GENE MUTATIONS AND BREAST CANCER

On the op-ed page of The New York Times, the actress Angelina Jolie revealed she recently had a preventive double mastectomy, both breasts removed and then reconstructed. Her mother died of breast cancer at 56 and Jolie herself had been diagnosed with the inherited BRCA1 gene mutation, which significantly increases the risk of breast and ovarian cancer. And so, she writes: I decided to be proactive and to minimize the risk as much as I could. Of course, there are women everywhere who carry the same gene mutation as Angelina Jolie. The majority of breast cancers are not caused by a BRCA gene mutation. But if you do have the mutation, you're much more likely to develop breast or ovarian cancer. About five to seven percent of breast cancer and about 14 to 20 percent of ovarian cancer is due to a gene mutation - so, not the majority. And people who inherit a BRCA mutation are at very high risk for both cancers and also at somewhat higher risk for other cancers, too. There are national guidelines that determine who should and who will get the most benefit from a genetic evaluation. It's important to us to make sure people know that you should see an expert known as a genetic counselor, or a medical geneticist, in order to find out what your risk is, rather than just going out and getting a blood test. And if the chance of having a mutation is high enough, based on expert guidelines, most insurances will cover genetic counseling and genetic testing.

BREAST RECONSTRUCTION AWARENESS

ARLINGTON HEIGHTS, Ill. - The American Society of Plastic Surgeons (ASPS) today announced its strong support of the "Breast Cancer Patient Education Act" (S. 931). This bipartisan legislation is being introduced today, coinciding with National Women's Health Week, in the U.S. House of Representatives by Reps. Leonard Lance (R-NJ) and Donna Christensen, M.D. (D-VI) and in the United States Senate by Sens. Roy Blunt (R-MO), Sherrod Brown (D-OH), with Jon Tester (D-MT) and Dianne Feinstein (D-CA) as original cosponsors.
Since 1998, health plans that offer breast cancer coverage have been required to provide coverage for breast reconstruction and prostheses. Yet published research shows that many women eligible for breast reconstruction following breast cancer, minorities in particular, are not informed of the variety of care options. Approximately 232,340 women will be diagnosed with breast cancer in 2013, according to the American Cancer Society's most recent estimates for breast cancer in the United States.

SKIN BACTERIA AND INFECTION

In adults, bacteria colonization is present on normal intact skin, with the estimated amounts being several million.  There may be a 1000 different bacterial species residing on the skin. Skin develops an ecosystem colonized with bacterial, viruses, fungi, and mites referred to the skin microbiome.  The acid nature of the skin keeps the resident bacterial attached to the skin and the consistent turnover or shedding of the outer layer of skin keeps the bacterial numbers fairly constant. Medical conditions (Diabetes; chronic renal failure; dermatitis; obesity); Certain medications (anti-inflammatories, prednisone; chemotherapy; immunosuppression drugs), age, geographic location of residence in terms of hot and cold climates and the products used on the skin and moisture affect the type and amount of bacteria present on the skin.

The identification of biofilms in wounds has complicated the diagnosis and treatment of wound infections.  A biofilm is a population or community of bacterial living in organized structures at the liquid interface.  Bacteria within a biofilm live in microcolonies that are encapsulated in a matrix composed of an extracellular polymeric substance separated by open waster channels.  The biofilm environment provides physical protection to bacterial and makes it difficult for antibiotics to penetrate and treat the infection.

Appropriate hand washing, disinfecting and hand drying with disposable paper towels are the most effective ways of removing bacteria from the skin.  Quantities of bacteria experience a temporary decrease after hand washing, but are back to their usual amount within 2-4 hours. Skin and its outer colonies of bacteria have a normally symbiotic relationship, but anything, externally or internally, can  disrupt the delicate relationship.   When a wound occurs in the skin, the potential for infection exists.  Probably the most important factor in preventing infection is the immune system of the individual.  Even intact immune systems can be overwhelmed if there are large amounts or very virulent bacterial introduced.

YOU HAVE TO GO TO MEDICAL SCHOOL TO BECOME A DOCTOR

When you work the desk for long enough in a doctor’s office, interacting with your boss and co-workers, handling patients and taking their information, you may have occasionally entertained this thought: “Hey, I’ve been doing this so long I bet I could even perform that person’s rhinoplasty.”

Then you chuckle because you’re a smart person and you know that you’re not actually certified to perform rhinoplasty on human beings. Or animals for that matter, because that would just be weird.
This tiny detail appears to have escaped Christine Patterson.
As the Herald-Tribune reports, Patterson, an office manager at her brother’s Sarasota, Fla. plastic surgery clinic, stands accused of treating one of her brother’s patients in his absence.
The patient reportedly came in for a post-op follow-up the day after her surgery in April 2011. With her brother out of town, Patterson allegedly examined the patient, rewrapped her bandages and sent her on her way. Not surprisingly, the patient returned the next day with major swelling. The term used by a pair of witnesses was “swollen like a pumpkin,” which is probably not the look she was going for when she submitted to voluntary cosmetic surgery.
Patterson is said to have drained the patient’s excess swelling herself, telling a witness she’d seen it done “plenty of times.” "Not only did she diagnose her facial swelling with a hematoma, she put in a drain to drain the excess fluid," Wendy Rose, a spokesperson for the Sarasota County Sheriff's Office, told Tampa’s Channel 10 News.
Using that logic, most of us should be qualified to fly commercial jets and filibuster our way through five years of city council. But anyway, you can imagine how well that went for the poor patient, who described the pain as “excruciating.” Police charged the 44-year-old woman with practicing medicine without a licence, a charge her husband denies. "My wife never went to medical school," John Patterson told the news network. "She won't even know how to attempt to do something like that."

YOUR TAX DOLLARS "AT WORK"

Exotic dancers, robotic squirrels, and a reality TV show in India—your tax dollars supported all of these this year. Two reports just released—“Federal Spending by the Numbers 2012” by The Heritage Foundation and “Waste Book 2012,” a report by the office of Senator Tom Coburn (R–OK)—shed light on these and other examples of Washington’s irresponsible spending.

If you value your tax dollars, you’re sure to be outraged by these wasteful projects. Following are the top 10 examples, five from each report. Though not necessarily the biggest ticket items, they are no doubt wasteful and representative of Washington’s spending addiction that must end.

Federal Spending by the Numbers 2012:

1.A reality TV show in India. The Department of Agriculture’s Market Access Program spends $200 million a year to help U.S. agricultural trade associations and cooperatives advertise their products in foreign markets. In 2011, it funded a reality TV show in India that advertised U.S. cotton.

2.Studying pig poop. The Environmental Protection Agency awarded a $141,450 grant under the Clean Air Act to fund a Chinese study on swine manure and a $1.2 million grant to the United Nations for clean fuel promotion.

3.Amtrak snacks. Federally subsidized Amtrak lost $84.5 million on its food and beverage services in 2011 and $833.8 million over the past 10 years. It has never broken even on these services.

4.Using military exercises to boost biofuels. The U.S. Navy bought 450,000 gallons of biofuels for $12 million—or almost $27 per gallon—to conduct exercises to showcase the fuel and bring it closer toward commercialization. It is the largest biofuel purchase ever made by the government.

5.Conferences for government employees. In 2008 and 2009 alone, the Department of Justice spent $121 million to host or participate in 1,832 conferences.

Waste Book 2012:

1.“RoboSquirrel.” $325,000 was spent on a robotic squirrel named “RoboSquirrel.” This National Science Foundation grant was used to create a realistic-looking robotic squirrel for the purpose of studying how a rattlesnake would react to it.

2.Cupcakes. In Washington, D.C., and elsewhere across the country, cupcake shops are trending. The 10 cupcake shop owners who received $2 million in Small Business Administration loan guarantees, however, can only boast so much of their entrepreneurial ingenuity, since taxpayers are backing them up.

3.Food stamps for alcohol and junk food. Though they were intended to ensure hungry children received healthy meals, taxpayer-funded food stamps were instead spent on fast food at Taco Bell and Burger King; on non-nutritious foods such as candy, ice cream, and soft drinks; and on some 2,000 deceased persons in New York and Massachusetts. Food stamp recipients spent $2 billion on sugary drinks alone. Improper SNAP payments accounted for $2.5 billion in waste, including to one exotic dancer who was making $85,000 per year.

4.Beer brewing in New Hampshire. Despite Smuttynose brewery’s financial success and popularity, it is still getting a $750,970 Community Development Block Grant to build a new brewery and restaurant facilities.

5.A covered bridge to nowhere. What list of government waste would be complete without a notorious “bridge to nowhere”? In this case, it’s $520,000 to fix the Stevenson Road Covered Bridge in Green County, Ohio, which was last used in 2003.

Some of this waste hardly amounts to a rounding error by current federal budget standards. However, no spending cut is too small. Congress should root out even small instances of waste. Doing so will build momentum for it to tackle difficult, long-term budget challenges, such as entitlement program reform.

Fiscal year 2012 is the fourth consecutive year with a trillion-dollar-plus deficit. Total federal debt has surpassed $16 trillion. Federal spending reached $3.6 trillion—or 22.9 percent as a share of the economy—in 2012. Despite these frightening figures, which are on track to worsen, Congress continues to expand government.

Wasteful spending is intrinsic in big government, because government is concerned primarily with getting checks out the door and only secondarily with spending the money properly.

As both “Federal Spending by the Numbers 2012” and “Waste Book 2012” warn, it is long past time for Congress to put the brakes on this wasteful spending—full stop.

MALPRACTICE CLAIMS

Malpractice Claims Consume Years
of a Physician’s Career

On average, each physician spends 50.7 months, or approximately 11 percent of an average 40-year career, on resolving medical malpractice cases—the majority of which end up with no indemnity payment. That’s the conclusion of a recent study¹ by the RAND Corporation based on data provided by The Doctors Company, the nation’s largest medical malpractice insurer. Researchers found that 70 percent of the time physicians spend on claims is spent defending claims that end in no payment to the plaintiff.
Key findings of the study include:

• Physicians experience additional stress, work, and reputational damage from the time spent defending claims.
• Fighting claims takes time away from practicing medicine and from the opportunity for the physician to learn from his or her medical errors.
• The lengthy time required to resolve claims also negatively impacts patients and their families.

The effect of malpractice claims on physicians’ careers is discussed further by Richard E. Anderson, MD, FACP, chairman and CEO of The Doctors Company, in two short videos that can be viewed at www.youtube.com/doctorscompany.

Plastic Surgeons in the U.S. average 1 malpractice claim every 2 years. The average cost of Malpractice coverage for plastic surgeons is $60,000 to $100,000 per year.

PLASTIC SURGEONS PARTICIPATE IN BOSTON'S TRAUMA INJURIES

BOSTON — For years, Dr. Michael J. Weaver, an orthopedic trauma surgeon, went to meetings of his professional society and heard surgeons from the military describe what they had learned treating blast injuries. Then he would return to his practice at Brigham and Women’s Hospital in Boston, where he mostly treated people injured in auto accidents or falls.

All that changed on Monday when victims of the bombings at the Boston Marathon arrived.

“We’ve seen similar injuries, but never of this magnitude,” Dr. Weaver said. “This is completely different.” The military experience, he added, “has been phenomenally helpful.”

But doctors said they had also prepared for a disaster, with regular drills. At Massachusetts General Hospital, for example, part of the emergency department’s disaster preparedness included bins of special wristbands to identify disaster patients. “We can’t sit there and write names of patients” on wristbands, said Dr. R. Malcolm Smith, chief of the medical center’s orthopedic trauma service. Instead, medical personnel in the emergency department slapped wristbands on patients that identified them with special disaster numbers. The bands said simply, Disaster Victim 001, Disaster Victim 002, and so on. Patients’ names were added later.       

It turns out to be an art — and a delicate balancing act — to treat people with blast injuries that can pulverize muscle and rip blood vessels, that can drive pieces of metal into soft flesh and shatter bones. Trauma surgeons call it damage control, and say the military experience showed how important it is. The idea is not to try to solve all of a patient’s medical problems at once, but instead to deal with the urgent and life-threatening ones immediately. Patients often have to return to the operating room again and again as their injuries are successively repaired. The first priority for those who were severely injured was to prevent them from dying, often from bleeding to death. Many had tourniquets on their legs when they arrived at the hospitals. But that was just a temporary measure to slow the bleeding. They needed immediate surgery to get their bleeding under control and prevent muscles and nerves from dying for lack of blood.  That requires a vascular surgeon to repair the torn blood vessels and restore blood to legs and feet that may no longer have a blood supply. To do those repairs, surgeons often sew in part of a vein from the other leg, if it is uninjured, or from an arm. Or they use a synthetic tube. Meanwhile, an orthopedic surgeon must stabilize a bone that might be flopping because it is fractured in several places. Surgeons do that with a temporary solution — they drill into the bone from outside the leg and attach pins that they screw into a metal bar also outside the leg. Plastic surgeons clean the wound. In this case, blast victims had BBs or nails or debris embedded in their legs and feet. Everything the surgeons took out of the wounds was placed in plastic bags for the F.B.I., said Dr. Samuel J. Lin, a plastic surgeon at Beth Israel Deaconess Medical Center who helped care for blast victims. “The crime scene extends to the hospital,” Dr. Lin said.       

Patients then are sent back to intensive care or their hospital rooms for the next few days while doctors wait to assess the damage to muscles and nerves and blood vessels. “With a blast injury in particular, we can’t always be sure how widespread the soft tissue injury is,” Dr. Smith said. Badly injured, dead tissue needs to be removed to avoid infection. And that may mean repeated visits to the operating room. But there are no other options. “If we leave dead tissue in place, it gets infected,” Dr. Smith said. And if the soft tissue dies, a leg might have to be amputated. The next priority is repairing soft tissue — muscle and nerves and skin. “Everything depends on soft tissue repair,” Dr. Smith said. “If you don’t have healthy soft tissue, bone will not survive.” That means that plastic surgeons have to close what may be gaping wounds.       

Wound healing has been revolutionized by a vacuum device, Dr. Lin said. Patients with large wounds used to just be bandaged and have their dressings changed several times a day. Now, doctors put a black sponge over the wound, cover it with a thin sheet of plastic wrap, and attach it to a vacuum hose. Wounds heal faster, and patients are in less pain.

A big advance, Dr. Weaver said, whose value was proved by the military, is taking tissue from smaller areas to close a large open wound. Surgeons used to take big chunks of muscle along with blood vessels from a person’s abdomen or back and move it to the wound to repair the injury.

Now, he said, they take much smaller pieces of tissue from places like the forearm or thigh. It means a smaller surgery and fewer complications.

But uncertainty about the fate of soft tissue surrounding a wound can remain for days after a repair. If it dies, and if further attempts to trim the dead tissue and repair the wound fail, patients face amputations.

When it comes time to repair shattered bones, orthopedists make use of stabilizing metal plates developed over the last decade or so that are vast improvements over earlier ones, Dr. Weaver said. They still have to attach the plates directly to the bone, where they will remain for the rest of the patient’s life. But the new plates are designed to fit exactly against the shape of the bone, making the bone more stable.

“To restore the function of a knee or ankle, you have to put the pieces of bone together like a jigsaw puzzle,” Dr. Weaver said.

The military also greatly improved reconstruction, prosthetics, and rehabilitation for those who need amputations. Of course an amputation is still devastating, but now, with the improved prosthetics, many patients can walk, run and enjoy essentially normal lives, Dr. Weaver said.

For many of the blast victims, the path to recovery will be long and arduous, with weeks in the hospital and rehabilitation lasting as long as a year. While bones can heal, patients may be left with stiffness from torn muscles, bad scars from the operations, and, if a joint was severely damaged, arthritis in it.

The victims, Dr. Smith said, were mostly younger people who were watching the race. The blasts went off behind them, ripping the backs of their legs.

Some know what they are facing in the months to come, Dr. Weaver said. But others, he added, do not. “Many who are critically ill in intensive care are still waking up,” he said.