Monday, July 18, 2016

Some Thoughts About Skin Cancer

The weather is beautiful and people are headed to the beach, the pool or the park. What sometimes is forgotten is the risk of too much sun exposure and the most common type of cancer: skin cancer.  Skin cancer is the most common kind of cancer. This list is from

Skin cancer risk factors

Risk factors for skin cancer include:
  • Too much exposure to ultraviolet (UV) radiation (from sunlight or tanning beds and lamps)
  • Pale skin (easily sunburned, doesn’t tan much or at all, natural red or blond hair)
  • Exposure to large amounts of coal tar, paraffin, arsenic compounds, or certain types of oil
  • You or members of your family have had skin cancers
  • Multiple or unusual moles
  • Severe sunburns in the past
  • Weakened immune system
  • Older age (although melanomas are also found in younger people)

Signs and symptoms of skin cancer

Skin cancer can be found early, and you and your health care providers play key roles in finding skin cancer. Learn how to examine your skin for changes. If you have any of these symptoms, see a provider:
  • Any change on your skin, especially in the size or color of a mole, growth, or spot, or a new growth (even if it has no color)
  • Scaliness, roughness, oozing, bleeding, or a change in the way an area of skin looks
  • A sore that doesn’t heal
  • The spread of pigment (color) beyond its border, such as dark coloring that spreads past the edge of a mole or mark
A change in sensation, such as itchiness, tenderness, or pain

Can skin cancer be prevented?

The best ways to help lower your risk of skin cancer is to stay out of intense sunlight and practice sun safety. You can still exercise and enjoy the outdoors while practicing sun safety at the same time. Here are some ways to be sun safe:
  • Seek shade, especially in the middle of the day (between 10 am and 4 pm) when the sun’s rays are strongest. Teach children the shadow rule: If your shadow is shorter than you, the sun’s rays are at their strongest.
  • Follow the Slip! Slop! Slap!® and Wrap! rules:
  • on a shirt: Use protective clothing to cover as much skin as possible when you’re out in the sun. Choose comfortable clothes made of tightly woven fabrics that you can’t see through when held up to a light.
  • on sunscreen: Use broad-spectrum sunscreen and lip balm with a sun protection factor (SPF) of 30 or higher. Apply a generous amount of sunscreen (about a palm full) to all unprotected skin. Reapply every 2 hours and after swimming, toweling dry, or sweating.
  • on a hat: Cover your head with a wide-brimmed hat, shading your face, ears, and neck. If you choose a baseball cap, remember to protect your ears and neck with sunscreen.
  • on sunglasses: Wear wrap-around sunglasses with 100% UVA and UVB absorption to protect your eyes and the nearby skin.
  • doesn’t protect you from all UV rays. Do not use sunscreen as a way to stay out in the sun longer.
  • these practices to protect your skin even on cloudy or overcast days. UV rays can travel through clouds.
  • other sources of UV light. Tanning beds and sun lamps damage your skin and can cause cancer.

Wednesday, March 16, 2016

What is a Photo Facial?

    A photo facial is a light based skin treatment to revitalize your skin! It can be performed with a variety of lasers or IPL (intense pulsed light) systems.  The goal of the treatment may vary based on what issues you are concerned about. Light therapy can be used to reduce redness of the cheeks in patients with rosacea , decrease sun damage, eliminate facial veins and pigment, reduce wrinkles and scars, and decrease pore size.  

    Lasers produce a single wavelength of light while an IPL uses a number of different wavelengths of light across a specific range.  There are advantages and disadvantages to each system.  Sometimes, they both may be used during a treatment.

    The most gentle type of photo facial performed at NJ VeinCare and Aesthetic Center is done using a Cynosure Elite+ Nd:YAG laser. This laser is safe for all Fitzpatrick skin types.  Laser energy is used to revitalize the skin, making it look healthier, smoother, reduce pore size with minimal down time, usually less than half a day of mild redness, easily covered by makeup. It is commonly done a day or two before a prom, a wedding or another event. If you have a special occasion coming up, it is a great way to make sure you look your best! This laser can also be used to treat unwanted red and blue facial and leg veins.

    The small capillary blood vessels and diffuse red cheeks in people with sun damage or rosacea responds well to IPL. Using advanced technology, the Cynosure Icon delivers optimized light pulses to target unwanted sun damage, small red blood vessels and facial redness. The light energy activates the body’s healing response to naturally improve skin imperfections without harming the surrounding skin. Over time, the immune system will work to reduce the appearance of brown spots and veins on the area treated to reveal your beautiful skin. Icon IPL light therapy  treatments are safe for most skin types, but works best in people with lighter skin tones, Fitzpatrick types I-IV. There is minimal down time after a treatment. No swelling, but some mild redness for a couple of days.

    Some patients have severe problems with sun damaged skin, age spots, freckles and birth marks. These skin issues can be significantly improved with the Elite+ Alexandrite laser. The  wavelength of high energy light emitted by the laser is converted to heat energy and this damages the targeted skin. Alexandrite lasers cause precise destruction of the lesion and leave tissue in the surrounding area undamaged. This laser technique can be used most anywhere on the body, not just the face.

    Fractional non-ablative lasers are extremely effective advanced technology and an aggressive form of skin resurfacing. The ICON 1540 laser can address acne scars, surgical scars, stretch marks, pigment problems, wrinkles and even melasma (facial pigment problem following pregnancy). It is safe for all skin types. Fractional non-ablative resurfacing differs from the older ablative carbon dioxide lasers that were traditionally used. There are fewer skin side effects and less down time with the newer technology. No skin is actually destroyed. In non-ablative resurfacing, fractional lasers deliver heat into the skin through thousands of narrow, deep columns. The treatment eliminates old epidermal pigmented cells and deposits heat deep into the dermis to tighten skin and stimulate collagen remodeling reducing the presence of scars, wrinkles and stretch marks. Surrounding tissue is unaffected. The fractional approach allows the skin to heal much faster than if the entire area was treated. With the fractional non-ablative approach, there is more downtime than the other methods listed here. There can be some swelling for a couple of days and redness of the area treated for 5 to 7 days.

    Some patients do best with a combined method of skin revitalization. The Elite+ Alexandrite laser can first be used to eliminate pigmented spots, the ICON IPL with the MaxG treatment head then applied to reduce the small red blood vessels and sun damage, and finally the 1540 Laser to further reduce pigment, wrinkles and scars in one setting.

   If you are not sure that a photo facial is right for you, please call 973-778-2222 for a no-cost consultation to discuss possible treatment options.

Monday, February 29, 2016

On Vein Problems of the Leg

     Over the last decade, there have been major advances in the minimally invasive approach to vein problems. The key to proper treatment is the correct diagnosis of the root cause of the vein problems of the leg. We start with a careful history and physical examination to identify risk factors along with the signs and symptoms of venous disorders. The next step is the use of noninvasive ultrasound diagnostics to create a road-map of the venous system to identify and locate valve dysfunction. Only then can an appropriate treatment plan be developed. If ultrasound evaluation identifies that the valves of the saphenous vein or perforator veins are not functioning normally, a minimally invasive catheter based treatment can be used. Radiofrequency ablation, the Venefit procedure, is the technique of choice for the NJ VeinCare to treat valve dysfunction resulting in reflux of the long and short saphenous veins along with the perforator veins. This treatment is covered by most health insurance plans!

     Venefit™ is a clinically proven, minimally invasive procedure that treats varicose veins and their underlying cause, venous reflux, with little or no pain. Venefit patients can walk away from the vein procedure and be back to everyday activities – either at home or at work – typically within a day.

     The Venefit procedure is the treatment for venous reflux and varicose veins patients seek when they want a minimally invasive treatment alternative with less pain and less bruising when compared to traditional vein stripping surgery and laser treatment. Using the Venefit system, physicians close the diseased veins by inserting the Venefit catheter and heating the vein wall using temperature-controlled RF energy. Heating the vein wall causes collagen in the wall to shrink and the vein to scar close. After the vein is sealed shut, blood then naturally reroutes to healthy veins with normal valves.

     The Venefit procedure does not involve pulling the diseased vein from the thigh as with vein stripping surgery, or using 700° C laser energy which boils blood to occlude a vein as with endovenous laser (EVL).  In the RECOVERY Trial, a multi-center head-to-head comparative randomized trial comparing Venefit with EVL, the Venefit procedure was found to have less patient pain and less patient bruising than EVL for the best patient recovery experience available from a minimally invasive vein treatment.2  Additionally, in other randomized comparative studies have shown that patients receiving the Venefit procedure return to normal activity and work significantly faster than those receiving vein stripping.1

     The ClosureFast catheter, which represents the latest advancement in the Venefit procedure, has been shown in a multi-center study to have a 97.4 efficacy rate at one-year.3This shows that the treatment is highly effective.

     Venefit catheters are inserted into the vein via a tiny incision in the lower leg, eliminating the need for groin surgery and general anesthesia. The Venefit procedure is performed using local anesthesia in the office.

     Because treatment with Venefit is minimally invasive and is catheter-based, it results in little to no scarring.

     Venefit can be used for the long and short saphenous veins. In addition, incompetent perforator veins can be treated with excellent success using the Venefit technique. Dr. Nackman presented one of the first series of patients at a national meeting treated with Venefit for perforator disease.5

  1. Lurie, F, et al.Prospective randomized study of endovenous radiofrequency obliteration (Venefit procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study), J Vasc Surg 2003; 38(2):207-14.
  2. RECOVERY Trial – Data on File – Venefit Medical Technologies, Inc.
  3. Dietzek A, Two-Year Follow-Up Data From A Prospective, Multicenter Study Of The Efficacy Of The ClosureFast Catheter, 35th Annual Veith Symposium. Symposium. November 19, 2008. New York.
  4. Weiss RA, et al. Comparison of Endovenous Radiofrequency Versus 10nm Diode Laser Occlusion of Large Veins in an Animal Model. Dermotol Surgery 2002; 28: 56-61.
  5. Nackman GB, et al. Radiofrequency Ablation of Incompetent Perforator Veins. Presented at the 19th Annual Meeting of the American Venous Forum. Feb. 2007. San Diego, CA.

Thursday, February 11, 2016

Looking for a last minute Valentine's Day Special? Call for an appointment and say "Valentine" for a 50% off special on any Cosmetic office treatment. May not be combined with other offers. One per patient.

Thursday, February 4, 2016

On Competency

     What does it mean to be competent at something?  Competency may be defined as the ability to do something successfully or efficiently.  When it comes to determining if a physician is competent in his profession, no one, board, no organization, no government, no residency training program or hospital actually will state that an individual is competent.  There are significant legal ramifications to declaring someone as competent to practice medicine, and a mal-occurence  happens.  Would the organization that states a physician is competent become legally responsible?

     In medical school, residency and fellowship programs, trainees need to demonstrate proficiency in core competencies specific to medicine.  The ability to gather information, interpret the information and form a management strategy along with the ability to perform a variety of interventional tasks are inherent to the role of being a physician.  Medical students must pass national subject exams, national board exams, mock patient interview and physical exams.  Residents and fellow must pass annual inservice exams for advancement and board exams regulated by the American Board of Medical Examiners to become "Board Certified".  To take the board exams, one's residency director certifies that the trainee has completed and met the requirements of the training program. 

     The State mandates that physicians are licensed to practice medicine. One's application includes diplomas from medical schools and residency programs, and a certificate of completion from the national board of medical examiners.  One then is licensed to practice "medicine and surgery".  Most physicians practice beyond the four walls of their office and may have admitting and or operating privileges at a hospital or surgical center.  The assumption is that licensure and having one's "Boards" is a measure of competency, and for the most part it serves well.  

    In 1989, New York State enacted the 405 regulation, limiting resident work hours, as the result of a commission evaluating the causes of the death of the daughter of a prominent journalist at NY Hospital.  The commission blamed resident work hours and poor supervision for the death. This was a controversial finding with little data to support such sweeping changes. I was a junior resident at St. Luke's/Roosevelt Hospital center at the time, and we were very concerned about the impact on our training as surgeons.  A surgeon has to know a lot and do a lot.  Less hours in the hospital meant fewer chances to perform surgery and follow patients.  We worried that  when "on call" were covering far more patients than we normally did. Patients that we did not normally cover , so we were at a disadvantage in providing care.  We used to joke that "405" meant the 4th or 5th yr resident now did all the work, while the intern and junior residents went home.  The choice was between having a tired doctor that knew you vs. a less tired doctor that had never seen you before.

    In 2003, the Accreditation Council for Graduate Medical Education made the cap of an 80 hr work week mandatory nationally. Length of shifts were limited. Time off between overnight shifts required.  In a surgical residency, what had been a full time duty, had become shift work with penalties to the training institution for violation.  As a faculty member of a University, I was concerned that we were making a major change to how we train physicians without first defining how competent our current "product" was and not knowing if the decreased "time on topic" would result in less competent trainees.

     In a recent article in the New England Journal of Medicine (N Engl J Med. 2016 Feb 2), the end points of patient mortality and complications along with resident satisfaction were compared between surgical training programs that adhered to the work hour mandates vs. more flexible policies that waved the rules on maximum shift length and time off between shifts.  The results were that there was no difference in patient outcomes among the groups.  No mention or measurement standard was applied towards assessing resident competency.  Shouldn't the competency of residents be the subject in a training program?

Monday, January 18, 2016

Rosacea Facts

 Rosacea is a chronic inflammatory condition of the skin that effects millions of Americans. It may start as a general redness of the cheeks and nose. It may progress to bumps and thickening of the skin. It may be confused as "Adult Acne". It most commonly develops in people with fair skin in the 30-50 age group. The exact trigger for Rosacea is unclear. Rosacea can cause emotional distress and lack of self-confidence. There are treatments for Rosacea, but no cures. The redness and prominent visual veins of Rosacea may be effectively reduced with Intense Pulsed Light treatments. IPL is safe and effective in improving the appearance of Rosacea. Contact NJ VeinCare and Aesthetics Center for a free consult: 973-778-2222

Friday, January 15, 2016

Are You at Risk?

You just got home from vacation last night. You spent 6 hours on an airplane traveling back from some exotic location. In the morning you wake up with a painfully swollen left calf. Should you be worried? The answer is a resounding yes!

What is a DVT?

DVT or deep vein thrombosis is a life threatening medical condition with serious consequences that affects 2 million Americans each year. A blood clot forms in a deep vein within the leg or in some cases an arm. The most common presentation of a DVT is a painful, swollen leg. The clot can travel to your lung causing a PE or pulmonary embolism, which kills over 300,000 people in the US per year. That is over 7x the number of people that are killed annually in automobile accidents.

What is the postthrombotic syndrome?

DVT can also cause something known as the postthrombotic syndrome in the years following the event. This condition includes a painful swollen leg, itching, and difficult to heal leg ulcers near the ankle. It is caused by continued blockage of the veins or destruction of the valves in your veins that normally prevent blood from pooling down by the ankle. To avoid this condition, proper medical care is needed. Patients with DVT should be seen by a Vascular Surgeon to avoid this difficult to treat chronic illness. The best way of avoiding this condition is to use doctor prescribed compression stockings or socks following the DVT. Should you develop a leg ulcer following a DVT, there are new treatments that we employ to help heal the wounds in far less time than in the past.

What is your risk for DVT?

The best way of finding out your risk for DVT is to talk with your doctor. I have spent over 20 years taking care of patients with DVT. Sometimes the only risk factor is a long car or airplane ride during which the patient was immobile for many hours. There are known risk factors for DVT, and you should be aware of them. The greatest risk is recent hip or knee replacement surgery, serious trauma with a broken leg or pelvis bones, and spinal cord injury. Other important factors are a prior blood clot in you or a family member, a family history of clotting disorders, and age over 75. There are other less obvious health problems that also put you at risk for DVT: cancer, recent surgery, being in a cast, bed rest, being over age 60, the use of birth control pills, hormone replacement therapy, inflammatory bowel disease, being overweight, heart disease, lung disease, and even just garden variety varicose veins.

How is DVT diagnosed?

If you suspect you may have a DVT, it is important to immediately contact your doctor or go to an emergency room. Sometimes a blood test, known as d-dimer is done to see if you have a blood clot. It is considered a good, but not perfect screening test. A positive result in a patient whom the doctor expects has a DVT is a strong indication that a clot is present. However, a negative test in a patient that the doctor has a strong suspicion of DVT is not enough to rule out that diagnosis. The best test to determine if a DVT is present is a venous ultrasound. Venous ultrasound, sometimes know as a venous duplex, looks at the blood flow and appearance of the veins. If blood flow is blocked, a clot exists. Venous duplex is over 95% accurate in the detection of DVT.

Recently, I had a patient come to see me in my office for a same day, urgent appointment. She had been having leg pain and swelling for ten days. I performed an ultrasound in my office and was able to diagnose a DVT in under 15 minutes with this non-invasive technique. I was able to talk with her primary care doctor and coordinate her treatment. She was lucky that she sought medical attention, before she experienced a life threatening pulmonary embolus, or PE.

How is DVT treated?

The standard treatment for DVT is anticoagulation (thinning of the blood in layman’s terms) with the use of a drug called heparin. Heparin prevents the blood clot from getting larger, but it does not destroy the clot that is there. In the past, all patients were admitted to the hospital and heparin was given through an intravenous catheter for about one week. There are new forms of heparin that patients can take just once or twice a day as an injection just under the skin, very much like insulin, allowing treatment as an outpatient. Following heparin therapy, a pill called warfarin or other newer non-vitamin K dependent anticoagulants is started, to further prevent the spread of the clot. Treatments last typically for 6 months to 1 year. For patients with very extensive DVT, clot-busting drugs similar to what is used for a heart attack or brain attack can be used to destroy the clot. This would be followed by anticoagulation with heparin and warfarin.  Sometimes, patients have medical conditions that prevent them from being anticoagulated with drugs. In those situations, a medical device called a vena cava filter can be placed in the inferior vena cava (the large vein in the abdomen that collects the blood from your legs) to trap a blood clot travelling.

Rarely, surgery by a Vascular Surgeon is required to save a leg that DVT has threatened. In 15 yrs, I have only had to perform limb saving surgery 3x for DVT. In those situations, the blood clot had spread throughout all the major veins of the leg, and blood could not get back to the heart. There was no room in the leg for new blood to enter by the arteries. In surgery, the clot was removed with catheters allowing blood to return to the heart and supply the leg.

How is DVT prevented?

Ask your doctor to assess your risk at your annual check-up. For some patients, preventative blood thinners are needed. For others, just wearing compression stockings or socks is enough. If you had a DVT in the past, it is important for your doctor to try to find out why the DVT happened in the first place, and see if your risk factors can be modified to make it less likely to happen again.

Wednesday, January 13, 2016

New Guidelines for DVT Management

Interesting new guidelines for treatment of patients with Deep Vein Thrombosis:
-Goodbye to Warfarin
-Goodbye to compression stocking recommendations

I agree with the first, but the second is kind of silly. Warfarin was difficult to manage and newer oral anticoagulants have been shown to be as effective or better with similar or safer safety profiles. I don't understand the second recommendation or new recommendation not to offer compression stockings post DVT. The stockings don't prevent the post thrombotic syndrome but due decrease acute and chronic pain.  Acutely, they decrease pain and swelling. Chronically, they aid to prevent ulcers.