Saturday, December 20, 2014

My top seven posts of 2014

I'm now in my fifth year of blogging. Thanks to everyone who has taken the time to read what I have written—especially those who have commented. I've learned a lot from you.

My seven most read posts of 2014 are listed below. Click on the title to read the post.

"That electric hand dryer study was bogus" was an analysis of a study that made outrageous claims about electric hand dryers and dispersal of bacteria.

"What are the residency prospects for graduates of offshore medical schools?" took a look at the realities associated with graduating from medical schools outside the 50 states and Puerto Rico.

"Preventing infection: The "bare below the elbows" rule for doctors doesn't go far enough" discussed the role of clothing in the transmission of disease and the ultimate solution to the problem.

"A medical student says to abandon the match" was my take on a proposal to do away with the residency matching program in the US. Spoiler alert: I didn't think it was a good idea.

"How to select surgical residents: The evidence" was a review of the limited evidence concerning how surgical program directors select candidates to interview and rank.

"A paper of mine was published. Did anyone read it?" spoke to the proliferation of medical journals, the likelihood that a single paper will be read, and what the future may hold.

"Health Care and the $20,000 Bruise: A different take" raised a lot of questions about a Wall Street Journal article written by a doctor who took his son to an emergency room for an 11-day-old bruise on his head.

And the all-time winner so far is this post, "Appendicitis: Diagnosis, CT Scans and Reality," which was the tenth post I ever wrote and is approaching 22,000 page views.







Best wishes to all.

Wednesday, December 17, 2014

More germs: Planes, desks, and even kisses

Airplanes are so permeated with bacteria that it is truly a wonder that anyone survives a flight. I'll bet you thought it was the air in the cabin, but a recent story in USA Today says otherwise. "The real problems lie on the chair upholstery, the tray table, the armrests and the toilet handle."

What should germophobic passengers do? "First, they should travel with and use an alcohol-based hand sanitizer. They should also travel with a small pack of disinfectant wipes," said the microbiologist who did the study. "The first thing I do when I sit down is to wipe down the armrest and tray table because that's where my arms will be. You need to decontaminate where you'll be spending your time and eating."

From MailOnline: "Millions of us spend our days slaving over a keyboard. But lurking between the keys, hidden on the mouse and nestled in your phone lies [sic] more than 10 million bacteria—400 times more than on the average toilet seat." [Despite what I reported in my last post, the toilet seat will remain the gold standard for comparing contamination levels until it is unseated.]

At least that is way fewer bacteria than the next study found.

"Every Kiss Begins With 80 Million Germs" headlines WebMD about a paper published in the journal Microbiome. WebMD story says, "In one experiment, the researchers gave 21 couples a probiotic drink containing bacteria before they kissed. Swab samples afterwards showed the transfer of those 80 million germs."

From the methods section of the paper: "One of the partners was invited to consume 50 ml of a probiotic yogurt drink containing L. rhamnosus GG, L. acidophilus LA5, and B. lactis BB12 [all non-pathogens]. After 10 seconds, saliva and tongue swabs were collected from this partner (donator) and after a second intimate ["full tongue contact and saliva exchange"] kiss of 10 seconds, saliva and tongue swabs were directly collected from the other partner (receiver)."

Saliva has some antibacterial properties. Maybe the researchers didn't wait long enough to test for bacteria after one of the partners drank the yogurt? People who have 80 million pathogenic bacteria in their mouths probably have bad breath and poor oral hygiene. I doubt they are indulging in 10 second tongue kissing.

And here's an excerpt from the conclusion. "This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is most pronounced in couples with relatively high intimate kiss frequencies of at least nine intimate kisses per day [my emphasis] or in couples sampled no longer than 1.5 hours after the latest kiss."

Ten second kisses? Nine intimate kisses per day? Other than perhaps high school kids, who is kissing 9 times a day for 10 seconds at a time?

Bottom line? After eating yogurt, wait at least 90 minutes before tongue kissing someone.


Friday, December 12, 2014

Germs found on credit cards, but there's hope for civilization

Regular readers of my blog know that I am a connoisseur of studies about bacteria in the environment and on human tissue. If you click on the "Infection" label to your lower right, you can read my previous posts on the subject. Not surprisingly, I am skeptical of inflammatory headlines claiming that germs on various surfaces are dangerous.

Money has been the subject of many studies, most of them showing it is covered with bacteria. A recent video from the Cleveland Clinic discussed a study from England which found bacteria on the hands of 11% of people tested, on 8% of the credit cards tested, and either 14% or 6% of paper money [the accompanying story was contradictory].

This is old news. A 2012 study from the European Cleaning Journal [not a peer-reviewed journal] found that 26% of paper money, and 47% of credit cards showed "high levels of bacteria including E.coli and Staphylococcus aureus," and "around 80% of banknotes and 78% of credit cards tested showed traces of bacteria, and some carried more germs than [wait for it…] the average toilet seat."

For those of you new to the field of culturing everything in sight, the toilet seat has been the gold standard for comparison of contamination as I noted in a 2013 post.

Tuesday, December 9, 2014

Should radiologists tell patients their test results?

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Thursday, December 4, 2014

Antibiotics vs. surgery for appendicitis: It's time for a randomized trial

Maybe you've heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You don't have to read the Washington researchers' post to take the survey.

You may click here to answer that question. Thanks.




Tuesday, December 2, 2014

Patients can chew gum immediately before surgery. I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Friday, November 28, 2014

Work hours limits in Sweden: It's complicated

A physician in training from Sweden emailed me some questions, and the topic of work hours came up. To protect his identity, I have slightly altered a some of his responses, but I have not altered his message.

It´s quite interesting as physician work hours, or rather productivity, are debated a lot in Sweden right now.

The work hour restriction
[50 hours/week in Sweden] is not enforced at all. This summer I was working as a junior house officer in a surgical specialty at a county hospital, and I can´t say I noticed anyone trying to cap my work hours, on my first day I was encouraged to work as much as I could.

On the other hand I was not put on the on call schedule, as that involved covering the ED (outside of academia EM-physicians are scarce) and all surgical services. It is hard to get to work 50 hours a week covering only a 12-bed service, when the nurses do all the blood tests (except blood gases), urinary catheters, do all patient transporting, and such. I did get some OR time though.

I think there is no enforcement of the 50 hours/week restriction because doctors here don´t get paid as fee-for-service. There is zero difference if you do 5 or 10 cases during your shift. There is no incentive to work more than 50 hours/week, and doctors don´t.

A problem that is more particular for surgery is the limited capacity of operating theaters, in many hospitals productivity is low, case turnover time is long, and you can only do elective cases between 8:30-16:00 (and God forbid you operate past 16:00). In the hospital I worked, we were not allowed to start elective cases after 14:30, and we only had 2.5 days/week when we could operate.

If you want to make money, you take a leave, go to Norway, work 80-100 hours/week in some rural hospital there for a few months, and earn three times as much.
[I was also told about this by some Swedish surgical residents I met while attending a conference there last year.]

We do a lot of administration. A study published in a Swedish medical journal, in Swedish sadly, found that Swedish surgical residents spend 40% of their time on administration and 40% of their time taking care of patients. Their British counterparts did 15% admin and 66% patient care. An average work day was 8.2 hours in Sweden and 12.2 hours in England.

Because of this, few physician hours are "productive" and Swedish doctors see very few patients compared to most Organization for Economic Co-operation and Development (OECD) countries. Queues build up and the hospitals don´t want that. So I guess they want us to work.

There was however a government crackdown on a rural hospital in northern Sweden where the county (which is the governmental body running hospitals in Sweden) was fined for imposing too long work hours. So there may be change, but rural northern hospitals are not in an ideal position to recruit more doctors.

Right now work hours are restricted formally but in practice it is hard to get that amount of meaningful work done. It has some perks however, as residents can pick up their children from day care.
[Emphasis added]

Is this where we are heading in the United States?