moving youtube video

Medinnovationblog -- two posts:  In Remembrance of Military Doctors and God Bless the USA

And if you'd like to hear "God Bless the USA Bless the USA"

Sunday, May 25, 2008

SurgeXperiences 122 is Up

First time host Sheepish, The Paper Mask, has published SurgeXperiences 122. It can be found here.

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. The next edition will be hosted by The Sand Man on June 8th. The deadline for submissions will be June 6th. Please submit your posts here.

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

PS. The two posts I submitted somehow did not make the edition. You can view them here and here.

Saturday, May 24, 2008

Laced Ribbons Quilt

I finished my little quilt for the swap. It is 19.5 inches square. I machine pieced it and then hand quilted it. The pattern is called Laced Ribbons. If you follow each "ribbon" you will notice that it goes over, then under other ribbons.

Detail picture showing some of the fabrics.

Friday, May 23, 2008

Poison Ivy Warning

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

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

If you are like me, then you may wish to check out this product, Zanfel, that Dr Paul Auerbach wrote about recently (photo credit).

Zanfel™ is a soap mixture of ethoxylate and sodium lauroyl sarcosinate surfactants. When "activated" (worked into a paste that can be spread effectively on the skin), the soap is able to bind urushiol and thus allow it to be removed from the skin by rinsing.
Zanfel™ is unique with respect to poison ivy/oak/sumac remedies in that it is supposed to remove resin from the skin after the rash has appeared. In one study, this effect was present even at 144 hours post exposure. However, it seems logical that at some point post exposure, urushiol is no longer present in the skin and that the allergic contact dermatitis (manifested as redness, itching, swelling, and blisters), would not be lessened by Zanfel™, unless it has some direct anti-inflammatory properties

REFERENCE

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

Thursday, May 22, 2008

How much pain will there be?

Often I am asked about pain. I'll give you a couple of examples.

"Will the it hurt?"

This from a patient who wanted her earlobe repaired. She had missed out on a pair of diamond ear rings for Christmas, so now she had worked up the courage to have the repair done.

"I have to use a needle to put the numbing medicine in your earlobe. There will be a little pain with that, but you won't feel any pain with the actual repair. You may feel me gently move your ear as your cheek and the surrounding area won't be numb. You may also hear me cut the suture with the scissors as I will be working so near your ear."

"So you have to use scissors?!"

"Yes, I will use scissors for the suture. I will have to use a knife to cut the skin."

"But I won't feel you cut?"

"Correct. Your earlobe will be numb."

"Okay"

So I keep chatting with her as I get the local ready and do the injection. I finish and turn to busy myself with getting everything else set up for the procedure.

"You're done? That didn't hurt."

I smile and say, "Good. That's all the pain involved. You won't need anything other then ibuprofen when the numbing medication wears off."

Example Two

A young woman who wants a cosmetic breast procedure.

"How much pain will there be after surgery?"

I recheck her surgery history. None listed. No children yet.

"Have you ever had any cuts that needed stitches? Any broken bones? Pulled muscles?" I'm looking for something to compare the pain/soreness to.

"No."

"Well, the pain of the incision is often a burning, stinging kind of pain for the first several hours. Think paper cut. Then there will be a pain similar to a deep bruise. The first couple of days are the worst. Remember it will feel less painful, less sore each day."

She seems satisfied, but I am left wondering how I could better prepare her. When someone has had surgery before, I can use it as a reference point. The purposed surgery will have less, similar, or more pain involve. When the patient is female, has had children, and the surgery is breast implants -- patients have taught me that it feels very much like "when the milk first comes in--full and tight" initially. That often helps when discussing this question.

Anyone have any suggestions when it's the patient's first surgery and there seems to be no history of painful injury (past surgery, past injury, etc) to use as a reference point? I am always looking for better ways to communicate with my patients.

Wednesday, May 21, 2008

Spring & Gardening

I don't have the right kind of soil for a garden. Too many crystal rocks. Still I love spring and the flowers it brings. Here's a picture of one of my clematis plants. It's a Ramona.

TBTAM seems to have a rooftop garden and Dr Smak has some lovely flowers. If you are one of those gardeners who grow from seeds, then you may want to check out this post on "How to Make Newspaper Seedling Pots" (photo from her post). Head on over to Patricia's website (a wonderful Arkansas quilter/teacher) if you are interested. The post has lots of photos that make the instructions very clear. Great way to recycle and be green.

And if you just need some inspiration check out the website for the Chelsea Garden Show. Wow!!! They have even shared some detailed planting plans from some of this year's garden designers. Makes me want to have several truck loads of good soil hauled into my yard. Maybe in the next few years I'll do it.

Tuesday, May 20, 2008

Grand Rounds is up over at Dino's

Dino, Musings of a Dinasaur, is this weeks host for Grand Rounds. It is a great edition you can read here.

IN THE BEGINNING, Nick Genes created Grand Rounds. And the Rounds were unformed and void; and Nick Genes said, "Let there be Hosts!" And there were Hosts; and Nick Genes saw that it was good, so he did pre-Grand Rounds interviews with the Hosts on Medscape. And it came to pass that on May 20, 2008 Grand Rounds did come to be hosted by #1 Dinosaur, who was pleased as punch to be hosting for the second time.

Next week's host will be Emeritus (Parallel Universes).

Monday, May 19, 2008

Elective Surgery in the HIV Positive Patient

Antiretroviral therapy has decreased the number of deaths from Acquired immunodeficiency syndrome (AIDS). Many patients with AIDS live with improved health and longer life expectancies. One of the adverse effects of antiretroviral therapy is the lipodystrophy syndrome. Patients are seeking treatment for this (elective reconstructive or therapeutic procedures), but also for other cosmetic procedures. The guidelines given in the article listed below could be used for other surgical procedures (ie hernia repair) that might be needed but are not emergencies.

The article listed below is well worth reading. Here are their conclusions:

1. The number of HIV-positive patients who still seek cosmetic surgery treatment for lipodystrophy is likely to increase.

2. HIV-positive patients are not at increased risk for complications unless their medical health indices are poor, their CD4 count is less than 200 cells/mm3, their CD4 ratio is changing, or their viral load is greater than 10,000 copies/ml.

3. The relative risk for transmission is unknown but is probably 0.03 percent for surgical sharps, considerably less than for hepatitis.

4. Ethically, it is difficult to refuse an HIV-positive patient services if you provide those services to non-HIV-positive patients.

5. Medicolegal implications: Refusing an HIV-positive patient appropriate care based on HIV-positivity alone is malpractice for omission of care and is a violation of the Americans with Disabilities Act.

Pre-operative Recommendations

  • Highly active antiretroviral therapy medications should be continued throughout the perioperative period to avoid the development of resistant viral strains.
  • Preoperative workup should assess cardiovascular status, insulin resistance/hyperlipidemia, viral hepatitis, tuberculosis, nutrition, and disease status (by means of absolute CD4 count and viral load within 3 months of surgery date).
  • Prophylactic antibiotic therapy has not been evaluated adequately in immunocompromised patients. So HIV-positive patients should be regarded in the context of normally associated risks factors (ie smoker, diabetes, etc) for surgical infection.

Post-operative Recommendations

  • If the patient cannot tolerate oral medications following the procedure, highly active antiretroviral therapy should be held and parenteral alternatives for antimicrobial prophylaxis should be used.
  • Follow normal patient care for given procedure.

Risks of Exposure to Surgeon and Team

The risk of HIV transmission is dependent on the type of exposure.

Percutaneous transmission through hollow-bore needlesticks with the transfer of one drop of blood (1/30 cc) has been estimated to be 0.3 percent per occurrence.

The risk of transmission from suture needlesticks and other sharps is thought to be on the order of a magnitude lower than that, or 0.03 percent.

Mucous membrane exposure transmission risk is approximately 0.09 percent.

The risk of transmission from nonintact skin exposure is estimated to be less.

The risk of transmission from fluids or tissue other than blood is considered to be significantly lower than the risk of transmission from blood.

It should be noted that the average risk of hepatitis C seroconversion from occupational exposure is 1.8 percent, 10 times greater than HIV. The risk of seroconversion after exposure to hepatitis B is 37 to 62 percent

Postexposure Prophylaxis

Postexposure prophylaxis is associated with a reduction in the risk of HIV transmission by approximately 81 percent. The current Centers for Disease Control and Prevention recommendations are as follows:

* Postexposure prophylaxis should be initiated within hours of exposure.

* Start a basic two-drug regimen immediately (zidovudine or stavudine or tenofovir plus lamivudine or emtricitabine).

* If the source blood is drug resistant or the injury involves an increased risk for transmission, a third drug (lopinavir/ritonavir) should be added.

* If the source is determined to be HIV-negative, postexposure prophylaxis should be discontinued.

* The Centers for Disease Control and Prevention recommends 4 weeks of postexposure prophylaxis therapy.

* Unfortunately, nearly 50 percent of health care personnel report adverse events while taking postexposure prophylaxis and approximately one-third stop taking the drugs. The three-drug regimen should therefore be avoided when possible to decrease toxicity and increase compliance.

REFERENCES

Perioperative Guidelines for Elective Surgery in the Human Immunodeficiency Virus-Positive Patient; Plastic and Reconstructive Surgery:Volume 121(5)May 2008pp 1831-1840; Davison, Steven P. D.D.S., M.D.; Reisman, Neil R. M.D., J.D.; Pellegrino, Edmund D. M.D.; Larson, Ethan E. M.D.; Dermody, Meghan M.D.; Hutchison, Paul J. M.A.

Sunday, May 18, 2008

SurgeXperiences 122 -- Call for Submissions

The 22nd edition will be hosted by an Australia surgeon, The Paper Mask, who calls himself Sheepish. The edition will be published on May 25th. You should submit you posts here by May 23rd. All previous and upcoming editions of SurgeXperiences are listed here.

Submissions are welcome from all (surgeons, anesthesia, nurses, scrub techs, patients, etc) as long as the post is surgery-related.

Saturday, May 17, 2008

Quilt for Mark's Baby Boy

Here is the quilt I made for Mark's baby boy who is due to enter the world next month. I used several fabrics with just fun stuff -- trucks, bugs, cowboys, horses, and lots of balls (soccer, football, basketball, etc). The quilt is 44.5 in X 55.5 in, machine pieced and quilted.

Here is the back of the quilt done in airplane and star fabric. The horse in the corner is the signature label.

Friday, May 16, 2008

One Year Blogiversary

It has been a year since I began this blog. I am amazed to find that I have the same anniversary as T (Notes of an Anesthesioboist). I was sure she had been around for several years. She seems so polished. So congratulations to her and also to Dr Rich, Covert Rationing, whose blog turned 1 yr yesterday! (photo credit)

It has been a good year. I was nominated for the "Best New Medical Blog 2007" which was won by Dr Val (deservedly so). I have hosted SurgeXperiences twice (here and here). I was given the honor of hosting Grand Rounds (here). I won a Scrubby Award for this post, but still haven't received the red scrubs (they must be in the mail). I did get this T-shirt for my birthday last year after seeing it on Emergiblog's post.

I have made many new friends through this blog. My husband and I took Dr Val to dinner when she came to Little Rock, AR back in October. I was invited by a quilting friend, Kate, who lives in England (the country not the town in Arkansas) to participate in a quilt swap. I am almost done with my little quilt. I have grieved with Dr Smak over Henry, but am gladden by his response to chemotherapy. I have traded e-mails regarding our dogs with another quilter Penny and grieved with her when one of hers died as I did when I lost Girlfriend in September.

I would like to meet more of you in person, but until then thanks for the chats in Dr Anonymous' BlogTalkRadio chat room and the connects on Facebook, Pownce, and Twitter. Thank you all for welcoming me into your fold. It's been a very good year! I'm looking forward to another good one.

THANK YOU!

Thursday, May 15, 2008

Dermal Fillers -- Some Tips

The Dermatology Journal Club (Elsevier) published a CME-related activity on "Achieving Optimal Outcomes with Dermal Fillers". It is reviewed two articles. The CME exam is available here, but I can't find the on-line publication of the journal. You will need to register to use the site, but it is free. The two articles are listed below under references. If you use dermal fillers, these articles are well worth reading. I reviewed several of the different fillers here. The results can be great as in the photo to the right (credit) when used properly.

Tips for both patient and doctor:

  • All dermal fillers have the potential for complications.
  • Appropriate filler and injection-site selection, correct injection technique, and appropriate patient selection will minimize most complications.
  • Temporary side effects associated with all fillers include swelling, redness, itching, bruising, and mild pain.
  • Patients should limit their expressions and normal facial movements for 3 days after injection.
  • The face should also be protected from extreme cold postinjection (ie snowmobiling without facial protection).
  • By 3 months, permanent implants will have assumed their final shape. Touch-ups can provide additional symmetry and correction at this point.

Early complications include

  • Persistent erythema (long-lasting redness) is the most frequent early complaint. It is usually due to unintended intradermal injection. If the erythematous area is flat, then intense pulsed light (IPL) can be used to effectively reduce the lesion.
  • Ridges along the injection site and superficial beading are due to superficial intradermal injection and generally appear within 2 weeks. Injected strands (in particular those in the nasolabial folds) can separate unless an attempt is made to minimize motion at the injection site for 3 days. Limiting motion will allow the implanted material to become encapsulated and prevent it from dislocating.
  • Blanching after a particulate injectable indicates that a ridge may form later unless pressure is applied to the area to distribute the implant evenly.
  • Nodules will often appear within the first 4 weeks. They are often due to superficial or improper technique or inappropriate injection location. They tend to be small, isolated, well encapsulated, and respond poorly to intralesional steroids. They may require excision.

Late complications include

  • Hypertrophic scarring may occur in patients who are prone, but only if the substance is injected too superficially (intradermally).
  • Late inflammatory reactions include localized redness, swelling, and paresthesias. These can occur years after injection in all but the temporary fillers. Treatment with IPL or intralesional steriods is frequently effective.
  • Granulomas tend to appear 6-24 months after injection. They are true foreign-body reactions. They can occur despite proper injection technique. They are characterized by their late-onset rapid growth, inflammatory appearance, relatively large size, discoloration, and projections into surrounding tissues. They seem to appear simultaneously at all injection sites. They usually respond well to intralesional steroids. (photo credit)
  • Steroid atrophy, depending on the dose, may occur in 5-30% of patients treated for chronic redness, nodules, or granulomas.

Recommended intralesional corticosteroids include

  • Triamcinolone 20-40 mg
  • Betamethasone 5-7 mg
  • Methylprednisonlone 20-40 mg
  • Betamethasone (0.5 mL) in combination with 5-fluorouracil (1.6 mL) and lidocaine (1 mL)
  • Triamcinolone (10 mg/mL) with 5-fluorouracil

Intralesional steroid injections can be associated with secondary effects such as skin atrophy, treatment resistance, and risk of recurrence.

A few summary points from the second article:

  • Some patients are better candidates for aesthetic volumizing with Sculptra than others, because they are better at making collagen.
  • Ideal locations for Sculptra injection are the nasolabial folds or creases, marionette lines, cheek hollows, zygomatic arches, temporal depressions, and depressed, scarred areas.
  • Some physicians also use Sculptra for lateral eyebrows and dorsal hand areas.
  • Large areas, such as cheek hollows benefit from serial injections of very small volumes (0.1-0.2 mL or less) applied in a cross-hatched pattern. Advanced needle techniques such as fanning and retrograde tunneling using very small volumes work well in these areas. Specialized training and experience are necessary to utilize these techniques.
  • Sculptra should not be used in the body of the lip. This site offers a high probability of having nodules or papules form. Injections into the glabella and forehead are not recommended because of the risk of necrosis (photo credit)with any particulate product in these areas.
  • Nodule or papule development can be prevented by proper injection technique and appropriate identification of areas to be injected. Ice application postinjection may minimize bruising. A massage several times a day postinjection to the area can minimize papule formation.

REFERENCES

Treatment Options for Dermal Filler Complications; Aesthetic Surg J 2006; 26:356-365; Gottfried Lemperle MD, PhD and David M Duffy MD

Use of Sculptra in Esthetic Rejuvenation; Semin Cutan Med Surg 206; 25:127-131; Kenneth R Beer, MD and Marta I Rendon, MD

Wednesday, May 14, 2008

Antibiotic TX for Seawater Injuries

I wanted to share this article (reference below) as many of us may either see these patients as tourists or after they return from vacation. It is nice to have a logical choice for empiric antibiotic therapy. (photo credit)

The proposal of the article was "that the analysis of seawater pathogens will act as a guide for rational empiric antibiotic therapy, either as prophylaxis at the time of penetrating injury or as early treatment of a developing infection." To do this, 50 ml samples of seawater were collected from 25 preselected locations along a 12-km segment of the southern portion of the Galveston beach area in Texas. These water samples were taken over four seasons, the fall and winter of 2002 and the spring and summer of 2003.

"Despite variations in water temperature and beachgoer population size, the seasonal variations of bacterial species were minimal. Throughout all four studies, the most effective antibiotics against most Gram-positive microorganisms were penicillin, ampicillin, vancomycin, and levofloxacin, whereas the most effective antibiotics against all Gram-negative microorganisms were levofloxacin, lomefloxacin, and cefepime. Because all four studies contained similar trends in both Gram-positive and Gram-negative microorganisms, these authors believe that it is necessary to prescribe initial antibiotics that provide dual coverage of Gram-positive and Gram-negative organisms to patients with seawater-contaminated wounds, regardless of the season. Although the majority of organisms analyzed showed some sensitivity to levofloxacin, this drug has somewhat limited Gram-positive coverage that the addition of penicillin will address more appropriately. Thus, prescribing a combination of penicillin or ampicillin with levofloxacin to patients with seawater-contaminated penetrating wounds at any time throughout the fall, winter, spring, or summer should provide the necessary coverage to promote proper wound healing and functional recovery of the injured site. As is usually practiced, antibiotic therapy should be administered for a period of 5 to 7 days, with further changes being made based on the treating physician's clinical judgment. Using this regimen will also cover the dangerous Vibrio species and aid in preventing the morbidity and mortality associated with such infections."

The decision to treat any wound with antibiotic therapy should be based on clinical judgment. Abrasions and superficial injuries may only require debridement and copious irrigation. Lacerations and penetrating wounds that have a clearly visible base and no signs of infection in the wound or surrounding tissues may be irrigated and closed primarily using clinical judgment. However, seawater-contaminated wounds that are penetrating deeper than the dermis and associated with erythema and/or edema in the surrounding tissue will most likely benefit from dual-coverage prophylactic antibiotic therapy pending culture results.

REFERENCES

Empiric Antibiotic Therapy for Seawater Injuries: A Four-Seasonal Analysis; Plastic & Reconstructive Surgery. 121(4):1249-1255, April 2008; Jennifer S. Kargel, B.S.; Vanessa M. Dimas, B.S.; Dennis S. Kao, M.D.; John P. Heggers, Ph.D.; Peter Chang, M.D., D.M.D.; Linda G. Phillips, M.D.

Tuesday, May 13, 2008

Grand Rounds is Up

David E. Williams of the Health Business Blog is this week's host for Grand Rounds. It is a wonderful edition you can read here.

Welcome to the latest edition of Grand Rounds at the Health Business Blog. This is my fourth time hosting (fifth if you include the April Fool’s edition).

Next week's host will be Dino (Musings of a Dinasaur).

Monday, May 12, 2008

Guidelines for von Willebrand Disease

The National Heart, Lung, and Blood Institute (NHLBI) recently issued guidelines for the diagnosis and management of von Willebrand disease.

Von Willebrand disease (VWD) is an inherited bleeding disorder that is caused by deficiency or dysfunction of von Willebrand factor (VWF), a plasma protein that mediates the initial adhesion of platelets at sites of vascular injury and also binds and stabilizes blood clotting factor VIII (FVIII) in the circulation. Therefore, defects in VWF can cause bleeding by impairing platelet adhesion or by reducing the concentration of FVIII.

VWD is a relatively common cause of bleeding, but the prevalence varies considerably among studies and depends strongly on the case definition that is used. VWD prevalence has been estimated in several countries on the basis of the number of symptomatic patients seen at hemostasis centers, and the values
range from roughly 23 to 110 per million population (0.0023 to 0.01 percent)

Suggested Questions to Ask Patients in Screening

1. Do you have a blood relative who has a bleeding disorder, such as von Willebrand disease or hemophilia?
2. Have you ever had prolonged bleeding from trivial wounds, lasting more than 15 minutes or recurring spontaneously during the 7 days after the wound?
3. Have you ever had heavy, prolonged, or recurrent bleeding after surgical procedures, such as tonsillectomy?
4. Have you ever had bruising, with minimal or no apparent trauma, especially if you could feel a lump under the bruise?
5. Have you ever had a spontaneous nosebleed that required more than 10 minutes to stop or needed medical attention?
6. Have you ever had heavy, prolonged, or recurrent bleeding after dental extractions that required medical attention?
7. Have you ever had blood in your stool, unexplained by a specific anatomic lesion (such as an ulcer in the stomach, or a polyp in the colon), that required medical attention?
8. Have you ever had anemia requiring treatment or received blood transfusion?
9. For women, have you ever had heavy menses, characterized by the presence of clots greater than an inch in diameter and/or changing a pad or tampon more than hourly, or resulting in anemia or low iron level?

If the patient answers yes to one or more of the above:

An initial hemostasis laboratory evaluation usually includes a platelet count and complete blood count (CBC), partial thromboplastin time (PTT), prothrombin time (PT), and optionally either a fibrinogen level or a thrombin time (TT).

If these are suggestive of VWB, then the initial tests commonly used to detect VWD or low VWF are:

  • VWF:Ag -- an immunoassay that measures the
    concentration of VWF protein in plasma.
  • VWF:RCo -- a functional assay of VWF that measures
    its ability to interact with normal platelets.
  • FVIII coagulant assay -- a measure of the cofactor
    function of the clotting factor, FVIII, in plasma.

There is a very nice section on management. For me, it is probably best to work with the patient's Hematologist as it is very dependent on which type of VWB's the patient has and what type of injury (laceration, etc) or surgery (repair of laceration, breast reduction, etc). I did a breast reduction on a Type I VWB a couple of years ago with suggested DDAVP (Desmopressin: 1-desamino-8-D-arginine vasopressin) therapy preoperatively. The patient hardly bled or bruised. By working together, it worked well for all of us.

The guidelines can be read in its entirety here (PDF file).

Also, available for CME credit through Medscape: Management of Surgical Patients with VWD: New Research-based Options [CME available through May 5, 2009];released May 5, 2008; Joan Cox Gill, MD; Prasad Mathew, MD

Sunday, May 11, 2008

SurgeXperiences 121 and Mother's Day!

Necessity is said to be the mother of invention. Mother's Day is then the perfect day for this edition of SurgeXperiences (121). The host The Sterile Eye chose surgical instruments as the theme. What a great edition! You can read it all here.

Happy Mother's Day!

This picture is of my mom, Cathy (sister), me, Krystal (niece), and Jeanne (sister).

Friday, May 9, 2008

Stamp Out Hunger

The National Association of Letter Carriers will be collecting non-perishable food items like canned meats and fish, canned soup, juice, pasta, vegetables, cereal and rice on Saturday, May 10th.

You and I can help by placing food donations at the mailbox on May 10th before the letter carrier arrives. The food donations will then be taken to the Post Office. Later it will be delivered to local food banks or pantries. Please make sure the food items do not have expired use dates. They also ask that there be no glass containers.

For more information check out these sites:

Help Stamp Out Hunger

National Association of Letter Carriers Community Service


Abby's Quilt

This quilt was made for a little girl. The block pattern is called "Alabama". It is made of blues, purples, deep reds, and white. It measures 40 in X 58 in. It is machine pieced and quilted.

The back is fabric I found at a garage sale years ago. The fabric was licensed through the American Greetings Card Company, 1970's --Holly Hobbie. The current Holly Hobbie has been updated (website). You can find more history of Holly here.

Thursday, May 8, 2008

Words to Live By

The following was the conclusion of an article I recently read on David Cheever in the Journal of Plastic and Reconstructive Surgery (referenced below). I would like to share it. I think it applies to whatever field you choose to study, not just medicine.

"Although we may remember David Cheever as a surgical innovator, his character is more aptly revealed in the following passage from a lecture, delivered before the Harvard Medical School class of 1871, entitled “How to Study Medicine”21:

If you seek for wealth you have mistaken your avocation. There must be something more, and something higher. That something is a love of your profession; a passion for science for its own sake; a broad humanity, which covers all the sick with a mantle of charity. Never lose sight of that motive, for if it once takes flight, your profession is reduced to a trade, and there is absolutely nothing left. As long as you can keep alive the sacred flame of this early passion which first called you to embrace the medical
profession, so long shall you be warmed, sustained, upheld amid disappointment, unjust treatment or reverses."

Cheever's Double Operation: The First Le Fort I Osteotomy; Plastic & Reconstructive Surgery. 121(4):1375-1381, April 2008; Halvorson, Eric G. M.D.; Mulliken, John B. M.D.

Wednesday, May 7, 2008

Dermatomes

dermatome /der·ma·tome/ (der´mah-tom)

1. an instrument for cutting thin skin slices for grafting.

2. the area of skin supplied with afferent nerve fibers by a single posterior spinal root.

3. the lateral part of an embryonic somite.

It's the first definition that I will be discussing.

Padgett invented the first dermatome in 1939. This one was a drum dermatome and was manually operated. It was a surgical instrument for easily removing large flaps of skin of a prescribed depth. This helped move skin grafting to common practice from a miraculous one.

Today dermatomes can be operated manually, air-powered, or electrically. Many are named after their inventors. There are what I would consider three main types:

Blade dermatomes

  • These provides rapid harvest of large grafts of uniform thickness. These may be air powered, electric, or manually operated.
  • All of these harvest by the same mechanism: a rapidly oscillating side-to-side blade is advanced over the skin with thickness and width settings adjusted by the surgeon.
  • Commonly used dermatomes include the Castroviejo, Reese, Padgett-Hood, Brown, Davol-Simon, and Zimmer (photo credit)
  • When using the air or electric powered dermatomes, the operating surgeon must be familiar with the installation of the blade and how to adjust the setting for graft thickness and must check these before operating the device. There is a correct and an incorrect orientation of the blade, and the two may easily be confused.
  • Insertion of a No. 15 blade scalpel simulates a thickness of 0.015 inches and can be used to check that thickness settings are uniform and correct. After the blade orientation, width guard and depth setting are confirmed, and harvesting may begin.

Drum dermatomes

  • Drum dermatomes are less frequently used today but are available for specialized grafting needs.
  • On these instruments, the oscillating blade is manually powered as the drum is rolled over the skin surface. These dermatomes can be used to harvest broad sheets of skin of exacting thickness.
  • They are useful when the donor site is irregular, with a convexity, concavity, or bony prominence (neck, flank, buttock), because the skin to be harvested is first made adherent to the drum with a special glue or adhesive tape.
  • These dermatomes also allow precise irregular patterns to be harvested by varying the pattern of adhesive applied to the skin and drum.
  • Disadvantages include the risk of injury to operating personnel by the swinging blade, the need to use flammable agents such as acetone or ether to cleanse the donor site and remove surface oils to ensure secure adhesion of the skin to the dermatome drum, and greater technical expertise required to safely and effectively operate these devices.
  • Reese and Padgett-Hood (photo credit) are examples of this type. Check out the 5th reference article.

Free-hand Knives

  • Called knives and not dermatomes, these still fit the definition. Examples include the Humby knife (photo credit), Weck blade, and Blair knife.
  • The disadvantages include grafts with irregular edges and varying thicknesses. As with the drum dermatomes, greater technical expertise is necessary, and graft quality tends to be operator dependent.
  • Check out this link on "preparing a Humby knife"

REFERENCES

1. Hand Knife Versus Powered Dermatome: Current Opinions, Practices, and Evidence; Annals of Plastic Surgery. 57(1):77-79, July 2006; Tehrani, Hamid MBBS, MRCSEd; Lindford, Andrew MBBS, MRCSEd; Logan, Andrew M. FRCS (abstract online)

2. Skin, Grafts; eMedicine Article, Feb 17, 2006; Don Revis Jr MD and Michael Seagle MD

3. Applying Split-Thickness Skin Grafts: A Step-by-Step Clinical Guide and Nursing Implications; Ostomy/Wound Management , Volume 47, Issue 11, November 2001 , Pages: 20 - 26;

4. History of Skin Grafting; Brown University Online Article

5. Grafting of Skin: Advantages of the Padgett Dermatome; Calif West Med. 1942 July; 57(1): 16–18; George Warren Pierce

Tuesday, May 6, 2008

Grand Rounds 4:33

I had no theme for this Grand Rounds, but thought I would share some links and photos of Arkansas. This first one is of the Trail of Tears (photo credit). This first post may well bring tears to your eyes --

David, Marianas Eye, describes his thoughts while awaiting a diagnosis of cancer in his six-year-old son in his post "On the Other Side of the Diagnosis". A well written post about a very emotional time in his life.

Dr Rob, Musings of a Distractible Mind, remembers his own son in "The Cry of a Tiny Baby". His son turned 16 this week.

Doctor Shazam is back from a trip to Honduras. "I can’t wait for my next machete wound in Hondura!" Check out the post on the extensor tendon repair done there.

Buckeye Surgeon presents a case of Fournier's Gangrene. Read the comments as well.

Bruce, Reflections in a Head Mirror, looks at Fear. His posts are always thoughtfully written.

Chris, Spinal Cord Injury and Healing, lives in Brooklyn, NY. He sustained an injury to his spinal cord in late January 2008. He talks about his Inspiration. "Many people who know me also know that I have wanted to be a surgeon, or at least some type of physician, since I was a child........ But just after I was injured, although I knew I could complete medical school, I became very scared that surgery might be out of my reach forever."

PalMD, Denialism Blog, writes Never say "hopeless". "I can't tell you the number of people who complain to me about having their hope taken away. Exactly what this means, though, isn't always clear."

Scalpel has seen some pretty nasty things happen to people over the years, but nothing like this Horror.

Bongi, other things amanzi, writes about a time when he was a less experienced surgeon, operating alone:  "so i took her to theater. i was so scared i could almost not talk. ....... i did the operation alone. my hands were shaking so much i'm surprised i got it done."


Landmarks and monuments are featured in some parks, like this one of the Louisiana Purchase State Park or the Crater of Diamonds State Park (Arkansas actually has a diamond mine open to the public -- you get to keep what you find). (photo credit)


Here are some folks who received honors or should have this week--

Shadowfax states "When finally they were done, I made it a point to express my admiration and gratitude in the most direct way I could -- I went down to the hospital Starbuck's and bought them their favorite drinks (white chocolate mochas). Nurses rock!" I agree.

Christine, But Your Don't Look Sick, was recently honored at the NY Lupus Alliance Gala Brunch. Her acceptance speech focused on the " Yes, this has been my battle, my war with lupus… but luckily I have had an army to fight with me. We all have had lupus."

MedGadget highlights the National Marrow Donor Program's registration campaign to boost the ranks of committed bone marrow donors by allowing potential donors to register for free during the month of May.

Within five Arkansas state parks are cabins, pavilions, bridges, trails, a lodge, and other works that endure as a legacy to the craftsmanship of the Civilian Conservation Corps, part of Franklin D. Roosevelt's New Deal. (photo credit)

Sometimes policies/politics leaves behind a grand legacy, sometimes they don't. I'll let you decide about these next posts--

Annie, Home of the Brave, writes Nurses Week 2008: "There Were No Nurses". "I wrote this post over a year ago, but the more things change, the more they stay the same. The first week in May - to be more precise, May 6-12 - has been designated - mostly by hospital and nursing employers’ marketing departments - as Nurses Week."

Dr Val asks, "Do you know what your state's momscore? " Check out her post to find out what a mom score is.

Anybody practicing medicine today needs to be serious about medical guidelines. Dr Rich, Covert Rationing Blog, has a post that should not be missed on the the growing tyranny of medical guidelines.

Dr Anonymous asks a simple, yet, controversial question: If someone has used marijuana - even if used for medical reasons - should this prohibit him or her from being considered to be on a transplant list? Hospitals throughout this great nation struggle with this question every day.

John, NHS Blog Doc, submits an article regarding a major controversy in the UK. It seems that at present independent midwives work outside the NHS and do not feel bound by conventional medical practice. Consequently they cannot get insurance. So, unbelievably, they work without insurance. This article looks at one such Midwifery practice in Kent.

Laurie, A Chronic Dose, begins a series looking at the candidates healthcare plans beginning with John McCain. She attempts to look at the key policies of the candidates that resonate most with her perspective: someone with multiple chronic conditions whose problem isn’t lack of insurance per se, but lack of confidence in my insurance and lack of the comprehensive coverage I used to have.

Dr Couz, Tales from the Emergency Room and Beyond, is still plugging away at the incredibly misguided assumption that doctor shortages can be blamed on women.

Robert, Health Care Blog Law, writes a post on the new CHCF Report on the social media impact on health care (think blogging about health/medicine).

Sam, Canadian Medicine, feels that pathology is in a sorry state up in Canada. His post is about the discovery of a fourth scandal over a short period of time. Pathologists are mostly blaming the system's failure to devote enough resources to pathology and laboratory diagnostics.

There are many places for rock climbing (photo credit), hiking, fishing, and boating within Arkansas. Granted we are land-locked so no major sailing for us.

Paul, Medicine for the Outdoors, warns ocean swimmers to be careful. From the month of May through September, if you swim in the waters along the U.S. Gulf coast be mindful of sea bathers eruption, a particular form of skin rash caused by tiny jellyfish.

Vijay, Scan Man's Notes, writes about an old man who had sustained an injury to his left forearm on the farm a month ago and was being ‘treated’ by a traditional bone setter.

Whitecoat allows us to play detective in his post CSI Whitecoat #2 . "What can you tell the detectives based on the appearance of the patient’s hand?"

Dr Clairebear writes "I Don't Smoke". She discusses how well (or not) we doctors follow the advice we give to patients. It's not just the smoking advice; it's the cholesterol diet, the exercise, etc.

TBTAM shares "I'm Glad She's Not My Patient". Every rose has it's thorns, but ...........

Joey MD explains why it is important to be careful with self medication. In the Philippines, antibiotics can still be bought over the counter in some drugstores.........

Dr Benabio, The Derm Blog, wants you to know that Botox can get into your head. Literally! Check out his post "Your Brain on Botox".

How to Copy with Pain Blog wants you to know that Mindfulness matters when it comes to back pain -- “awareness that emerges through paying attention on purpose, in the present moment and non-judgmentally, to the unfolding of experience moment by moment.” You may find that making small changes in your posture will ease the pain.

Doc Gurley wants to help you with your spring cleaning -- spring cleaning your thoughts -- or, how to stop worrying about things you can't control (like the price of gas, the election, whatever).

In her post For Goodness Sakes Cosmetics Can Kill You, Nancy (Teen Health 411), writes about the safety of the cosmetics that our teens like to use. Very interesting and not just for teens.

Want to reduce your stress level, spend less money at the pump and do your part to help save the planet? Here’s one of the most simple yet effective tips that will accomplish all three. Walter, Highlight Health, may be able to help you.


I know that Arkansas' history is short compared to Africa or India's. Still there are the prehistoric Native American Indian burial mounds (Toltec) and farming-based, aboriginal civilization that lived here from 1400 to 1650 A.D. (Hampson Museum). (photo credit)

Blogger and type 1 diabetic Kerri Morrone, Six Until Me compiles a second edition of the Diabetes Terms of Endearment, with some of the best jargon bits of the community.

What do stereos and health care have in common? Henry Stern, InsureBlog, thinks that we're watching an evolution in how health care is delivered.

Louise, Colorado Health Insurance Insider, points out that Smoking Can Be Hazardous to Your Career. The post discusses Whirlpools potential termination of 39 employees for lying about tobacco use. The comments are very interesting, also.

Amy over at Diabetes Mine wants to announce The 2nd Annual DiabetesMine Design --- a competition designed to foster innovation in diabetes design and encourage creative new tools that will improve life with diabetes.

David, Health Business Blog, reviews a helpful little book that provides advice for board members of not-for-profit health care organization. It is an e-book: Navigating the Boardroom, 40 Maxims… Things You Must Know and Do to Be a Great Director. He provides a link to the book. He'll be hosting next week's Grand Rounds (May 13).

Clinical Cases Blog shares with us 5 Tips to Stay Up-to-Date with Medical Literature.

Tell a nurse how valued she/he is. Maybe buy them a cup of coffee or something.

Thank you for allowing me to present Grand Rounds to you. I hope you will visit each blog that submitted a post. Have a GRAND week!



Come visit us here in Arkansas. We'd love to see you. (photo credit)

Sunday, May 4, 2008

Six Word Memior

I was tagged by Midwife with a Knife who was tagged by TBTAM for the six word memior meme.

The instructions? Write a 6 word memior and tag 6 others. Leave a comment on the tagged blogs with an invitation to play.

MWWAK's --- Catch a baby, watch the floor.

TBTAM's --- I want to do it all.

Dr Wes' --- Show them kindness, integrity, and love.

So here's mine:

My life is full of stitches.

To me that covers my work (plastic surgery), my hobbies (quilting, sewing, knitting), my jogging (the occasional side-stitch), and my enjoyment of good jokes (keep me in stitches).

It somehow doesn't cover my family, friends, dogs. Unless you allow me to call them the threads that hold everything together.

Here are some links to others who have played:

Seaspray, Whitecoat, Monkey Girl, Scalpel

I'll tag: Sterile Eye, Knudsen, Bongi, Scanman, Bruce, and Val. And Dr David because he feels left out and we don't want that (added 5-7-08).

Call for Submissions

I am hosting this week's edition of Grand Rounds Rounds (May 6th).  There is no theme this week, but I have set a deadline for submissions.   All posts must reach me by Monday, May 5th at 12 noon CST (1:00pm EST).  Send them to me at rlbatesmd(at)gmail(dot)com    

 

The next edition of SurgeXperiences (121) will be hosted by Sterile Eye on May 11th.  He is a Norwegian medical videographer.

His request for submissions:

Unlike last time, I thought I’d go for a themed edition this time around. And the theme will be: Tools of the trade. Nuff said. The rest is up to you.

Please submit your posts by May 9th here.

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. The deadline for submissions is April 25th. Please submit your posts here.

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

Saturday, May 3, 2008

Hound Tooth Baby Quilt Finished

I recently finished the hound tooth baby quilt. It is 38 in X 50 in. I messed up one of the blocks, but didn't notice until the quilting was more than half done. Too late to change it then. I could say I planned it that way as a game of "Find the Different Square", but the truth is I just missed it. Still I like the over-all quilt.

The quilt is machine quilted. Here is a close up view.

Here is a view of the backing which is made up of five different flannel pieces.

Friday, May 2, 2008

Toad Suck Festival

There is a small community in Arkansas that sits on the Arkansas River named Toad Suck. It is near Conway. In 1982, Conway began holding a festival to raise money for scholarships to help local students further their education. Over the years the festival has raised over $500,000 for local students to attend Central Baptist College, Hendrix College, University of Arkansas Community College at Morrilton, and the University of Central Arkansas. CBC, Hendrix, and UCA are all colleges located in Conway, Arkansas. (photo credit) The festival is the first weekend of May (this year May 2-4th).

What does "Toad Suck" mean anyway?

Well, The answer is quite simple...
Long ago, steamboats traveled the Arkansas River when the water was at the right depth. When it wasn't, the captains and their crew tied up to wait where the Toad Suck Lock and Dam now spans the river. While they waited, they refreshed themselves at the local tavern there, to the dismay of the folks living nearby, who said: "They suck on the bottle 'til they swell up like toads." Hence, the name Toad Suck. The tavern is long gone, but the legend and fun live on at Toad Suck Daze.

The festival has grown to include multiple sports events: basketball, golf, 5K/10K, bicycling, and softball. There are free music concerts. This year some of the bands featured are: Hwy 5, Riverbilly, Blake Shelton , Ben Coulter, Culpepper Mountain Band, FreeVerse, KickBack, The Blue Meanies, Shaw Blades .

 

Each year they sell T-shirts (photo credit), lots of food and craft vendors, and there are toad races. This year as in the past few years there has been some difficulty finding the toads (don't confuse them with frogs). The article below may help explain why the numbers are decreasing.

There is a nice article on Amphibians (frogs, salamanders, and others) slipping into oblivion in Defenders (a conservation magazine of Defenders of Wildlife). You can read it online here. The photo below is of a female marsupial frog and her offspring (credit) and is from the article. The article states that amphibians are the most threatened group of animals in the world.