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.
Aspiration of the contents (72% success rate with multiple aspirations, 2-5 treatments)
Cyrotherapy (56% to 86% success rate)
Steroid injection
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:
Epidermoid cyst
Heberden node or Rheumatic nodule
Fibrokeratoma (DMCs may resemble this when they form between the proximal nail fold and the nail and protrude with a keratoticlike tip.)
Giant-cell tendon sheath tumor
Myxoid malignant fibrous histiocytoma
Myxoid variant of liposarcoma (These are less likely to present as firm circumscribed masses and more likely to be deeply seated.)
Soft-Tissue Chondroma in the Thumb; Plastic and Reconstructive Surgery. 110(6):1599-1600, November 2002; Avc, Gülden; Aydogdu, Eser; Ydrm, Serkan; Aköz, Tayfun
It’s always a bit of a landmark when something like the Happy Meal reaches a big milestone in years. This week marks it’s 30th anniversary of being introduced into our lives. That’s a lot of years, a lot of meals and a lot of small cute toys!
A meal in a box…who would have thought! I do remember when they first came out and parents with little kids flocked to them like flies to sticky paper. However, coming in at 600 calories for an average meal, packed a huge punch on the typical child’s health and waist band. Indeed, as noted by ABC News, childhood obesity has increased by 4x over the last 3 decades moving from only 4% the child population to 17%!!
The McDonald’s rep interviewed by ABC News mentioned that the “most popular” Happy Meal, the chicken nuggets with apples, is now only 360 calories. That is a great decrease by just shy of 50%.
Let’s not celebrate yet. What we need to consider is what proportion of a daily calorie amount this mean eats up.
Chicken nugget meal with Apple dippers & Apple Juice: 380 cals
Chicken nugget meal with fries, 1% chocolate milk: 580 cals
Hamburger meal with apple dippers, white milk: 460 cals
Hamburger meal with fries, chocolate milk: 650 cals
Cheeseburger meal with apple dippers, white milk:500 cals
Cheeseburger meal with fries, chocolate milk: 700 cals
Finally, what percentage of a child’s daily calorie count will each of these meals snatch up for a toddler at 1000 calories a day?
Chicken nugget meal with Apple dippers & Apple Juice: 38% Chicken nugget meal with fries, 1% chocolate milk: 58%
Hamburger meal with apple dippers, white milk: 46%
Hamburger meal with fries, chocolate milk: 65%
Cheeseburger meal with apple dippers, white milk:50%
Cheeseburger meal with fries, chocolate milk: 70%
What about if the child is a 5 year old girl requiring only 1200 cals/day?
Chicken nugget meal with Apple dippers & Apple Juice: 32%
Chicken nugget meal with fries, 1% chocolate milk: 48%
Hamburger meal with apple dippers, white milk: 38%
Hamburger meal with fries, chocolate milk: 54%
Cheeseburger meal with apple dippers, white milk:42%
Cheeseburger meal with fries, chocolate milk: 58%
The kicker here is that if we run these numbers for the teens, the percentages wouldn’t be quite as bad but teens go for the bigger meals which put them right back into these ranges in the end! (A Quarter Pounder alone is 400 calories! Check this list out for more details.)
Fast food such as Happy Meals is one of the big players in obesity in general for all populations. There are times we all have to grab and go because of work, travel and circumstances beyond our control. The key to not have the loaded calories make too much of a long term dent is to have a fast food plan and to work on being more healthy over all. Here are my suggestions:
1. Pick small portions and healthy alternatives at fast food places, and teach our children to do so as well. When in doubt, down size and pass on the fries or split them.
2. Eat healthy in general so the fast food day is the exception, not the rule.
3. Be as active as possible daily so your body and your children’s bodies have a way to burn the added calories.
McDonald’s job is to sell food and lure you and your kids’ through the doors. Your job is to keep your kids healthy and teach them how to be healthy life long. Have a Happy Meal once in a while…but do so thoughtfully and don’t delude yourself that these meals are anything close to healthy. The new packaging and food choices are just new hype for the same old unhealthy song.
*This blog post was originally published at Dr. Gwenn Is In*
Asking a bunch of doctors and nurses what they want out of health care reform is like asking a group of teens what toppings they want on a pizza: You’re going to get a lot of different answers, with the loudest proclamations reserved for what they don’t want.
Such a group came together July 17 at the National Press Club in Washington, D.C. at an event called Putting Patients First, hosted by Better Health. The unanimous conclusion: Get government out of the health care delivery continuum.
Val Jones, M.D., CEO of Better Health, said, “I don’t think people outside the doctor-patient relationship should be making life and death decisions” on behalf of the patient or doctor. Rep. Paul Ryan (R-Wis.), the event’s keynote speaker, said government has an obligation to establish conditions for free markets to thrive. Ryan blamed insurance companies for the problems with health care today – essentiually stating that insurers dictate the care that providers can deliver – and he called for a solution that does not involve heavier government.
“Government bureaucracy is not the answer to insurance bureaucracy,” Ryan said. The government’s failure to control costs in Medicare and Medicaid “shows us we should get government out of the way and put more faith in the market. Providers should compete against each other for our business.”
Ryan claims that the so-called ‘public option’ in President Obama’s proposed health care reform initiative would allow the government to be “referee and player in the same game,” and that companies hoping to compete for consumer health care dollars would be at an unfair disadvantage. Obama’s plan would result in “cookie-cutter standards” for determining individual patient care, set unfairly low reimbursement rates and create an economic barrier to young talent hoping to enter the medical profession.
Ryan added that Obama’s plan offers no incentives for people to get and stay healthy, which would lower health care costs. But offering reduced insurance rates to a consumer who, say, quit smoking or lost excess weight “would be illegal” under Obama’s plan, Ryan noted. “So there’s no incentive” for people to take better care of themselves. Ryan has a plan that he says would include a “carrot and stick” provision to reward people for maintaining a healthy lifestyle.
Between two expert panels, Robert Goldberg, Ph.D., co-founder of the Center for Medicine in the Public Interest, showed a video, complete with scary background music, of patients in Canada and the U.K. complaining about abhorrent wait times to see doctors and government-mandated denial of life-saving treatments. Goldberg concluded that government-run health care in the U.S. would yield a similar system, with patients wasting away in the long shadows of a bureaucratic monster while doctors and nurses stood by, helplessly bound by the new rules. (One panelist later noted that polls show 70 percent to 80 percent approval among Canadians for that country’s health care system.)
The event did yield some progressive ideas for improving the U.S. system.
Alan Dappen, M.D., associate clinical professor at Virginia Commonwealth University School of Medicine, Department of Family Practice, and founder of DocTalker, a practice in Fairfax, Va., has moved a huge chunk of his patient consultation onto the phone. Patients still pay for his time – just as they would for an office visit – but the system is much more efficient than having every patient come in for every ailment. “If you have a tick bite or an ear infection I don’t necessarily have to see you,” he says. Further, he says, the documentation for treating such minor ailments “should not go through 30 people” at an insurance company to ensure the doctor is paid or the patient is reimbursed. “That’s just ridiculous.”
Dappen has been practicing this way for eight years and says it takes on average 10 minutes to solve a patient’s issue over the phone. “Most of our patients are helped to satisfaction,” he said. And as a result of the time saved on patient visits, he added, he has time to do house calls – and is the only doctor in Fairfax County who does so.
Rich Fogoros, M.D., a former professor of cardiology and cardiac electrophysiology and longtime practitioner and researcher who is now a consultant and writer, suggested that primary care physicians go “off the grid” – i.e. refuse to participate in any insurance plan. That, Fogoros said, will force regulators and insurers to acknowledge that current practices by insurance companies have destroyed the doctor-patient relationship.
Kevin Pho, M.D., an internal medicine physician in Nashua, N.H., and author of the blog Kevin, M.D., said the most common complaint he hears from his patients is how little time they get to spend with him during a typical visit. “We are incentivized to see as many people as possible,” Pho said, not to provide the best care possible for each patient. One solution: hourly pay for doctors, siilar to the ‘billable hours’ system used by lawyers.
James Herndon, M.D., an orthopaedic surgeon and chairman emeritus of the Department of Orthopaedic Surgery at Partners health care (an integrated health system founded by Massachusetts General Hospital and Brigham and Women’s Hospital) in Boston, Mass., voiced concern about doctors in hospitals who won’t take care of the uninsured and underinsured. The doctors “keep pointing them elsewhere until they end up in the trauma unit, which is the last resort,” he said. “I would mandate that [all doctors on staff] see their share” of those patients.” Herndon added that he favors “public support,” such as some form of a tax, to ensure doctors are compensated for providing that care. He also conceded that the health care industry has become too profit focused. “The CEO of United Health made $1.2 billion” in one recent year. “We need to get rid of excess profit in insurance.”
Kim McAllister, R.N., the author of Emergiblog, said that, no matter which plan emerges from the ongoing debate in Washington, “People will circumvent it by showing up in the emergency room.” She recounted a story of a patient in California who went to the emergency room for a headache – twice – because he couldn’t get a timely appointment with his physician. She favors a health care savings account model under which each consumer could then “decide what provider they see and when they see that person.” McAllister suggested allowing the money to roll over from year to year – another nod to rewarding healthy lifestyles – although she strongly implied that allotments would be scaled based on a person’s income.
And this hit a point on which most of the participants seemed to agree: For consumers who really cannot afford health care in a free-market system, the government should have funds available to help them pay.
I received the two comments below from readers and use this opportunity of their tragic experiences to revisit a concern that I raised about two years ago regarding methotrexate therapy for the presumptive diagnosis of ectopic pregnancy….
Melissa O. said…
I was told I had an ectopic pregnancy and was advised I was in need of a Methotrexate shot. I got it. One week later my hormone level was continuing to rise. Low and behold 4 days later my ultrasound showed I was carrying twins. The Dr.’s had presumed ectopic too early. Getting the shot caused me to loose Twin A and to give birth to a very much underweight 28 weeker. This experience has changed my life forever. My son fought to survive…he continues to today now 13 months old. I would hope anyone who is told they have an ectopic pregnancy would be cautious when it comes to this shot. Yes I agree it helps if your life is in danger due to an ectopic pregnancy. Just take time to ensure there is no doubt that’s what it is. My Dr couldn’t see the baby so assumed ectopic, however carrying twins like I was you’re not able to see as early as a single pregnancy. My son is paying everyday because of my mistake and doing as one Dr. said make sure you have more than one confirmation, it could cost you a perfectly healthy baby in the end.
Fri Jun 19, 05:45:00 PM 2009
Anonymous said…
Hi can someone help me? My husband and I were trying for a baby and I fell pregnant (good news). I started having a few brown spotting and slight cramping which I was advised by my GP to go to the hospital for a scan. Whilst there I had many tests and the doctors thought it might be ectopic and said he was going to keep me in for a few days to monitor my blood levels. I had a scan but being only five weeks it was hard to say. I was referred to another doctor on the ward and he told me it was ectopic. I trusted his knowledge and he said he needed to give me methotrexate now as it was Friday so the pharmacy would be shut. I was shocked but agreed of course. 3 days later I was told the baby is still alive and is in my womb. My blood levels increased after 3 days and then decreased from 7000 to 6000 on the 7 days. How long will it take to lose my baby as it’s hard to know its alive?
Fri Jul 03, 11:15:00 AM 2009
Ever since methotrexate became popular for treating ectopic pregnancies, I have seen the unfortunate scenario reported by our readers above played out time and time again. Methotrexate (MTX) is an analog of folic acid. It binds tightly to an enzyme called dihydrofolate reductase and when it does so, interferes with the production of tetrahydrofolates. In the end, this interferes with the normal production and repair of DNA by limiting the production of a key nucleotide, thymidine. Other metabolic effects are also known, but the take home message is that MTX can result in lethal damage to cells that are replicating, particularly those that are replicating rapidly, like certain cancer cells.
Because of its documented efficacy in the treatment of malignant trophoblastic cells (choriocarcinoma), MTX has been employed in recent years as an alternative to surgical therapy in selected cases of ectopic pregnancy (Lipscomb, et al. NEJM 2000;343:1325-29). Ectopic pregnancies, by definition, implant ‘outside the uterus’ with more than 95% occurring in the fallopian tubes and about 2.5% in the cornua of the uterus (where the fallopian tubes enter the uterus). For that reason, they are frequently referred to as ‘tubal pregnancies,’ although they can also occur in the cervix, ovary and intra-abdominally. The fallopian tubes cannot restrict the growth of invasive placental tissues, as can the endometrium, and they certainly cannot accommodate a growing embryo beyond a certain point before they rupture and hemorrhage. Indeed, ectopic pregnancies can be quite deadly if not treated appropriately. They are still a major cause of maternal mortality, accounting for 10-15% of all maternal deaths, and they are the leading cause of death in pregnant women in the first trimester. A ruptured ectopic pregnancy is a true medical emergency.
Because of the rising incidence of ectopic pregnancy, the risk (maternal and medical-legal) of not identifying and treating an ectopic pregnancy in a timely fashion, and the widespread acceptance and success of MTX therapy as an alternative to surgical management of an ectopic pregnancy if caught early enough, there has been a coincident increase in the inadvertent use of MTX in unrecognized early intrauterine pregnancies. The usual scenario is one in which the pregnancy is not quite as far along as anticipated and the patient happens to present with complaints of abdominal pain or some spotting and no clear intrauterine pregnancy is identified by ultrasound. The ‘absence’ of an intrauterine pregnancy can be misdiagnosed because the pregnancy really is too early, but in at least one of the scenarios above was more likely the result of the inexperience of the individual(s) performing the ultrasound study.
This situation can be especially confusing if the pregnancy hormone levels (hCG) appear to be low for the expected gestational age based on last menstrual period (as is often seen in women who ovulate later, and hence conceive later, in their cycles) or if a woman has a tender adnexal mass because a hemorrhagic corpus luteum (intraovarian bleeding at the site from which the egg was ‘hatched’) or torsion of an adnexal mass (rare this early in pregnancy) which might be very difficult to differentiate from an ectopic pregnancy.
Since MTX is a category X drug, known to be teratogenic in humans, it is important to ascertain the presence of an ectopic pregnancy rather than simply to use it empirically. Unfortunately, its inadvertent use with an intrauterine pregnancy is most likely to occur during the time of neural tube and very early cardiac development, both of which rely on folate-dependent pathways. Various algorithms are in place that employ ultrasound imaging, quantitative hCG levels, and progesterone levels to differentiate abnormal from potentially normal pregnancies and these protocols can be useful in minimizing the chance of the inadvertent use of MTX and also in directing its use when appropriate for the management of an ectopic pregnancy. Perhaps the greatest risk of ectopic pregnancy is not suspecting that one could be present. Patients who are adequately counseled and followed closely are much less likely to end up in emergency situations.
To our readers above, I am SO SORRY for both of you. This is a failing of the medical system and is a growing concern of mine due to the ready accessibility and simplicity of use of methotrexate (and also another drug, misoprostol, that is used in the ‘medical evacuation’ of the uterus when an inevitable miscarriage is suspected).
My feeling is that it should never be used in an asymptomatic or minimally symptomatic patient until either an ectopic pregnancy is seen, no intrauterine pregnancy is documented (by a competent sonographer) at hCG levels where an intrauterine pregnancy should readily be visible, the patient has significant ‘risk factors’ for an ectopic pregnancy (e.g., previous ectopic, known history of pelvic inflammatory disease or tubal reconstructive surgery) or when there are well-documented abnormalities in the rise of hCG that are highly suggestive of an ectopic pregnancy. My heart goes out to both of you.
In the May 14, 2009 issue of the New England Journal of Medicine, in an article entitled “Antivenom for Critically Ill Children with Neurotoxicity from Scorpion Stings,” Dr. Leslie Boyer and colleagues report the results of a study in which the efficacy of scorpion-specific F(ab)’2 antivenom was compared to placebo in the treatment of 15 children ages 6 months to 18 years who were admitted to a pediatric intensive care unit with clinically significant signs of scorpion envenomation (N Engl J Med 2009;360:2090-8). The primary clinical end point was the resolution of the clinical syndrome within 4 hours after administration of the study drug. Secondary end points included the total dose of concomitant midazolam (Versed) – a sedative – and quantitative plasma (bloodstream) venom levels, before and after treatment.
The results showed that the clinical syndrome resolved more rapidly among recipients of the antivenom than among recipients of placebo, with a resolution of symptoms in all 8 antivenom recipients versus one of 7 placebo recipients within 4 hours after treatment. More midazolam was given to the placebo recipients (by necessity to treat symptoms) than in the antivenom recipients. Plasma venom concentrations were undetectable in all 8 antivenom recipients, but in only one placebo recipient one hour after treatment, which indicates that the antivenom neutralized circulating antivenom.
The conclusions are very helpful for clinicians treating scorpion envenomation syndromes with neurotoxic manifestations in critically ill children. They are that intravenous administration of scorpion-specific F(ab)’2 antivenom resolved the clinical syndrome within 4 hours, reduced the need for concomitant sedation with midazolam, and reduced the levels of circulating unbound venom.
This is very important new information. It is estimated that in North America, predominately in Mexico, more than 250,000 people per year are stung by scorpions. The major culprits are of the genus Centruroides. The antivenom used in this study was scorpion-specific F(ab)’2 antivenom (Anascorp, Centruroides [scorpion] immune F(ab)2 intravenous [equine], Instituto Bioclon).
The authors note that there has never been an approved, marketed antivenom therapy for scorpion envenomation in the United States. The only previously available scorpion antivenom in the U.S. was a goat-derived whole IgG (immunoglobulin G) preparation that has not been produced since 1999. Based on the current study, it now appears that there is a relatively safe product for treatment of critically ill children. Its use for critically ill adults and for children and adults with non-critical scorpion envenomation syndromes remains to be studied with the degree of rigor necessary to suggest its regulatory approval for use in the U.S.
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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)
It’s always a bit of a landmark when something like the Happy Meal reaches a big milestone in years. This week marks it’s 30th anniversary of being introduced into our lives. That’s a lot of years, a lot of meals and a lot of small cute toys!
