Monday, August 31, 2009

Suture Allergy vs Suture Reactivity

This past week I was once again asked about suture allergy.  It has prompted me to revisit the issue which I have posted about twice now. (photo credit).
Sutures by the vary nature of being foreign material will cause a reaction in the tissue.  This tissue reactivity is NOT necessarily a suture allergy.
Many factors may contribute to suture reactivity.
  • The length of time the sutures remain.  The longer the sutures are in, the more reactivity occurs.
  • The size of the sutures used.  The larger the caliber of the suture, the more reactivity.  The increase of one suture size results in a 2- to 3-fold increase in tissue reactivity.
  • The type of suture material used.  Synthetic or wire sutures are much less reactive than natural sutures (eg, silk, cotton, catgut).  Monofilament suture is less reactive than a braided suture.
  • The region of the body the suture is used affects tissue reactivity.  The chest, back, extremities, and sebaceous areas of the face are more reactive.
In general, accepted time intervals for superficial suture removal vary by body site, 5-7 days for the face and the neck, 7-10 days for the scalp, 7-14 days for the trunk, and 14 days for the extremities and the buttocks.  The deeper placed sutures will never be removed.
Sutures meant to dissolve (ie vicryl sutures) placed too high in the dermis (which happens often when the dermis is thin) can “spit” several weeks to several months after surgery. This is a reactive process, NOT a suture allergy.  It usually presents as a noninflammatory papule (looks very much like a pimple) and progresses with extrusion of the suture through the skin. The suture material may be trimmed or removed if loose, and it is not needed for maintaining wound strength.  Rarely does this affect the scar outcome.

The remaining portion is a “repost” about suture allergies:
Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.
Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.
MONOCRYL Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP(triclosan).
PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).
VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).  [In rechecking facts, I found that only Vicryl Plus has the triclosan, so simple vicryl or coated vicryl should be okay.]
Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.
Dermabond -- Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.

SO WHAT IS LEFT TO USE
So what is left to use in a patient who may have or has a proven allergy to suture or closure material?
Silk, Dexon, Nylon(monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn't react negatively.
The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.
The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.


REFERENCES
Allergic Suture Material Contact Dermatitis Induced by Ethylene Oxide: G. Dagregorio, G. Guillet; Allergy Net Article
Johnson and Johnson Product Information
Current Issues in the Prevention and Management of Surgical Site Infection - Part 2; MedScape Article
MECHANICS OF BIOMATERIALS: SUTURES AFTER THE SURGERY; Raúl De Persia, Alberto Guzmán, Lisandra Rivera and Jessika Vazquez
Materials for Wound Closure by Margaret Terhune, MD; eMedicine Article
Product Allergy Watch: Triclosan; MedScape Article by Lauren Campbell; Matthew J. Zirwas
New References
  • Surgical Complications; eMedicine Article, May 29, 2009; Natalie L Semchyshyn, MD, Roberta D Sengelmann, MD
  • Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature. Ann Allergy. Apr 1986;56(4):317-20. [Medline].
  • Fisher AA. Nylon allergy: nylon suture test. Cutis. Jan 1994;53(1):17-8. [Medline].

Related Posts
Allergies from Suture Material (September 7, 2007)
Suture Allergies Revisited  (April 30, 2008)
Suture (June 7, 2007)
Basic Suture Techniques (June 8, 2007)

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Sunday, August 30, 2009

SurgeXperiences 305 – Call for Submissions

SurgeXperiences 304 (August 23rd)  will be hosted by Amanzimtoti.   The deadline for submissions is midnight on Friday, September 6th.  Be sure to submit your post via this form

Amanzimtoti blogs out of Mpumalanga, South Africa.  She has this to say about herself:

I'm a doctor and a mother. When I'm not practicing medicine, I'm taking care of the kids: a little boy, a little girl and their slightly less mature father.

Check out her recent post, Don't judge a book by its cover.

………….I saw this patient a while back. He didn't speak English to me so I used an interpreter to take his history. He had a miriad of complaints, none of which I can remember now because none of them were very serious. When I examined him, I noticed he had a rash which looked suspiciously like a drug induced rash. I asked the interpreter to ask how long he'd had it and whether he'd been taking any medication before it started. He answered her in Swazi. I said out loud "This looks like a drug rash". He looked at me and said "It was a Stevens-Johnson syndrome that was caused by TB treatment. I was in hospital for about a week and then it got better."

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.

 

 

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Friday, August 28, 2009

Coins Quilt

This summer I have been trying to use up some of my fabric scraps as they seem to be taking over my sewing room.  This is one of the quilts made from those scraps.  It is machine pieced and  quilted.  It is 42 in X 52 in.  I have given it to a nephew and his wife.

 

Here is a detail photo of some of the fabrics.  I love the flying pig.

 

Here is another detail photo which shows some carolers, a zebra, some boots, and lots of colors.

 

In this photo you’ll find flowers, dots, dogs, and trees.

 

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Thursday, August 27, 2009

Abortion Coverage and Health Insurance Reform

I’m going to wade right in here.  I am not a fan of abortions, but neither am I of amputations.  Both are sometimes necessary.  To me, too often abortion opponents forget the mother.  She is a life present before us.  Her care should not be forgotten.

I have been listening and reading the discussions over how the abortion coverage may sink health care reform.  I think it would be a shame if this one issue does sink reform.

If my understanding of the Hyde Amendment (and it’s amendments over the years) is correct the Federal Government covers the cost of abortions in cases of rape or incest or when the life of the mother is at risk.  It does not cover the cost when the health of the mother is at risk:

With these bans, the federal government turns its back on women who need abortions for their health.  Women with cancer, diabetes, or heart conditions, or whose pregnancies otherwise threaten their health, are denied coverage for abortions.  Only if a woman would otherwise die, or if her pregnancy results from rape or incest, is an abortion covered.  The bans thus put many women's health in jeopardy. 

I agree with opponents who do not wish to cover abortions for simple any reason (ie the timing for a pregnancy is not good, etc).  Abortion should never be used for birth control.  That should be done using birth control pills, condoms, abstinence, etc.

Currently, the only abortions available under Medicaid are the ones mentioned above.  I think it a shame that distinctions can not be made to provide coverage for a woman who’s HEALTH would be negatively affected by her pregnancy.  All insurance policies should do so in my opinion. 

Opponents of abortion want language that would prohibit any private insurance company that accepts federal funds from offering to policyholders abortions other than those already eligible under Medicaid.

 

Sources

How Abortion Could Imperil Health-Care Reform by Michael Scherer; Monday, Aug. 24, 2009; Times.com

What is the Hyde Amendment? (July 21, 2004); ACLU

 

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Wednesday, August 26, 2009

Standards for This Blog

Thanks to Paul Levy, Running a Hospital, for allowing me to use his post and with minor changes using it here. 

I thought it would be good to reiterate the standards that I apply for this blog.

First, as noted in the disclaimer and privacy sections below, I cannot comment on individual and legally confidential patient care issues here.  I will not give individual medical advice, as I am not your treating physician. If you submit a comment that falls in to these categories, I may post it or not.  I most likely will not give you an answer you are looking to receive, but more likely a “no comment” reply.

Second, I will not post comments that make ad hominem arguments and use foul language, that "flame" rather than make points in a civil fashion, or that have prejudicial implications about race, religion, ethnicity, or sexual orientation.

Third, I will not post comments that are clearly designed to advertise a for-profit product, service, or company in the health care field. I retain discretion to post comments that advertise something that would be of general interest.

Fourth, I usually will not post comments that are excessively long. This is tricky because sometimes the person has something interesting to say, but my sense is that most blog readers do not want to drag through very long posts and comments. Encountering a really long comment, many will give up and not reach other comments that follow. So please do the opposite of Pascal: If you have something to say, take the time to write a short letter.

Anonymous comments are fine, and I understand why they might be prudent in some cases, but I personally think you can often be more persuasive if people know who you are and where you come from. Also, it feels good to "stand on a soapbox" and be "seen." People have given their lives to allow us to have freedom of speech. Try it!

So, please dive in, keep reading, and send us all your thoughts on the issues of the day. Thank you for your loyal readership and for spreading the word about this blog.

 

Amendment:

As Dr Wes mentions in the comments section, the comment should be in English.  I confess that is the only language I speak or read well.  I did take Spanish in college, but am not proficient in the language.  I do not seem to have a knack for them which I regret.  So please be sure the comments are in English.  Thanks.

Tuesday, August 25, 2009

Shout Outs

Dr Charles is this week's host of Grand Rounds. You can read it here (photo credit).  It’s the “old school” edition.

Welcome to Grand Rounds, a weekly gathering of medical people interested in sharing their best writing from the past week.  I was there in the beginning, back in 2004, when Grand Rounds first started.  Some might say that makes me old, but I prefer the term old school.

Scattered among excellent posts are flashbacks to the old school world of 2004 in which Grand Rounds was first conceived.  To add some extra relevance I’ve visited some of my favorite medical blogs and mined them for good stuff. Here we go, Old School Grand Rounds, a nod to 2004 when it all began, with some of my homies lending their street credibility:

 

The latest edition of Change of Shift (Vol 4, No 4) is hosted by  Kim!   You can find the schedule and the COS archives at Emergiblog.  (photo credit)

Welcome to this edition of Change of Shift, the blog carnival by, about and for nurses!  We have old friends, new bloggers and few “editor’s choice” picks thrown into the mix.   Enjoy!

 

Nice article by Dr Pauline Chen -- Treating Patients as Partners, by Way of Informed Consent – discusses how doctors are trained (or not) how to discuss consents.

This week I thought about those experiences and my conversation with Pete after reading a study about pediatric cancer patients, their parents and informed consent in the current issue of Academic Medicine. Investigators at the Cleveland Clinic found that after a single day-long training session, doctors were better at eliciting questions and clarifying comments than doctors who had not been trained. Moreover, when researchers later interviewed the parents, they found that parents who had spoken with trained physicians were more likely to have a better understanding of the consent itself.

H/T to Kevin MD:  In this interesting article (Mastering Mirror-Image Medicine by Crystal Phend, August 17, 2009) from MedPage Today, several surgeons are interviewed about their experiences performing procedures on patients with situs inversus. (photo credit)

When the appendix isn't where it's supposed to be, the classic appendicitis symptoms are anything but, noted Peter Mattei, MD, a general and thoracic surgeon at the Children's Hospital of Philadelphia.

He saw his first appendectomy in a situs inversus patient as a resident.

"Pain on the left side is the first thing that makes you rule out appendicitis," he said, and that misdirection can delay diagnosis, potentially long enough for rupture to occur.

 

Check out this article from our own Buckeye Surgeon in the September issue of the Reader’s Digest:  The Do-Something Culture of Medicine

If a doctor orders too many tests and treatments, it can be easy to blame greed, or the fear of a malpractice suit. But blogging physician Jeffrey Parks argues that the problem has deeper roots.

 

Along the lines of this tweet from @doctorwes [RT @EndoGoddess RT @TweetACritter: Your dog would make a great therapy dog! Check out Delta Society: http://bit.ly/2JGKzL<<My daughter did 2] is the T.A.I.L.S. program at Arkansas Children’s Hospital (photo credit)

The Child Life and Education department at ACH just celebrated the fifth birthday of its animal assisted therapy program at ACH, also known as T.A.I.L.S. (Therapeutic Animal Interventions Lift Spirits). Since the program began, 22 certified dogs have taken part in the program, helping to brighten patients’ days at ACH as well as assist in their therapy. All participating
dogs are specially trained and certified through the Delta Society. Each Tuesday and Wednesday, a pre-selected dog and his or her trainer visit the hospital and participate in group sessions. Patients can also receive one-on-one visits in their rooms.

 

Listened to a nice piece on the local NPR station highlighting the Arkansas school of knife making (photo credit).  The school is named after Bill Moran (1925 –2006).  You can listen to the article, “Arkansas' School of Bladesmithing attracts students from around the world” by Karen Tricot-Steward  here.

 

The Charleston Museum invites you to participate in a new program, the Charleston Museum Quilting Bee.

Our first project will be based on a Chimney Sweep album quilt in the Museum’s collection.  This sweet 1853 quilt, pictured left, is believed to have been made for a bride by her friends in Sumter, South Carolina.  Click for more information about the original quilt. 

Please consider participating in Phase One of the project by making a quilt block.  Click here for the instructions.  Please send us your block no later that August 31.   Your time and contribution are so greatly appreciated. View contributed blocks

 

                            

This week is Dr Anonymous’ second anniversary show!  Celebration!   Come joint us.  The show starts at 9 pm EST.

Upcoming Dr. A Shows 

9/3 : Brandice Schnabel author of Columbus Groove (9:30pmET)
9/5 : Saturday Night
9/10 : Dr. A Show
9/17 : Dr. A Show

You may also want to listen to 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

 

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Monday, August 24, 2009

Mastectomy Flap Necrosis – an Article Review

This study (full reference below) comes out of Memorial Sloan-Kettering Cancer Center.  Flap necrosis following mastectomy and reconstruction using a tissue expander has always concerned me.  I will never (due to the size of my practice) have the numbers they have or experience.  They state their purpose as

The purpose of this study was to assess the outcomes of our approach to mastectomy flap necrosis and to establish an algorithm that may be useful to other surgeons faced with this complication.

They were able to use the “prospectively maintained database” of all patients treated at Memorial Sloan-Kettering Cancer Center to identify patients with documented mastectomy flap necrosis following immediate tissue expander placement between January of 1995 and March of 2008.  A total of 178 patients were identified (4.3% of 4158 pts who had immediate tissue expander placement).

Of these 178, 29 patients (16%) had a history of prior irradiation. Twenty-five patients (14%) had a history of neoadjuvant chemotherapy, and 68 patients (38%) received adjuvant chemotherapy during expansion or after excision. 

Most healed with local wound care, but 58 (33% of 178) needed surgical excision of the eschar once the flap necrosis was fully demarcated.   Of these, five patients (9%) had prior irradiation, eight (14%) had prior chemotherapy, and 29 (50%) had chemotherapy during expansion or after excision.

In nine patients (15.5% of the 58 who need surgical excision), extensive mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure. 

 

I appreciate the authors sharing their treatment algorithm which led to their low incidence of failure.

….a more conservative approach that consists of a period of observation during which time the mastectomy flap necrosis is observed clinically over the initial 2 weeks.

Local wound care such as alcohol or Betadine swabbing may be utilized during these first 2 weeks, particularly to manage partial-thickness wounds to keep the necrotic skin clean and dry.

Expansion continues as the full-thickness demarcation becomes more evident over the next 3 to 4 weeks.

Antibiotics are not routinely administered, other than the typical oral course used for the duration that closed-suction drains remain in the breast pocket. However, if significant erythema surrounding the mastectomy flap necrosis is present and there is a clinical suspicion of infection, a more aggressive strategy using antibiotics and earlier excision may be implemented.

At about 4 to 6 weeks, full-thickness excision and closure are performed, typically in the clinic setting, with sterile removal of expander fluid to allow closure without tension.

Re-expansion is then carried out after closure approximately 2 weeks later

 

 

 

REFERENCE

Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis: A 13-Year Experience Using Timed Excision with Continued Expansion; Plastic and Reconstructive Surgery. 124(2):356-363, August 2009; Antony, Anuja K.; Mehrara, Babak M.; McCarthy, Colleen M.; Zhong, Toni; Kropf, Nina; Disa, Joseph J.; Pusic, Andrea; Cordeiro, Peter G.

 

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Sunday, August 23, 2009

SurgeXperiences 304 is Up!

Øystein, Sterile Eye, is the host of this edition of SurgeXperiences. You can read the “history” edition here.

Welcome to edition 304 of SurgeXperiences, the one and only biweekly collection of surgery-related blog posts.

The pictures in this edition are all from the US National Museum of Health & Medicine’s collection of public domain photographs, available at Flickr. Click on the pictures for larger versions.

The host of the next edition (305), September 6th, will be              . The deadline for submissions is midnight on Friday, August 21st. 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.

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Saturday, August 22, 2009

Geverfde Quilt

I received my quilt from the 3rd ALQS earlier this week.  It arrived from the Netherlands.  The quilt was made by Margreet.  You can read her description of how she made the quilt and see her photos (better than mine) here.

The quilt is 19 in X 19 in.  Margreet forgot to make a label for it, so I added one with her name, country, date, and ALQS3 on it.  The quilt is hanging my front office at work.

You may recall the quilt I did for this swap was Fractures I.  To view the other quilts and see who got which ones go here.

 

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Friday, August 21, 2009

Symmetry in Wool

I finished another shawl! The pattern is “symmetry in silk” from the Shawls and Scarves book. The yarn is Harmony 100% wool, color HC03. It was extra I had from the Estonian Garden Shawl I finished back in February. Sorry if the photos aren’t great, I have not yet learned the best way to take photos to show off lace knitting.

The shawl measures 15 in X 88 in. It is knitted on the bias.


I think I may keep this one for myself.

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Thursday, August 20, 2009

Nipple Sharing &/or Sparing Breast Surgery

Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery.   Full references are given for both below.

There are many techniques used for nipple reconstruction which should tell you that none is perfect.  One of the main issues is loss of nipple projection over time.  So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect! 

The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios.   Spear and colleagues did a literature review and came to the following conclusion:

It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.

There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….

Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial.  There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….

The collective data suggest that, using the above  below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.

The tumor criteria listed include:

  • The tumor should be 3 cm in diameter or less
  • The tumor should be 2 cm away from center of the nipple
  • Clinically negative axillae or sentinel node negative
  • No skin involvement, and no inflammatory breast cancer.
  • If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.

 

 

When the nipple can be spared then there is no need for nipple reconstruction.  When it can’t be, then the nipple sharing technique can be useful.  As with the above, the cancer risk is addressed:

Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.

 

The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.

Both articles are worth your time to read.

 

 

 

REFERENCES

Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza

Unilateral Nipple Reconstruction with Nipple Sharing: Time for a Second Look; Plast & Reconstr Surg 123(6):1648-1653, June 2009; Zenn, Michael R.; Garofalo, Jo Ann

 

Related Posts

Breast Reconstruction – Part I

Breast Reconstruction – Part II

Integrating Radiation Therapy & Breast Reconstruction

 

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Wednesday, August 19, 2009

Weight Lifting Good for Breast Cancer Patients

Historically, we healthcare providers have cautioned breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.  We often use 15 lbs as a guideline for a save weight to lift using the arm on the mastectomy side.  A new study suggests this advice turns out to be misguided.

The study has been published in the August 13 issue of the New England Journal of Medicine.  It is a small study, but the results do challenge our current reluctance to allow lymphedema patients to weight-lift.

Kathryn Schmitz, PhD, MPH and colleagues enrolled 141  breast cancer survivors with lymphedema.   The enrollees were then placed into two groups.  One was assigned to a weight-lifting group who lifted twice-weekly for 13 weeks.  The other group was used as a control group and did no weight-lifting.

The weight-lifting women (71) wore a custom-fitted compression garment on their affected arm during their workouts.  Their arms were measured monthly to ensure any changes were noted as soon as they occurred.  Each week were asked about changes in symptoms.

Both groups had the same proportion of women who experienced an increase of 5% or more in their limb swelling.  However, the weight-lifting group had fewer exacerbations of their condition which required treatment from a physical therapist; 9 compared to the 19 women in the control group.   The weight-lifting group also had a reduction in symptoms such as pain.

Further studies need to be done to verify their results, but I would allow motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.

Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.

 

REFERENCE

Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene

 

Related Posts

Lymphedema (December 5, 2007)

ARM Technique (October 15, 2008)

 

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Tuesday, August 18, 2009

Shout Outs

Invisible Illness Week is this week's host of Grand Rounds. You can read it here (photo credit).  It’s the “back to school” edition.

It’s Back to School time and also coming up is National Invisible Chronic Illness Awareness Week, September 14-20. 2009. About 133 million people, nearly 1 in 2 in the USA live with a chronic condition and most of these are not visible. We hope you will join us for our virtual conference with 20 online free seminars for Invisible Illness Week (9/14-9/28).

This week the Grand Rounds Carnival takes a “look” (ironic choice of words) at invisible illness issues as well as the best of the medical bloggers who update us on everything from new medical gadgets to their personal experiences.

 

I know Laikas’ post is part of Grand Rounds, but want to highlight it here.  Her post is on her “invisible illness” Addison's disease.

I won’t write about this professionally -being a librarian-, but I will speak from my own experience.

As many of you know, I’ve the chronic illness Addison’s Disease. Not that I feel ill. It doesn’t affect me, really… Not anymore.. I think.

 

Dr Val wants to invite you all the the less expensive version of TEDMED – BIL:PIL

….. so some creative young folks decided to create a free sister conference at the same venue. They called it “BIL:PIL” as a kind of riff on Bill & Ted’s Excellent Adventure, and keeping “PIL” for a rhyming medical theme. Pretty funny.

…… has lured me into presenting at BIL:PIL. I’ll be joined by some speakers from TEDMED and a gaggle of social media and medical technology innovators. In fact, it’s not too late to register or vote for your favorite speaker at BIL:PIL as programming will not be finalized until September 30th.

The meeting will be held October 30th and 31st at the San Diego State University BioScience Center in San Diego, California.

 

Interesting segment on NPR regarding health co-ops,  What Health Care Co-Ops Might Look Like.  You can hear it here.   A companion piece, “Health Co-Ops Explained” by Scott Hensley, is also worth reading.

 

Dr Rob has made his local paper, “Doctor 's humor is a hit on iTunes!"  Check out his podcast,  “House Call Doctor.” You can find the list of his podcasts here.  Enjoy!

 

Crazy for Quilts Contest Gallery is up!  The quilt I did is #4.  

All contest quilts will be auctioned via eBay. All proceeds will support AAQ. All auctions begin and end at 9:00 PM Eastern

On eBay search keyword "Alliance for American Quilts." Never used eBay? No problem! View a great tutorial on the eBay website.

 

                            

This week Dr Anonymous guest will be Dr. Rob talking about his House Call Doctor podcasts.  Come joint us.  The show starts at 9 pm EST.

Upcoming Dr. A Shows 

8/27: Dr. A Show 2nd Anniversary & BlogWorldExpo
9/3 : Dr. A Show (9:30pmET)

You may also want to listen to 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

 

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Monday, August 17, 2009

Should Excised Mastectomy Scars Be Routinely Sent for Analysis?

Surgeons are commonly faced with the question of whether or not a surgical specimen should be submitted for histologic analysis. Routine histologic examination of clinically unsuspected mastectomy scars that are excised during secondary corrective surgery is considered good practice, but in this era of cost containment in medicine should it be done? 

Locoregional recurrence of breast cancer following mastectomy occurs mainly in the first 3 to 5 years at an incidence rate of  3 to 7%.    That risk after breast-conserving therapy is 1.5 to 2 % per year, stabilizing around 10 to 20 % at 10 to 15 years. 

The first reference article below involved a retrospective review of 433 patients with a history of breast cancer whose mastectomy or breast-conserving surgery scars (455 scars, 22 pts had bilateral surgery) were excised and sent for histopathologic examination.   This included all their patients who had delayed breast reconstruction between January of 2000 and December of 2006 at the three National Health Service plastic and reconstructive surgery units in the West Midlands, United Kingdom.   Four (o.9% of 455) of the mastectomy scars (only three patients as one had bilateral scar recurrence) were positive for carcinoma recurrence.    None of the patients had any preoperative clinical suspicion of recurrent disease.  Their patients mean interval from primary breast surgery to reconstruction was 46.8 months (range, 2 months to 32 years).

This studies authors concluded:

In keeping with cancer surgery principles and with the potential for improved patient outcome, we recommend routine histologic examination of mastectomy scars at the time of delayed breast reconstruction.

 

The second reference article had a similar number of patients (424) treated by plastic surgeons of The Netherlands Cancer Institute from January of 1994 through May of 2004.   They sent 728 scars for routine histologic examination, 503 (70 percent) of which were excised within the first 3 postmastectomy years.  None of the patients had any preoperative clinical suspicion of recurrent disease.  Several patients (210 of 424) had multiple scars excised.  No evidence of metastatic or de novo tumor was found in any of the 728 scars, but residual glandular tissue was found in 11 scars. 

This studies authors concluded:

Because we found no evidence of tumor in any of the 728 scars we, more convincingly, support and extend their conclusion that routine submission of clinically unsuspected scars excised at the time of breast reconstruction or scar correction after prophylactic or curative breast surgery did not benefit our patients.

 

Which is the correct answer?  I honestly don’t know.  For now, I’ll continue to routinely send any postmastectomy scars.

 

REFERENCES

Mastectomy Scars following Breast Reconstruction: Should Routine Histologic Analysis Be Performed?; Plast Reconstr Surg. 123(4):1141-1147, April 2009; Warner, Robert M.; Wallace, David L.; Ferran, Nicholas A.; Erel, Ertan; Park, Alan J.; Prinsloo, Daniel J.; Waters, Ruth

Routine histologic examination of 728 mastectomy scars: Did it benefit our patients?;  Plast Reconstr Surg. 2006;118:1288-1292; Woerdeman LA, Kortmann JB, Hage JJ.

Locoregionally recurrent breast cancer: Incidence, risk factors and survival;  Cancer Treat Rev. 2001;27:67-82; Clemons M, Danson S, Hamilton T, Goss P.

 

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Sunday, August 16, 2009

SurgeXperiences 304 – Call for Submissions

SurgeXperiences 304 (August 23rd)  will be hosted by Øystein at Sterile Eye.   His suggested theme is “History.”  The deadline for submissions is midnight on Friday, August 21st.  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.

 

Here is a list of some of my past posts with a surgical history

Dr. Joseph Murray, Plastic Surgeon & Scientist (Sept 1, 2007)

Paul Brand, MD (1914-2003)  (November 7, 2007)

DeBakey and Cooley (November 27, 2007)

Spare Parts (December 10, 2007)

Dermatomes (May 7, 2008)

The Blalock-Taussig-Thomas Collaboration (July 23, 2008)

How Poland’s Syndrome Was Named (June 25, 2009)

 

 

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Friday, August 14, 2009

Shirley's Arbor Windows

I made this quilt for one of the circulating nurses I work with at the surgery center.  She asked for greens and mauves.  I found all the “center” fabrics in my stash and decided use them.  I liked the way it looked as I lay it out, but now I wish I had mingled the pinks into the green rather than concentrating them in the center.  Still, I like the quilt and more importantly Shirley does.

The quilt uses a pattern called “arbor windows.”  It is machine pieced and quilted.  It is 46 in X 63 in.

Here is a close photo to show some of the fabrics.  I used eight different pink/mauves.  I used three different greens.
This near photo shows the backing fabric that I had initially intended to use for the border, but I like the green border better. 

 

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Thursday, August 13, 2009

ASPS Task Force Updates Position on Fat Grafting

I have written about fat grafting to the breast previously here and here. 

The Fat Graft Task Force of the American Society of Plastic Surgeons (ASPS) convened to try to answer the question of whether fat grafting compromises breast cancer detection and/or results in potentially catastrophic sequelae in patients?  Their conclusion:  there is no indication that fat grafting is an unsafe procedure with qualifications that more research is needed.

Sydney R Coleman, MD is quoted in the Cosmetic Surgery Times article, "In review of the multitude of evidence-based results of clinical trials, case series and reports, the Task Force found that there is no evidence that indicates that fat grafting is an unsafe procedure.  Nevertheless, the report did say that in order for the Task Force to make concrete recommendations for or against fat grafting for specific applications, high-quality randomized controlled trials would be needed to further evaluate safety and efficacy."

The following conclusions are from the February 2009 Task Force Report:

CONCLUSIONS
Clinical Applications
Based on a review of the current literature and a lack of strong data, the Task Force cannot make specific recommendations for the clinical use of fat grafts. Although fat grafts may be considered for use in the breast and other sites, the specific techniques of graft harvesting, preparation, and injection are not standardized. The results therefore may vary depending on the surgeon’s technique and experience with the procedure. Although there are little data to provide evidence for long-term safety and efficacy of fat grafting, the reported complications suggest that there are associated risks. Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting. There is a potential risk of fat grafts interfering with breast physical examination or breast cancer detection; however, the limited data available suggests that fat grafts may not interfere with radiologic imaging in detecting breast cancer.


Future Research
The Task Force believes autologous fat grafting is a promising and clinically relevant research topic. The current fat grafting literature is limited primarily to case studies, leaving a tremendous need for high-quality clinical studies. While this evidence-based review resulted in few, if any, new data that would prompt a substantial change in the current state of fat grafting, the lack of new information poses two important questions: (1) are current methods of fat grafting still the "gold standard," or (2) is more research needed and should funding be directed toward new studies? For many aspects of fat grafting, the Task Force found the latter to be true and has
suggested the following areas for future research:

  • Randomized controlled trials to assess safety and efficacy of fat grafting for different indications
  • Randomized controlled trials to assess safety and efficacy of specific fat grafting techniques
  • Studies to further assess the effect of fat grafting on breast cancer detection and treatment.
  • Studies to identify risk factors and improve patient selection for procedures involving fat grafting.
  • Studies to investigate aspects of cell/tissue viability and graft survival, as well as long term storage and banking of fat grafts.
      

 

REFERENCES

ASPS' Fat Graft Task Force updates position on safety of autologous fat grafting; Cosmetic Surgery Times, Aug 1, 2009; Ilya Petrou, MD

Current Applications and Safety of Autologous Fat Grafts: A Report (pdf); American Society of Plastic Surgeons; Feb 2009

Fat Transfer/Fat Graft and Fat Injection:  ASPS Guiding Principles (pdf); January 2009

 

 

Related Posts

Fat Injections for Breast Augmentation (November 6, 2008)

Complications After Autologous Fat Injections to the Breast – an Article Review (April 2, 2009)

Recent NPR Stories on Plastic Surgery (June 3, 2009)

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Wednesday, August 12, 2009

Internal US Technique Treats Hyperhidrosis—an Article Review

This was suppose to simply be an article review. I was intrigued by the potential of using ultrasound (US) to damage the sweat glands when I read this article in the August issue of Cosmetic Surgery Times. I even went back and read the Aesthetic Plastic Surgery Journal article referenced, but I have gotten sidetracked by this photo. It troubles me.

See how it is labeled an intra-operative photo? Notice the surgeon is wearing what appears to be a large jeweled ring under her sterile glove. Who wears jewelry in the OR??? That’s not proper sterile technique!

Intra-operative photo shows application of internal ultrasound therapy to damage the sweat glands. (Photo credit: Sharon Giese, M.D., F.A.C.S.)

In the article Dr. Giese states the procedure uses the heat energy of the ultrasound liposuction to “presumably kills the sebaceous glands. Permanently." No biopsies done to know for sure. No starch– iodine testing to quantify the decrease in sweat.

Dr Giese reports good results with her patients, but doesn’t quantify the number of patients. She reports that all the women no longer need deodorant. She reports that one male has had 65% reduction in sweating which can now be controlled by deodorant.

In looking further into the technique I found two more recent articles (the 3rd and 4th below).

In the 4th article, the researchers had 13 patients (3 males, 10 females) with significant axillary hyperhidrosis which they treated with the VASER ultrasound and followed for 6 months. Eleven of 13 patients had significant reduction in sweat/odor with no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree they desired. No significant complications were noted. They report the complete procedure takes less than 1 h to treat two axillae using local anesthetic.   Once again, no objective measures of sweating.

I remain intrigued with this procedure, but would love more scientific measures and studies.  Still, I suppose the patients only care about the subjective measures when it comes to sweating.

 

 

REFERENCES

Internal ultrasound technique treats hyperhidrosis; Cosmetic Surgery Times, Aug 1, 2009; Donley-Hayes, Karen

Very Superficial Ultrasound-assisted Lipoplasty for the Treatment of Axillary Osmidrosis; Aesthetic Plast Surg. 2000 Jul-Aug;24:275-279; Park S

Characteristics of Refractory Sweating Areas Following Minimally Invasive Surgery for Axillary Hyperhidrosis; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; Falk Georges Bechara, Michael Sand and Peter Altmeyer

Treatment of Axillary Hyperhidrosis/Bromidrosis Using VASER Ultrasound; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; George W. Commons and Angeline F. Lim

Related Posts

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Tuesday, August 11, 2009

Shout Outs

DrRich, The Covert Rationing Blog, is this week's host of Grand Rounds. You can read it here (photo credit).  It’s the “cost containment in healthcare” edition.

Critics of the Obama health (insurance) reform plan have been formally served notice that they are under observation, ……….. So, as he embarks on this week’s edition of Grand Rounds, DrRich would like to welcome any visitors who are here on behalf of such important surveillance efforts, and hasten to tell you that DrRich is on your side. Indeed, this version of Grand Rounds is dedicated to exploring the many ways in which the proposed health (insurance) reforms will succeed in all its goals, and most especially in achieving cost containment…….

 

 

The latest edition of Change of Shift (Vol 4, No 3) is hosted by Man-Nurse Diaries who used a video game theme!   What fun!You can find the schedule and the COS archives at Emergiblog.  (photo credit)

It's August and school is looming around the corner, so kids everywhere are scrambling to waste time and do as much nothing as possible. What better way to dampen your brain activity than with video games? So here it is, your video game themed Change of Shift Vol 4 No 3: The Revenge!

 

H/T to  @EvidenceMatters for the link to this article:  A new superbug found in Britain is major concern: Government scientists by Rebecca Smith, Medical Editor.  The article talks about an un-intended consequence of medical tourism – the global spread of antibiotic resistant bacteria.

A new superbug that is resistant to all antibiotics has been brought into Britain by patients having surgery abroad, Government scientists said.

Doctors are urged to be vigilent for a new bug that has arriving in Britain with patients who have travelled to India and Pakistan for cosmetic surgery or organ transplants and is now circulating here.

 

Great show on NPR yesterday on “End Of Live Decisions And The Health Care Bill.”  You can listen to it here.

A portion of one health care bill in congress states that the cost of consultations between patients and doctors over "end-of-life" issues would be covered. The proposal has sparked fears that the bill promotes euthanasia.

 

Dr Rob has made his local paper, “Doctor 's humor is a hit on iTunes!"  Check out his podcast,  “House Call Doctor.” You can find the list of his podcasts here.  Enjoy!

 

Did you know that approximately 200 people die each year in the U.S. after being struck by lightning?  H/T to @laikas  for the link to this article: ER Doc explains how to avoid or respond to lightning strike

Prevention begins by seeking cover at the start of a storm. “Lightning seems to be concentrated at the forefront of a storm,” according to Zinzuwadia, “so there tends to be a greater risk of being hit by lightning at the beginning of a storm.”

 

WhiteCoat raises an interesting question in his post Charity Care Tax Exemptions

If exemption from federal income and/or state property taxes for non-profit hospitals is based upon providing “charity care” to their surrounding communities, how will hospitals qualify for income tax and property tax exemptions if health care coverage becomes “universal” and there is no longer a need for “charity care”? ………….

 

Crazy for Quilts Contest Gallery is up!  The quilt I did is #4.  

All contest quilts will be auctioned via eBay. All proceeds will support AAQ.
All auctions begin and end at 9:00 PM Eastern

On eBay search keyword "Alliance for American Quilts." Never used eBay? No problem! View a great tutorial on the eBay website.

 

                            

This week Dr Anonymous guest will be  The Hollums Adoption.  Come joint us.  The show starts at 9 pm EST.

Upcoming Dr. A Shows 

8/20: Dr. Rob & House Call Doctor podcast
8/27: Dr. A Show 2nd Anniversary & BlogWorldExpo
9/3 : Dr. A Show (9:30pmET)

You may also want to listen to 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

 

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Monday, August 10, 2009

SurgeXperiences 303 is Up!

Dr Bruce Campbell, Reflections in a Head Mirror, is the host of this edition of SurgeXperiences. You can read the “dog days of summer” edition here.

Welcome to the August 9, 2009 edition of surgeXperiences! I'm happy to be hosting again. Here in the Northern Hemisphere, these are the "Dog Days of Summer," so in honor of dogs everywhere, lets chew into the best of the surgical blogosphere. Along the way, we will sniff around a few categories and search for the "Best of Show."

 

Thanks Dr Campbell for the “vote” for Rusty!

The winner of the "BEST IN SHOW" Trophy:
Rusty, who lives at Suture for a Living, is one of the medical blogosphere's beloved mascots (along with a certain lobster and some llamas). Rusty is a contestant in the Top Dog in Arkansas Contest! You can vote for him (registration required) at the Arkansas Democrat-Gazette's website from now until August 26. Go, Rusty!

 

The host of the next edition (304), August 23rd, will be Sterile Eye. The deadline for submissions is midnight on Friday, August 21st. 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.

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Sunday, August 9, 2009

It Happens

Many of the surgeries I do are elective. They can and should be scheduled to be convenient. It happens – God laughs at our plans or life interrupts or …..

Last week was such a time for one patient. She called, very apologetic, “Dr Bates, I need to reschedule my surgery. My father is having tests done. He hasn’t been feeling well.”

I quickly assure her that no apology is necessary. Her family comes first. I suggest we simply cancel the surgery for now until the “dust settles.” She can call me back when she is sure things are okay with her family. We’ll reschedule then.

She is still worried. “The surgery center called me today. Do I need to call them? Will I need to pay them or anesthesia or you for the canceled time?”

Again I reassure her, “No, I’ll call them and take care of cancelling the surgery. No, we don’t charge you for surgery we don’t do. It happens. It’s okay to cancel surgery for whatever reason – another family member gets sick, an accident happens, you just get scared.”

It happens on both sides. Sometimes (as for me earlier this year when my mother had surgery) it’s the doctor who has to cancel or reschedule. Sometimes it’s the patient. I once had a patient not show up for surgery, only to find out later she had been in a motor vehicle accident the evening before her scheduled surgery. She turned out to be okay, but it really cemented how I fell about patients who call to cancel or reschedule. It’s okay. No need to apologize. Thank you for letting me know.

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