July 31st, 2009 by RamonaBatesMD in Better Health Network, News
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H/T to MedGadget who’s post introduced me to “bioactive sutures.” What a great idea by the Johns Hopkins biomedical engineering students!
……have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself.
The project team of 10 undergraduates focused on Achilles tendon injuries which require repair in approximately 46,000 people in the United States every year. The surgery may fail in as many as 20%. Recovery can take up to a year even with successful surgery. If this new suture speeds healing and lowers failure rates – what potential!
At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage……………
As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.
*This blog post was originally published at Suture for a Living*
July 23rd, 2009 by RamonaBatesMD in Better Health Network, Health Tips
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Earlier this month I received an e-mail asking for information. I have changed it slightly:
I have been pouring over the computer, searching for information on a tumor. I had removed last week from my left long finger (third finger). The pathology report came back as a myxoid tumor. I was told it was a tumor, not a cyst. Could you help me give me more information?
To begin, most digital myxoid or mucous tumors are cystic in nature. Very few are not. It is difficult to find much information in the literature, especially the current literature.
Digital mucous cysts (DMCs) are benign ganglion cysts. They most often are located at the most distal joint of the finger or in the nail fold. Physicians call this joint the distal interphalangeal (DIP) joints. The fingers are most commonly involved, but DMCs may occur on the toes. (photo credit)
The etiology of these cysts is not known. DMCs are also called myxomatous cutaneous cysts, periungual ganglions, mucous cysts, myxoid cysts, synovial cysts, dorsal cysts, nail cysts, cystic nodules, digital mucoid cysts, digital myxoid cysts, and digital mucinous pseudocysts.
The cyst often has a smooth shiny surface on exam. If located near the nail, there will often be a groove in the nail as in the photo above. The cyst’s size may vary.
If the cyst is asymptomatic, then treatment is not required. Recurrence is common regardless of which treatment is used.
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Aspiration of the contents (72% success rate with multiple aspirations, 2-5 treatments)
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Cyrotherapy (56% to 86% success rate)
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Steroid injection
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Surgical excision (88% to 100%)
Restriction of joint mobility, nail dystrophy, and changes to the contour of the proximal nail fold are potential drawbacks.
When considering a difference diagnosis keep in mind the following:
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Epidermoid cyst
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Heberden node or Rheumatic nodule
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Fibrokeratoma (DMCs may resemble this when they form between the proximal nail fold and the nail and protrude with a keratoticlike tip.)
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Giant-cell tendon sheath tumor
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Myxoid malignant fibrous histiocytoma
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Myxoid variant of liposarcoma (These are less likely to present as firm circumscribed masses and more likely to be deeply seated.)
REFERENCES
Digital Mucous or Myxoid Cyst
Digital mucous cyst – emedicine dermatology, the online textbook
Myxoid Cyst
Cystic Lesions of the Hands; Clinical Advisor, November 12, 2008; Noah S. Scheinfeld, MD, JD
Digital myxoid cysts: a review; Cutis; Feb 1986;37(2):89-94; Sonnex TS.
Myxoid Cysts; JAMA, Dec 1965; 194: 1239; Frederick A. J. Kingery
Ganglion of the Distal Interphalangeal Joint (Myxoid Cyst): Therapy by Identification and Repair of the Leak of Joint Fluid; ARCH DERMATOL/VOL 137, MAY 2001; David de Berker, MRCP; Clifford Lawrence, FRCP
Ray Amputation As A Treatment for Recurrent Myxohyaline Tumor of the Distal Extremity; Plastic and Reconstructive Surgery. 111(4):1573-1574, April 1, 2003; Mowlavi, Arian; Quinn, Brendon M.; Zook, Elvin G.; Milner, Stephen
Soft-Tissue Sarcomas of the Upper Extremity: Surgical Treatment and Outcome; Plastic and Reconstructive Surgery. 113(1):231-232, January 2004; Steinau, Hans-Ulrich; Kuhnen, Cornelius
Soft-Tissue Chondroma in the Thumb; Plastic and Reconstructive Surgery. 110(6):1599-1600, November 2002; Avc, Gülden; Aydogdu, Eser; Ydrm, Serkan; Aköz, Tayfun
*This blog post was originally published at Suture for a Living*
July 14th, 2009 by RamonaBatesMD in Better Health Network
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Macrodactyly is an uncommon anomaly of the extremities. It can affect both the fingers or toes which become abnormally large due to overgrowth of the tissues composing the digit. All the tissues are involved: bone and soft tissue-particularly the nerves, fat and skin. (photo credit)
Other names used for macrodactyly include megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis.
Hands are more commonly involved than feet. Most of the time (~90%) patients present with unilateral (one side affected) macrodactyly. Often more than one digit is involved. The most frequently involved digits of the hand are the index finger, followed by the long finger, thumb, ring, and little fingers. Syndactyly may be present in 10% of patients. Men are more often affected than women.
It is not known why macrodactyly occurs. It does not appear to be an inherited anomaly, but there are some syndromes (ie Proteus Syndrome, Maffuci syndrome, and tuberous sclerosis) which may be associated with enlarged digits. There are some surgeons who believe that macrodactyly is a variant of neurofibromatosis.
Macrodactyly may be either static or progressive. The progressive type is more common than the static.
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In static the enlarged digit (finger or toe) is present at birth and continues to grow at the same rate as the normal digits of the hand. The involved digits are generally about 1.5 times the normal length and width of the normal digits.
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In progressive the affected digits begin to grow soon after birth and continue growing faster than the rest of the hand. The involved digit or digits can become enormous.
There is no medical treatment for this disorder. It is treated by surgery. In the hand, the indications for surgery can often be cosmetic in nature as the hand can functionally tolerate a digit with some increased width and length. In the foot, the enlarged digit can make shoe fitting/wearing difficult.
Surgical treatment of macrodactyly is complex as multiple tissue layers are involved. It typically will involve debulking, epiphyseal arrest, and shortening. Multiple surgeries are the norm.
Soft tissue debulking:
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This is done to help correct the width of the digit. This is often done at the same time as the epiphyseal arrest. The affected fingers are approached volarly with Bruner-type incisions/flaps. The fat is removed from the skin and the tissues are debulked.
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Care is taken to preserve the ulnar and radial digital neurovascular bundles. Sometimes the enlarged nerve branches will need to be sacrificed along with the enlarged subcutaneous tissues.
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When a sufficient amount of tissue has been removed, the skin flaps are overlapped and excised, which allows for tension-free closure. It needed, skin grafts using healthy skin will be done.
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Debulking is often need to be done in staged procedures.
Shortening procedures:
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This is done to help correct the length of the digit. Shortening procedures usually involve either surgical excision (removal) of one of the phalanges of the finger or toe, or removal of a metacarpal (hand bone) or metatarsal (foot bone).
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Barsky and Tsuge originally introduced the two most described methods. Barsky’s technique involves removing the distal portion of the middle phalanx and proximal portion of the distal phalanx, thereby reducing the length of the finger while preserving the nail. Tsuge’s technique also preserves the nail by overlapping the dorsal portion of the distal phalanx with the volar portion of the middle phalanx.
Ray resection:
Epiphyseal Arrest:
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The timing of the this surgery is critical. An attempt to “guess” the adult finger length is done by comparing the child’s digits with those of his/her parents. When growth of the affected digits matches those of the parent, epiphyseal arrest can be performed. This in effect will stop the bone growth of the digit.
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The epiphyses of the proximal and distal phalanges are the ones treated by disruption or removal. The middle phalanx epiphyses is not treated to help preserve motion at the proximal interphalangeal joint.
Other surgical options include amputation and wedge osteotomies. Amputation is reserved for patients with nonfunctioning digits or digits that are extremely difficult to correct. Wedge osteotomies are performed in patients who have digits that are grossly deviated.
Complications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.
REFERENCES
Wood VE. Macrodactyly. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingston; 1998:533-544.
Treatment of macrodactyly; Plast Reconstr Surg. 1967; 39:590-599; Tsuge K.
Congenital anomalies of the hand; Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New York, NY: Little, Brown and Company; 1994; Upton J, Hergrueter C.
Macrodactyly; Boston Children’s Hospital website
Macrodactyly; Wheeless’ Textbook of Orthopaedics
*This blog post was originally published at Suture for a Living*
July 5th, 2009 by RamonaBatesMD in Better Health Network, News
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As we move towards EMR’s, the ability to know who has looked at the medical record may get more and more people in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story shows the importance of this respect.
Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.
I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.
I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.
The hospital said in November that it fired up to six people for looking at Pressly’s records after a routine patient-privacy audit showed that as many as eight people gained access to them.
It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.
With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….
If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.
My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressly case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.
We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.
Dr Holland had no malicious intent, just curiosity. Be careful.
Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter
3 charged with getting TV anchor’s medical records by Jon Gambrell (no subscription required)
*This blog post was originally published at Suture for a Living*
July 3rd, 2009 by RamonaBatesMD in Better Health Network
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Poland’s syndrome is a congenital disorder. The classic ipsilateral features of Poland syndrome include the following: absence of sternal head of the pectoralis major, hypoplasia and/or aplasia of breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of rib cage, and upper extremity anomalies. These upper extremity anomalies include short upper arm, forearm, or fingers (brachysymphalangism). (photo credit)
Additional features of Poland syndrome include the following: hypoplasia or aplasia of serratus, external oblique, pectoralis minor, latissimus dorsi, infraspinatus, and supraspinatus muscles; total absence of anterolateral ribs and herniation of lung; and symphalangism with syndactyly and hypoplasia or aplasia of the middle phalanges. (photo credit)
The name of this condition pays homage to Dr. Alfred Poland of Guy’s Hospital, who in 1841 described a case of these two deformities during the autopsy of a 27-year-old convict, but as this article points out he wasn’t the first to recognize the syndrome.
If you enjoy medical history, then you will enjoy this article. It explores the historical literature to reveal the progression of knowledge about this syndrome. Here is a quick summary of different investigators who contributed to the understanding of Poland’s syndrome. The article goes into more detail of each.
| 1826 |
Lallemand is first to describe the absence of the pectoralis. |
| 1835 |
Bell is the first to record the absence of the pectoralis |
| 1839 |
Forlep is first to describe the paired absence of the pectoralis and ipsilateral syndactyly |
| 1841 |
Poland is the second to describe the paired absence of the pectoralis and ipsilateral syndactyly |
| 1895 |
Thomson is the first to document an understanding that the deformities accompanied one another |
| 1900 |
Furst is the first to propose that the anomalies constituted a syndrome |
| 1902 |
Bing is the first to present a case series of patients with the syndrome |
| 1940 |
Brown and McDowell are the first to document a thorough review of the syndrome |
| 1962 |
Clarkson is the first to propose the name “Poland’s Syndactyly” for the syndrome |
As the authors conclude:
Honoring physicians for notable achievements in the form of eponyms can be viewed as a harmless way to bring a little bit of warmth to an otherwise cold world of facts. The least we can do, though, is to recognize the contributions of those who endeavored to shape our current understanding of disease.
Perhaps if history took another course, Poland’s syndrome would instead be called Frolep’s syndrome or Furst’s syndrome. Or perhaps it might simply have been called pectoral-aplasia-dysdactylia syndrome
REFERENCES
Poland’s Syndrome: Current Thoughts in the Setting of a Controversy; Plastic & Reconstructive Surgery. 123(3):949-953, March 2009; Ram, Ashwin N. B.S.; Chung, Kevin C. M.D., M.S. (subscription required)
*This blog post was originally published at Suture for a Living*
