CT Scan – with or without constrast

Diagnostic Indications: Noncontrast-Enhanced CT vs. IV Contrast

Noncontrast-enhanced CT is used in patients with head trauma and acute stroke. Unenhanced CT is also used in patients with spine and extremity trauma. High-resolution CT, which is used to evaluate diffuse lung disease, does not use IV contrast.17 Noncontrast imaging of the abdomen is routinely done to screen for renal stones in patients with flank pain.18  Common clinical scenarios in which noncontrast-enhanced CT is appropriate are summarized in Table 4,19  and common clinical scenarios in which contrast enhancement is recommended are summarized in Table 5.19 Indications for selection of imaging studies for specific clinical scenarios can be searched using the American College of Radiology Appropriateness Criteria at http://www.acr.org/ac.19

Common Indications for Noncontrast-Enhanced CT

Acute stroke (suspected)	Noncontrast-enhanced CT of the head is the preferred initial study if performed within three hours of acute symptom onset; contrast-enhanced CT should be obtained for patients with symptoms lasting longer than three hours; contrast-enhanced CT combined with CT angiography of the neck may be needed for follow-up
Closed head injury	Spinal CT if spinal injury is suspected
Diffuse lung disease/chronic dyspnea	Thin section high-resolution CT without contrast
Extremity soft tissue swelling, infection, or trauma	Contrast is necessary if vascular involvement or injury is suspected
Kidney stone (suspected)	Specify renal stone protocol
Spinal trauma (suspected)	Scan suspected area of trauma in cervical, thoracic, or lumbar spine

Common Indications for Contrast-Enhanced CT

Acute appendicitis	Abdominal and pelvic CT; oral or rectal contrast agent based on institutional preference
Cancer staging	Protocols vary depending on cancer type and stage
Diverticulitis; suspected complications of inflammatory bowel disease	Intravenous contrast agent for diverticulitis; oral and/or rectal contrast agent can be administered to visualize bowel
Pancreatitis	Noncontrast-enhanced CT is sensitive for calcifications (chronic pancreatitis); contrast-enhanced CT is best for evolving pancreatitis or pancreatic pseudocyst
Pulmonary embolism (suspected)	Many centers now include venous phase CT of the pelvis and lower extremities in combination with CT angiography of the lung

Contraindications to IV Contrast

Concerns for using IV contrast during CT include a history of reactions to contrast agents, pregnancy, treatment of thyroid disease with radioactive iodine, use of metformin (Glucophage), and chronic or acutely worsening renal disease. Contrast may also be avoided when the suspected pathology is likely to be visible on noncontrast-enhanced CT.

Contraindicated:

HISTORY OF REACTIONS TO CONTRAST AGENTS

PREGNANCY

THYROID DISEASE

METFORMIN USE

RENAL FAILURE

Source: https://www.aafp.org/afp/2013/0901/p312.html

When to Order Contrast-Enhanced CT

 

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ROJ@20jul3

MRCP

MRCP

An MRCP test is a specialized MRI exam that evaluates the hepatiobiliary and pancreatic systems, including the liver, gallbladder, bile ducts, pancreas and pancreatic duct.

MRCP stands for Magnetic Resonance Cholangiopancreatography:
Cholangio = bile vessel
Pancreato = pancreas
Graphy = image
An MRCP scan looks for abnormalities like

• Obstructions or blockages caused from gallstones
• Stones in the bile duct
• Swelling/inflammation
• Tumor/mass
• Infections such as cholangitis (infection of the bile duct)

An MRCP test can also be ordered to find the cause of pancreatitis or diagnose unexplained abdominal pain.

Additionally, MRCP is a less invasive alternative to ERCP, a procedure that uses an endoscope combined with an IV injection of x-ray contrast dye and fluoroscopy (x-ray images).

About the MRCP scan

An MRCP scan takes about twice as long as a regular MRI scan; 10 minutes for the MRCP imaging and about 30 minutes for abdominal imaging. Depending on the reason why the MRCP test was ordered, IV contrast may be given during the scan.

Some people may experience claustrophobia during an MRI. At Suburban Imaging, our technologists are trained in techniques to alleviate anxiety and claustrophobia; oral sedation is also available at our locations.

Additional preparation for an MRCP test includes:

• Nothing eat or drink four hours prior to the exam appointment.
• Since MRCP is a specialized MRI scan, certain metal safety precautions must be taken; please review our MRI metal safety checklist.

 

After the MRCP test
After your MRCP test, your images will be interpreted (reviewed) by one of our board-certified radiologists who specializes in. The findings will be sent to your healthcare provider who ordered the MRCP scan. Your healthcare provider will then contact you to discuss the results and any follow-up care or treatment plans.

Source: https://subrad.com/blog/2016/01/what-mrcp-test/#:~:text=An%20MRCP%20test%20is%20a,Pancreato%20%3D%20pancreas

 

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Trigger:

20jul1

DTan – being recommended for MRCP by ALO.

Cost- 14K in ManilaMed

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ROJ@20jul3

Hand-foot Syndrome after Capecitabine Intake

Breast Cancer

59 / F

Had been taking Capecitabine continuously for 3 months prescribed by a medical oncologist.

She consulted me under ROJoson Telemedical Consultation on April 8, 2020.

After I saw her lesions on the hands and feet, I diagnosed her to have hand-foot syndrome secondary to capecitabine intake.

Advised to stop Capecitabine.

April 15, 2020 – Resolution of hand-foot syndrome after one week

 

April 23, 2020 – Complete resolution of hand-foot syndrome after one week

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ROJ@20may7

Renal Cysts

20may6

Somebody consulted me with this report:

RENAL CYSTS

Critical question:

Are the renal cysts on ultrasound highly suspicious for malignancy?

If yes, a urologist should be consulted who most likely will recommend cancer treatment such as surgery (nephrectomy).

If no, if asymptomatic, just watch and wait. No medical intervention or procedure.  Watch and wait includes self-monitoring for symptoms and may do imaging procedures at planned interval (say 6 months after the first ultrasound).

If no, but symptomatic, just as complicated with infection or hemorrhage, a urologist should be consulted who may recommend some procedures like aspiration, sclerotherapy and excision of cyst.

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When to suspect malignancy in renal cysts?

Bosniak Classification of Renal Cystic Disease (based on CT Scan)

Category I: Malignant risk less than 1%; no follow-up required ·         – uncomplicated, simple benign cyst ·         – anechoic, posterior enhancement (through transmission), round or oval shape, thin, smooth wall ·         – homogeneous water content, sharp delineation with the renal parenchyma, no calcification, enhancement or wall-thickening

Category II: Malignant risk less than 3%; no follow-up required ·         – Cystic lesion with some abnormal radiological features ·         – <1 mm septations (hairline thin) ·         – fine calcifications within the septum or wall ·         – ❤ cm in diameter ·         – hyperdense cysts (>20 Hounsfield units)

Category IIF: Malignant risk 5-10%; follow-up recommended ·         – Cystic lesion with increased abnormal findings ·         – multiple thin septum ·         – septa thicker than hairline or slightly thick wall ·         – calcification, which may be thick ·         – intrarenal, >3 cm ·         – no contrast enhancement

Category III: Malignant risk 40-60%; surgical excision recommended ·         –More complicated ·         – uniform wall thickening/nodularity ·         – thick/irregular calcification ·         – thick septa ·         – enhances with contrast

Category IV: Malignant risk greater than 80%; surgical excision recommended ·         – large cystic components ·         – irregular margins/prominent nodules ·         – solid enhancing elements, independent of septa

Ultrasound Classification Correlated with Bosniak’s Classification

A systematic approach should be applied to initially identify unilocular and multilocular cysts.

In unilocular cysts, those with solid components will fall into Category III or IV, then contrast-enhanced US, CT, or MRI should be arranged.

For those without solid components, calcification patterns and septa or wall thickening should be interpreted next.

Renal cysts without calcifications, septa, or wall thickenings shall be classified into Category I.

Category II cysts have fine calcifications in short segments or slightly thickened calcifications on the cystic wall, whereas Category IIF lesions have thick or nodular calcifications.

Calcifications that are greater in number or size do not warrant upgrade to anything above Category IIF unless solid soft tissues appear. Therefore, calcification does not affect the differentiation between masses that are in Categories IIF and III.

Category II lesions have regular and hairline-thin septa. Category IIF lesions have smoothed multiple hairline-thin septa. Warren and McFarlane suggest that if the wall or septa thickness exceeds 1 mm, it is a sign of malignancy. However, other authors suggest that walls or septa of “more than hair-line thin” thicknesses favor malignancy.  Accurate measures are difficult to obtain; some interindividual or intraindividual differences in measurements can be found.

A unilocular cyst with slightly irregular and grossly thickened (≧ 2 mm) septa falls into Category III, and contrast-enhanced US, CT, or MRI is required. Wall thickening in cystic lesions can also be seen in hemorrhagic cysts, infected cysts, or abscesses. Sometimes it is difficult to differentiate cysts from tumors using US; therefore, patient history is important for the differential diagnosis and follow-up or intervention is needed.

Multilocular cysts separated from the normal renal parenchyma and lacking solid components can be classified into Category IIF. Contrast-enhanced US, CT, or MRI is required when cysts have solid components.

A multilocular Category III cyst is an encapsulated cystic mass containing numerous thickened smooth or slightly irregular septa and uniform smooth or slightly irregular wall thickening. The cyst wall and septa are grossly thickened (≧ 2 mm), but vascularity in soft tissue components is not enhanced or increased. If it is, the cyst will be classified into Category IV.  Multilocular cystic renal masses with lobulated contours but no soft tissue components  shall be classified into Category III.

 

Characterization and management of various renal cystic lesions by sonographic features

Journal of the Chinese Medical Association

Volume 81, Issue 12, December 2018, Pages 1017-1026

https://www.sciencedirect.com/science/article/pii/S1726490118301746

 

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The average size of Stage I renal cysts are 5–10 mm in diameter, though they can be larger [4]. While the original definition of a Stage I renal cyst does not include size, the revised Bosniak renal cyst classification system highlights a diameter of ≥3 cm as worthy of follow-up and utilizes this size among the features to distinguish between a Stage II or IIF cyst [10].

 

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Renal cysts

Incidence

Autopsy studies in patients over the age of 50 reveal greater than a 50% chance of having at least one simple renal cyst.¹ In 1983, using early computed tomography (CT) scan technology, renal cysts were discovered in 33% of patients in the same age group.²

One third of people older than 50 years develop renal cysts.

Simple cysts are the most common cystic renal lesions; they are present in 5% of the general population, increasing in frequency to 25-33% of patients older than 50 years, and account for 65-70% of renal masses

Causes

• Developmental – Multicystic dysplastic kidney(MCDK)
• Genetic – Autosomal recessive polycystic kidney disease(ARPKD), autosomal dominant polycystic kidney disease (ADPKD), juvenile nephronophthisis (JNPHP), medullary cystic kidney disease (MCKD), glomerulocystic kidney disease (GCKD)
• Cysts associated with systemic disease – Von Hippel-Lindau syndrome(VHLS), tuberous sclerosis (TS)
• Acquired – Simple cysts, acquired cystic renal disease, medullary sponge kidney(MSK)
• Malignancy – Cystic renal cell carcinoma(RCC)

Clinical classification:

• Simple cysts
• Complicated cysts

Renal cysts, in general, may be classified as “simple” or “complex.” “Simple” cysts are best defined using sonographic criteria. These include: (1) absence of internal echoes, (2) posterior enhancement, (3) round/oval shape and (4) sharp, thin posterior walls.⁴ When all of the criteria are met, the cyst is benign and no follow-up is required. The difficulty arises when cysts do not meet the rigid characteristics of the “simple” definition.

 

What are renal cysts?

Renal cysts are sacs of fluid that form in the kidneys. Most of the time, they are simple kidney cysts, meaning they have a thin wall and only water-like fluid inside. They are fairly common in older people and typically do not cause any symptoms or harm.

The cause of renal cysts is not known, although age is a major risk factor. An estimated one-third of people older than age 70 have at least one simple renal cyst. It can be normal to have more than one simple cyst in each kidney, especially with increasing age.

Having a few simple renal cysts is different from having many cysts in the kidneys because of polycystic renal disease (PKD). PKD is a genetic disorder characterized by clusters of cysts that can impair kidney function.

How are renal cysts diagnosed and evaluated?

Since they rarely cause symptoms, renal cysts are most often found during imaging tests performed for other reasons. In such cases without any symptoms, simple renal cysts are usually left alone and do not need any further tests. However, some renal cysts look more complex than the usual simple renal cyst. These complex renal cysts can have a thicker wall, or solid material inside instead of just fluid. Once complex renal cysts are discovered, additional imaging tests may be performed to monitor them and distinguish benign cysts from cancer.

How are renal cysts treated?

Renal cysts generally do not require treatment unless they are causing symptoms or harming kidney function. Treatment options include:

• Sclerotherapy: Also known as percutaneous alcohol ablation, sclerotherapy involves the insertion of a long needle through the skin and into the cyst under ultrasound guidance. The doctor will drain the cyst and fill it with an alcohol-based solution that causes the tissue to harden and shrink, reducing the chance of recurrence. The procedure is usually performed on an outpatient basis with a local anesthetic.
• Surgery: For larger cysts, a surgeon will make a small incision and access the cyst with a laparoscope. The surgeon will then drain the cyst and burn or cut away its outer layer. Laparoscopic surgery requires general anesthesia.

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ROJ@20may6

Tamoxifen and Pregnancy – ROJoson Notes

A breast cancer patient got pregnant a month after modified radical mastectomy for breast cancer.  Node was 1 positive.  ERA and PRA are positive.

Is tamoxifen contraindicated?

Breast Cancer Research and Treatment

May 2019, Volume 175, Issue 1, pp 17–25| Cite as

Tamoxifen and pregnancy: an absolute contraindication?

Abstract

Purpose

Breast cancer is the most common malignancy among young women of reproductive age. Adjuvant treatment with tamoxifen reduces the risk of recurrence in hormone-sensitive breast cancer. However, the use of tamoxifen is considered contraindicated during pregnancy, because of a limited number of case reports demonstrating potential adverse effects on the fetus. The objective of this report is to give a more broad overview of the available data on the effect of tamoxifen exposure during pregnancy.

Methods

A literature review was performed using PubMed and the databases of the Netherlands Pharmacovigilance Centre Lareb and of the International Network on Cancer, Infertility, and Pregnancy.

Results

A total of 238 cases of tamoxifen use during pregnancy were found. Of the 167 pregnancies with known outcome, 21 were complicated by an abnormal fetal development. The malformations described were non-specific and the majority of cases concerned healthy infants despite exposure to tamoxifen.

Conclusion

There seems to be an increased risk of fetal abnormalities when taking tamoxifen during pregnancy (12.6% in contrast to 3.9% in the general population), but the evidence is limited and no causal relationship could be established. The possible disadvantage of postponing or discontinuing tamoxifen for the maternal prognosis is unclear. Patients should be counseled about the use of tamoxifen during pregnancy instead of presenting it as being absolutely contraindicated.

 

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Tamoxifen Pregnancy Warnings

Use is contraindicated.

AU TGA pregnancy category: B3
US FDA pregnancy category: D

Comments:
-This drug can harm a developing fetus.
-Women should be advised not to become pregnant while taking this drug or within 2 months of discontinuing therapy and should use barrier or nonhormonal contraceptive measures if sexually active.
-If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus.

Animal studies of doses at or below equivalent human doses have revealed evidence of fetotoxicity, lower incidence of implantation, and an increased incidence of low birth weight. There are no controlled data in human pregnancy; however, the manufacturer reports spontaneous abortions, birth defects, fetal deaths, and vaginal bleeding associated with this drug during pregnancy.

AU TGA pregnancy category B3: Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the significance of which is considered uncertain in humans.

US FDA pregnancy category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

https://www.drugs.com/pregnancy/tamoxifen.html

Last updated on Jul 25, 2019

 

 

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ROJ@20jan26

Dexterity of Surgeons

Dexterity of a surgeon
When does one say a surgeon has achieved the status of a skilled surgeon, skilled or dexterity in operating or a surgeon is very skillful in operating? Is there a credible certifying body? Have not heard one. I don’t think it should rely on somebody or anybody commenting or appreciating that a particular surgeon is very skilled or dexterous in operating. This is too subjective to be a criterion or basis. The somebody can be anybody who saw the surgeon operating – an anesthesiologist, a surgical consultant colleague, and / or a surgical resident. Very subjective. Am still looking for a credible basis.December 27, 2019 – ROJoson 

Surgery is an art. Other artists recognize each other’s signature work. – Edwin Espinosa

its usually the senior surgeon who will watch the surgeon do his job and comment on things that the operating surgeon does unconsciously that may or may not be good for the operation. – Manley Uy

Track record. Number of hits compared to misses. – Joaquin Sy

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DOCTOR AND PATIENT

A Vital Measure: Your Surgeon’s Skill

BY PAULINE W. CHEN, M.D.

 OCTOBER 31, 2013 12:57 PM October 31, 2013 12:57 pm 261

But even with the most compulsive adherence to these pre- and post-operative protocols, and much to the chagrin of many a well-intentioned health care expert, payer and policy maker, significant disparities in patient outcomes after surgery have persisted.

Now an innovative collaboration between researchers, payers and weight-loss surgeons, the Michigan Bariatric Surgery Collaborative, has addressed that-which-could-not-be-named. And their findings have confirmed what patients have long suspected and trainees have long known – the dexterity of a surgeon’s hands can account for much of the differences in how well patients do.

Researchers from the group asked a panel of surgeon-experts to review videotapes of operations performed by 20 unnamed surgeons who were part of the collaborative. They then asked the surgeon-experts to come up with a ranking based on the deftness with which operating instruments were used, the gentleness with which tissues were handled, the degree to which the surgeons were able to expose key areas, the time and amount of movement required to perform each step and the general flow of the operation. The researchers then confirmed that the rankings remained consistent by asking a different group of surgeon-experts to evaluate the videotapes.

 

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https://publishing.rcseng.ac.uk/doi/pdf/10.1308/147363510X507837

LEFT OUT: A STUDY TO
DETERMINE BIMANUAL DEXTERITY
IN PRACTISING SURGEONS

The subjects were then requested to perform a minimum basic task of brushing their teethwith their non-dominant hand at least twice a day using a manual toothbrush.
Enthusiastic subjects also volunteered to shave with their non-dominant hand and
to hold knife and fork in their nondominant and dominant hand, respectively.
The ultimate aim was to increase the use of the non-dominant hand to as many daily
activities as possible. Each subject was given one week to perform these exercises vigorously and was tested again at the end of one week (test 2).

 

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https://www.bmj.com/content/327/7422/1032Clinical Review

Objective assessment of technical skills in surgery

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7422.1032 (Published 30 October 2003)Cite this as: BMJ 2003;327:1032

Surgical competence entails a combination of knowledge, technical skills, decision making, communication skills, and leadership skills. Of these, dexterity or technical proficiency is considered to be of paramount importance among surgical trainees.

The introduction of the Calman system in the United Kingdom, the implementation of the European Working Time Directive, and the financial pressures to increase productivity4 have reduced the opportunity to learn surgical skills in the operating theatre. Studies have shown that these changes have resulted in nearly halving the surgical case load that trainees are exposed to.5 Surgical proficiency must therefore be acquired in less time, with the risk that some surgeons may not be sufficiently skilled at the completion of training.6 This and increasing attention of the public and media on the performance of doctors have given rise to an interest in the development of robust methods of assessment of technical skills.7 We review the research in this field in the past decade. Our objectives are to explore all the available methods, establish their validity and reliability, and examine the possibility of using these methods on the basis of the available evidence.

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https://www.quora.com/How-do-you-know-if-you-have-the-manual-dexterity-required-of-a-surgeon

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512796/

J Grad Med Educ. 2015 Jun; 7(2): 234–237.

doi: 10.4300/JGME-D-14-00546.1

PMCID: PMC4512796

PMID: 26221441

Evaluation of Surgical Dexterity During the Interview Day: Another Factor for Consideration

Dinchen Jardine, MD, MS, Benjamin Hoagland, MD, Angel Perez, MD, and Eric Gessler, MD

The Purdue Pegboard Test (Lafayette Instrument) is a commercially available validated evaluation of gross and fine finger dexterity.¹ Participants used their dominant, nondominant, and both hands to place pegs into a board within 30 seconds. Scores were collected for total number of pegs placed.

The Rey-Osterrieth Complex Figure drawing is a widely used test of visual spatial construction and executive planning functions.^1,2 Applicants first copy the complex figure, then immediately reproduce the figure from memory, followed by another reproduction 20 minutes later. Scores are based on position and accuracy of 18 drawing subunits.

Applicants were given 2 endoscopic skills modules (3 and 6) from the Lap Mentor (Simbionix) trainer in Practice Hall mode.^1,3 The modules were abstract task representations selected for their subjective ease of instruction and their 2-handed requirement. The first module timed participants touching spheres with the matching color right- or left-hand instrument. The second test consisted of the concurrent use of 2 Maryland graspers to push a tactically stimulating “blob” of tissue off a colored sphere in order to grasp the sphere with the other hand. Each module was completed 3 times, with efficiency of movement scores (as determined by the computer program) and time to complete the modules averaged over the trials.

The laparoscopic peg transfer task of the Fundamentals of Laparoscopic Surgery program was selected for its standardized implementation,⁴ and for the extensive testing ensuring its validity for use in teaching and assessment. Applicants were given 3 attempts with a maximum time of 4 minutes each. Their average time was used for comparison.

The final test was a microvascular knot-tying station based on the protocol described by Carlson et al⁵ as a “go, no-go” evaluation used at their institution. Our modified setup used video-recording equipment and 2 independent reviewers blinded to participants’ identities. A Penrose drain with a midline slit was anchored to a stable base under a microscope. After a standard orientation and familiarization period, applicants tied as many knots as possible in 10 minutes. They were video-recorded in 2 views: (1) a microscope working view, and (2) a distant view behind the participant’s back, observing body position. Grading was done by 2 independent reviewers (a senior surgeon and a senior resident with microvascular training) using a standard form for grading effective microscope use, tissue handling, suture technique, body position, and evidence of concentration or frustration. The total number of successful knots was recorded.

During the US Military Graduate Medical Education Selection Board, an objective, numerical score is assigned to all applications by nonaffiliated reviewers. For postgraduate year 1 selections, applicants’ Electronic Residency Application Service composite scores are based on standardized board scores (United States Medical Licensing Examination or Comprehensive Osteopathic Medical Licensing Examination of the United States), medical school grade point average, interview scores, research experience, prior military and medical experience, letters of recommendation, and program director’s assessment.

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Lower Extremity Edema and Leaking Legs

19nov6

November 5, 2019 – I visited a friend in a hospital.  He told me he has lower extremity edema or pedal (leg and foot) edema with fluid actually oozing out and seen on the skin of the leg surface.

I told him you are the third or fifth patient that I have personally encountered with leaky legs associated with lower extremity edema.

Today, November 6, 2019, I went back to my files and tried to retrieve pictures of my personal experience.  Got them and will share.

2012

First one, I think, was in 2012.  A male patient with malignancy in the abdomen with ascites and extensive edema of the lower legs.  I suspected the edema was due to the malignancy in the abdomen causing obstruction of big blood vessels in the abdomen preventing circulation of the lymph up to the upper body or heart.

I took pictures of this patient’s legs showing the swollen legs and leaking fluid.  He eventually died of the malignancy.

2015

An elderly female about 90 years old with swollen lower extremity oozing fluid. She underwent acupuncture for this with increased protein intake. The leaky legs disappeared after about 5 to 6 months.

November 2015

November 2015

February 2016 – leaky legs subsiding after acupuncture and high protein diet.

November 2015 – leaky legs subsiding after acupuncture and high protein diet.

February 2016 – leaky legs subsiding after acupuncture and high protein diet.

February 2016 – leaky legs subsiding after acupuncture and high protein diet.

April 2016 – no more leaky legs (6 months after).

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Excerpts from Internet:

How do wet and edematous legs develop?

The body naturally allows fluid to leak from the blood vessels into the surrounding tissue as a means of transportation from blood to cells.  Most of the fluid (about 90%) is
reabsorbed back into the capillaries, while the remainder is absorbed by the lymphatic system (World Union of Wound Healing Societies [WUWHS], 2007).

There is a fine balance between the fluid leaking from the capillaries and the fluid being reabsorbed back into the capillaries and lymphatic system. When there is a change in the volume of fluid leaking or being reabsorbed, an imbalance occurs, and this may eventually lead to swollen, oedematous legs that can start to leak outside the body. Identifying the cause of this change is important to resolving the oedematous, wet legs.

This article considers the use of superabsorbent dressings, compression bandages, skin care and barrier creams to improve care.

file:///C:/Users/rojoson/Downloads/the-causes-and-treatment-of-wet-weeping-legs.pdf

[PDF] The causes and treatment of wet weeping legs – Wounds UK

https://www.wounds-uk.com › download › resource

 

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https://www.webmd.com/heart-disease/heart-failure/edema-overview#1

EDEMA 

Edema happens when your small blood vessels leak fluid into nearby tissues. That extra fluid builds up, which makes the tissue swell. It can happen almost anywhere in the body.

Types of Edema

Peripheral edema. This usually affects the legs, feet, and ankles, but it can also happen in the arms. It could be a sign of problems with your circulatory system, lymph nodes, or kidneys.

Pedal edema. This happens when fluid gathers in your feet and lower legs. It’s more common if you’re older or pregnant. It can make it harder to move around in part because you may not have as much feeling in your feet.

Lymphedema. This swelling in the arms and legs is most often caused by damage to your lymph nodes, tissues that help filter germs and waste from your body. The damage may be the result of cancer treatments like surgery and radiation. The cancer itself can also block lymph nodes and lead to fluid buildup.

Pulmonary edema. When fluid collects in the air sacs in your lungs, you have pulmonary edema. That makes it hard for you to breathe, and it’s worse when you lie down. You may have a fast heartbeat, feel suffocated, and cough up a foamy spittle, sometimes with blood.

Cerebral edema. This is a very serious condition in which fluid builds up in the brain. It can happen if you hit your head hard, if a blood vessel gets blocked or bursts, or you have a tumor or allergic reaction.

Macular edema. This happens when fluid builds up in a part of your eye called the macula, which is in the center of the retina, the light-sensitive tissue at the back of the eye. It happens when damaged blood vessels in the retina leak fluid into the area.

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Possible causes of edema:

Low albumin. Your doctor may call this hypoalbuminemia. Albumin and other proteins in the blood act like sponges to keep fluid in your blood vessels. Low albumin may contribute to edema, but it’s not usually the only cause.

Allergic reactions. Edema is a part of most allergic reactions. In response to the allergen, nearby blood vessels leak fluid into the affected area.

Obstruction of flow. If drainage of fluid from a part of your body is blocked, fluid can back up. A blood clot in the deep veins of your leg can cause leg edema. A tumor blocking the flow of blood or another fluid called lymph can cause edema.

Critical illness. Burns, life-threatening infections, or other critical illnesses can cause a reaction that allows fluid to leak into tissues almost everywhere. This can cause edema all over your body.

Congestive heart failure. When the heart weakens and pumps blood less effectively, fluid can slowly build up, creating leg edema. If fluid builds up quickly, you can get fluid in the lungs. If your heart failure is on the right side of your heart, edema can develop in the abdomen.

Liverdisease. Severe liver disease, such as cirrhosis, causes you to retain fluid. Cirrhosis also leads to low levels of albumin and other proteins in your blood. Fluid leaks into the abdomen and can also cause leg edema.

Kidney disease. A kidney condition called nephrotic syndrome can cause severe leg edema and sometimes whole-body edema.

Pregnancy. Mild leg edema is common during pregnancy. But serious complications of pregnancy like deep vein thrombosis and preeclampsia can also cause edema.

Head trauma, low blood sodium (called hyponatremia), high altitudes, brain tumors, and a block in fluid drainage in the brain (known as hydrocephalus) can cause cerebral edema. So can headaches, confusion, unconsciousness, and coma.

Medications. Many medicines can cause edema, including:

• NSAIDs (such as ibuprofen and naproxen)
• Calcium channel blockers
• Corticosteroids (like prednisone and methylprednisolone)
• Pioglitazone and rosiglitazone
• Pramipexole

CANCER can also cause edema.

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TREATMENT

Edema from a block in fluid drainage can sometimes be treated by getting the drainage flowing again. A blood clot in the leg is treated with blood thinners. They break down the clot and get drainage back to normal. A tumor that blocks blood or lymph can sometimes be shrunk or removed with surgery, chemotherapy, or radiation.

Leg edema related to congestive heart failure or liver disease can be treated with a diuretic (sometimes called a ”water pill”) like furosemide (Lasix). When you can pee more, fluid from the legs can flow back into the blood. Limiting how much sodium you eat can also help.

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Ascites and Edema

Ascites is the abnormal accumulation of fluid in the peritoneal cavity.

Ascites can be considered as a subtype of edema (abnormal accumulation of fluid anywhere in the body).

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Ascites

Ascites is an abnormal buildup of fluid in the abdomen, specifically the peritoneal cavity. It occurs when the body makes more fluid than it can remove. Ascites can occur with cancer and other conditions. When ascites is due to cancer, or if the fluid in the abdomen contains cancer cells, it is often called malignant ascites or malignant peritoneal effusion.

Causes

People with cancer can develop ascites for different reasons. It may be caused by:

• cancer cells that spread to and irritate the thin membrane that lines the inner wall of the abdomen (called the peritoneum)
• tumours that block the lymphatic system so lymph fluid can’t flow properly
• the liver not making enough protein (albumin), which may upset the body’s fluid balance
• cancer cells that block blood flow through the liver

Ascites develops most often with ovarian, uterine (endometrial), cervical, colorectal, stomach (gastric), pancreatic or primary liver cancers. Cancer that spreads to the liver can also cause ascites.

https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/ascites/?region=on

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Lymphedema vs Edema

Lymphedema vs Edema

 

EDEMA	LYMPHEDEMA
Edema is the body’s normal response to an injury such as a sprain. As healing progresses, the excess fluid leaves the area and the swelling goes down.	Lymphedema is condition that occurs when the lymphatic system is impaired to the extent that the amount of lymphatic fluid within a given area exceeds the capacity of the lymphatic transport system to remove it.
Edema is usually caused by excess tissue fluid that had not yet returned to the circulatory system.	Lymphedema is swelling caused by excess protein-rich lymph trapped within the tissues.
Edema due to an injury, such as bumping into something, is caused by additional tissue fluid coming into the area to help with healing.	Lymphedema  impaired tissues respond to injury with slow healing and/or a potentially serious infection.
Edema is also caused by circulatory system problems, such as chronic venous insufficiency, and this swelling usually occurs in the lower areas of the body.	Lymphedema  is caused by damage to the lymphatic system and this swelling occurs near the affected area.
Edema swelling does not leave a mark when a finger is pressed into it. This is known as nonpitting edema.	Lymphedema  swelling leaves a mark when a finger is pressed into it. This is known as pitting edema. This occurs only in the early stages of lymphedema.
Edema due to some causes can be relieved with diuretics.	Lymphedema is harmed, not helped, by treatment with diuretics.

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Pedal edema is the accumulation of fluid in the feet and lower legs.

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ROJ@19nov6

 

 

 

 

 

 

 

Bell’s Palsy – ROJoson’s Notes

August 2019

I recently encountered a 29-year-old male with Bell’s palsy.

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https://www.webmd.com/brain/understanding-bells-palsy-basics

Bell’s palsy is a condition in which the muscles on one side of your face become weak or paralyzed. It affects only one side of the face at a time, causing it to droop or become stiff on that side.

It’s caused by some kind of trauma to the seventh cranial nerve. This is also called the “facial nerve.” Bell’s palsy can happen to anyone.

If it happens to you, you may fear you’re having a stroke. You’re probably not. A stroke that affects your facial muscles would cause muscle weakness in other parts of your body, too.

The symptoms of Bell’s palsy tend to come on all of a sudden. You may go to bed one night feeling fine. But when you look in the mirror the next morning, you see that part of your face seems to be drooping.

Facial weakness and drooping typically reach their peak within a day or two. Most people start to feel better within a couple of weeks. They usually recover completely within 3 months. Some people who develop Bell’s palsy have a longer recovery period. In rare cases, they may have some permanent symptoms.

There’s no test that can tell you for sure if you have Bell’s palsy. In fact, doctors usually find out through what they call a “diagnosis of exclusion.” That means in most cases, they determine you have Bell’s palsy only after other conditions have been ruled out.

There aren’t any that can stop it. If your doctor suggests your symptoms might be triggered by the herpes virus (herpes simplex 1) or by shingles (herpes zoster), he may give you an antiviral medication, like acyclovir. But there’s no research to show these medications work to reduce Bell’s palsy symptoms.

Your doctor may also give you a short course of corticosteroids (like prednisone). The goal is to decrease swelling of your facial nerve. This may shorten the duration of your Bell’s palsy symptoms.

In the meantime, your doctor will tell you to take extra care to protect your eye on the affected side. He may suggest you wear an eye patch, since you won’t be able to blink. If your eyes are tearing less than normal, you may have to use eye drops to keep them from drying out.

Finally, your doctor may suggest massage of your facial muscles. In very rare cases — where symptoms don’t improve after some time — he may suggest surgery to reduce pressure on your facial nerve.

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Symptoms started July 22, 2019 with sudden onset of facial weakness and drooping.

He consulted me on August 17, 2019.

I diagnosed him to have Bell’s palsy.

I advised him massage while waiting for a referral to a Physical Therapy Center.  However, with constant massage, patient found gradual improvement that he forego going to a Physical Therapy Center.

The symptoms lasted for about one month with spontaneous resolution.

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Patient gave permission to post his pictures.

Paired pictures – Left – August 17, 2019 (with paresis) vs  Right – August 29, 2019 (with recovery)

Frowning of forehead – note the absence of frowning on the right forehead on the left picture

Closing eyes tightly – note the no tight closure of the right eye on the left picture

Grinning – note the shallow nasolabial fold on the right side on the left picture

Pouching of the lips – note the asymmetry of the lip on the right side on the left picture

 

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ROJ@19aug29

Patient-centered Care Management

References:

https://catalyst.nejm.org/what-is-patient-centered-care/

https://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/

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Definitions:

1.

In patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. Patients are partners with their health care providers, and providers treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective.

2.

Patient-centered care is the practice of caring for patients (and their families) in ways that are meaningful and valuable to the individual patient.  It includes listening to, informing and involving patients in their care. The IOM (Institute of Medicine) defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” ¹

¹ Institute of Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century”

 

1. Respect for patients’ values, preferences and expressed needs

Involve patients in decision-making, recognizing they are individuals with their own unique values and preferences. Treat patients with dignity, respect and sensitivity to his/her cultural values and autonomy.

2. Coordination and integration of care

During focus groups, patients expressed feeling vulnerable and powerless in the face of illness. Proper coordination of care can alleviate those feelings. Patients identified three areas in which care coordination can reduce feelings of vulnerability:

• Coordination of clinical care
• Coordination of ancillary and support services
• Coordination of front-line patient care

3. Information and education

In interviews, patients expressed their worries that they were not being completely informed about their condition or prognosis.  To counter this fear, hospitals can focus on three kinds of communication:

• Information on clinical status, progress and prognosis
• Information on processes of care
• Information to facilitate autonomy, self-care and health promotion

4. Physical comfort

The level of physical comfort patients report has a significant impact on their experience. Three areas were reported as particularly important to patients:

• Pain management
• Assistance with activities and daily living needs
• Hospital surroundings and environment

5. Emotional support and alleviation of fear and anxiety

Fear and anxiety associated with illness can be as debilitating as the physical effects. Caregivers should pay particular attention to:

• Anxiety over physical status, treatment and prognosis
• Anxiety over the impact of the illness on themselves and family
• Anxiety over the financial impact of illness

6. Involvement of family and friends

This principle addresses the role of family and friends in the patient experience.  Family dimensions of patient-centered care were identified as follows:

• Providing accommodations for family and friends
• Involving family and close friends in decision making
• Supporting family members as caregivers
• Recognizing the needs of family and friends

7. Continuity and transition

Patients expressed concern about their ability to care for themselves after discharge. Meeting patient needs in this area requires the following:

• Understandable, detailed information regarding medications, physical limitations, dietary needs, etc.
• Coordinate and plan ongoing treatment and services after discharge
• Provide information regarding access to clinical, social, physical and financial support on a continuing basis.

8. Access to care

Patients need to know they can access care when it is needed. Focusing mainly on ambulatory care, the following areas were of importance to the patient:

• Access to the location of hospitals, clinics and physician offices
• Availability of transportation
• Ease of scheduling appointments
• Availability of appointments when needed
• Accessibility to specialists or specialty services when a referral is made
• Clear instructions provided on when and how to get referrals.

• The health care system’s mission, vision, values, leadership, and quality-improvement drivers are aligned to patient-centered goals.
• Care is collaborative, coordinated, and accessible. The right care is provided at the right time and the right place.
• Care focuses on physical comfort as well as emotional well-being.
• Patient and family preferences, values, cultural traditions, and socioeconomic conditions are respected.
• Patients and their families are an expected part of the care team and play a role in decisions at the patient and system level.
• The presence of family members in the care setting is encouraged and facilitated.
• Information is shared fully and in a timely manner so that patients and their family members can make informed decisions.

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ROJ@19aug25

Every operation is a stress for the surgeon

Every operation is a stressful experience.

This is true not only for the patient and his / her relatives, but also for the surgeon and anesthesiologist.

For the surgeon, stress begins even before the operation, continues up to the time and during the operation and still continues after the operation.  Stress usually begins to dissipate when patient is discharged, particularly, when there are no complications.

Level of stress is highest after the operation with the surgeon hoping there will be no complication which implies that no surgeon can’t be 100% sure what will happen to the patient and his / her operation.  Even before the operation, no surgeon guarantees to any patient no complication.

Case in point (19aug14):

I did a left hemicolectomy today, August 14, 2019, from 1000H to 1400H.  Right after skin closure, I pray and hope that there will no complications particularly in terms of anastomotic leak.

At 1930H, my cellphone beeped signifying that I had a message.  Before I opened the message box in my cellphone, I was praying and hoping the message do not come from my resident monitoring the patient or it come from him/her, I was praying and hoping it will not contain bad news.  Fortunately, no bad news at this time.

For the next hours and days, I will keep on praying and hoping that I will not receive bad news for my patient.  I will update this.

At 1730H, during my walking exercise, I included in my rosary prayer, asking God not to allow complications to set him for the patient.

This story illustrates the life of a surgeon, every operation is a stressful experience.

I will continue to develop and expand this blog. 

ROJ@19aug14