Better Health: Smart Health Commentary

Featured

Are You Allergic To Stitches (Sutures)?

September 10th, 2009 by RamonaBatesMD in Better Health Network, Health Tips

Tags: Allergic, Allergies, Allergy, Plastic Surgery, Stitches, Surgery, Sutures

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 their very 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)

*This blog post was originally published at Suture for a Living*

What Food To Bring With You On Wilderness Expeditions

September 9th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips

Tags: Camping, Energy Bars, food, Food Preparation, Home made, Nutrition Bars, Outdoor Medicine, Trekking, US Army, Wilderness Expedition, wilderness medicine

The Wilderness Medical Society held its Annual Meeting in Snowmass, Colorado from July 24-29, 2009. The meeting was very well attended and once again demonstrated that the Society is the hub organization devoted to advancing the science and clinical practice of wilderness medicine. The format this year was to add a great number of presentations suggested by, and in many cases, delivered by members. In this and subsequent posts, I will present some of the wisdom offered in these presentations. For each post, I will put up a photograph I took while hiking in the Maroon Bells Scenic Wilderness Area.

Wayne Askew, Ph.D. and his colleagues taught on the topic of planning and preparing food for wilderness expeditions. Their goals were to allow the participants to develop an appreciation for the role that food and food planning plays in successful and enjoyable backcountry recreation; understand the similarities and differences between small and large group food planning; estimate energy and other nutrient requirements for individuals and groups; review guidelines for planning nutritional support for backcountry expeditions and recreation; and observe demonstration of recipes and preparation techniques for some useful backcountry food items.

A number of terrific observations were made. In no particular order:

1. Food planning is very important in outdoor activities, with emphasis on the word “planning.” One can enhance backcountry travel and survival with good nutrition.
2. Food planning is also important for morale. If people are hungry, malnourished, or unsatisfied, they are not “happy campers.”
3. The food planner for a trip or expedition should be chosen carefully, and should take care to take into account the dietary preferences of the participants.
4. Energy requirements for specific activities related to physical performance and caloric expenditure can be calculated and taken into account for food and meals planning.
5. There are sometimes foods for special needs (e.g., such as allergies, deficiencies, diseases, etc.). While many of the participants can handle their own needs, whomever is managing food should be aware.
6. There are persons who specialize in wilderness nutrition planning. They advise expedition planners on food, water and logistics; plan menu and food supplies for backpackers, wilderness tour groups and expeditions; assist in search and rescue operations; consult with food companies specializing in backpacking foods; and cook food.
7. If a person wants to accomplish nutrition planning, he or she should have a basic knowledge of human nutrition, understand human physiology and the role of food nutrients in extreme environments, know how to utilize food item selections to provide recommended nutrient intakes, and be a good cook in the outdoors.

Food planning by definition means thinking about food in advance. Dr. Askew and his colleagues recommended answering the following questions:

How much room is in your pack?
How much weight can you carry?
How long will you be traveling?
Where are you going?
How much fuel will you need and will you have access to water?
With whom will you be traveling?

Factors that affect food choices in the backcountry are food preferences; weight, perishability, taste and texture of foods; space in the pack; duration of trip; availability of water and fuel for food preparation; environmental conditions; experience with food preparation; special dietary needs; and personal beliefs.

This was a terrific educational experience, with terrific information such as this Planning Guide Nutritional Standards for Backpacking Food for One Person for One Day, based upon U.S. Army AR 40-25 Nutritional Standards for Operational Rations:

http://www.army.mil/usapa/epubs/pdf/r40_25.pdf

Energy (kcal) 3600 (will vary depending upon activity level)
Protein (g) 100
Carbohydrate (g) 440
Fat (g) 160
Vitamin A (RE) 1000
Vitamin C (mg) 60
Vitamin E (mg) 10
Calcium (mg) 800
Iron (mg) 18
Sodium (mg) 5000-7000
Fiber (g) 20-35

Finally, consider the following recipe for energy bars. This is one way to prepare less expensive and more nutritious (than store-bought) bars for personal use. As recommended by Askew and colleagues, you can be creative with this recipe, and use a variety of fruit, nuts, and grains. It is sufficient to make approximately 20 small bars.

Preheat oven to 350°

½ cup brown sugar
1 egg
¼ cup peanut butter
2 tsp vanilla extract
½ cup apple juice (unsweetened)
1 cup whole wheat flour
1 cup quick cooking oats
½ cup wheat germ
½ tsp baking powder
½ tsp baking soda
¼ tsp salt
½ tsp ground cinnamon
½ cup dried fruit (raisins, apricots, dried cranberries, etc.)
½ cup chopped nuts (walnuts, almonds, peanuts, etc.)
½ cup semi-sweet or dark chocolate chips

Mix dry ingredients in one bowl, wet ingredients and added “goodies”
(chocolate chips, raisins, nuts, etc.) in another, then combine. Spread the batter over a lightly greased cookie sheet about ½ -¾ inch thick. Use a spoon dipped in hot water to press the batter into the sheet and shape to the proper thickness. Bake for 10-15 minutes. Allow the pan to cool completely before cutting into bars. The bars can be refrigerated or frozen for longer shelf life.

Nutrition Information: calories 140, protein 5 grams, carbohydrates 20 grams, fiber 2 grams, fat 6 grams (saturated 1 gram) (% of calories from carbohydrates = 52%)

Tags: food, food preparation, wilderness expedition, wilderness medicine, outdoor medicine, healthline

This post, What Food To Bring With You On Wilderness Expeditions, was originally published on Healthine.com by Paul Auerbach, M.D..

The Secret To Long Life: Do Nothing?

September 8th, 2009 by Dr. Val Jones in Health Tips, True Stories

Tags: Family Medicine, Geriatrics, Long Life, Oncology, Prostate Cancer, Secret, Urology

Ed Walker is 102 years old. I met him by chance on a steep hill in Lunenburg, Nova Scotia – not long after my husband blurted, “I hope you’ve got good brakes on that scooter!” Ed pulled up next to us (to demonstrate his brakes) and jubilantly announced his age, along with his suspected reason for it: “I have prostate cancer but chose to leave it alone.”

I chuckled to myself, thinking that he was probably right about his longevity-hospital avoidance connection.

Of course, the diagnosis and treatment of prostate cancer is being hotly debated these days. While no one likes the idea of leaving cancer untreated, slow-growing prostate cancer may be less of a threat to men at a certain age than the treatment required to cure it. And that’s a difficult truth to accept – especially for Americans.

My fellow blog contributors have noted the disconnect between scientific evidence and clinical practice in regards to prostate cancer. According to a recent study in the New England Journal of Medicine, PSA (a screening test for prostate cancer) testing has not made a difference in overall longevity. Urologists still favor testing (the American Urological Association guidelines recommend initiating PSA testing for all men starting at age 40) while family medicine physicians don’t usually recommend it. Is there a conflict of interest driving this difference in recommendation? Perhaps – though I suspect it has more to do with a surgical mentality (to cut is to cure!) than a conscious decision to protect one’s income. If you think there’s a shortage of urologic procedures to go around, then I’d recommend you simply consider the increasing age of the US population. It’s not as if the prostate gland is the only thing that needs work “down there.”

Perhaps Americans can take some cues from their elderly neighbors to the north – and try to accept that doing something is not always better than “doing nothing.” In the case of some prostate cancers, it’s cheaper, safer, and a lot less painful.

Just ask Ed Walker.

Healthcare And Illegal Immigrants: Why The Confusion?

September 7th, 2009 by DrWes in Better Health Network, Health Policy, Health Tips

Tags: Congress, Federal Payments, Healthcare reform, House Bill 3200, Illegal Aliens, Illegal Immigrants, Undocumented Aliens

“I don’t know what could be more clear,” said Representative Bruce Braley, Democrat of Iowa, who has read aloud from a section of the House bill with the title “No Federal Payments for Undocumented Aliens.”

“Heath Care Debate Revives Immigration Battle,”
New York Times, 6 Sep 2009

From House Bill 3200, page 143:

SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED
4 ALIENS.
5 Nothing in this subtitle shall allow Federal payments
6 for affordability credits on behalf of individuals who are
7 not lawfully present in the United States.

* * *

Taxpayers are concerned whether they will have to foot the bill for illegal aliens in the upcoming health care bill. Many ask good questions, like how will health care workers know who’s an illegal alien? If they are included, how will it be paid for? These are important questions that we would hope could be dealt with squarely, openly and with full transparency.

But this is a sensitive topic for Congressmen interested in securing reelection.

During the summer recess, many Congressmen were barraged by questions to this effect. So it was interesting reading this New York Times piece this morning on whether illegal aliens will be covered under the new health care plan before Congress. On one hand we have Congressmen placating his constituents by assuring voters that “I don’t know how it could be more clear” as they suggest taxpayers will not fund illegal aliens, but careful inspection discloses that illegal aliens will just not be eligible for federal subsidies to reduce their payments for federally-supplied health insurance.

But from here, it gets even more byzantine:

… the report finds that the House bill would not prohibit illegal immigrants from enrolling in a health insurance exchange. The exchange would allow participants to buy coverage from one of several plans, including a public option offered by the federal government.

At the same time, illegal immigrants would not be exempt from the obligations in the House bill. According to the research service, most illegal immigrants in the country would be required to buy health insurance or face tax penalties.

And since they would be barred from subsidies, they would have to pay for coverage at full rates, regardless of their income level.

So here we have illegal aliens, already strapped for cash, paying their “full payment” and if they don’t, the tax man will come after them (which is confusing to me, because I didn’t know that illegal aliens pay taxes).

So what is wrong with the public? How could they possibly be confused?

Here’s a thought: the only real way out of these shameful machinations is to deal with the immigration and health care issue separately, incrementally, and without this shell game. Doesn’t the American public deserve a more thorough discussion of this issue, rather than shoving it in to our upcoming health care legislation?

My personal sense of it is that such an issue will never be decided at the Emergency Room door. Rather, it is part of a systemic immigration control and reform question that involves our borders, employee verification, and a decision about existing illegal immigrants.

What we’re observing instead, is a Congress is too scared to deal with this issue honestly.

*This blog post was originally published at Dr. Wes*

One Lucky Canadian

September 6th, 2009 by Dr. Val Jones in Health Tips, True Stories

Tags: Canada, Colon Cancer, Gastroenterology, General Surgery, Healthcare System, Perforated Colon, Peritonitis, Ruptured Bowel

Today an elderly physician friend of mine woke up with some very mild abdominal pain. He is a stoic man, and never complains about anything – not even the pain associated with a dislocated/shattered hip and multiple bone fractures from a car accident (he was very nonchalant about that event 2 years ago).

So when I heard that he was going to see a doctor about his belly pain – I knew that something serious was afoot. His doctor ordered an abdominal x-ray series, noted a tumor, and sent him to the O.R. within the hour.

In the O.R. the surgeons found a perforated colon (it must have ruptured minutes to an hour or two prior) without signs of peritonitis. There was a cancerous mass (without metastases) that they were able to remove completely. They washed his peritoneal cavity extensively to remove all fecal matter and potential cancer cells and transferred him to the ICU for observation overnight and IV antibiotics.

So far it seems that my friend will make a full recovery – and there is no evidence of remaining cancer, though we’ll need to be vigilant with follow up.

I can’t get over how lucky he was to have discovered the perforated colon within hours of it occurring, that the surgeons took care of him immediately, and that the cancer seems to have been contained and removed. I don’t know if his “luck” was partially due to his physician’s intuition about his own body, professional courtesy extended to him by peers, or that the Canadian healthcare system is not as burdened in his part of the country (Nova Scotia) as it is in others where there may be longer wait times.

All I can say is that my friend is one lucky Canadian!