Surgical Skin Closure, Staples vs Sub-cu

Yesterday I posted about Zika virus and how it is dangerous to neural tissue, especially for a fetus. This Zika problem will be with us for a couple of years until we can get a handle on it. I've seen pictures of the "war room" at the CDC where the epidemiologists have their daily meetings. I think the CDC is in Atlanta but it might be located at least partially near Washington DC.

Today a patient came in for her PP visit and we discussed her surgical closing technique. I had a doctor covering my practice who is a very skillful and caring physician. The patient needed a C-Section and I wasn't on.

My covering doc closed her skin incision with cosmetic subcuticular dis-solvable stitches.  So my patient has had the skin closed both ways now. First with staples, second with sub-cu.  And she now has a strong preference.

I know that the staples are a bit more work, and patients are worried about the removal. The removal is usually almost painless as the staples slide ride out once they are unbent.

Why are the staples beneficial?

-They are completely removable.
-They are very smooth and shiny, so no germs can get a hold of them.
-They never break down and fail their job of holding the skin
-When they are gone, they are utterly gone, leaving nothing behind to dissolve.
-When they are gone there is skin touching skin and nothing else in between. This is far more comfortable, softer, and smoother.

Why don't people like staples?

They feel and look unsightly while they are in. And they have to be removed.

In my opinion staples just do a better job and are worth the extra work.

The science does not show a preference between between staples and subcu dissolvable sutures. There have been a number of randomized trials. Obviously the trial cannot be blinded because the doc doing the stitching can see what they are doing. I suppose the incision can be evaluated later by someone who is blinded as to the closing technique.

In any case the studies showed no difference in the quality of the skin incision outcome. Of note, though, the studies that I read were done in academic medical centers where the infection and complication rates were far higher than a private community hospital. The academic centers infection rates were about 8 times higher than my hospitals. This surgical complication rate is a reflection of the socio-economic stress of poverty, the higher workload of the staff, and the riskier patient mix. I doubt if the less experienced staff has anything to do with it, but it remains possible. It is possible that the older facilities have less modern infection control technologies, such us laminar flow air handling in the operating room.

I think that if that same study were done in a place like my hospital, there is possibly a different outcome.

In my experience the staples provide a better outcome. Once they are removed they provide a far more comfortable and smoother incision.

Every once in awhile a patient will pick a doctor based on their known closure technique. I would like everyone to know that I will do whatever technique they want. I will give them my advice and then honor their wishes. Hopefully that will satisfy the needs of those who don't like the idea of staples. I am perfectly qualified to do cosmetic sub cu. I studied 6 weeks of cosmetic surgery at the Cook County Hospital in Chicago Illinois. That was a great time for me. I learned a lot. And I have been doing surgery every since.

So if you don't want staples, then I will do the sub cu. But if you want the best, then ask your surgeon if they can do metal removable staples. (The dissolvable staples are more like the sub cu).

Zika Virus in Pregnancy. 

Zika Virus has been in the news quite a bit. It seems very bad. How bad is it? 

7 days ago there were very few cases known and published in the US. 

3 days ago there were 33 cases. All were cases caught outside the US, and brought here. 

Yesterday was the first case caught in the US, given from one person to another by sexual exposure. Sexual transmission seems to be a previously unknown method of transmission of Zika Virus. 

As of yet, there are no known mosquito transmissions in the mainland US. Although Puerto Rico, Guam, etc may be at higher risk, because of their tropical climates. 

It seems inevitable that there will be mosquito borne cases in the US. 

In Brazil, there are 4000 cases of microcephaly in newborns. This is a huge increase, and is thought to be possibly from Zika infections. Zika seems to have an outsize affect on neural tissue. Zika gives adults a case of Guillen Barre Syndrome: 

https://en.wikipedia.org/wiki/Guillain%E2%80%93Barr%C3%A9_syndrome 

Guillen Barre is a disorder of neural tissue. 

And in fetuses, it somehow affects the neural tissue of unborn children. Somehow the neural tissue is destroyed. I have seen the CT scan pictures, and the brains are seemly destroyed, at least partially. It is a real disaster for these children, families, and societies. I don't think anyone knows for sure how the neural tissue is destroyed but it is certainly possible that the virus gets into the cells, grows there, and kills the cells. Once the brains are destroyed, the head stops growing, and the child has a small head. This is called microcephaly.

There are no antizika antiviral medicines.

There is no Zika vaccine. 

The official position of the Brazilian Government is that women should put off being pregnant until something more is known about Zika Virus.   This will take some time. Delaying an entire countries childbearing has not been done in recent memory. Again, this is something new. 

As of this moment, there are far more questions than answers about Zika. 

Here are a few helpful links: 

http://www.cdc.gov/zika/pregnancy/question-answers.html

http://wwwnc.cdc.gov/travel/page/zika-information

http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html

http://www.cdc.gov/zika/pregnancy/index.html

http://mothertobaby.org/fact-sheets/deet-nn-ethyl-m-toluamide-pregnancy/pdf/

There are a few facts:

Eliminating mosquito bites will likely eliminate risk. How can we eliminate mosquito bites?
-Keep doors, windows, and screens closed.
-Don't travel to tropical climates right now, without precautions.
-Don't have unsafe sex with anyone who has been to a Zika prevalent area.
-When summer comes use air conditioning. Mosquites prefer the warmth. Cold keeps the mosquitoes out or inactive.
-If outside, use long tight pants, sleeves, socks, etc.
-Use special clothes that are permeated with permethrin. Personally, I have never seen such clothes for sale, but this is what the CDC says to do. I suppose if you can get Permethrin, you can spray your own clothes with it.
-Use highly effective insect repellent. DEET seems to be the best, in my opinion. Use it on all exposed skin, and even on your clothes. And use it even if pregnant. Use it copiously.
-Don't go outside when mosquitoes are active and present.
-Remove all standing water from the land. This is where mosquitoes breed.
-Treat standing water with insecticide or some other effective treatment.
-Use insect foggers outside, on a personal or municipal basis.

And finally, as a society, we need to control the Aedes Aegypti  mosquitoes.
https://en.wikipedia.org/wiki/Aedes_aegypti.
This is not the only nasty virus or disease transmitted by this mosquito.

There are some biological control mechanisms to control this mosquito. But we will have to get over our natural inclination to protect species. It is rare for humans to conduct deliberate annihilation of a species, but it has been done before. Smallpox has been destroyed. Some agricultural pests have been destroyed. Other infectious diseases are on their way out. If we can vaccinate everybody we can stop more infectious diseases. But vaccinating everyone requires some force, as there will always be selfish individuals who wish to take advantage of the herd immunity we provide them, while not simultaneously helping to provide that immunity. These individuals will need to be either convinced or coerced. Somehow. My personal politics preclude the use of force on people, but I would support some kind of strong coercion for this. Like keeping unvaccinated kids out of schools.

Worldwide, 140,000 people die of measles every year:
http://www.usatoday.com/story/news/2015/07/02/measles-death-washington-state/29624385/
These deaths are preventable with the vaccine. Everyone who declines the vaccine is part of the problem, not the solution. We all must accept the risk of the vaccine in order to benefit from the vaccine. And the risk of the vaccine is very very low. My children have been vaccinated as per the normal schedule. There was no doubt in my mind that it was a good idea. And now my kids cannot kill anyone by transmitting measles to someone. This, to me, is profoundly beneficial. And sensible.

So this Zika virus is going to infect a lot more people.

We can control it in the USA because we have measures to control mosquitoes that other nations don't have. Of note, living in a cold climate is not a protection. As anyone who has fished in Canada or Alaska knows, in the summer, there are tons of mosquitoes. And the mosquitoes come back every year. They survive the winter.

We have been down this road before. West Nile Virus was a similar kind of event. Ebola had a very high mortality, but was controlled with really heroic efforts by some people who deserve a Nobel Prize, like Doctors Without Borders. There are significant new epidemics every year or two.

And in fiction, I have read several doomsday novels about killer viruses. Mostly man made viruses.

Steven King wrote "The Stand". There is a very good movie as well.
More recently, Russel Blake wrote "Upon a Pale Horse".
Both are good books.

Here is a list of books about epidemics:

http://www.goodreads.com/list/show/19535.Best_Fiction_Books_About_Diseases_or_Viruses

Please use the links above. I hope to be able to give better answers in the future.

Thanks
Dr Marcus
Blog is at doctorjohnmarcus.blogspot.com

89 North Maple Ave
Ridgewood NJ USA 07450 

Hummus Food Recalls and Listeria

Food Recalls and Listeria

As part of my job as an Obstetrician I like to follow the news.

One thing that is frequently in the news is Food Recalls.

Not too uncommonly there will be news that the various Departments of Health will recall a particular type of food because there is some food-born illness lurking in that food. Sometimes companies will recall food on their own.

It is always something different.

Sometimes, the spinach farm is next to the pork farm, and there is heavy rain, and the pork "droppings" run into the spinach. So the spinach might be found to harbor E Coli bacteria.

Sometimes the barn that grows eggs is found to have bird droppings on the eggs, because the wrong kind of bird has flown into the barn. And those bird droppings carry bird borne infections. Egg farmers have been shut down for this.

A few years ago it was Melons. Before that it was brussel sprouts.

And recently a peanut butter company executive was charged with a crime because he didn't do enough to make sure the peanut butter was uninfected. I don't know the outcome of that trial.

Sometimes the recall is very specific. Like frozen food from a specific shift of a factory.

A few weeks ago a pregnant women informed me that she had a mild flu like illness. Then she informed me that she ate food that was subject to recall for listeria.

Listeria is dangerous to fetuses. It does unspeakable damage to them, or they die. I have seen these babies. Listeria hides because the maternal illness is very mild or nothing, but the fetal illness is extreme.

If we know of the exposure we can monitor and treat the mother and fetus with antibiotics. Ampicillin can  be effective, but it takes a high dose. So high a dose that the pharmacist calls to ask if I am sure. Ampicillin is very safe, and Listeria is very dangerous, so I will treat preventatively if possible.

Most of the time we don't know of the exposure. And the baby and family pays the price. It is rare, but it really does happen. And most Obs have seen the terrible end results.

The latest recall is from a popular brand of Hummus. It was found to contain Listeria.

Do a google search for Hummus Listeria Recall and you will find the brand. It is called Sabra.

Here is the CNN link:

http://www.cnn.com/2015/04/09/us/sabra-hummus-recall/index.html

Please, if you have Hummus in your fridge, check the recall and throw out the Hummus. It is just not worth it.

I have put a poster up in my office as this particular Hummus is really good and it is really popular around here. It is my favorite brand.

So watch the news for food recalls. Especially if you are pregnant.

Thank you very much.

Dr John Marcus
doctorjohnmarcus.blogspot.com

89 North Maple Ave
Ridgewood NJ 07481

Friday Night

Hi Everybody.

It is Friday7 about 8 pm and I just got back from rounds. I signed out for the weekend to my friend Dr Damien-Coleman. She is a very nice person and a great doctor. For my goals this weekend I am looking at about 8 hours of work going through my lab results and reports from other doctors. I will restart on this tomorrow as I have been working 12 hour days since Monday. I will get my lab results interpreted and my opinions out to my patients. I hope to use my "patient portal" for most of my results. More about that later in this post.

Today's belated blog is about the future. The future is here, and it is bringing tremendous changes to our culture and society. A hundred years ago calling on someone meant going to their door and knocking. It was like that for thousands of years. But since 100 years ago or so calling on someone meant dialing your phone. At first, 80 years ago, it was picking up the phone and asking the operator to plug your phone line into someone else's line. 50 years ago, the operator was replaced with equipment. Every person's phone had a ring with holes to actually spin to dial. Kids nowadays have no idea what that means. The next change, when I was young, a person could pay a few dollars a month to push buttons instead of turn the dial. Nowadays, I doubt if a dial phone would even work any more. Only push buttons with tones remains. Then, when I was in high school,  the cell phones came. Now, people are dropping their home "land line" phones like hot potatoes. People are just using their cells. But there are two further changes that have come up unexpectedly.

The first: most people don't even answer the phone anymore. Most people don't even use the phone anymore. People have moved to cell texts to move information around. Some people still call others. But most don't. And the kids, forget it. A phone call? They don't want it. It is much too slow. In the time of one call, then could have made 20 texts. Now we are also losing email.

The second change: kids have abandoned email. The kids now are no longer filling in the email spot on application forms. They don't want email. It is too slow, cumbersome, and polluted with spam.  It still has business uses. But for rapid personal connections, email is dead. Everyone is using texts and micro-blogging sites.

Why am I wasting time on a gynecology blog to say this?

Because today I received about 10 phone calls from patients asking for some information or advice. I called every one of them back before I closed up the day. And only one answered the phone. There are now 9 calls into me that are just completely unanswered. I feel awful about it.

The phone, as a reliable form of communication, is completely useless. Nobody uses it reliably any more.

But I have a solution to this awful and vexing problem.

But first, let me explain the technology changes in my office. We of Lifeline have moved our EMR software to a much bigger package called NextGen. We have been doing this for months now.  Those of you who have read my blog in the past will realize the huge difficulties of moving from paper to EMR. I have described how hard it is here on this blog.

But now, the original software package was not fulfilling our needs. So we, as a group, moved ourselves, our practices, and our Electronic Medical Records, to a new software package called NextGen. The move to NextGen EMR software was just as big and just as traumatic as our move to our original EMR. But NextGen has some much more powerful functions.

One of the more powerful functions is called the "Patient Portal". The patient portal is a website. The patients can log on to this encrypted and secured website and access a ton of functions related to their health care on the portal. They can review whatever medications the computer thinks they are taking. They can ask for, get, and review their appointments. They can read their "patient plans". This is the end of the medical note that is created for them when they are in for their appointment. The patient plan function is still being rolled out so don't expect it there every time. But it is nice to see. In the patient plan people can see their "problem list". The problem list is generated by myself by the conduct of general medical practices.  The problem list has already generated questions to me about something they don't understand. So the resolution of their lack of understanding is... wait for it... Their Understanding. And that is a Good Thing. And if there is a Mistake in their records (theoretically that might be possible), then there can once again be a correction, and then an... Understanding (an understanding that goes the other way, patient to doctor). And any correction to the medical records is a Good Thing.

It goes without saying that I am starting to love the patient portal.

But the biggest lesson here is that of Communication.

Today, on Friday afternoon, I made 10 phone calls and only one phone call was actually answered. I left no protected health information on any answering machine. At the very same time, I made about 15 protected email responses, some with multiple round trips both ways. And each and every one of them was at least potentially received and read by patients. And the information was received and understood in a completely secure and confidential manner. There is no way that a nosy neighbor, a jealous husband, or a worried mother, can read or hear the information in that secure portal controlled email. Remember the email never went out on a normal email server. It is only fake as an email. The email is really only served by an encrypted web site. That only one person can read. The person who holds the password for that email.

So today I made 10 phone calls, 9 of which went nowhere with no results, as I cannot leave any substantially private information on an answering machine, and 15 secure portal messages, all of which went through, and many of which were started by patients themselves. All of which contained highly valuable personally important information.

How secure is this information? I can tell you that it is as secure as NextGen can make it. NextGen is based on some very advanced encryption. It satisfies the requirements of HIPAA. It satisfies the Feds. If HIPAA is violated without due care, there is a potential for a fifty thousand dollar per incident fine. So you can be sure that I am keeping my passwords secure.

The hardest part of making the portal work is getting the patients actually started on it. Starting a portal account requires some hard work making sure that patients actually get secure access. So the account is set up with some very personal communications of passwords, followed by a round trip of emails to a pre-existing email account.

This set up process is actually too much of a hurdle for some people. There are many people out there who either will not or cannot go through this process of creating a secure account on the portal. But for those who do, there is a connection with really fast and secure access to communication between them and myself.

And that connection can do a lot to help people. I promise to do my best.

But I'll tell you what. 90 percent failed phone calls vs 100 percent successful secured emails tells a story.

I'll take the successful communications vs the failed ones any day of the week.

....

I haven't posted a blog here in some time. It has been much too long. Perhaps I need an editor who can give me assignments and deadlines.  Like I've said before I have not abandoned this blog. I have been working very hard. One of the things that has been keeping me busy has the process of moving my EMR over to NextGen. NextGen is a much more complicated piece of software. It requires a tremendous amount of work to make it go. I am working and succeeding at it.

I just reviewed my side of this blogspot site. I have sort of the "back" side of the site. I have about 20 blog posts that have been started and are at some  stage of completion. There is never enough time to write and complete these posts but I do enjoy writing them. And it has been very popular. I haven't looked at it in awhile but there are still thousands who find these blog posts and read them, from all over the world. I have more readers from worldwide than from the USA. There are many readers from Germany, from Africa, from Russia, and of course from Canada. Here near NY City I am only a few hours driving time from Canada. But the readership continues, even when I am not actively blogging. Thank you all for reading this. It is really rewarding.

...

Now for something new.

I have a problem that I have been thinking about for a long time.

This really should be a new blog post but I want to start it now.

One of my jobs as a Gyne is that of dealing with the problem of Breast Cancer. The problem is that about one in 8 women are destined to get breast cancer. That means if you personally know 100 women, you know that 12 of them will get breast cancer.

The good news is that breast cancer is treatable. It is something that can be removed. People can be saved. Lives saved. Wives, mothers, sisters, can be saved.

But the key is diagnosing it early.

There are three ways to diagnose it early, before it becomes an obvious and deadly problem. The first is by routine Gyne checkups. This is basic good medical care, and all women need a Gyne checkup once a year, without fail. A Gyne checkup can get a history and examine the breasts and pelvic parts of women. It is important and it is my job.

The second early diagnosis is mammograms. Mammograms have gone through a process of technical improvements through the years. They are constantly evolving. There are more improvements than you can count. Sterotactic, 3D, computer enhanced, tomographic, focal, compressed, and on and on. Then there are other imaging techniques, like ultrasound, sonograms, CT, MRI, thermography, etc. All of these may have their uses. But they have challenges too, like expenses, scheduling hassles, radiation exposure, lack of scientific proof, lack of financial resources, coverage limits, etc.

But the final and cheapest early warning system for breast cancer is "Self Breast Examinations". For the last 25 years I have been asking women to examine their own breasts for lumps. There seems to be good science that says that SBE works for women. And it can easily save lives. Once women get over the shock of finding a lump, they can get down to the hard work of diagnosing it. And they can get down to the hard work of protecting their own children's mother, who is a very important person. An irreplaceable person.  Or, if they have no kids, then they can get down to the hard work of protecting their mothers daughter. Who is also very important.

There is an overwhelming problem with Self Breast Examination.(SBE). Most women recognize this problem. And they complain about this problem to me a dozen times a day.

The problem is women examining their breasts are not experienced enough to know what they are finding.

I explain to them a hundred times a day that all women go through this same problem. There aren't any women with a tremendous amount of experience doing SBE. All women who do SBE are beginners with an experience level of one and only one set of breasts to examine.

I have a solution.

It is radical and will be roundly criticized. And it will be viciously criticized.

But I believe that it will save a lot of lives.

If what I am going to propose comes to fruition, the problem of SBE might be solved.

I will propose to form an organization organized around the principle of generating a group of people dedicated to one thing and one thing only. The examination of each others breasts.

This will take the "Self" out of "Self Breast Examinations". And it will replace it with "Shared Breast Examination". I am not proposing that a women expose her breasts to the world. But that she come together with other women who have a similar goal in life, and train each other in the principles of breast examination.

I think that woman can learn how to examine breasts. And by sharing and teaching and learning, the knowledge can expand.

Women can learn how to feel the difference of glands, ducts, cysts, and tumors.

In my office I used to buy breast lump models. These were artificial breasts that had artificial lumps. They were pretty cool teaching aids but they got grungy really fast and fell apart in a matter of weeks.

But imagine instead that I had Real Breasts to show women. Well, this is what I am going to propose.

I would propose that this organization become real. With a mission statement. And a website. And all that goes with it. And some means of protecting women's privacy and rights as well.

I am in the early stages of thinking about this proposal. I have not come up with any insurmountable problems

For instance, the first probem: One needs a medical licence to examine someones breast. Solution: we are teaching women to examine their own breasts. And using many real breasts as examples. And besides, these are consenting adults. They can examine each others breasts as they need to without hassles from outsiders.

Another problem: There is no scientific proof this will work. Answer: we will not know unless we try.

Problem: woman may be harmed by anxiety and unnecessary biopsies. Solution: there is tremendous anxiety now, and lack of skill as well. And biopsies can be minimized by using needles and fine needle aspiration instead of open procedures.

I would ask the reader and the community to think about the meaning of breasts to the world. Breasts are perceived as beautiful. Boys fantasize. Girls compare. Babies love and feed. Women have surgery to make them bigger, smaller, and firmer. Breasts are part of birth. Breasts feed life to babies. Breasts are much visible to world, appreciated, and loved by everyone. But they are also one of the biggest sources of fear. Most women fear breast cancer more than a heart attack. And heart attacks are more than 15 times more likely to strike a woman dead, as her breasts. All breasts are beautiful, no matter the shape nor size. But the fear surrounding their health is so out of proportion that it is unreasonable. I don't think there is any subject in the world that has such a dramatic juxtaposition of beauty, love, fear, and danger, as human breasts.

It is time we started helping women get over their fear of SBE and bringing reason back to the subject of early diagnosis of breast cancer.

I hope to be part of the solution.

I realize this is a big dream.

But it might be possible to do better than we are doing now.

Thank you for reading.

Please pass the link to this blog on to others.

Thank you sincerely,

Dr John Marcus
doctorjohnmarcus.blogspot.com

Member of Lifeline Medical Associates

89 North Maple Ave
Ridgewood NJ 07450

Comments are of course welcome. Please post comments.