Friday, November 30, 2007

It's hard to outsmart mother nature.

Just thinking about the human body today.....

Reports in the medical literature continually reinforce my belief that it's nearly impossible to outsmart mother nature in terms of the bodies inflammatory response. The inflammatory response is critical to your bodies compensatory mechanisms for stress or infection, but it has a tendency to go haywire and (apparently) make things worse. Billions of research dollars have been invested in characterizing (and manipulating) this cascade of biochemical processes. Every time we think we've figured out the big picture, eventually we are humbled by the bodies' "counter offensive".

In an international study (summarized awhile back here ) comparing bare metal versus the fancy new metal stents coated with medicines to inhibit re-occlusion of the artery showed dramatic increases in post procedural deaths as these patients were followed out from their procedure. When these drug-eluding stents were first introduced in 2003, they became the fastest-selling medical device in recent history despite being nearly 400% more expensive then the older bare metal stents.

We've witnessed a lot of similar outcomes in the trauma and septic response literature as multiple stages of the inflammatory cascade are suppressed or modulated, only to come back with a vengeance thru alternate "work around" pathways that must exist somewhere in the body.

When you see diagrams of what we think the immune response looks like, it is a frighteningly busy graphic. Despite millions of man hours in labor and billions of research dollars, complete understanding of these processes is elusive.


Saturday, November 24, 2007

Give me you hungry, tired, and poor. Hold the fat, please!

Want to see a logical extension of federalized health care and the kind of rationing choices that will be made?

This story here is fascinating.

Richie Trezise, 35, a rugby-playing Welshman, lost weight to gain entry to New Zealand after initially being rejected for being overweight and a potential burden on the health care system.

His wife, Rowan, 33, a photographer, has been battling for months to shed the pounds so they can be reunited and live Down Under but has so far been unable to overcome New Zealand’s weight regulations.

Robyn Toomath, a spokesman for Fight the Obesity Epidemic and an endocrinologist, said the BMI limit was valid in the vast majority of people. She said she was opposed to obese people being stigmatised. "However, the immigration department’s focus is different," she said. "It cannot afford to import people into the country who are going to be a significant drain on our health resources.

"You can see the logic in assessing if there is a significant health cost associated with this individual and that would be a reason for them not coming in."

The implications of this are interesting. Is it discrimination or is it making people take personal responsibility when you treat someone different based on what are (often) controllable health risk factors?

We've already clearly made this value judgement with smokers and we're moving that direction with obesity. It's clear that obesity (as opposed to be merely overweight), much like smoking, is a devastating drain on our resources from a systems level. This was federally recognized in this example from New Zealand. Expect to see some incentives for BMI parameters to more frequently appear in your health insurance policy or be sponsored by your employer, as they've clearly fingered this subgroup as an area for cost containment in their employee costs.


Thursday, November 22, 2007

Happy Turkey Day!

Happy Thanksgiving to you and yours! I've got a lot of ideas floating around for some interesting (to me) writing coming up here on Plastic Surgery 101

Stay Tuned!

Monday, November 19, 2007

Why Doctors do not trust the government to administer health care?

Exhibit A: Wisconsin Democrat governor, Jim Doyle, is trying to do an audacious end run around the intent of a state-administered trust fund meant to control medical malpractice costs.

In 1975, the Wisconsin legislature set up a fund for physicians, hospitals, and other health professionals to contribute to called the Injured Patients and Families Compensation Fund. It was essentially a self-insurance "buffer" against rising med-mal costs and has been widely credited with stabilizing Wisconsin malpractice insurance premiums.

The assets of this fund are substantial, in excess of $735 million in 2007 (covering an estimated $685 million in potential liabilities). Such a large "pot of gold" has proven irresistible for Democrats in Wisconsin, and Gov. Doyle has proposed pillaging nearly $200 million to cover budget deficits the state is running up on their Medicaid program. While it's noble to fund a state's uninsured & under-insured, raping a successful program whose mandate and charter is very specific to the med-mal relief program is going to lead to a bitter court fight in Wisconsin between the Wisconsin medical association and Gov. Doyle.

In 2003 a state law declared the trust "for the sole benefit of health care providers participating in the fund and proper claimants. Monies on the fund may not be used for any other purposes of the state". Keep in mind that individual doctors have essentially been paying into this pool at somewhere between $8-10,000 annually for nearly 30 years. So in a nutshell, this Democratic proposal would turn an insurance program into a massive retroactive tax hike on providers while potentially causing the whole program to go insolvent (as assets would drop ~ $150 million below liabilities).

Gov. Doyle, you're the proud recipient of the inaugural Plastic Surgery 101 cheesehead award!

Tuesday, November 13, 2007

Vultures circling over Kanye West's mother's death after surgery

The tabloids are in overdrive digging up dirt on the surgeon who performed Kanye Wests' mother's surgery. The surgeon in question was kind of a minor media figure, having hosted some TV shows on plastic surgery. In an instant, this doctor's career has been reduced to "the guy who killed Kanye's mom" which is kind of sad.

Still to be determined is what exactly was the cause of death?

The implication being circulated is that she should not have been done as an outpatient surgery. That's a judgment call, but it's one that has to take into consideration her age, medical comorbidities, type of proposed surgery, and length of surgery. Her surgery was apparently almost 8 hours long, which while longer then you like, is certainly not outside the vague notion of "standard of care". Publicized cases like this tend to lead to reactionary measures, and I would not be surprised with some fallout in California as to how office surgery is regulated.

A woman her age (almost 60) who dies shortly after this kind of surgery would make me think of a few things

  1. Did she have a post-operative heart attack( MI)?

  2. Did she have hypovolemic shock from intra-operative or post-operative bleeding?

  3. Could she have had toxicity from lidocaine (a local anesthetic) used in high volume liposuction?

  4. Did she get nauseated, throw up, and subsequently go into respiratory arrest from aspiration?

There's a couple of less likely things that can happen, but they usually don't present quite like Mrs. West's case. Those would be pulmonary embolism (a blood clot which migrates to the lungs & usually happens a few days later), bowel perforation (usually has a more gradual onset of sepsis), and acute necrotizing infections (usually from Streptococcal group A or B bacteria).

Post operative deaths are rare, but tragic. They reportedly occur in only one of 51,459 cosmetic procedures, according to the journal Plastic and Reconstructive Surgery. It's been suggested that number may actually slightly under-represent the problem as not all deaths get reported accurately. For example, a study a few years ago by some dermatologists claiming no deaths from high volume office-based liposuction cases performed by dermatologists flew in the face of numerous anecdotal reports by General & Plastic Surgeons having to deal with major complications which showed up in the hospital from some of these same dermatologists.

Friday, November 09, 2007

Stripper Mistakenly Sent to School.....(Thanks, Mom!) and how stripper sales tactics mirror other business

From The Newsvault:

A teenage schoolboy in the UK was pulled around his classroom on a leash and spanked by a stripper after a birthday surprise mix-up. The teen's mother had ordered an agency to give her son a 'surprise' on his 16th birthday - and the teacher had also agreed to allow the surprise. But it all went wrong when the company sent a stripper dressed as a policewoman instead of a man in a gorilla suit - in what it called a booking error.

One student told Sky News: "She asked the lad to stand up, which he did, and told him he had been a very naughty boy because he hadn't been doing his homework."

"Then she put on some Britney Spears music and got out a collar and leash from her bag and told him to put them on." After walking the boy around the classroom and spanking him with a whip, the action got even more steamy.

"She took off some clothes until she was down to her bra and pants, pulled out some cream, put it on her buttocks and told him to rub it in," the student said. It was at that point the shocked teacher - who had not been told what the surprise was - called an end to the show. A spokeswoman for the school in Nottinghamshire said they were investigating how the incident happened.

What strikes me as so surreal is that up until the massaging cream on the butt, that the teacher was just watching this kid being lead around in a dog collar while being spanked with the rest of these 16 year olds. Too, too funny!

While doing "research" looking for a picture to frame this post with, I stumbled across something funny about how strippers and business tactics. It made me reflect that cosmetic surgery/medicine and strippers are alike in how sales are done.

From the Wise Camel Blog

Sales Technique #1 - Give them something for nothing One of the first things a stripper will do is come up to you and flirt with you. She will likely sit on your lap or do something to raise your excitement level. For this, you have to do nothing. But you do get a sample of the service and if it is a good one, your chances of buying the service increases. This also applies to the dances they do on the stage.
Sales Technique #2 - Understand your customers Strippers get to know their customers by asking questions. This allows them to develop a rapport and tailor the sales pitch…
Sales Technique #3 - Tailor the Sales Pitch Strippers will try different sales pitches to different people based on what she thinks they like. “I like to get dirty” or “Have you seen my great ass?” or “My tits are real”. Each pitch may be the one thing that converts the potential customer into a buyer. (Pointing out a tight ass works well for me). And she revises her pitch based on experience.
Sales Technique #4 - Make sure you are selling a great product/serviceShe knows she has to have a great product. If she put on 30 pounds or hadn’t showered for the past 4 days, she would likely not get as many customers. Regardless of how great of a salesperson you are, you can’t do much with a crappy product/service.
Sales Technique #5 - Provide Good Customer ServiceShe will make sure you are happy on your first dance or she won’t get repeat business or won’t be able to do what she ultimately set out to do…Upsell.
Sales Technique #6 - Upsell She sells the customer on a relatively cheap service, a lapdance, but then markets her other services to them. She tries to get them to the “champagne room” and sell an upgraded service, which is where the money is at. However, without the first sale, she would never get the larger sale. Customer acquisition is tough. Once she does it, she needs to get as much business as she can.
Sales Technique #7 - Closing Techniques. She will use a variety of closing techniques to get you to buy her services. There are a variety of closing techniques, but two popular ones used by strippers are the compliment close (usually flirting with you) and companion close (getting your buddies to push you into closing the deal).
Sales Technique #8 - Target your audience Strippers market to individuals that are interested in her service. First, she works in a strip club where guys go specifically for her service, that is obvious. But she also knows which guys to go after within a group or which groups will likely spend the most money. Spending time with cheap-asses only wanting to pay a dollar for a dance will not be a wise use of he precious time.
Sales Technique #9 - Persistence Even though the audience is qualified, she knows she will get rejections. Even so, she will go up to every guy and ask if they need a lap dance. She also knows that the more guys she asks, the more yes’s she will get.
Sales Technique #10 - Branding I don’t know any strippers that are named Ethel, Mildred or Agnus. Instead, you will get the pleasure to do business with Cookie, Destiny, Candy, or Raven.

Monday, November 05, 2007

Obesity- it's effect or mortality and can Plastic Surgery do anything about it

A real gauntlet was thrown down this past week with the publication reviewing the effects of excess weight and morbid obesity on our health. Dr. Walter J. Willett, a professor of epidemiology and nutrition at the Harvard School of Public Health, and 20 co-authors, compiled the 500+ page report, entitled "Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective".

Their meta-analysis of several thousand existing studies found that "excess body fat influences the body's hormones, and these changes can make it more likely for cells to undergo the kind of abnormal growth that leads to cancer." In short, "[t]he risk from excess weight begins at birth." Therefore, obese girls who begin menstruation earlier in life "will have more menstrual cycles. This extended exposure to estrogen is associated with increased risk for premenopausal breast cancer."

This staggering review, which took over five years to develop, indicates that "excess body fat increases the risk of cancer of the colon, kidney, pancreas, esophagus, and uterus as well as postmenopausal breast cancer."Obesity seems poised to become the number one risk factor for cancer in America, as obesity increases and the number of smokers decreases.

What can we do surgically about this?

Well, it appears the weight loss procedures, gastric bypass & gastric banding, can significantly reduce or eliminate many associated comorbidities including diabetes, hypertension, obstructive sleep apnea, and progressive osteoarthritis from excess weight load. In 2006, almost 180,000 patients underwent bariatric surgery of some type.

Last year researchers found that gastric bypass surgery patients were 40% less likely to die from any cause during a mean 7 years of follow-up, compared with the obese controls. It's kind of intuitive that there should be some risk reduction for some of these cancer risks associated with obesity, but I don't believe we have evidence to leap to that conclusion. It might be a very small effect statistically unless it was done on an obese adolescent in whom you'd have decades to track this.

I found a nice collection of review studies re. to Gastric Bypass here at Thinner Times if you're interested.

What about plastic surgery?

Unfortunately there is fairly poor evidence that plastic surgical treatment of weight, whether by resecting excess skin/fat or by liposuction, has an effect on any of these benchmarks. What we can do is cosmetic changes only. A paper from Washington University (St. Louis) published in the New England Journal of Medicine in 2004 found no benefit from high volume liposuction (as you''d expect from weight loss via other methods or diet), where as much as 20% of patients subcutaneous fat stores were removed via liposuction. There have been a small handful of lesser quality papers (like this) suggesting that large volume liposuction may improve glucose control in some type-2 obese diabetics, but the evidence is weak and the studies not really well done (it's a hard subject to study with any uniformity).

However, there is some rationale for a mechanism of how it could work. Large areas of lipodystrophy (fat deposits) are essentially your bodies "batteries" for energy storage. Obese people have a resistance to the effect of insulin mediated in part by their excess fat. In more than 80% of patients who are severely obese and have diabetes and then have gastric bypass surgery, the diabetes is cured. So remove the fat, remove the diabetes, right? Well it turns out it's not quite that simple. It appears the visceral fat (fat inside your abdomen and liver) may be the bigger culprit then the fat outside that you remove with excision or liposuction.

Below is a photo of a visceral fatty deposits in a mouse liver in two different species of mice involved in obesity research. The upper photo shows an "obese mouse", while the lower photo shows the "fit mouse" liver. You can clearly see the "marbling" of the fatty liver.


Friday, November 02, 2007

Patients in clinical trials - a footnote to the breast implant patients in the New York Times article

Today's entry is kind of an "inside baseball" thought that occured to me reading an article on medicine.

There was a breathless article on the news wire "Participants Left Uninformed in Some Halted Medical Trials" (syndicated from a New York Times story) earlier this week about the fate of patients who were enrolled in clinical trials for devices or drugs that had been discontinued. In many instances these patients (and occasionally their doctor) were apparently unaware of this fact. They used two medical devices as examples - vascular stents used to treat aortic aneurysms and a type of breast implant used in cancer reconstruction.

The stents are a potential big problem in that if they don't perform as designed, the patient will die. The breast implant patients (two women in south Florida) seem to be having much less an urgent issue. From the thumbnail description it sounds like the women were having some degree of capsule pain, which is not terribly uncommon especially in breast reconstruction patients who've been radiated. Capsular contracture is also the way some silicone implant ruptures present.

Implied in the NYT article is the implication that these women are "sitting on a time bomb" with their implants which is really silly and makes the juxtaposition from the stents scenario kind of ridiculous. In this instance, I'm not sure you'd do anything at all different for these women other then checking for rupture. No one would recomend "prophylactic" removal of those implants in the abscence of documented rupture, particularly if the implants were less then 10 years old. We have plenty of information about the treatment of silicone breast implant ruptures, and it's well established that the problems you get are local issues to the chest wall. A capsular contracture or ruptured implant is it's own issue, but to hold it up next to potential life-threatening device failures misses the real serious problems with medical devices and their surveillance.

They don't really go into much detail other then identifying the implant manufacturer, Allergan, and that the particular implant had been discontinued recently (~2005). If I had to guess, it's probably the Inamed "Style 153" implant these women had, which was an anatomically shaped silicone gel device that preceded the more advanced Style 410 "gummy bear" implants. Those implants, which were voluntarily pulled from the market by the manufacturer during their approval process negotiations with FDA for their conventional type of silicone gel breast implants.

The style 153 implant had an innovative "double lumen" core that had an apparent higher failure rate when you studied them on MRI scans (the best test for rupture). Confusing the issue is the resemblance of the double shell for some of the described signs of intracapsular implant rupture which is well described in this full text American Journal of Radiology article. There are a great many surgeons who strongly believe MRI's (or at least the radiologists reading them) have a tendency to over-estimate ruptures, particularly with this specific implant. At the end of the day Inamed made the decision in 2005 to "cut bait" on such a minor product to better their chances of FDA approval for their other products. The style 153 was a good implant for it's time, but it really was just a transitional model to the form-stable devices like the 410.

* Below is an MRI showing the characteristic "double lumen" sign confused for rupture occasionally with style 153 device