Friday, February 5, 2016

What? A woman with no appendix undergoes attempted appendectomy

A surgeon found no appendix when he operated on a 69-year-old woman with abdominal pain in Saskatchewan. She had been admitted with chronic diarrhea and right-sided pain. A colonoscopy showed what was thought to be impacted stool in the orifice of her appendix, a finding often associated with appendicitis.

Laparoscopic surgery was done through three small incisions, and after an hour of searching, the appendix was not located.

After the operation, the doctor claimed the patient did not tell him she had had an appendectomy possibly during either gallbladder or tubal ligation surgery in the past. On one of those occasions, she may have had an incidental appendectomy—removal of a normal appendix to theoretically prevent appendicitis in the future. It's an operation rarely done today.

She was discharged after a brief hospital stay. There was a bit of a fuss about "unnecessary surgery" and what, if anything, the surgeon told the patient after the procedure. A phone conversation with him was secretly recorded by the patient's daughter. An investigation is underway.

You might be interested in two questions. Can you get appendicitis again after you've had an appendectomy? Other than previous surgery, is there another explanation for a patient who does not have an appendix?

Wednesday, February 3, 2016

Another reason not to rely on medical advice from the Internet.

On New Year's Eve, The Daily Beast published an article with suggestions about how to avoid a hangover.

Some of the tips were reasonable such as limiting yourself to one alcoholic drink per hour and maybe avoiding certain beverages like wine, bourbon, and Scotch, which contain congeners and have been associated with worse hangovers.

However, some of the advice is wrong.

The article recommends this on the day you plan to party:

6 a.m.: Rise and hydrate! Drink early and drink often. One of the main causes of a hangover is dehydration. Women should be drinking 2.7 liters per day, and men should get 3.7 liters. That's 0.7 gallon and 0.97 gallon, respectively.

Saturday, January 30, 2016

Basketball is still an awful sport to watch

From the current issue of Sports Illustrated:

So why do I care about this?

Four years ago, I said the same thing in a blog post called "Basketball is an awful sport. Here's why." If you don't want to read the whole thing, I will summarize.

Basketball is the only sport I can think of where a team can be rewarded for breaking the rules. Specifically, by deliberately fouling and opponent's weaker free-throw shooters, a team that is losing can catch up when the weak free-throw shooter misses and the team that is losing gets the rebound.

All of the fouls and free throws plus the seemingly unlimited number of timeouts that each team has result in the last two minutes of the game taking 20 or more minutes.

To me, it's unwatchable.

Pertinent to Van Gundy's comments is that Detroit Pistons center Andre Drummond, who will play in the All-Star game, set an NBA record by missing 23 free throws in a single game on January 20.

This was part of a deliberate strategy by the Houston Rockets who were losing the game by nine points at the start of the third quarter. Houston's K.J. McDaniels fouled Drummond five times within nine seconds and the team fouled Drummond on seven straight Piston possessions. During that stretch, Drummond made 5 of his 16 free-throw attempts.

It must have been quite an exciting couple of minutes of play.

The All-Star Drummond had to be taken out of the game in the fourth quarter so that Detroit could hold on and win the game.

Yahoo Sports reporter Eric Freeman said: "While it's a little inexact to say that sending a player to the line over and over again 'isn't basketball' given that the rules allow it, it's downright enervating to watch and not an ideal product for a league that ultimately sells entertainment above all else. Intentional fouling is also increasingly common, with seemingly each team having at least one player who gets sent to the line in opportune moments."

He suggested that NBA commissioner Adam Silver is going to have to do something about the issue.

Here's what I've done about it. For the last few years, I haven't watched basketball.

Wednesday, January 27, 2016

My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isn't one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe it's because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Here's what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

Wednesday, January 20, 2016

OR delays: Who's responsible and what can be done?

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."

Thursday, January 14, 2016

Can patients shower immediately after surgery?

Here’s what a recent paper published ahead of print in Annals of Surgery says:

Between May 2013 and March 2014, 222 patients were randomized to the group allowed remove their dressings and shower at 48 hours and 222 to the group permitted to shower only after the original dressing and the sutures were removed in clinic. There were 4 (1.8%) superficial surgical site infections in the early shower group and 6 (2.7%) in the late shower group, an insignificant difference with p = 0.751.

The authors concluded that clean and clean-contaminated wounds can be safely showered 48 hours after surgery, and early postoperative showering may increase patient satisfaction.

I have always been an advocate of early showering after surgery. Wounds properly closed will be bridged by epithelium within 48 hours. Tap water is relatively sterile or we couldn't drink it. Many studies have shown that even irrigating open wounds with tap water instead of sterile saline does not lead to more infections. [Links here and here.]

Much as I would like to believe the Annals study, I can’t because it is probably underpowered to show a difference between the two groups.

Here is a nice definition of statistical power from a website called

“In plain English, statistical power is the likelihood that a study will detect an effect when there is an effect there to be detected. If statistical power is high, the probability of making a Type II error, or concluding there is no effect when, in fact, there is one, goes down.”

To their credit, the authors did try to estimate the sample sizes they would need by doing a power calculation. They knew that the wound infection rate for the cases they intended to enroll was about 1%. The problem is they estimated that showering at 48 hours would result in a wound infection rate of 5%. That seems very high to me for the types of cases included in their investigation—thyroid, lung, inguinal hernia and skin tumors.

If they had hypothesized that early showering would merely triple the rate of wound infections from 1% to 3%, they would have needed at least 1536 patients in each arm of the study. Then if there was no difference, one could conclude that early showering truly does not cause more wound infections.

Even if the known incidence of wound infection was much larger, say 5%, and the rate of infection with showering was presumed to be doubled (10%), to have enough power a study would need 434 patients in each arm.

Many websites provide calculators for determining the appropriate sample sizes to detect with a reasonable degree of certainty whether one intervention is better than another. Anyone thinking about doing a prospective randomized trial should realistically estimate the expected difference and calculate the power.

Whenever you read a negative study, the first question to ask is, “Was the study adequately powered to avoid a type II error?”

Monday, January 11, 2016

More evidence that the manuscript peer review process is broken

To the surprise of almost no one, asking authors of research papers to submit names of potential peer reviewers for their manuscripts turns out to be a bad idea.

According to a recent New England Journal of Medicine article by Dr. Charlotte J. Haug, a number of research papers have been retracted because reviews were fabricated. Email addresses of suggested peer reviewers were not legitimate. The bogus email addresses were almost all created by authors of papers who then reviewed their own work favorably using fake identities. 

More about the problem can be found on the blog Retraction Watch.

This type of fraud is simple to do because anyone can set up an email address on Gmail or Yahoo mail using any name. Unless a reviewer has an academic email address, proving legitimacy is impossible.

However even if a reviewer has an “edu” address, how would an editor know that a suggested reviewer is not the author’s sister-in-law or a former mentor?

Every medical student who applies for residency knows that you don’t ask someone for a letter of recommendation unless you are sure that it will be favorable. Why would an author take a chance on recommending someone to review a paper without knowing that the review would be a good one?

I agree with the Dr. Haug that soliciting the names of possible reviewers from authors can save editors time and bother. Having spent three years as an associate journal editor, I have experienced the frustration of trying to find high quality reviewers or even a warm body of any quality to do the job.

I also agree with her that a root cause of this problem is the pressure on faculty to publish.

Another problem is that there are too many journals. In 2014, well over 5000 journals and 760,000 papers were included in Medline. The combination of “publish or perish” and superfluous journals leads to the proliferation of marginal papers.

The problem is not simply fake reviews. Since journal reviewers are not paid and have many other responsibilities, they may not thoroughly read papers or provide useful comments about manuscripts.

Some have suggested paying peer reviewers, but who would pay them? Certainly not publishers, even though they make tons of money. And paying might attract unqualified people looking to make a little extra cash.

What about post-publication peer review? It is already happening on blogs, on sites like PubPeer, and even on PubMed. However, the volume of papers published in medicine alone certainly precludes post-publication review of all of them.

Maybe it doesn’t matter. New journals are appearing every day. Most are “open access” and the charge authors “processing fees.” For many of these publications, processing fees do not include even a cursory manuscripts peer review.

With so many journals publishing just about anything for the right price, readers will have to do their own peer reviewing. Be skeptical my friends.