Neuticles: Testicular prostheses ...for pets

First of all, this post was not lifted from The Onion.

Do you think the economy is bad? Do we spend too much on healthcare for people?

Let me introduce you to “Neuticles,” which are, no kidding, testicular prostheses for neutered pets.

According to the product’s website, “Over a half million caring pet owners worldwide have selected Neuticles as a safe, practical and inexpensive option when neutering their beloved pet.”

Neuticles come in dog or cat versions with multiple sizes and the price ranges from $114 to $149 for a pair of polypropylene implants. Solid silicone will cost you from $254 to $299. The “UltraPlus with ScarRetard” will run you up to $449 a pair. If your dog is extremely self-conscious, you may want to go with the UltraPlus model which has an epididymus for an extra $150 per pair.

The implants are also sold individually for pets who don’t mind being lopsided.

The price does not include the veterinarian’s fee for the neutering/implantation procedure.

The company’s slogan is “It’s like nothing ever changed.” Furthermore unlike human medical implants, the folks at Neuticles say this “is a 100% safe and effective alternative option” and claim there have been no complications or rejections of the devices when implanted as directed.

Apparently, they never get infected or need to be removed.

Videos of the procedure are posted on the site. A “drop or two” of penicillin is place on each implant as prophylaxis. In one video, the dog’s package was between two sizes so the owner (no doubt a man) opted for the larger size. The vet in the video says both the owner and the dog are very happy with the choice.

And just what is “ScarRetard”? It’s “a special textured exterior which virtually eliminates the risk of potential scar tissue development.” In case you don’t want to go for the extra cost of “ScarRetard,” the website suggests the owner “gently massage the Neuticles weekly to break up any possible [scar] formations.” I suspect that advice leads to better sales of the implants with ScarRetard.

Can you imagine the conversation when a guy who works for Neuticles tries to pick up a girl at a bar?

She: “So, what do you do?”
He: “I sort sizes of artificial testicles for dogs and cats.”
She: “Right. Get lost.”

The inventor of this item, Gregg A. Miller, received the “Ig Nobel Prize” for medicine in 2005.

If it’s true that 500,000 have been sold at say $400 per animal, that’s $200 million worth of testicle prostheses for dogs and cats. Who’s laughing now?

Don’t get me started on the doggie treadmill ($699 for the medium version, $899 for the large).

Amazing breakthrough in minimally invasive robotic surgery

You have probably read about natural orifice cholecystectomy and appendectomy or removal of the gallbladder or appendix without an abdominal wall incision. These procedures have been limited to women because the natural orifice through which the surgery is performed and the diseased organ is removed has heretofore been the vagina.

The author of the first large study of transvaginal appendectomy, Dr. Kurt E. Roberts of Yale Medical School said men would need to have surgery through the stomach or rectum and quipped, “Finally, an advantage for women"

But now via Presse-Agentur Österreich (Austrian Press Agency) comes a report from the Schweinsteiger Institut für Experten-Chirurgie (Institute for Expert-Surgery) in Vienna of minimally invasive robotic gallbladder surgery in three men. The natural orifice employed was the urinary bladder via the penis.

The men had elective surgery for chronic symptoms of right upper abdominal pain and gallstones. They are said to have tolerated the operations well and were discharged home within three hours of completion of their cases.

At a hastily called press conference, lead author of the research team and his eponymous institute, Professor Herr Doctor Bastien Schweinsteiger, explained how the revolutionary procedure was accomplished:“Using miniature instruments machined especially for the institute’s proprietary robot, called Michelangelo, the penis is cannulated and the bladder entered. A small enterotomy is made in the dome of the bladder and the gallbladder is grasped. A metallic grid is deployed and attached to the gallbladder. A powerful electromagnet is placed on the skin of the upper abdomen. When activated, the magnet lifts the gallbladder into a suitable position for dissection. After the cystic duct and artery are divided, the gallbladder is dissected free of the liver.

According to Dr. Schweinsteiger:“The most challenging part of the procedure was devising a method of extracting the gallbladder and stones through the penis. We finally realzed that we could place the gallbladder into a bag inside the abdomen and emusify the contents of the bag using the same type of sound waves used for lithotripsy of kidney stones thus allowing the gallbladder and bag to be drawn out through the penile urethra.“

Study co-author Dr. Miroslav Klose told the throng of curious reporters that an unexpected but welcome consequence of the surgery was improvement in urination in all three men presumably due to the dilatory effect of the gallbladder and bag traversing the prostate gland.

The researchers expect to launch a full-scale Phase II trial of this latest advance in minimally invasive robotic surgery sometime in late summer of this year.

Drs. Schweinsteiger and Klose disclosed that they are officers and stockholders in Scherz Roboter, the company that manufactures the Michelangelo robot.

More details are available at a link to the Presse-Agentur Österreich article here.

Surgical smoke: Is it dangerous to your health?

An operating room nurse from the UK has asked me to comment on the burning issue of surgical smoke. [Pun intended.] I don’t think she’s going to like what I have to say.

For several years, studies have found that all kinds of chemicals and organic bits can be found in smoke plumes generated by electrocautery and lasers in the operating room. Some of the chemicals are said to be carcinogens and the organic material reportedly contains intact viral genetic material.

Many organizations have called for the establishment of government regulations regarding the amount of stuff that should be allowable in OR smoke. However, OSHA has been surprisingly reluctant to do anything and has not officially commented on the subject since 1996. The OSHA website does say that about half of the states have various regulations in place.

Some groups, particularly nursing organizations, are calling for the placement of smoke evacuators in all operating rooms. As you might suspect, these efforts are being vigorously supported by the manufacturers of smoke evacuators.

I attempted to find some real evidence about all this, but it is hard to come by. There have been no randomized trials involving surgical smoke.

A very interesting presentation by a group from the Centre Hospitalier Universitaire de Québec (CHUQ) at the 2011 Cochrane Canada Symposium addressed the subject in a health technology assessment.

For biologic and chemical substances, the CHUQ health technology assessment said the risks of transmission of diseases were unclear.

They measured the air in operating rooms and said, “[A]mbient air concentrations of carbon monoxide, volatile organic compounds, and particulate matter are very low and far below the occupational exposure limits.”

They concluded, “There is no clear evidence that surgical smoke may represent health hazard,” but hedged by saying that smoke evacuators should be restricted to specific types of cases such as breast surgery. They offered no evidence to support that recommendation.

There are only two case reports in the literature claiming transmission of viruses in surgical smoke from patients to healthcare workers. These case reports are frequently cited by advocates of smoke evacuation devices.

The first case report, cited in PubMed 16 times but many more times in other documents, is from Norway. Here is the complete abstract. I added emphasis in bold.

A 44-year-old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA types 6 and 11. Past history revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patient may have been caused by inhaled virus particles present in the laser plume.

The second case report, cited 3 times, is from Germany. Here is its abstract.

A 28-year-old gynecological operating room nurse, who assisted repeatedly in electrosurgical and laser surgical excisions of anogenital condylomas, developed a recurrent and histologically proven laryngeal papillomatosis. The expert opinion of a virological institute confirmed a high probability of correlation between the occupational exposition and the laryngeal papillomatosis so that it was accepted as occupational disease. HPV-DNA has been repeatedly detected in laser-plume after excision of papillomas and condylomas. As of the present an exact proof that these particles are infectious has not been brought forward.

There are other ways to acquire HPV virus in one’s throat.

The CDC reports that 48 million inpatient operations were performed in the United States in 2009. In the last 25 years, not a single case of proven (or unproven) transmission of any disease by surgical smoke has been diagnosed. Had such a case been found, it no doubt would have made headlines.

The Anesthesia Quality Institute estimates that there are 35,000-45,000 operating rooms in the United States. A smoke evacuation machine costs a minimum of $1000, not including the costs of disposable tubing for every case and filters which need periodic replacement.

Let’s say 40,000 ORs X $1000/smoke evacuator = $40,000,000 to prevent exactly zero cases of disease. This does not take into account the costs of disposable tubing.

In these economic times, can anyone think of a better place to spend $40,000,000?

Staying ahead of the news: Why you should follow Skeptical Scalpel

During the last three months, seven stories have appeared on major news or medical sites well after I had blogged about them. Here they are.

“Why Failing Med Students Don’t Get Failing Grades” was published in the New York Times on February 28, 2013. I blogged about this subject and why med school is like T-ball (everyone gets a trophy) on October 17, 2012. Links are here: Times/Me

 

On February 24, 2013 an article called “‘Bloodless’ Lung Transplants Offer Hint at Surgery’s Future” appeared in the New York Times. The need to reduce blood transfusions was the subject of a blog on February 4, 2013, 20 days earlier. Times/Me

The Wall Street Journal ran “Study Raises Doubts Over Robotic Surgery” on February 19, 2013 and on February 21, 2013, The Atlantic's version was “Robots taking a record number of human uteri.” They both discussed a paper appearing in JAMA that week on the failure of robotic hysterectomy to show improved outcomes for benign disease. I had published 15 blogs about the shortcomings of robotic surgery prior to that date. WSJ/Atlantic/My blog (Search “robot”)

“Intensive care MDs: More white coats, fewer piercings preferred” was in the Los Angeles Times on February 19, 2013. I explained why I wear a white coat way back in July of 2012. Times/Me

New York Times wrote about declining law school admissions and fewer jobs for lawyers on January 30, 2013. I addressed these issues on January 7, 2013. Times/Me

In the January 23/30, 2013 issue of JAMA, an editorial the problems associated with using 30-day readmissions as a quality indicator. I dealt with this in early October of 2012. JAMA/Me

This one was at least close. Bill Keller's January 27, 2013 opinion piece in the New York Times on why pay-for-performance for doctors won't work was only three days behind my blog on the subject. Times/Me

Misleading headline of the month: “Weekend worse for surgery”

“Emergency surgeries performed on a weekend may have poorer results than the same operation performed on a weekday, a new study concludes,” says an article in the New York Times.

However, the statement is not true.

First of all, it implies that all operations done on weekends have poorer results by failing to mention the fact that the study that found this result only concerned patients with inflammatory bowel disease (IBD)—that is, ulcerative colitis and Crohn's disease.  And although the paper looked at both types of IBD, only patients with ulcerative colitis were found to have significantly different outcomes based on day of admission.

Second and most important, the paper's significant result was that patients who were admitted on weekend days had worse results. On page 6 of the paper (the full text of which is available online), the authors state, “Hospitalisation [sic, the journal is from the UK] day of surgery did not influence post-operative outcomes.”

To recap. What the paper really says it that for one type of IBD, ulcerative colitis, admission to the hospital on a weekend day, not necessarily the day the surgery took place, is associated with a significant increase in mechanical wound complications (I assume they mean wound dehiscence or “burst” wound) and need for repeat laparotomy.

Some limitations of the study are as follows:

• It is a retrospective review of an administrative, not a clinical database.
• There was no information about the surgeons or other physicians in the database.
• It is quite possible that by chance more patients in the weekend admission group were on corticosteroids, which are known to have a negative effect on wound healing.
• The authors admit that “Unmeasured confounders beyond what we were able to capture in our study could also influence the estimates.”
• It is not surprising that rates of wound dehiscence and need for repeat laparotomy would both increased since the former begets the latter.
• The authors could not explain why wound problems occurred in ulcerative colitis but not Crohn's disease patients, nor could they explain what mechanism could lead to the adverse outcomes they found.

There is a plethora of literature on whether or not a “weekend effect” really exists. The Times article would have been better if in addition to getting the facts straight, some balance had been offered. 

 

A brief PubMed search reveals that patients admitted with strokes on weekends fare worse or do not fare worse according to which study you read. Similarly, patients with upper gastrointestinal bleeding fare worse or do not fare worse if admitted on weekends. Take your pick.

The times article concludes with a quote from the lead author, “If you need surgery, you should get it.”

That is the one part of the article I can agree with.

Medical television hits a new low

Tipped off by a reader, I watched “Married to Medicine,” a reality program about doctors' wives and female doctors in Atlanta, which premiered on the cable network Bravo last night.

What a colossal embarrassment to the medical profession, women, black people, television and humanity.

In the beginning, some “highlights” were shown, which featured a pushing match between two of the characters. I should have stopped right there, but regrettably, I kept watching.

I hope the cast members were paid well because they could not have looked worse had they been on Jerry Springer.

What could they have been thinking?

They were portrayed as shallow, materialistic caricatures. And their husbands, the doctors, looked like fools. Two of them were emergency medicine physicians whose practices probably won't suffer. But the orthopedic surgeon—who would go to him after hearing his wife say surgeons bring home the cash?

After about five minutes, I couldn't take it any longer.

The reviews of the show have been mixed. But the New York Times, an organization that should know better actually had a favorable slant. Its reviewer said, A confederation of mostly black women, some of them doctors’ wives and some of them doctors, enacts scenes of petty jealousy and scorched-earth class warfare that reinforce every pernicious cliché about female treachery and the shallowness of buppie culture and that are also, as it happens, reliably entertaining. 

Entertaining if you are a moron.

Black women of Howard University Medical School, who petitioned the network to cancel the show before it ever aired, have different views.

Comments on the petition's website at Change.org were decidedly negative. Here are some excerpts:

Another show depicting black women as shallow, angry, weave wearing, sassy women that can't get along with each other. The bigger issue here is that they are representing a serious community of professionals that have to fight really hard to be taken serious by their white peers.

As a young black woman in the medical field, I was excited about the show, foolishly thinking there would be some sort of mention of, well...medicine. Instead I was incredibly disappointed, disheartened & embarrassed for what I saw. It was a mockery of medicine, and a modern day minstrel show.

This show is not reality! I have many friends that are African American female physicians and I am also married to a surgeon and we are both African American. This is NOT how we live and this is NOT our reality! This is a very negative image and against ALL that we stand for.

Sadly, the petition has only a little over 2000 signatures.

The good news is that one can simply choose not to watch.

Unbelievable Wisconsin Supreme Court ruling on informed consent

I normally wouldn't do this but you need to see excerpts from an article in the Wisconsin State Journal to understand the nature of this case. I have abridged as much as possible.

Thomas Jandre was driving to a job site when the left side of his face started drooping. He began drooling, his speech became slurred and he felt dizzy and weak in his legs.

He went to the emergency room at St. Joseph’s Hospital in West Bend. Dr. Therese Bullis did a physical exam to rule out a stroke. She ordered a CT scan to rule out a hemorrhagic stroke, or bleeding in the brain. To check for an ischemic stroke, from a clot, she used a stethoscope to listen for unusual blood flow in his carotid artery. She diagnosed Jandre with Bell’s palsy, inflammation of a nerve that controls facial movement.

Eleven days later, Jandre had a massive stroke that caused permanent damage to the left side of his body. An ultrasound showed the carotid artery along his neck was 95 percent blocked.

Bullis was negligent in not telling Jandre he could have had a carotid ultrasound when she saw him, the Wisconsin Supreme Court ruled in April. The test might have led to treatments to prevent the stroke.

The supreme court affirmed an appeals court decision that upheld a $2 million jury award in 2008 to Jandre, now 57, whose stroke occurred in 2003. The jury said Bullis wasn’t negligent in her diagnosis of Bell’s palsy but found her negligent in her duty of informed consent because she failed to discuss the carotid ultrasound.

The decision “leaves physicians in the difficult position of not knowing how much information a physician should provide to a patient about tests for diagnoses already ruled out by the physician,” said a statement by three Wisconsin MD organizations.

The groups said the decision could drive up health care costs by requiring unnecessary tests. They’re calling for state legislation to clarify informed consent.

But Dr. Sheldon Wasserman, chairman of the state Medical Examining Board, said he agrees with the ruling. “You should give patients all the information they need and more,” he said.

Jim Weis, the Wausau attorney who represented Jandre, said if Bullis had conducted a “one-minute conversation” with Jandre about the ultrasound, “the stroke would have been avoided.”

A second article noted that the doctor was reprimanded by the state medical board and fined $300. It also says that the state legislature may introduce a bill to clarify the informed consent law.

Wow! I agree that the ED physician was not negligent in arriving at the wrong diagnosis. That can happen. It's not negligence if you do everything right and come up with the wrong answer. According to the courts, her “negligence” was in not telling the patient that a carotid ultrasound could have been done.

Just how would a “one-minute conversation” with the patient have avoided the stroke? Would the patient then have had the option to demand the test? If that is so, why not skip the history and physical examination by the doctor altogether and let the patient choose from an a la carte menu of diagnostic tests when he comes through the door?

This case opens up a huge can of worms. Should all patients who are determined by an ED MD to not have appendicitis be told that they could have a CT scan and if that is negative, an ultrasound? Might as well throw in an MRI too, even though it has never been proven to be useful for that illness.

And who believes that the state legislature will solve the problem of informed consent brought up by this case? Not I.

If you think healthcare is expensive now, wait until the emergency medicine community gets wind of this case.