Wednesday, August 30, 2017

New varieties of water offer health benefits, but don't deliver

What if you could get more oxygen into your system by a method other than breathing?

A company says its oxygenated water, containing O4, also known as “activated stabilized oxygen,” can do just that. When you drink Oxigen [notice the clever spelling], O4 supposedly is absorbed under your tongue and in your stomach.

An article about this wonderful product states, “These aren’t just claims, but actual scientific processes supported by studies on stabilized oxygen.” Due to the limitations of space on the Internet, references to the studies are not provided.

The product “contains 1000 ppm of bioavailable oxygen” which is said to be about 20 times as much as the oxygen in tap water. Stabilized oxygen supposedly helps the body clear lactate and is beneficial for hangovers.

Friday, August 25, 2017

Quick takes on three recent stories


The magazine Popular Science reported on a paper which found after 20 subjects washed their hands at water temperatures of 100, 80, and 60 degrees, the temperature had no impact on bacterial counts. They also found antibacterial soap was no better than plain soap and water.

What did matter was time—10 to 20 seconds of lathering was better than 5 seconds, and 40 seconds was no better than 10 or 20.

The authors concluded that hands should be washed in water that was most comfortable for the individual.

In a blog post from last year, I pointed out that washing hands for more than 40 seconds, as advocated by a paper in Infection Control and Hospital Epidemiology, was impractical due to the excessive amount of time busy hospital staff would need to invest in doing so multiple times per day.

For example, 10 washes per hour at 40 seconds per wash is almost 7 minutes of hand washing times 8 hours equals 56 minutes.

Drivers who follow other drivers

The journal Frontiers in Psychology published a paper called “I’ll Show You the Way: Risky Driver Behavior When ‘Following a Friend.’” The authors, from the Human Systems Engineering department of Arizona State University, found that in order to keep up with the lead driver, drivers who don’t know the way took more chances when they followed someone.

The work was done by testing 16 college student subjects on a simulator. Drivers who followed were more likely to drive significantly faster, change lanes quicker, and in general “engage in riskier behaviors” than when listening to audible directions from a simulated GPS system.

The authors recommended that following another driver to a destination not be done. However if following is necessary, the driver of the lead vehicle should go slower and anticipate what the following driver might have to do to keep up.

1) I think most of us could have predicted the outcome of this research and come up with the same recommendations. 2) Does anyone who drives a car not own a smartphone in 2017?

What not to do with a hotel room tea kettle

According to the website, this is a thing that some people in China do when staying in a hotel. Whether travelers in Western nations also do so is not known.

A reporter for Gizmodo Australia asked a molecular biology professor from New Zealand’s Massey University to comment. She said, “It is super super super super gross” and pointed out that boiling does not necessarily kill spores formed by some types of bacteria.

Even if boiling killed all known living things, I still wouldn’t want to drink a cup of tea from a kettle that had contained someone’s skivvies the night before.

Wednesday, August 23, 2017

Bladder catheter + oxygen supply tubing = death

You may not be aware that I blog twice a month for the Physician's Weekly website. My latest post is called "Bladder catheter + oxygen supply tubing = death" and it can be read by clicking here.

How a pneumoperitoneum can kill.
This x-ray shows what happened to an elderly man whose oxygen tubing somehow became connected to his bladder catheter.

Tuesday, August 22, 2017

Three new studies confirm germs are everywhere

These ubiquitous germs don’t seem to be harming anyone, but reporting on the studies generates lots of clicks.

For many years kitchen sponges have been known to harbor bacteria. Now comes the news that cleaning those sponges not only doesn’t work, it may make the situation worse by promoting the overgrowth of potentially disease-causing bacteria—for example Moraxella osloensis.

The New York Times reports German researchers found kitchen sponges contained 362 different types of bacteria and as many as 82 billion bacteria per cubic inch of space. The senior author of the study said, “That’s the same density of bacteria you can find in human stool samples” [but not the same types of bacteria] and suggested replacing kitchen sponges frequently.

These revelations were based on bacterial DNA and RNA samples from 14 [yes, just 14] used sponges. Note the use of the word “potentially” to describe the pathogenicity of Moraxella. A PubMed search for this microbe back to 1968 yielded only 82 references, many of which were not pertaining to any human illnesses. The few case reports of infections involved patients who were immunosuppressed.

Wednesday, August 16, 2017

Fatal internal jugular vein cannulation by a misplaced NG tube

A case report published last month involves a 79-year-old man with multiple comorbidities including depression, alcohol abuse, hypertension, CHF, and COPD who was admitted because of abdominal pain and distention which was found to be a perforation of the right colon. 

He underwent a resection and did well until the seventh postoperative day when he became distended. A nasogastric tube was inserted. Its position was checked by injecting air through the tube and auscultating over the upper abdomen [a notoriously inaccurate method of locating an NG tube’s position].

A few hundred mL of dark blood came out. He was treated for a presumed upper gastrointestinal bleed. A chest x-ray showed the tube in good position but the tip was not seen.

When the patient’s vital signs deteriorated, a new NG tube was put in and drained 2 L of blood. The patient suffered a cardiac arrest and could not be resuscitated. At autopsy, the NG tube was found to have gone through the right pharyngeal wall and into the right internal jugular vein. The tip was in the superior vena cava.

Although I had never heard of this complication before, it has been reported in the literature at least one other time.

Wednesday, August 9, 2017

What to do when a normal looking appendix is found at surgery for appendicitis

For patients undergoing surgery with a presumptive diagnosis of appendicitis in Norway and other parts of Europe, the protocol is if the appendix looks grossly normal in the operating room, it is usually not removed.

This approach was mentioned as part of a paper on the readmission of post-appendectomy patients from Oslo University Hospital. Most of the patients underwent laparoscopy based on clinical diagnosis with only 160 having CT scans and 67 having ultrasounds.

Of the 710 patients in the Oslo series, 94% of the appendectomies were done laparoscopically, and 111 had a normal appearing appendix at laparoscopy. The appendix was not removed in 88. The other 23 patients had appendectomies for various reasons, and those appendices were normal at pathology.

The cumulative rate of operating for what turned out to be a normal appendix (88 + 23 cases) was 15.6%, which the authors attributed to “the low use of preoperative CT” due to concerns about radiation exposure. That over 100 patients had unnecessary general anesthesia and surgery was apparently not a concern.

Monday, August 7, 2017

Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

Wednesday, August 2, 2017

Another chapter in “Surgical Cap Wars”

No one expected the AORN [Association of periOperative Registered Nurses] to meekly accept the conclusion of the paper which found no difference in infection rates when surgeons wore surgical skullcaps or a bouffant-style head coverings.

The AORN recently fired back with a letter to Neurosurgery, the journal that published the paper. It has not yet printed the letter or a response to it by the authors of the paper. I look forward to seeing both.

Meanwhile, Becker’s Infection Control and Clinical Quality revealed some tidbits an article entitled and “AORN experts respond to study on bouffant use and SSI rates.” [SSI = surgical site infection]

The AORN claims that it never mandated the use of bouffant headgear. It merely called for “a clean surgical headcover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn” because “hair carries bacteria that could [emphasis mine] cause an SSI.”

Lisa Spruce, the director of evidence-based practice for the AORN, said, “It’s up to the facility to determine what’s the best way to get everyone’s hair covered.” This is rather disingenuous as everyone knows the only way to cover every single hair on the head is to wear a bouffant or a hood.

The AORN did not offer any evidence that hair causes infections. Instead Spruce and the other AORN experts chose to nitpick the Neurosurgery study by pointing out a single scatter plot that showed what they said was a decrease in SSI rates after bouffants were worn.

They claim the figure below indicates fewer infections occurred late in the 13 month period of bouffant usage because it took some time for everyone to comply with bouffant use.
Blue is skullcap. Red is bouffant. Time in months
They offer no proof that adoption of the bouffant took several months. In my experience, when hospitals go from skullcaps to bouffants, the transition is abrupt. On the day the mandate takes effect, skullcaps are no longer available. And by the AORN's logic, one could argue that the plot shows a spike in bouffant-associated SSIs at months 4 and 5 of use.

What about statistical significance? The table directly above the figure they cited clearly shows that there was no significant difference in the SSI rate between the two types of headgear for all operations in the hospital, spine cases, or craniotomy/craniectomy procedures.
Click on table to enlarge it.
In fact if you believe in trends, there were slightly more infections for overall operations and spine cases in the bouffant group.

The AORN wants all hair covered. What about the eyebrows? As I mentioned in a post back in May, an outbreak of SSIs that occurred after some plastic surgery operations in Israel was traced to an organism found in the surgeon’s eyebrows.

Bottom line: If the AORN cannot cite evidence proving that scalp or facial hair causes infections, its experts should do their own research and publish it—otherwise stop damaging the organization’s already marginal credibility.

Thanks to Artiger, a loyal reader of my blog posts, for sending me the link to the Becker's article.