Breast Cancer Survivor Urbana Bulayan – 10 Years in Remission

Ms. Urbana Bulayan was 58 years old when I did a modified radical mastectomy on her breast cancer in September 2007.  The histopathology report showed invasive ductal carcinoma 4 cm with negative spread to the axillary lymph node.  She decided to take tamoxifen for 5 years after the operation.  She is now 68 years old, 10 years in remission.  We both thank God for this long remission.  (Published with permission from Ms. Urbana Bulayan and daughter Joyce)

 IMG_2176
ROJ@17sept30
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CDC Guidelines on Surgical Site Infection Prevention – 2017

From:

http://www.medscape.com/viewarticle/879502?nlid=114636_1382&src=WNL_mdplsnews_170505_mscpedit_surg&uac=122338FX&spon=14&impID=1342001&faf=1

The Centers for Disease Control and Prevention (CDC) has issued updated evidence-based recommendations for preventing surgical site infections (SSIs). The guidelines cover 14 core areas and are intended for incorporation into existing surgical quality improvement programs for greater patient safety.

The 2017 recommendations, published online today in JAMA Surgery, supersede the CDC’s 1999 SSI guidelines, which were published before the routine use of evidence-based grading.

Among the updated recommendations:

  • Advise patients to have a full-body shower or bath with soap (antimicrobial only as needed) or an antiseptic agent no earlier than the night before the day of surgery.
  • Before cesarean delivery, administer antimicrobial prophylaxis before incision.
  • In most cases, use an alcohol-based agent for skin preparation in the operating room.
  • It is not necessary to use plastic adhesive drapes with or without antimicrobial properties to prevent SSIs.
  • For clean and clean-contaminated procedures, do not give additional prophylactic antimicrobial doses after closing the surgical incision, even if the patient has a drain in place.
  • Do not apply topical antimicrobial agents to the incision.
  • Maintain intraoperative glycemic control in diabetic and nondiabetic patients, targeting blood glucose levels of less than 200 mg/dL.
  • Maintain patient normothermia.
  • In patients with normal lung function undergoing general anesthesia with endotracheal intubation, administer a higher fraction of inspired oxygen during surgery and after extubation in the immediate postoperative period.
  • Do not withhold transfused blood products as a means to prevent SSI.

“As with any guideline, implementation will require consideration of local systems, something quality improvement committees and officers routinely do.”

Details:

http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725


ROJ@17sept18

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Postoperative analgesics – how I usually prescribe

First, an introduction on analgesics.

What are Analgesics

Analgesics are medicines that are used to relieve pain (provide analgesia). They are also known as painkillers. Technically, the term analgesic refers to a medication that relieves pain without loss of consciousness, as opposed to an anesthetic, which is a substance that induces insensitivity to pain via a loss of consciousness and an absence of sensory perception.

A large number of medicines have pain-relieving properties, and analgesics with similar mechanisms of action are usually grouped together; for example, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids (narcotics). Analgesics can also be grouped depending on the severity of pain they are indicated for, for example, acetaminophen and NSAIDs are indicated for mild-to-moderate pain, and weak opioids, such as codeine, dihydrocodeine or tramadol are indicated for moderate-to-severe pain.

Central nervous system analgesics act in the brain or spinal cord to produce their effects; examples include opioids such as morphine and oxycodone. Peripherally acting analgesics act outside of the brain and spinal cord and include NSAIDs and COX-2 inhibitors.

https://www.drugs.com/drug-class/analgesics.html


Postoperative analgesics – how I usually prescribe it

Basic Guides

First guide – I determine first how painful or not painful is the postoperative pain usually experienced by patients who undergo a certain operative procedure.  Example, how painful or not painful is pain usually experienced by patients who undergo an excision of an epidermal cyst or lipoma; breast mass excision; mastectomy; thyroidectomy;   cholecystectomy; colon resection; herniorrhapy; hemorrhoidectomy; etc.  If the postoperative pain is usually mild, I usually prescribe a mild analgesics such as paracetamol.  If the postoperative pain is usually moderate, I usually prescribe an analgesic  stronger than paracetamol such as non-steroidal anti-inflammatory drugs such as mefenamic acid.  If the postoperative pain is usually severe, I usually prescribe COX-2 inhibitors or tramadol.

Second guide – I determine the pain threshold of the patient.  If low and patient is too anxious of postoperative pain he/she will experience, I make adjustment on the first guide above.  I give a stronger analgesics.  For example, for postoperative pain that are usually mild, I give mefenamic acid instead of paracetamol.

Other guides

Step-down and step-up analgesic ladder

I usually use the step-down analgesic ladder in managing postoperative pain, meaning starting from the stronger to less strong analgesics, particularly in patients with low pain threshold.

For example, I can start with a COX-2 inhibitor or tramadol then shift to mefenamic acid and then paracetamol as the postoperative days move on in which I expect the pain to decrease.

Another example, in patients undergoing operations under general anesthesia, such as mastectomy and thyroidectomy, I request my anesthesiologist to give one to two doses of parenteral strong analgesics first while patient is in the recovery room and patient cannot take oral analgesics yet.  Once the patient is ready,  I then shift to oral analgesics, either mefenamic acid or paracetamol when patient is in the room depending on the patient’s pain threshold.  In the recovery room, the patients may experience moderate to severe pain as the operation has just been completed.  As time goes by, when the patient is already in the room, say 2-3 hours after the operation, the pain usually decreases. With this and with mastectomy and thyroidectomy wounds usually being associated with mild to moderate pain, a shift to paracetamol or mefenamic acid can be done.  (Side note: circa 2004, in the Department of Surgery of Ospital ng Maynila Medical Center, we did a randomized controlled study comparing paracetamol and mefenamic acid in managing pain of post-mastectomy and post-thyroidectomy patients after an initial dose of parenteral ketoprofen.  Conclusion was that paracetamol can be used in pain control in post-mastectomy and post-thyroidectomy patients as the pain was usually mild.)

Shifting from parenteral analgesics to oral analgesics  

Patients with postoperative wounds that are commonly associated with severe pain are usually given parenteral analgesics.  As postoperative days move on, when the pain is controlled and decreasing already, shift to oral analgesics is in order (that is, if the patients can take oral medications).  I usually add the oral analgesics before the parenteral analgesics are totally discontinued.  If the parenteral analgesics are being given at 6-hour intervals, I usually start the oral analgesics half-way through, meaning 3 hours after the last dose of parenteral analgesic was given.  This is to ensure that there is continued supply of the analgesics in the patient’s bloodstream.

Postoperative pain management after excision of surface lump under local anesthesia and outpatient

I usually ask the patient to bring a paracetamol tablet to the operating room on the day of the excision under local anesthesia.  The assumption is that the postoperative pain is usually mild.  Right after the operation, usually less than one hour, I ask the patient to take the paracetamol tablet.  At home, the patient is advised to take the paracetamol as needed for pain at an interval of at least four hours.  (Commonly observed from my experience is: patients taking the paracetamol at home range from none or zero after the initial intake at the operating room to three tablets.)

Rationality and cost-effectiveness in postoperative analgesic prescription

I tried to do my postoperative analgesic prescription with reason or logic – see basic guides and other guides above.

I also factor in cost-effectiveness – achieving adequate pain control with the least cost.

The other factors that I consider are the past history of allergy to pain medications and potential side effects.


ROJ-TPOR@17sept18

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Antibiotics prophylaxis is given only when indicated

ROJoson’s Medical Anecdotal Report

Date of Observation: September 16, 2017

Dolores C, a 64-year-old female, followed up with me one week after her operation (excision of a submanbibular mass).  The histopath showed chronic sialoadenitis.

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She commented: “galing galing ninyo doc. walang antibiotics. No infection.”  (You are so good, doctor.  I was not prescribed / I did not take antibiotics. No infection.)

I answered her back that antibiotics was not needed as the operation is considered a clean operation.  The incidence of wound infection is about 1-2% only.  I give antibiotics only when indicated.

Insight:

Because of the rampant practice of surgeons giving antibiotics even when not indicated, the public expect they would have to take antibiotics after every operation.

We have to educate the public that antibiotics are given only when indicated.

Surgical wounds are classified into clean, clean-contaminated, contaminated and dirty.

“Clean — an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered.

Clean-contaminated — an incision through which the respiratory, alimentary or genitourinary tract is entered under controlled conditions but with no contamination encountered.

Contaminated — an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered.

Dirty or infected — an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (for example, emergency surgery for faecal peritonitis), and there is faecal contamination or devitalised tissue present”

https://www.ncbi.nlm.nih.gov/books/NBK174534

Before the routine use of prophylactic antibiotics, infection rates were:

1-2% or less for clean wounds

6-9% for clean-contaminated wounds

13-20% for contaminated wounds

about 40% for dirty wounds

Reference: Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60(1): 27-40.

Since the introduction of routine prophylactic antibiotic use, infection rates in US National Nosocomial Infection Surveillance (NNIS) system hospitals were reported to be:

2.1 % for clean wounds

3.3% for clean-contaminated wounds

6.4% for contaminated wounds

7.1% for dirty wounds

Reference: Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991; 91(3B): 152S-157S.

The following table summarizes the data above:

antibiotics-in-colorectal-surgery-23-728

https: // www. slideshare. net  / sanoopzac / antibiotics in colorectal surgery

One can see from above data that incidence of infection in clean surgical wounds is only about 1-2% and with use of prophylactic antibiotics, the incidence is the same and not lower.

Thus, as a rule, no prophylactic antibiotics is required for clean surgical wounds such as after a clean excision of breast mass, clean excision of skin and soft tissue mass, clean thyroidectomy, clean mastectomy and clean herniorrhaphy.  Those with contaminated and dirty surgical wounds definitely will need antibiotic prophylaxis.  Those with clean-contaminated surgical wounds may or may not need prophylactic antibiotics depending on the circumstances. (Note: above case may strictly be considered as a clean-contaminated surgical wound as the salivary duct is cut.  However, she did not receive antibiotics and did not develop infection.)

ROJ-TPOR@17sept17

 

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Concept of Health and Disease – Issues

Posted in Mayo Clinic website:

http://www.mayoclinic.org/diseases-conditions/hemophilia/basics/treatment/con-20029824

“While there’s no cure for hemophilia, most people with the disease can lead fairly normal lives.”

Hemophilia is a rare disorder in which your blood doesn’t clot normally because it lacks sufficient blood-clotting proteins (clotting factors).

There are such things as mild and moderate to severe hemophilias.


Issue 1:

Is the patient with hemophilia who is asymptomatic and living a normal life and who eventually dies due to a disease or event unrelated to or not associated with hemophilia such as pneumonia or drowning considered HEALTHY or NOT  HEALTHY?

My answer: HEALTHY!


Issue 2:

Is the patient with hemophilia who is asymptomatic and  who is living a normal life, socially and economically productive, considered HEALTHY or NOT  HEALTHY?

My answer: HEALTHY!


Issue 3:

Is the patient with hemophilia who has suffered bleeding episodes considered HEALTHY or NOT  HEALTHY?

My answer: NOT HEALTHY at the time of the bleeding!


Issue 4:

Is the patient with hemophilia who has suffered bleeding episodes but recovered from them and is currently asymptomatic and socially and economically productive considered HEALTHY or NOT  HEALTHY?

My answer: HEALTHY at the moment!



Note: A patient with hemophilia has to avoid bleeding incidents like injuries to remain HEALTHY!  

HEALTHY = socially and economically productive


ROJ@17sept15

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Submandibular Gland Sialolithiases

ROJoson’s Medical Anecdotal Report

Date of Observation: September 9, 2017

Submandibular gland is a salivary gland.

64-year-old female with a palpable mass at the right submandibular area which has been present for the past 5 years.

Ultrasound showed “heavily calcified solid nodule in the right submandibular gland, possibly neoplastic.”

Operative findings: sialolithiases with chronic sialoadenitis, right submandibular gland.

Operation: excision of whole right submandibular gland

IMG_5557

Note the 2 stones – one 1.5 cm in size (upper portion topmost) and another 5 mm (white structure just below the bigger stone).

IMG_5560

IMG_5563

Note the 2 white stones (calcified) and cut section of the submandibular gland showing chronic sialoadenitis.

IMG_5565

Note the duct that contains the bigger stone (placed on the side).


The patient presents with a picture like this – palpable mass at the right submandibular area – about 3 cm in size.

picture1


My preoperative diagnosis base on physical examination and ultrasound result was submandibular glannd benign tumor, right.   CT-scan or MRI was recommended by the ultrasonographer.  However, I did not do it anymore.  I proceeded with the exploration of the right submandibular triangle using the submandibular incision.

Operative findings: sialolithiases with chronic sialoadenitis, right submandibular gland.

Operation: excision of whole right submandibular gland

I was able to identify the digastric muscle and the hypoglossal nerve and the Wharton’s duct.  See pictures below.

nekL5024

Courtesy of Versalius.

1-s2.0-S1743919109001289-gr1

https://www.google.com.ph/search?q=submandibular+triangle&dcr=0&source=lnms&tbm=isch&sa=X&ved=0ahUKEwinvumynZjWAhWGFJQKHbb4DnMQ_AUICigB&biw=1366&bih=613#imgrc=Gnh8sCsShUnJkM:


Submandibular gland is one the 3 major salivary glands in the human body.

salivary_glands


ROJ@17sept9

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Practice of giving medical records to patients

In my clinic (ROJoson Medical Clinic), I have the practice and habit to give all my patients a duplicate or carbon copy of my notes and explanations.

I am still trying to trace when I started doing this, probably circa 2000.  Below is a copy of a 2005 record that I was able to retrieve.  I will keep on tracing the time I started this practice.

I usually ask my patients to sign the medical records that I made for them, either as part of informed consent or refusal for my recommendations on management or simply, for acknowledgement purposes.

I also usually ask my patients to always bring their past medical records whenever they come for check-up or follow-up with me.

scan0001

Note the date (2005) and the patient’s signature in red box.


ROJ@17sept5

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