Friday, April 30, 2010

Flying Colors Baby Quilt

Flipping through some of my quilting books, I decided to make an “airplane” quilt.  I looked at all the patterns in “Flying High:  the Airplane in Quilts” by Ragi Marino, but ultimately decided to use the “Lindy” airplane block from  BH&G’s America’s Heritage Quilts.  The book states the pattern was published in the Capper’s Weekly in the 1930’s.

The baby (or child’s) quilt is machine pieced with the propellers appliqued by hand.  The planes are in primary colors -- two red, two blue, two green, and two yellow planes. The quilt is 42.5 in X 43.5 in.

The quilt is machine quilted using outline quilting and grid quilting for the plane blocks.  The plain blocks are quilted with a “propeller” and circles.

Here is a close view of one of the yellow planes.
Here is a view of the back to show the quilting.

The quilt is for sale over at Etsy.

Thursday, April 29, 2010

Sun Sense

We are past spring breaks and headed toward the end of the school year and summer vacations.  I noticed this product in the April issue of PSP.  (photo credit)

UVSunSense is a wristband that monitors your exposure to sun.  If you and your children have trouble remembering to reapply sunscreen or to just get out of the sun, then this might be just the ticket. 

Even young children can be taught to recognize the color changes the band goes through with exposure to the sun’s UV rays.  You should use only one band a day.  After placing the band around the wrist, apply your sunscreen over your exposed skin AND the band.  The new band will turn a bright purple with exposure to the sun, indicating it has been activated. (photo credit)

 

 

When the band fades to light pink, it is recommended to reapply sunscreen on your body and on the band. 

When the band turns pale yellow, it is recommended to cover up or get out of the sun.

The bands are made of recycled plastic.  Recycle them after use.

 

 

Related blog posts:

Sun Protection (March 19, 2009)

Melanoma Review (February 25, 2008)

Skin Cancer—Melanoma (December 8, 2008)

Melanoma Skin Screening Is Important (April 29, 2009)

Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)

Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

Moles Should Not Be Treated by Lasers  (July 27, 2009)

Tanning Beds = High Cancer Risk (August 3, 2009)

Skin Cancer (March 24, 2010)

Wednesday, April 28, 2010

Can Anyone Help?

I continue to occasionally get comments on my facial/orbital fracture series (2008).  These days they are mostly from patients who are looking for advise.  The most recent one is from tyler has the post "Nasoethmoid Orbital Fractures"

With his permission (via email), I am posting it here and asking for help.

Hi I just came across this and I’m wondering if there’s anyone out there that can give me advice.  I suffered an orbital fracture 3 years ago resulting in double vision.  I had surgery once and it didn’t work. I still live with double vision and I’m thousands in debt.  If there’s anyone out there that could give me advice it would be greatly appreciated (charity programs, grants, anything).  My email is juoncl@gmail.com

The only suggestions I had were possibly state programs (ie Medicaid, etc), but these would be income dependent and maybe the Lion’s Club.   Though I didn’t ask and he didn’t say, I’m assuming he has no insurance because reconstructive surgery for “double vision” is something insurance would cover.

If you have any suggestions for him, please, either email him directly or leave a comment here or both.  I would love to know of any resources available.

Knowledge: What Kind and How Much?

Here is a second essay from Dr. Robert Goldwyn’s book “The Operative Note:  Collected Editorials” (published in August 1992).  

Knowledge:  What Kind and How Much?

A few years ago, when my daughter was a high school sophomore, she asked me to help her prepare for a biology quiz.  She was astounded that this paterfamilias, a certified physician, was ignorant of the precise base sequence of DNA-RNA.  In self-defense, I said that most of my colleagues would probably fail her test but were good doctors nevertheless.

“but how can they take care of patients properly if they don’t know all about these important nucleic acids?” she asked.

“Surprisingly,” I replied, “they do very well.”

This incident, aside from revealing my daughter’s knowledge and my lack of it, is relevant to the greater considerations of learning – What kind and how much?  Publilius Syrus, known for his maxims in the first centery B.C., said:  “Better be ignorant of a matter than half know it.”  Many centuries later, Alexander Pope expressed the same thought in his famous “a little learning is a dangerous thing.”  Huxley’s retort was “Where is the man who has so much as to be out of danger?”  In truth, most of us are in various stages of ignorance.

A medical student asked me, “How much basic science do I have to know to be a good doctor?”  The question, which may be unanswerable, is nevertheless perennial.  Because knowledge and wisdom are not synonymous, the central query is how much of each is necessary.  Any answer must take into account the individual’s needs at a particular time.  Students regularly complain about the irrelevance of the material they must digest, and teachers constantly chide them for their lack of perspective in not realizing that what may seem useless today may be helpful tomorrow.  What to teach and what to learn have stimulated curriculum committees to produce ponderous reports that rehash everything and resolve nothing.  Rare is the year without another “definitive” statement on the aims and strategies of education.

The human being functions astonishingly well knowing comparatively little.  Global enlightenment is unnecessary.  For most people, making a living in our complex society demands narrowness not breadth.  We are job-specific.  Major league pitchers would fail a high school physics test on mass, velocity, friction, and wind currents, yet they could easily strike out every professor at the Massachusetts Institute of Technology.  So also can a doctor do considerable good for a patient with more know-how than knowledge.  Deplorable, perhaps, but true.

Let us take the example of reconstructing the breast in a 45-year-old woman who has had a mastectomy.  How many plastic surgeons could discourse on the hormones at menopause?  Could we pass a thorough examination on the  various ways of treating breast cancer:  radiation, chemotherapy, surgery?  Are we well read in the history of each of these therapies?  Do we have a picture in our minds of the histology of the most common kinds of breast cancer?  Do we know the chemical structure of silicone and how the implant is made?  During the procedure are we familiar with the anesthetic agents and their pharmacology and physiologic effects?  Do we understand the manufacturing process of the surgical blade and suture material?  And what about wound healing, not only the names of the classic stages but the biochemical and biomechanical aspects?  Certainly, it would be better if we had this knowledge.  However, even if we possessed it, we still would have to know when to operate, on whom, and how.  And what about the not-so-small matter of being a compassionate physician with psychological understanding of this unfortunate person and a feeling of permanent responsibility toward her?

This editorial is not a plea or an apologia for ignorance, not is it a eulogy to it.  It is an attempt to recognize things as they are.  Often we are hypocritical in being hypercritical.  We usually demand more knowledge from others than from ourselves.  Furthermore, within the medical sphere, if we are honest, we would admit that many errors arise not from lack of knowledge but from absence of what moralist one called “character.”  In this situation, what motivates the doctor may imperial the patient to the detriment of both.

Unfortunately, I cannot offer a solution to the problem that prompted this editorial:  Knowledge: What Kind and How Much?  What is certain, however, is that knowledge without wisdom is like a ship without a rudder.  Correct timing and the proper application of  information hopefully come with experience.  Yet, as someone observed, there is a difference between a person who has 20 years of experience and someone with 20 years of 1 year’s experience.  Let us hope, at least, for the former.

Tuesday, April 27, 2010

Shout Outs

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

Hey laaaaadeeeeez! It's time again for Grand Rounds, ChronicBabe style, which means we've curated a collection of posts that are completely babelicious. We hope you enjoy this gathering of doctors, nurses, patients and just regular folk who like to write about medicine. And women.

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If you don’t have access to Discovery CME channel, you can still watch Dennis Quaid’s Chasing Zero: Winning The War On Healthcare Harm  online here

A made-for-TV documentary, 55 minutes long and entitled Chasing Zero: Winning the War on Healthcare Harm, is being shown four times globally beginning April 2010 on the main Discovery Channel. After it has aired, a commercial-free DVD will be produced and distributed for free to all U.S. hospitals by TMIT, and will be sent to the chairmen of the governance boards and their CEOs. A second hour of content composed of digital short stories and concept messages will be added to the DVD.

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Drew, Pallimed, writes about Surgical 'Buy-In' and the Surgical Contract 

Critical Care Medicine has a fascinating qualitative study about surgeons and end of life care which speaks directly to this, and similar, situation.  It's an excellent paper for the teaching file, particularly for fellows who don't have surgical backgrounds (which I assume is most, but thankfully not all, HPM fellows these days). 

The paper presents a small qualitative study of 10 physicians (mostly surgeons; a few non-surgeons who do extensive work in SICUs) …. and attitudes towards advance directives, ……..

This paragraph of Drew’s post struck a chord with me:

I have a distinct memory of one of my attendings, early on in my palliative fellowship, talking with me about surgeons.  …….  My attending told me something like 'Surgeons have a bond with their patients that is much stronger than internists. If you cut someone open, it changes your relationship with the patient in a way that internists just don't have.'  I thought to myself at the time that that was really weird.  Surgeons are cold heartless scalpel jockeys - how could they have a bond deeper than my patient-centered, humanistic, whole-person approach?  Well like a good fellow I remembered what he said, and slowly came to realize he was right…..

Perhaps it was because I had just read Bongi’s post significant moments or because I am a surgeon who felt sorrow for my mother’s surgeon last May even while grieving for her.

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The world’s first FULL face transplant has been done by surgeons in Spain.  Helen Briggs, BBC News writes about it:  Full face transplant 'success'

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Nice interview in the May 2010 issue of Reader’s Digest by Amy Wallace:  Michael J. Fox’s Recipe for Happiness.  The following is from the related RD article An Accidental Education: Exclusive Excerpt from Michael J. Fox's New Book 

At first I went into denial. …..

I realized that the only choice not available to me was whether or not I had Parkinson's.  Everything else was up to me. By choosing to learn more about the disease, I made better choices about how to treat it. This slowed the progress and made me feel better physically. …...

So let me make this suggestion. Don't spend a lot of time imagining the worst-case scenario. It rarely goes down as you imagine it will, and if by some fluke it does, you will have lived it twice. When things do go bad, don't run, don't hide. It will take time, but you'll find that even the gravest problems are finite, and your choices are infinite.

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My friend Gizabeth Shyder, Methodical Madness, wrote a lovely post Basketball in which she tells a patient to put him at ease during a needle biopsy:

I could tell it hurt by the expression on his face….

I prepared the second needle,... Decided to tell a story while I was doing the fine needle aspirate …..

"I was recruited hard by my high school basketball coach, because of my height. I was pretty shy in high school, so I resisted him for a long time. I realize in retrospect he probably looked at me and had big dreams of making a star."………….

As I pulled the needle out of his skin I noticed his eyes were all crinkled up and there were tears forming at the corners. I worried that I had hurt him, but he started laughing uncontrollably.

"That is the funniest basketball story I have heard in a long time."

I smiled, pleased I was able to entertain him.

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Sophie, Blocks & Swaps & Pattern Tips, gives a tutorial on this marvelous bag:   Summer Tote from Orphan Blocks

Do you have orphan blocks–blocks you made and loved but for which you have no project in mind? Then you might consider making a useful, beautiful tote bag of your own.

This bag is approximately 12 inches high and 16 inches wide (at the top edge). The bottom is 8 inches square. It is constructed from 6-inch pieced quilt blocks and squares of fabric.   It is based on Gay's So Sew Easy Schlep Bag pattern, which you can download from the linked page on her Sentimental Stitches site. My  Summer Tote differs in the following ways:………….

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There is no guest listed for this week’s  Dr Anonymous’ BTR show as of this morning.  

Upcoming shows

5/6: Dr. Daniel Lewis, Family Physician, Talking about recent mission trip to Central America
5/13: Medical Student and Video Blogger, Bryan McColgan
5/20: Larry Bauer from the Family Medicine Education Consortium

You may 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

Monday, April 26, 2010

Dr. Goldwyn’s “Surgeon”

After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note:  Collected Editorials” to reread (published in August 1992).  I’d like to share a few with you over the next weeks/months.

The first is entitled “Surgeon”

On a recent trip to Hawaii, I learned that in the Polynesian dialect spoken there, the word for surgeon is kauka oki:  doctor (kauka) who cuts (oki).  While some of us surgeons might resent such a graphic, “cut and dry” definition, we cannot deny its verity.  No matter how we may slice it, a surgeon is a doctor who makes incisions.  In fact, the origin of the word surgery is Greek, from cheir, meaning “hand,” and ergon, meaning “work.”  That surgeons work with their hands did not always bring honor.  Centuries ago, one recalls that those who cut on others, with their permission, generally held a lower status than those who eschewed the knife.

At the bottom were the barbers, and slightly above them, the surgeons.  In England in 1462, the Guild of Barbers became the Company of Barbers, and under Henry VIII, the Barber Company was united with the smaller Guild of Surgeons to form the United Barber-Surgeon Company.  In commenting on Henry VIII’s role in this episode, Garrison cites the painting by the younger Holbein, the court painter:  “Henry VIII—huge, bluff, and disdainful—in the act of handing the statute to Vicary [Thomas Vicary, First Master of the United Barber-Surgeon Company], in company with fourteen other surgeons on their knees before the monarch, who does not condescend even to look at them.”1  Perhaps Henry was irate at having to leave his dinner table and his newest wife.

The metamorphosis from the lowly barber to the glamorized surgeon has been long.  I am sure that Henry VIII did not envision the consequences of his royal decree.  The seesaw of history is marvelous as long as you are on the upswing.  The rise of the surgeon did not erase the schism (in fact, it may have intensified it) between the so-called thinkers and the doers.  This enmity, although lamentable, is centuries old.  some, however, such as Lanfranchi of Milan (the first to describe concussion of the brain and to distinguish between cancer and hypertrophy of the female breast), did rise above the petty, professional fray.  In his Chirurgia Magna, completed in 1296, he wrote:

  • Why, in God’s name, in our days, is there such a great difference between the physician and the surgeon?  The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations.  Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine.  It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations and that a surgeon is nothing if ignorant of medicine.  In a word, one must be familiar with both departments of Medicine. 2

We do accept the fact today that the best surgeon is one who knows not only how to operate, but when not to.  Harvey Cushing, about the time that he became the first Surgeon-In-Chief of the Peter Bent Brigham Hospital, Boston, said in his letter to his counterpart in medicine, Henry Christian:  “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” 3

Cushing, of course, did have hands, good ones, and more important, a superior brain, which he used prodigiously.  His remark was a hyperbole that reflected his correct view of surgery; it must grow from research and basic sciences and from its application to clinical problems.  Surgery, despite the awe it now has (for those who doubt this, see the afternoon “soaps”), represents a failure of nonoperative medicine.  Who would not want to take a pill rather than undergo an operation for cholecystitis, breast cancer, or benign prostatic hypertrophy if the results were the same?  Would not genetic engineering by medication to prevent facial clefts be preferable to repairing them, no matter how meticulous and innovative the surgeon?  The thought that a capsule could safely enlarge or reduce breasts or salve could eliminate Dupuytren’s contracture or a prominent dorsal hump may seem too fanciful even for the most imaginative, yet landing a man on the moon and retrieving him without mishap has long been a fait accompli.  However, since medical Shangri-La is many years hence, we heirs of Pare will be continuing our manual ministrations, our barbers’ burden.

References

1.  Garrison, F.H.  An Introduction into the History of Medicine with Medical Chronology.  Suggestions for Study and Bibliographic Data, 4th Ed.  Philadelphia: Saunders, 1929; reprinted in 1960. Pp. 238-240.

2.  Lanfranchi of Milan.  In M.B. Strauss (Ed.), Familiar Medical Quotations.  Boston: Little, Brown, 1968. P. 583.

3.  Fulton, J.F.  Harvey Cushing:  A Biography.  Springfield, Ill.:  Charles C. Thomas, 1946.  P. 352.

Sunday, April 25, 2010

SurgeXperiences – Call for Submissions

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

The host of the next edition (322) has not been announced, but don’t let that keep you from making your submissions.  It is scheduled to occur on May 2nd.   Be sure to make your submissions by the deadline: midnight on Friday, April 30th.   Be sure to submit your post via this form.

If you wish to host SurgeXperiences 322 or any future edition, please contact Jeffrey who runs the show here.

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

Saturday, April 24, 2010

Buckets for the Cure – Just Say No

I must say I was surprised (astounded) when I first saw the KFC commercial touting their Buckets for the Cure.  It is a partnership between KFC and Susan G. Komen for the Cure.  KFC donated 50 cents for each bucket purchased.

This after the recent addition to KFC’s menu of the double down!   It is my opinion that KFC does not have anyone’s health as their goal.

I want to encourage anyone who wants to support Susan G. Komen for the Cure or other breast cancer groups to simply bypass KFC and donate directly to the group. 

Benefits of donating directly:

  • You will get the tax write-off, not KFC. 
  • You might avoid a heart bypass procedure by eating healthier at home or elsewhere.

I’m not the only one who feels this way.  Check out this nice article by Jennifer LaRue Huget for the Washington Post:  Is that right? Buying KFC buckets fights breast cancer?

A 10-piece bucket of KFC fried chicken (including the sides) costs about $20. If you're really interested in supporting Komen for the Cure's efforts, why not just mail them a check directly?

Picture Worth a Thousand Words

“All done, just need a dressing.”

Can you take a photo?  I want to show my friends,” the teen holds out his cell phone.

“Sure, how’s your phone's camera work?”  removing my gloves, I reach take the phone.  “Do you want to know how many stitches?”

No, just the pictures.  Push this button.”

Friday, April 23, 2010

Global Quilt Project Squares

Last Friday I posted about Global Quilt Project Seeks Quilters Worldwide.  I made/finished six quilt squares – four 9.5 inch squares and two 12.5 inch squares.

Here are the 9.5 inch squares.  You may recognize some of the squares.  The upper left and lower right were left over from this baby quilt.  I added an extra round to make them large enough.  The upper right one was left over from this quilt and was the perfect size already.  The lower left was made up using left over blocks from this project.

This 12.5 inch square was made using left over pieces.  You may recognize some of the fabric from this quilt.
This one was too.  The floral fabric is left over from the back of this quilt.

Don’t forget they would like to have the donated blocks by May 30th in order to have the quilt pieced together and to allow time for showing and promoting this fund-raising project.

Wisp II Shawl

I liked the pattern I used for Kristen’s scarf so much I decided to make a shawl using it.  I cast on 50 stitches rather than 46 so it would be slightly wider.  I did 28 repeats rather than 17.  The result when blocked is a shawl 14 in X 74 in.

I used Kid Merino wool as I had some left from this shawl, but had to scramble to find another skein as the color (#4677) I had is a discontinued one. 

Here’s another photo while the work was in progress:

Thursday, April 22, 2010

Plastic Surgery ABC’s

A is for Abbe Flap, Abdominoplasty, Augmentation Mammoplasty

B is for Blepharoplasty, Breast Reconstruction, Burns

C is for Cubital Tunnel Syndrome, Chemical Peels, Cleft Lip Repair

D is for Decubitus Ulcer Care, Dermabrasion

E is for Estlander Flap, Extensor Tendon Surgery

F is for Facial Reconstruction, Fingertip Injuries, Flaps

G is for Grafts, Gorlin’s Syndrome, Gynecomastia

H is for Hand Surgery, Hemagiomas, Hemifacia Microsomia

I is for Implants, Inverted Nipple Correction

J is for Juvederm, Jessner’s Solution

K is for Keloids, Kraissel’s Lines, K-wires

L is for Langer’s Lines, Le Fort Fractures, Liposuction

M is for Madelung’s Deformity, Melanoma, Mastectomy

N is for Nail Bed Injuries, Nevus Excision, Neuromas

O is for Omphaloceles, Orbital Fractures, Otoplasty

P is for Poland’s Syndrome, Port-wine Stains, Ptosis

Q is for Q-switch Ruby Laser, Quadriga Syndrome

R is for Rhinoplasty, Rhomboid Flaps, Rhytidectomy

S is for Scalp Reconstruction, Scaphoid Fractures, Syndactyly

T is for Tendon Repair, Thyroglossal Duct Excision, TRAM Flaps

U is for Ulnar Nerve Repair, Umbilicoplasty

V is for Vaginal Reconstruction, V-Y Advancement Flaps

W is for Wound Care/Repair, W-plasty, Wydase

X  is for Xanthoma tuberosum, Xenografts

Y is for Yersinia (yes, I’m reaching here)

Z is for Z-plasty, Zygoma Fracture Repair

Wednesday, April 21, 2010

Anatomical ABC’s

A is for Abdomen, Aorta, Appendix

B is for Bones, Brain,  Breast

C is for Clavicle, Colon, Cornea

D is for Dermatomes, Diaphragm, Duodenum

E is for Ear, Epiglottis, Esophagus

F is for Face, Femur, Fibula

G is for Gallbladder, Ganglion, Glands

H is for Hand, Heart, Hip, Hyoid

I is for Ileum, Intestines, Iris

J is for Jaw, Joint, Jugular

K is for Kidney, Knee

L is for Ligament, Lip, Liver, Lung

M is for Mandible, Mouth, Muscles

N is for Nerves, Nipple, Nose

O is for Omentum, Orbit, Ovary

P is for Palate, Pancreas, Pelvis, Prostate

Q is for Quadriceps Muscle

R is for Radius, Rectum, Ribs

S is for Scalp, Spleen, Spine, Stomach

T is for Tendon, Thyroid, Tongue, Trachea

U is for Ulna, Umbilicus, Ureter, Uterus

V is for Vagina, Veins, Ventricle, Vertebra

W is for Wing (of sphenoid bone), Wrist

X  is for Xyphoid

Y is for Y-chromosome

Z is for Zygoma

Tuesday, April 20, 2010

Shout Outs

Sterile Eye is the host for this week’s Grand Rounds.   You can read this week’s edition here.

Welcome to Grand Rounds Vol.6 No. 30 here at the Sterile Eye (photo credit). The theme for this edition is Visual Communication. Some of the posts address this more directly than others, so to harmonize form and content I have chosen to represent the submitted posts not by words, but by 450×150 pixels each.

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Nurse Me is the host of the latest edition of Change of Shift (Vol 4, No 21) !   It is the first edition of the new year.  You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to this edition of Change of Shift. I’m sure you’ll all enjoy a little light reading after submitting your taxes weeellll beforehand, right? And surprisingly, none of this edition’s posts are money related. I guess that’s because we’re nurses and we know how much money we don’t make ;) Dr. Dean (www.blog.themillionairenurse.com) can help with that though. Dr. Dean…?

So without further adieu…..

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A thoughtful post from A Country Doctor Writes – “Off the Record

Gwen and Dan Olsen were a handsome couple with a stunning blonde eight-year-old daughter, Trina. They had just moved to the town where I did my residency and over the course of their first six months there I saw all three of them for routine health care needs.

One day Gwen came in for nausea……

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Steven Novella, Science-Based Medicine, discusses the rise of Autism in his post Social Factors in Autism Diagnosis

There is no question that the incidence and prevalence of autism are on the rise. Starting in the early 1990s and continuing to today, there has been a steady rise in the number of children diagnosed with autism. Prior to 1990 the estimates of autism prevalence were about 3 per 10,000. The most recent estimates from the CDC and elsewhere now have the number at about 100 per 10,000, or 1%.

The burning question is – why are the rates increasing steadily?

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I’d like to thank @Lakshmi for sharing on twitter the link to this article: Why are Your Bones Not Made of Steel?

In science it sometimes pays to ask silly questions. So let me ask, “Why are your bones not made of steel?”

It's a starting point for thinking about structural materials in nature, and in engineering……….

So let's look at the facts. The bones in your body are made from material which has a tensile strength of 150MPa, a strain to failure of 2% and a fracture toughness of 4MPa(m)½. For a structural material that's not good. We can make alloy steels that are ten times better in all three of those properties.  But of course there are some other factors we need to take account of in order to make a valid comparison. Bone is less dense than metals and this is important………

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Via Gruntdoc comes the link to this AmedNews article:  Donkey Kong record now held by plastic surgeon

Hank Chien, MD, woke up one morning as a New York-based plastic surgeon. He went to bed early the following morning as a king -- the King of Kong.

That day Dr. Chien scored 1,061,700 points in 2 hours, 35 minutes, breaking the world-record score for the classic arcade game Donkey Kong……..

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I have @docgrumpy who tweeted the info on this wonderful link.  If you need a “second opinion” then take my recommendation that you follow his orders.

Check out today's NASA picture of the day! Doctor's orders! http://antwrp.gsfc.nasa.gov/apod/

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The guest on Dr Anonymous’ BTR show this week will be DG & Tiffany Hollums discussing their adoption journey.

Upcoming shows

5/6: Dr. Daniel Lewis, Family Physician, Talking about recent mission trip to Central America

You may 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

Monday, April 19, 2010

When Healers Need Healing

In my office mail this morning I found my medical school classmate, Janet Cathey, looking back at me from the front of the last issue of the Journal of the Arkansas Medical Society. Her photo was linked to an article entitled “When Healers Need Healing: Physicians’ Experiences on the Receiving End of Medicine.”

I knew that Janet had been injured in a car accident last summer. I have tried reaching out to her with notes, etc. She had “closed” herself off from me and many others trying to reach out, so it was nice to see the report on her.  Janet had a busy Gynecology practice prior the accident. I have hear that she had since retired due to the back injury sustained in the accident.

“Things were happening at lightning speed,” she recalled of the scene at Baptist. “I had a burst fracture of L-1 and needed spine surgery….They were moving me, cutting off my clothes. I was scared and still screaming in pain and frustration,” she said. “At that moment, ER doctor Wendel Phals, MD, was at the head of my bed. He held my face and calmly and quietly said, ‘Janet, you’re going to be alright. We’re going to take care of you.’ For the first time since I’d hit the culvert, I felt calm, secure.”

The article also includes comments from Columbia University psychiatrist Robert Klitzman, MD who has written a book “When Doctors Become Patients

After his own recovery, Klitzman wanted to understand the rare, dual perspective of physicians who have confronted serious disease. His interviews revealed first and foremost that many physicians resist, at least initially, the idea of beiing “sick” or being “the patient.” Furthermore, many physicians most resist “not” being the doctor…..

The article includes another Arkansas physician, orthopedic surgeon Frank Griffin, MD who found himself a patient when he was diagnosed with a chondrosarcoma.

Griffin found both emotional and practical aspects of being a patient surprised him. “I was surprised at the size of my bills,” said Griffin, adding that he understands now the number of medical bankruptcies. ….

Also surprising to him was his embarrassment to ask for pain medicine. “I was afraid someone would think I was becoming addicted,” he said. “……..I imagine there are many more patients suffering from pain than are abusing pain meds.”

Janet is quoted making these observations

“As a physician, you never know what little thing a patient is going to latch onto…be impacted from,” she said, remembering that night eight months ago, in the Baptist ER. “As a patient, I felt my recovery began when amidst the chaos of the night, Dr. Pahls took a few moments to look at me and reassure me.”

All of that medical knowledge can be a blessing and a curse, especially when physicians suffer from something serious or debilitating, Cathey implied. “For me to have a devastating injury, it really hit hard. Being a physician takes away some of the hope that you’d have if you didn’t know your limitations,” she said.

All of us will be patients at some time during our lives. It is important for us to keep this in mind as we care for others. I wish I could link you to the entire above article, but it is not up online yet.

There is a post on the same topic over at Mothers in Medicine: Lessons learned on the wrong side of the stethoscope

I was walking down the hall at work on a very ordinary day in December. I had sudden onset of excruciating right shoulder, neck, and upper arm pain. For the first time in my life, the "...if 10 is the worst pain you can imagine" finally had meaning. ……. The next 48 hrs were a whirlwind: emails, calls, and pages to my internist (I am usually a once a year-ish whether I need it or not patient), a possible diagnosis of multiple sclerosis, MRIs of my brain, spinal cord, shoulder, appts with ortho, neuro, and ultimately neuromuscular, including the test that provided a diagnosis: an EMG/NCS. The diagnosis was something rare called Parsonage-Turner Syndrome. I had never heard of it before (which is a very bad feeling as a doctor).

So, what have I learned from this experience of being on the wrong side of the stethoscope? A lot that I am still struggling to put into words and a lot worth sharing.

Finger and Wrist Exercises

A few weeks ago I received an email from a reader who appreciated my past post on posture.  She then requested information on exercises and prevention of finger/hand issues from computer/keyboard use.  I replied that I would work on it.

Thanks to TBTAM who reminded me of this with this tweet last week.

Duration of EMR use and upper extremity musculoskeletal symptoms correlated. And I was blaming the blog.... http://bit.ly/bVbOvU

 

One of my earliest post (June 3, 2007) was  “Good Posture for Sewing (or Blogging)”.  Posture makes a huge difference in body mechanics, be it at the computer, sewing machine, or in the operating room.  Poor body mechanics lead to or contribute to many chronic use issues (ie back pain, carpal tunnel, cubital tunnel).

You and I should consider taking breaks every 30-60 minutes from our computer/desk/sewing machine work and do some stretching exercises for our wrists and hands and body

Most involve simply putting all the joints through as full range of motion as possible.

Flex (bend) and extend (straighten) each finger.  Spread your fingers as wide apart as possible and hold for a count of 5.

Flex and extend the wrist.  Move the wrist in a circular fashion with the fingers both relaxed and in a gentle fist. 

Straighten the elbow.  Rotate the forearm so the hand is palm up and then palm down.

Don’t forget the shoulders.  Shrug your shoulders and down, roll then in gentle circles.  Raise your arms above your head with your palms meeting.  Move your arm/shoulder as if you were swimming so as to move the joint through its full range.

Neck Rolls – relax your shoulders and let your head roll forward. Slowly rotate your head in a circle. Repeat five times.

E-Hand.com has some nice photos (including this one) with instructions on some exercises intended to help prevent carpal tunnel syndrome.

Extend and stretch both wrists and fingers acutely as if they are in a hand-stand position. Hold for a count of 5.

 

 

Here are some sites with more exercises:

Typing Games to improve dexterity 

Slide show: Hand exercises for people with arthritis by Mayo Clinic Staff

Finger Exercises for Arthritis By Kate McQuade, eHow

How to do Wrist Exercises to Help Arthritis in the Hand By LivingWellYoga, eHow

Finger injuries - causes, treatments and recovery exercises

Sunday, April 18, 2010

SurgeXperiences 321

This makes my 9th time to host SurgeXperiences since it began July 1, 2007.  The first season I hosted twice, the second season three times, and this one makes the fourth this season. 

There have been very few submissions for this edition, so I’m going to honor the ones who have hosted SurgeXperiences.  Many thanks to each of you.

The blog world being what it is, I suppose it should not be surprising that several of the past hosts have either retired or are infrequently posting.  I miss them.

Perhaps the above blogs will become more active again.  One can hope.  In the meantime, many remain active and I hope will continue:

 

Here are a few from folks who have not been host.  These posts are good.

Michelle, the Underwear Drawer, writes “the ballad of the unsung hero

Many people probably saw this already, it was printed in The New York Times on April 9th, but just in case you missed it, I thought I should give it a little bump:  Doctors Remove Ammunition From Soldier’s Head

The reason I'm posting this is not because it's one of those "Ripley's Believe It Or Not" medical stories (even though it is), but it's because if anything redeems the much maligned field of anesthesiology from the jaws of modern day television, in which we are all portrayed as lazy, unfeeling, drunken, drug-diverting billionaires who don't give a shit about our patients and leave whenever the going gets rough, it should be a story like this.

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Kerri, SixUntilMe, who is now a mother of a health baby girl.  She wrote this post before the C-section:  “Diabetes During the C-Section: Here's the Plan.

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Dr. Howard J Luks, an orthopedist asks In Reporting Symptoms, Don’t Patients Know Best? - Do docs downgrade complaints?

This is a very serious issue... and it comes up for discussion with our residents every now and then. A while back there was a young man in the emergency room of our institution. He claimed the CIA was after him and they injected him with a substance that made him pass out... When he woke up, his shoulder hurt and he had soiled his underwear. I was called because I was the attending on call for our department. My resident immediately dismissed all his complaints and was upset that he was called for a consult in the middle of the night. After I settled him down, we had a little talk...

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Dr. Benzil, Women Neurosurgeons blog, has a nice post on transplant and the neurosurgeon.

One of the things I love about blogging is how a link leads to a link leads to a great story.  SurgeXperiences 319 (available here ) related a link about Steve Jobs and his liver transplant. Most neurosurgeons spend a part of their residency learning the ins and outs of brain death testing-a critical link in the transplant world.  At first it may seem gruesome and unnatural ….

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SurgeXperiences is a blog carnival about surgical blogs that occurs every two weeks. 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.

Saturday, April 17, 2010

Delivery

I look at the Fed Ex guy, “Do you have any idea what you are delivering?”

“Not often.”

“These boxes from Mentor have breast implants in them,”  I tell him.

He blushes, “Deliveries to your office will never be the same.”

Friday, April 16, 2010

Global Quilt Project Seeks Quilters Worldwide

Yesterday, @GlobalChangeMe sent out this tweet:

Looking for quilters from around the world. Do you know any?

stuboo then tweeted

.@GlobalChangeMe Looking for quilters from around the world. Do you know any? <-- Try @rlbates - she's good.

And the introductions were made.  I ask GlobalChangeMe for more details and received the following email:

Our organization is seeking quilters from around the world to join us in our Global Quilt Project that will benefit a village in Central African Republic. There are several ways to become involved in this project. We hope you can join us.

Global Change, Inc is a non profit organization that provides safe, clean water and basic sanitation to people living in extreme poverty throughout our world. In one of the villages in the Central African Republic (CAR) we are raising funds for, the ladies have been taught quilting and they are really enjoying it. These ladies have sent our organization 2 beautiful squares and we are hoping to put theses squares together with other squares from around the world to make a beautiful quilt that will be auctioned off and 100% of the proceeds will go to a new well for a village in Central African Republic and a latrine for a school in CAR. 

The square tiled #1 in the attachment is exactly 12x12 inches  

and the square in attachment #2 is exactly 9 1/2 x 9 1/2 inches.

We would very much like for you to join us in this project. We are seeking quilters from around the world to donate a square or squares to be added to this piece. I have a friend here in Central Florida who will connect the squares for this piece. The colors or patterns need not follow the same design as the 2 squares the ladies sent from CAR, nor does the squares need batted. We would appreciate any comments or suggestion about our project and would greatly appreciate it if you would forward this email to others you think might want to join this effort for a good cause. Letting others know about this project is a wonderful way to become involved. As soon as we have several participants, we will add the project to our web site and include the participant's name and link to their site if we have your permission to do so.

The finished quilt will be auctioned in conjunction with World Toilet Day...Yes, I said "World Toilet Day" which is held on November 19th. We would like to have the donated pieces by May 30th in order to have the quilt pieced together and to allow time for showing and promoting this fund-raising project.

It would help this project if you would reply to this email (either yes, I will participate or sorry I cannot participate) so we can have an idea of how many squares we will have for the quilt. I have also attached a participation form for you to fill out and email back to me. The donated squares can be sent to the address below.

Our web site has information about our organizations and the projects we fund. Your donation will help stop the spread of disease due to lack of clean water and basic sanitation. People live more productive lives when they do not have to fight disease. Please take a look at our site and if you have any questions, please do not hesitate to contact me.

www.globalchange.me

Thank you for your time and consideration.

Amy Allen (407) 951-2826

Co-Founder and Development Director

Please mail donated squares to:

Global Change, Inc

854 Blue Sage Street #102

Celebration, Florida 34747

 

I plan on making a few and would like to encourage you to do so.  Remember there is no set pattern or colors, so it would even be a nice way to share “orphan” blocks as long as they are the correct size:  12.5 in square or 9.5 in square.

Let’s Ride Baby Quilt

I made this baby quilt using some novelty fabric my sister gave me (the dogs on motorcycles) and other fabrics in my stash.  The pattern is a nine-patch.  The quilt is machine pieced and quilted.  It is 41 in X 43 in.  The back is simply white Kona cotton. 

It is cross-hatch quilted using white thread.  I have listed it for sale on Etsy.

Thursday, April 15, 2010

Capsular Contracture

Capsular contracture is a complication of breast implants of all types:  saline, silicone, smooth, textured, etc. 

When the implant is placed, the body forms a capsule of fibrous material around it as it would for any foreign body (ie pace maker, breast implant, etc).  The capsule is initially thin and soft, with little or no effect on the appearance of the breast.  If it remains that way, then it is not called a contracture.

Capsular contracture occurs when the scar tissue or capsule that normally forms around the implant tightens and squeezes the implant. It can happen to one or both of the implants. There are four grades of capsular contracture known as Baker grades.

The Baker grading is as follows

Grade I
breast is normally soft and looks natural

Grade II
breast is a little firm but looks normal

Grade III
breast is firm and looks abnormal

Grade IV
breast is hard, painful, and looks abnormal

Capsular contracture may require reoperation, usually for Grades III and IV, and it may occur again.

The first article listed below looks at the current literature relating to this complication of breast implant surgery, focusing particularly on occurrence rates, risk factors, cause, and treatment modalities to provide the plastic surgeon with an up-to-date review of the current available evidence.

The authors did a literature search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases using three groups of key words --the first relating to the organ involved (breast), the second relating to the surgical procedure performed and related technical issues, and the third relating to the surgical complications. Potentially relevant articles were identified by means of the title and the abstract, and full articles were obtained and assessed in detail.

The authors note:  “Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of rates of capsular contraction occurrence.

Reported rates of capsular contractures vary widely, ranging from 1.3 to 30 percent of patients who receive implants.

The longer the implants were in place, the greater the cumulative risk of developing contracture, which would suggest a direct correlation between when the implant is placed and the time to developing contractures.

Approximately 92 percent of contractures occur within the first 12 months following surgery.

A number of parameters seem to influence the occurrence of contractures, including the indications for surgery (breast reconstructions versus cosmetic augmentations), type of prosthesis used (smooth versus textured and saline versus silicone), and positioning of the implant (subglandular versus submuscular).

Currently, Mentor lists the rate of capsular contracture in their patient information brochures (cosmetic not reconstructive) as 9% (Grade III – IV), but note the literature has a wide range of 1.3% to 30%.

Women having reconstructive rather than aesthetic (or cosmetic) augmentation have a higher risk of developing capsular contracture.

Radiotherapy increases the incidence of capsular contractures. Unfortunately, most studies are retrospective in nature and analyze groups of patients who received radiotherapy at variable time points (before, during, or after reconstruction), concomitant chemotherapy, implant positioning or type, and type of contractures reported (only Baker grade 3 or 4 versus all contractures).  All of these factors may partly explain the wide range of reported contractures in the irradiated groups (32- 73%) versus non-irradiated groups (0- 40%).

Numerous studies have looked at shell characteristics (smooth vs textured surface) in regards to contracture rate and tend to find textured surfaces produced a lower incidence of contractures when compared with smooth ones.  

In the first meta-analysis, Barnsley et al. proved the protective effect of textured implants over smooth surfaces (relative risk, 0.19; 95 percent confidence interval, 0.07 to 0.52), with smooth implants showing a five-times greater risk of contracture formation. 

In the second meta-analysis, 235 patients were analyzed, and textured implants were shown to produce fewer capsular contractures when compared with smooth implants at 1 year (relative risk, 4.2; 95 percent confidence interval, 1.6 to 11.0), 3 years (relative risk, 7.3; 95 percent confidence interval, 2.4 to 21.7), and 7 years of follow-up (relative risk, 3.0; 95 percent confidence interval, 0.9 to 10.4).

Only one study showed no significant differences between smooth versus textured implants for the occurrence of capsular contractures.  However, this trial had a Jadad score of 2, indicating a poor methodologic quality with a high degree of variance in the results.

Partial or complete submuscular placement and subfascial positioning are  association with lower rates of capsular contractures.  Many of the articles mentioned are either small or retrospective.

Seckel and Costas retrospectively studied 76 patients (146 breasts) who had undergone partial or total submuscular breast cosmetic augmentation.  No difference was observed between the total and the partial musculofascial coverage for the occurrence of capsular contractures [zero of 35 (0 percent) versus one of 41 (0.02 percent); Fisher's exact test, p = not significant].

Hendricks reviewed 650 patients who had received textured silicone gel implants beneath the pectoralis major muscle, the external oblique muscle, the rectus sheath, and the serratus anterior muscle fascia.  In this study, no cases of Baker grade 3 or 4 capsular contractures were reported.

Ventura and Marcello retrospectively analyzed 100 patients who had received primary breast enlargement with textured implants positioned in the subfascial compartment and found that only two patients (2 percent) experienced Baker grade 2 capsular contractures.

Finally, in a retrospective multicenter study of more than 500 patients, Gutowski et al. found that the use of subglandular positioning of the prosthesis increased the risk of capsular contractures by almost eight times.

It is a nice review of the literature which points out the short comings of our knowledge.

Although it is apparent from the articles studied in this review that a great deal of progress has been made over the past few decades toward elucidating the etiopathogenesis of capsular contractures, the exact nature and contribution of molecular, immunologic, and microbiological factors remain unclear.

Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of the rates of capsular contracture occurrence.

Therefore, there is a scant and often inconclusive body of evidence relating to this complication. For example, the contribution of chemotherapy to the occurrence of capsular contractures warrants more thorough investigation.

Likewise, the possibility of preventing this complication by use of experimental drugs needs to be looked at more closely.

Revision surgery remains the only effective treatment option available to us at this time but is limited by its high associated risk of recurrences and complications (hematoma or pneumothorax) when the implant is originally placed in the submuscular position. It is hoped that future studies will focus on attempting to resolve some of the issues highlighted in this review.

 

 

 

REFERENCE

Capsular Contractures: A Systematic Review; Plastic and Reconstructive Surgery. 124(6):1808-1819, December 2009; Araco, Antonino; Caruso, Riccardo; Araco, Francesco; Overton, John; Gravante, Gianpiero

FDA Breast Implant Info, May 2009

Wednesday, April 14, 2010

Lightening Up

MedEsthetics has a nice article on skin lightening in the March/April 2010 issue written by Linda Lewis.

Skin lightening is often needed to improve postinflammatory hyperpigmentation, dyschromia, and melasma. Others have uneven skin tones due to sun damage.

Several physicians were interviewed for the article. All agree that a good skin care regimen before, during, and after treatment is key.

For uneven pigmentation:

Marta Rendon, MD (dermatologist) -- “For mild photodamage, I start with antioxidants and retinoids, and then add peels or lasers for stubborn cases.”

Joel Schlessinger, MD (dermatologist) -- “Typically, these patients do well with intense pulsed light (IPL) or laser treatments, but these should always be accompanied by a homecare treatment regimen, such as Nu-Derm by Obagi or another hydroquinone-containing product such as Tri-Luma or Epiquin Micro by SkinMedica.”

Leslie Baumann, MD (dermatologist) – “For patients with light skin I recommend monthly IPL treatments. For home care I suggest a glycolic cleanser, NIA24 niacinamide moisturizer or Aveeno Positively Radiant active soy, and a good sunscreen in the morning. For nighttime use, I prescribe Tri-Luma. For patients with darker skin, I use the same home care regimen, but offer a Jessner’s peel solution every two weeks instead of IPL. ”

Tina Alster, MD (dermatologist) -- “For light-skin patients I use IPL or a Q-switched pigment specific laser (alexandrite or Nd:YAG), with or without mild to moderate chemical peels. For daytime home care, I suggest a topical vitamin C with sunscreen (SPF 30 or higher) and at night glycolic/retinoic/kojic acid on an alternating basis.”

For melasma:

Dr. Baumann “I recommend a glycolic cleanser in the morning, followed by a vitamin C serum, such as Skinceuticals CE Ferulic, and a moisturizing sunscreen, such as LaRoche Posay Anthelios 60 Sunscreen Fluid. At night, the patient uses the same glycolic cleanser followed by Tri-Luma topped with a moisturizer if they have dry skin.” She also recommends microdermabrasion followed by Jessner’s solution TCA peels twice a week until the hyperpigmentation clears.

Dr. Alster “For melasma, I use only mild to moderate chemical peels (resorcinol, glycolic/lactic/mandelic or trichoracetic acid) in the office.”

It’s interesting to see the similar yet different approaches. It is extremely important to use sunscreen daily during and after treatment for any skin pigmentation issues.

Other reference:

Melasma; eMedicine, Dec 16, 2009; Andrew D Montemarano, DO, Hugh Lyford

Drug-Induced Pigmentation; eMedicine, Dec 10, 2008; David F Butler, MD, Deborah Zimmer Henderson, BA, MPH,

Tuesday, April 13, 2010

Shout Outs

Parallel Universes is the host for this week’s Grand Rounds.   You can read this week’s edition here.

After a hiatus of almost a year from hosting Grand Rounds, I am back today to welcome you all to GRAND ROUNDS, Volume 6, No. 29. This is my 6th time to host this weekly round-up of the best in med- and health blogs. If one is passionate about it, hosting can be a taxing experience. More often than not, it eats precious time one should allocate for sleeping. Thank God I live on the other side of the planet, and most of those who submitted are on the opposite side --- I can still rest tonight. 'Kidding! I am always proud to host. I thank Nick for the invitation this week. Thank you also for all those who joined.

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Better Health has highlighted Dr V’s, 33 Charts, post:  We Need More Linchpin Doctors.

I just finished Seth Godin’s Linchpin. …..

Physicians have to be remarkable to remain relevant. ... Physicians need to make a difference and in their own way and serve as real leaders and innovators in their relationships with patients and their communities.

Physicians have to be linchpins…

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The April 7 issue of JAMA has a review of Dr. Deborah L. Bensil’s book: Heart of a Lion, Hands of a Woman: What Women Neurosurgeons Do. (review and photo credit)   Check out Dr. Bensil’s blog here.

This book is a remarkable compilation of essays, poems, and artwork by women neurosurgeons. It is a proud achievement for neurosurgeons who are women, enlightening for neurosurgeons who are men, and inspirational for both.

One-half of US medical students are now women. The percentage of women in neurosurgery has slowly increased from 0% to 10% during the last century. It is evident that for neurosurgery to thrive as the future unfolds, the specialty must welcome more women and remove barriers to their success…………

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Jill of All Trades, MD is a new medical blogger whom some of us met (& encouraged to blog) a few weeks back in the chat room of Dr. A’s BTR show.  Check out her recent post:  Be Prepared for Disasters: Learn How to Create Your Emergency Supply Kit

Having experienced a piece of this 7.2 earthquake in San Diego this past week, it made me revisit my special emergency supply kit that I designed when I first started working for the department of public health. ……. No matter where you live, you need to be prepared for disasters, whether it’s for flooding, hurricanes, Tsunamis, tornadoes, fires, winter snow, or earthquakes.

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Martina Navratilova has breast cancer (photo credit).  She was diagnosed with DCIS (ductal carcinoma in situ) in February after a  mammogram.

The nine-time Wimbledon champion, who still plays tennis and ice hockey and competes in triathlons, says she is lucky, as she had not been getting regular checkups.

"I went four years between mammograms," she tells PEOPLE. "I let it slide. Everyone gets busy, but don't make excuses. I stay in shape and eat right, and it happened to me. Another year and I could have been in big trouble."

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From Polite Dissent comes an old ad that touted isometric exercise as a way to a better figure:  Just Six Seconds a Day!

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I have @sandnsurf to thank for tweeting this:

Blown away by Walter Lewin and his Physics lecture series... http://tinyurl.com/oemffe.

If you have any interest in Physics, bookmark this series of lectures.

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Dr Anonymous’ BTR show is on Thursday evening at 9 pm ET.  His guest will be  psychiatric Social Worker Brandice Schnabel

Upcoming Dr. A Shows (9pm ET)

4/22: DG & Tiffany Hollums and their adoption journey

 

You may 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