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 couldnt 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 effectsizeFAQ.com:

“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?”

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Indian teenager dies after being raped and set on fire

A 16-year-old Indian girl who was raped and then set on fire on the roof of her home on Monday has died, police said on Wednesday, the latest in a string of horrific sexual crimes committed against women in India.

The investigating officer told AFP that the  teenager had sustained more than 90 percent burns on her body and could not be saved. He said she died in hospital early Wednesday.

"Unfortunately she could not be saved despite the best efforts of the medical staff," said Ashwani Kumar. "We have arrested the accused, who is 19 years old and sent him to judicial custody. "An investigation is on to find out more about the motive and details of the crime,".

"The body has been sent for postmortem. We are waiting for the report."he said.

The accused has been charged with a slew of offences including rape and murder, Kumar said.

 

According to media reports, the girls dad said the 19 year old man lived nearby in their village in the northern state of Uttar Pradesh had been harassing his daughter for a year despite the fact that he had warned him several times to leave his daughter alone.

The 19 year old has been arrested and charged with sexual harassment, rape and murder.

There have been so many rape incidents in India with the men getting arrested sometimes while others have shamed the victims and let the men go unpunished.

Last month, a teenage rape victim was sexually assaulted for a second time while in hospital receiving treatment for the initial attack in eastern Jharkhand state.

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Rising Star Productions Presents Getting Rich in Lagos

Starring Wole Ojo Oge Indiana Jode Kosoko Rachel Oniga Agbor Rykardo Stanley Chibuna (funnybone) Kiki Omeili. Directed by Darasen Richards.

Synopsis: A story of how a man rose from the slums to wealth. The movie walks us through the dynamics of a young man’s struggles; his good, bad and ugly experiences, stopping at nothing until he achieves his dreams. Premieres on the 24th of March at leisure Hall film House cinema surulere lagos Time 5pm. Watch trailer after the cut...

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Google v Squidoo and Hubpages

Matt Cutts, Google guru, has declared war on content farms.  It is a long war, involving a lot of algorithm tweaking.

The idea being to reduce the power of the content farm when compared to genuine content written for the purpose of it being there, rather than a quick buck.

The graph below shows the last few months of Hubpages v Squidoo traffic as measured by Quantcast.  HubPages is the one at the bottom.

There is a clear decline in HP traffic, and a corresponding rise in Squidoo.  It is as if turning down the dial on HubPages simply increased the views to Squidoo.  Im not a fan of Squidoo but that cant be what Google wanted.

The two sites are very similar.  Content written for marketing - either adsense or affiliate.  To me, Squidoo looks spammier but its a choice thing.

Heres the graph...

You can see the divergence in traffic around July, gathering pace in late September where HubPages took quite a knock.  As HP goes down then Squidoo rises.  All that traffic had to go somewhere, but it doesnt look like it went to individual sites.

Google just took it from HP and gave it to Squidoo.

I wonder if the Squidoo drop at the beginning of November is the next phase of Googles anti-content farm efforts?  No corresponding rise for HP, so a content farm drop overall.

This has long been promised by Google, the end of the writing sites that specialise in low quality generic material that serves little purpose.  The sites that I have spent my time writing on as it happens.

I havent bothered feeding my blog into Quantcast by the way, it wouldnt even register I should think.

Really, I should stop looking at traffic and just get on with writing.  The trouble is, it is so addictive.

Wouldnt it be nice if Google just set the dial higher on our own content and gave us millions of hits each day?  That really would be worth blogging about.

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What comes after the Heimlich maneuver

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyones skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aarons Tracheostomy Page and it bills itself as "The Internets leading tracheostomy resource since 1996."

Heres an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers dont need an airway in a hurry and they dont bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwells outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

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More on activity restrictions after surgery

In early January, I blogged about the dearth of evidence about activity restrictions after surgery.

A number of people commented and most agreed that there is little basis for most of the activity restrictions surgeons currently use.

An anonymous reader told me about a 2008 study from Creighton University that generated some interesting data about intra-abdominal pressures associated with some common activities. Here’s a summary of the paper.

The authors managed to find 10 healthy volunteers all of whom could bench press at least 100 pounds and were willing to have nasogastric manometry catheters placed and Foley catheters inserted into their urinary bladders.

Intra-abdominal pressures were recorded as each subject coughed 10 times as hard as possible, bench pressed varying amounts of weight from 26 to 114 pounds, and vomited after receiving ipecac syrup and drinking about 500 mL of water.

Pressures in the stomach and bladder correlated fairly well. To keep things simple, let’s look at gastric pressures only.

The highest mean and maximum pressures were found during vomiting. Coughing produced similar pressures. Most interestingly, intragastric pressures during weightlifting were significantly lower with a mean of 2 mmHg and a maximum of 52 mmHg, p <0 .001.="" br="">The authors mentioned that another group had found similar intra-abdominal pressures with subjects bench pressing 25 pounds.

Another unexpected finding was that although the differences were not significant, the mean intragastric pressures were inversely proportional to the amount of weight lifted.

Maybe we should tell postoperative patients not lift less than 26 lbs.

The authors were focused on measuring pressures that would disrupt a gastric anastomosis. They calculated that an intragastric pressure of 290 mmHg generated by vomiting was about 1/50 of the 20N [Newton] force that would disrupt a gastric suture line in a porcine model as demonstrated by other investigators.

The effect of repetitive stress such as found in patients with a chronic cough were unknown, but they said “the intra-abdominal pressures generated in our study alone do not appear to be responsible for hernia formation.”

The Creighton study authors concluded, "The common postoperative lifting restriction, although logical, has little evidence to support it." They called for more research in this area.

Unfortunately, their call has not been answered.

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What about activity restrictions after surgery

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology services description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.



I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I cant think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to forever [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.

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Cool Business Opportunities by Marc Charles

Cool Business Opportunities in 2014

7:04 AM

Dear Entrepreneur:

I discovered three opportunities with “over the top” profit potential.

I’ll give you the details in a second.

I usually focus on one opportunity each week…so consider this a Happy New Year present!

But know this……Ive been identifying great business opportunities for more than 30 years.

I’m referred to as “King of Business Opportunities” for good reason. 

Here’s what R.F. said about me recently:

“Marc has an uncanny ability for spotting profitable trends and creating simple profitable businesses around them.  There are a ton of people selling push-button “sit by the pool” type programs which claim to make a million dollars instantly. That’s not what Marc Charles does. He’s a simple guy, making a ton of money in simple ways.  If you have a chance to meet Marc in person you will be a richer person, guaranteed”

I’m not tooting my own horn! I just want you to know identifying “legitimate” business opportunities is in my blood.  I’ll be doing this until they find me found face down on my keyboard!

“Yeah….But What Have You Done For Me Today”?

There hundreds of magazines, newsletters, websites, podcasts, newspapers, TV and radio shows devoted to exploring business opportunities today.

But most of the opportunities people are talking today about are history - nada, toast!

My focus is on business opportunities which capitalize on rising trends right now!

And listen…..I’ve watched entrepreneurs lose millions on “sure things” such vending routes, franchises, restaurants, flipping real estate, nightclubs, discount clubs, software, MLM, kiosks, airport gift shops and “life changing” inventions.

My approach is pretty simple…I don’t want align myself with obsolete products, businesses or dying trends.

On top of that, you don’t want to risk a boatload of cash either.

 

My preference….although it’s not always available….are businesses that don’t require a ton of employees, inventory, paperwork, lawyers, regulation or physical assets.  

My columns are for entrepreneurs who want the gut-wrenching truth about legitimate business opportunities. 

Most of the opportunities I research are not a good fit for readers because the cost of entry is too high.

For example, a typical Subway “franchise” will set you back $100,000 - $250,000 - and that’s just for starters. 

The real money pit for any restaurant (and especially a franchise like Subway) is the operating capital. 

On top of that, most franchises require you to cough up a percentage of the profits every month in the form of royalties too. 

But that’s not all…..there’s more downside risk

Most franchise businesses are required to buy food, supplies and equipment from the parent corporation. Wow! If you do a search in Google News on Stone Cold Creamery you’ll see what I mean.

Twenty-five years ago a Burger King franchise was considered one of the best opportunities around. 

But today, you can’t unload a Burger King franchise fast enough. 

There’s even a group of franchisees suing the company because they
“can’t get out”!

The trend of owning a MacDonald’s or Burger King franchise for a start up entrepreneur is over for most entrepreneurs. Not to mention sales are down big time at these places.

Granted, restaurants can be profitable. 

If you’re completely out of your mind and still decide to open one – my suggestion would be to partner with a rising brand such as Johnny Rockets, Baja Fresh or Famous Dave’s BBQ. For higher end restaurant franchise consider KEO Japanese or Morton’s Steak House.

You can go it alone – and try to copy the formula of a rising franchise brand – but the odds are against you.

There are hundreds of business opportunities in the world today that don’t require massive capital, employees, buildings, inventories, accountants, lawyers or huge learning curves.

Three Cool Opportunities for 2014 (and beyond) 

1)    Internet Direct Response

Internet ecommerce continues to climb and there’s no end in sight.

Internet direct response businesses which provide “over the top” service and reasonable prices should perform well – even in a downturn.

Internet direct response businesses would include selling products on eBay, Yahoo! Marketplace and Amazon.com.

This also includes selling information and digital products.

ClickBank.com is a wildly successful digital marketplace for small entrepreneurs. 

2)    Self-Storage Real Estate (in Select Areas)

The self-storage business generates more revenue per square foot than any other real estate investment. I know it’s hard to believe - but it’s true.

Granted, the 70s and 80s were the boom time for the self-storage industry.

In 2010 there was a consolidation in the market and a pull back in the trend.

But in my opinion the trend is back. This market presents some great opportunities for entrepreneurs of every size.

The downside is the capitol required. But you’ll find hundreds of self storage properties for sale and many with owner financing.

Or you can build your own facility.

The one thing I like about this business….(and I know it better than most)…is the multiple streams of income.

You can generate income from unit rentals, ancillary products, insurance, truck rentals, late fees and self storage auctions.

The key to success in a self storage business is marketing, which includes capuring drive by traffic.

I’m not convinced the new trend in portable self-storage units or “pods” is a hit rising trend. I know they’re gaining popularity. But the “numbers” I’ve seen do not compare with traditional self storage operations or self storage REITs.

3)    Import Export Businesses

There’s a misconception regarding most import and export businesses.

You can start this business on a shoestring, and even become a middleman or finder and profit this way.

Importing and exporting is a rising trend. You can run successful import export business from anywhere in the world.

One of the hottest sites on the Internet for helping import/export entrepreneurs is Alibaba and AliExpress

eBay and Amazon.com will continue to play a role in helping import and export entrepreneurs too.

I’ve developed an exciting new program called China Wholesale Trader. It’s designed to help entrepreneurs make money quickly and easily in the import market.

There you have it!

I’ve shown you three new “over the top” business opportunities for 2011 and beyond.

I’m interested in hearing what you think…..not only regarding these opportunities but my weekly articles for The League of Power.

Drop me a note or post your comments on the forum.

Until next week!

Your Humble Host,

Marc Charles

******Valuable Resources *******

Internet Direct Response Gurus:

Bob Bly

Frank Kern

Ken Envoy

Joe Vitale

Allan Gardyne

Self-Storage Real Estate Gurus

The New Real Estate Riches Seminar

B. Wayne Hughes

Import Export Gurus

China Wholesale Trader (Yours Truly)

Ty Hicks

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Woman dies after being trapped in elevator for a month

A womans corpse was discovered in an elevator in the Chinese city of Xian which has led to the detention of an elevator maintenance crew who improperly cut off power to the elevator a month ago without checking if anyone was inside or not.

In a statement posted Saturday, the Gaoling district government said two maintenance workers turned off the power source on Jan. 30 to the elevator in a residential building after they were called to check on a glitch without making sure it was empty first.

When they returned a month later, on March 1, for repairs, they found a female corpse there, the government said.

The woman was identified as a 43-year-old resident who was living by herself. Police ruled out any foul play but concluded her death was caused by the gross negligence on the part of the maintenance crew in a case of involuntary manslaughter, the government said.


Source: ABC News

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Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Heres what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

The hospitals own press release, published on the science website EurekAlert, said this: "The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patients vital signs, and documentation errors."

Mistakes in labeling syringes, occurring 24.2% of the time, were the most common type of error despite the presence of a bar code-assisted labeling system. This begs the question, how valuable is a bar code system that only prevents problems 75% of the time?

A website called FierceHealthcare took it up a notch saying, "While the research was conducted on procedures that took place at MGH, it indicates that similar failures happen at hospitals around the country."

It indicates no such thing. The paper actually says "our findings may not be generalizable to nonteaching hospitals." Or as is the case with most papers from a single institution, the results may not be generalizable to any other hospital.

Finally, the lead author of the study poured more gasoline on the fire with this comment, "Patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation."

The study found nothing to suggest that 50% of patients suffered "lasting permanent harm." In fact, it isnt clear that any patients suffered lasting permanent harm, and most (66.7%) of the medication errors and adverse drug events were only potentially harmful.

Google “medication errors” and click on “News” for links to several more hand-wringing reports about the MGH study.

Although the paper and its accompanying media blitz may have overstated the severity of the problem, too many potentially harmful errors are occurring in the operating room and anesthesiologists need to clean up their act.

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Unproven athlete training and recovery devices

A recent Wall Street Journal article reported that #1 ranked Novak Djokovic and several other tennis players frequently spend time in hyperbaric chambers after matches. This supposedly helps athletes recover and prevents injury.

A hyperbaric pod

Malcolm Hooper, the owner of the Melbourne "clinic" where the hyperbaric pods are located and a former chiropractor, said he has "seen gains in his patients, and the research suggests hyperbaric treatment can help many ailments." The article also quoted several athletes who favored the treatment but cited none of the research.

Also mentioned in the Wall Street Journal article was the Vacusport,, "a long tube with a skirt that seals the players legs in a vacuum and flushes lactic acid." Again, no evidence that it works was provided.

The Vacusport

I found a paper presented at a 2013 conference in Egypt called "Sport Science in the Arab Spring" that looked at 10 basketball players with an average age of 17 who exercised on a treadmill at increasing inclines for about 20 minutes. Lactate levels were drawn at several intervals during the period of exercise and after the subjects spent 30 minutes in the Vacusport. The average lactate concentration fell from 8.8 mmol/L after exercise to 1.1 mmol/L which the authors said was a significant difference [statistics not provided].

Before you jump on the Vacusport bandwagon, I must point out that we dont know how fast these athletes would have cleared their lactates without the device. Thats what is known in research parlance as a "control group."

A study of 33 swimmers found that after intense racing they reduced their lactates of  >10.5 mmol/L to normal levels by simply swimming a modified workout for 20 minutes.

The Vacusport paper looks a like Nobel Prize candidate compared to a study of the Elevation Training Mask, a device which supposedly reduces the level of inspired oxygen without the expense of training at altitude where the percentage of oxygen in the air is lower due to the decreased atmospheric pressure.

Elevation Training Mask

Through a series of valves which can be opened or closed, the mask increases resistance to breathing. How this translates into lowering the partial pressure of oxygen in the air I do not know.

A case report published on the Elevation Training Mask website [but not in a scientific journal] must be read to be appreciated fully. An intrepid chiropractor wore the mask himself during 6 weeks of exercising.

Over the course of the experiment his peak expiratory flow rose 4%, his 1 second forced expiratory volume rose 1.3%, and his oxygen saturation rose from 96% to 99%,. No statistical analysis was performed, but the author said, "I do feel that this change was significant that oxygenation reached the 99%." I disagree. Even it was significant, an oxygen saturation rise of 3% is not clinically significant. [See my post on why oxygen is not a performance enhancing drug.]

A website called Bodybuilding.com explains in more detail why the mask could not possibly simulate altitude training.

Rather than rack my brain trying to come up with a pithy comment about the mask, Ill use one I found on Bodybuilding.com. "According to Alex Viada, a successful hybrid-training coach and founder of Complete Human Performance, such high-altitude devices simulate altitude in the same way sticking your head in a toilet simulates swimming."

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