Do many to do it well

"people should do what they do best and what they do best is what they do often" - D DeS.
Systematic review across many specialties showing a positive association between patient volume and outcomes:
http://www.ncbi.nlm.nih.gov/m/pubmed/12230353/

Ngrams

When you google the definition of a word, google also provides a history of the word's prevalence over the last century, which they've called "n-grams." Sometimes these make an interesting social comment, as in the decline of using "ladies and gentlemen", or the rise of the word chicken at the expense of the word beef. 

http://n-grams.tumblr.com/

Building Stonehenge - Wally Wallington Can Move Anything!

Recreating Stonehenge by hand

http://youtu.be/uYQBDhkBfr0


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Why Strange Lights Sometimes Precede Earthquakes | Popular Science

Strange light warns of quakes as rocks dissipate electrical charge -weird.

http://www.popsci.com/article/science/why-strange-lights-sometimes-precede-earthquakes


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Unusual instruments

Glass harmonica

http://youtu.be/XKRj-T4l-e8
Mbira

http://youtu.be/Z3b1bz_9gEo
Harp guitar

http://youtu.be/cqeyvKQKEq0
gravikord

http://youtu.be/uRdNBQCjQq8
This guy invented hundreds of instruments so there wouldn't be a "burden of expectation" of how to play them.

Marble music machine

https://youtu.be/IvUU8joBb1Q
Concrete guitar

http://youtu.be/-azkQAlwRdI
Tablas

http://youtu.be/Joyk_EMtzn0
Dholak

https://youtu.be/pRFerFw550g
Harmonium

http://youtu.be/G5jSSDZncyI
Psaltery

http://youtu.be/MKeFa1LgCZc
Mandolute

http://youtu.be/7bJAub4sn5A
Xalam

http://youtu.be/kOaLjU1CyTE
Rhaita

http://youtu.be/pD6zGkchsaY
Gue

http://youtu.be/f_mQjqSsulk
Hydraulophone

http://youtu.be/GVTcv7t_iCU

Re: Human-Powered Helicopter - AHS Sikorsky Prize Flight

I think Mark needs one - then he wouldn't have to worry about ice On
this morning ride into work :) Thanks for sending - so cool!
Fiona

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On 2014-01-08, at 9:06 PM, Tom Elwood <tomelwood@hotmail.com> wrote:

> Did you hear about this? What an amazing feat!
>
> http://youtu.be/syJq10EQkog
>
>
> Sent from my iPhone

Human-Powered Helicopter - AHS Sikorsky Prize Flight

Did you hear about this? What an amazing feat!

http://youtu.be/syJq10EQkog


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Paper Towels or Hot Air Dryers - Which is Better & Why?

I've often wondered which is better for drying and which costs less environmentally.

Advising Your Customers on the Benefits of Paper Towels vs. Hot Air Dryers

January 8, 2013

When it comes to cleanliness and the prevention of the spread of bacteria and viral infections, everyone will agree that hand-washing is hands-down one of the most important measures one can take. A less clear question is, which method of hand-drying is more effective in preventing the spread of germs? The answer is paper towels, according to a recent study from the Mayo Clinic published in the Wall Street Journal and the Washington Post. http://www.mayoclinicproceedings.org/article/S0025-6196(12)00393-X/abstract

In a selling situation, it may be difficult to argue thebenefits of paper towels over hot air dryers when the customer is price-sensitive. Many business owners are inclined to install a hot air dryer to reduce the expenseassociated with stocking paper towels. If your customer's primary concern is cost, you can discourage using hot air dryers and still offer savings by suggesting value brandpaper towels such as Nova, Vintage or Advantage. This saves your customer money, while still preserving the convenience and health of their customers and employees during this year's flu season. This is important since,  when given a choice, many busy patrons are inclined to choose paper towels due to the high cost to them of standing under a hot air blower for 60-90 seconds, only to walk away with damp hands that double as germ incubators. Read on for more valuable insight on the health benefits of paper towels to better prepare you for advising your customers.

Studies in 2009 and 2000 found a significant majority (55 percent in the 2009 study, 62 percent in  2000) preferred paper towels to hot air or jet air dryers (no more than 28 percent in either study). -Washington Post

Today's "green" society encourages  less waste, financially and ecologically. For hot air dryers, the argument has been that they are a hands-free, low-waste method of drying your hands that helps reduce deforestation and landfill waste, while drying your hands in a gentler way. (According to the Wall Street Journal, "The electric blower uses more energy than making a paper towel," Dr. Rodney Lee Thompson says- which refutes many environmentalists claims that hot air blowers are better for the planet.)

On the other hand, the argument for paper towels has shown solid evidence that hot-air dryers may not be as efficient or as hygienic as once thought, and perhaps deserves a second look. While paper towels are often associated with higher cost as well as waste, they have been shown in multiple studies to be much more effective in drying hands and preventing the spread of germs and bacteria- making the cost of hot air dryers much higher when it comes to our health, especially during a record-breakingly early flu season.

As stated in an article in theStar Tribune, "The trouble with blowers is they take so long," Rodney Lee Thompson, a hospital epidemiologist at the Mayo Clinic, told the Wall Street Journal. "Most people dry their hands for a bit, then wipe them on their dirty jeans, or open the door with their still-wet hands."

The issue there is, wet hands are not clean. The Wall Street Journal states that "In June, the Mayo Clinic published a comprehensive study of every known hand-washing study done since 1970. The authors concluded that drying skin is essential to staving off bacteria, and that paper towels are superior to driers: They're more efficient, they don't spatter germs, they won't dry out hands and most people prefer them. (A co-author of the study has served as a consultant for Kimberly Clark Australia, a maker of paper towels.)" (See full report from the Mayo Clinic here.)

To end-users as well as business owners, the benefits of paper towels   greatly outweigh the benefits to hot air dryers. With paper towels, a customer can dry their hands and be done in about ten seconds; their hands are dry, and the friction from the paper towel has removed more bacteria than hot air would. They can also turn off the faucet and open the restroom door with a paper towel, further preventing the spread of germs from patrons who opted-out of hand-washing altogether. A hot air dryer enables germs to spread, either through use or non-use, making the money saved over using paper towels a greater expense to public health and society overall, making the electric hand-dryer's claims essentially nothing more than, well, hot air. 

http://blog.rjschinner.com/?s=Paper+towels

See also 
http://info.debgroup.com/blog/bid/297155/Paper-Towels-or-Hot-Air-Dryers-Which-is-Better-Why?utm_campaign=Paper%20Towels%20or%20Hot%20Air%20Dryers%20-%20Which%20is%20Better%20&%20Why?07122013&utm_source=press-release


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What was the recent biggest gain ever by Intel | Popular Science

"The result is an up to 50 percent increase in battery life over the previous generation—the largest gain in Intel's history."

http://www.popsci.com/bown/2013/product/intel-4th-generation-core-processors-haswell


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Perioperative beta blockade more harm than good.

Wow! Discredited for falsified research yet his recommendations are still widely followed, and may be killing patients. 

Perioperative Beta-Blocker Controversy Begins Again With New Meta-analysis

Michael O'Riordan

August 01, 2013

 

LONDON, UK — The debate over the perioperative use of beta-blockers in noncardiac surgery is flaring up once again with the publication of a new meta-analysis suggesting their use increases the risk of death[1]. In an analysis that excluded discredited clinical trials, investigators report that treatment of patients undergoing noncardiac surgery with beta-blockers resulted in a statistically significant 27% increased mortality risk.

"I would urge all my colleagues to consider the analysis in this paper and reconsider very carefully whether they wish to routinely use perioperative beta-blockade," senior researcher Dr Darrel Francis (Imperial College London, UK) told heartwire .

Published online July 31, 2013 in Heart, the findings are likely to stir up more controversy, given that the 2009 European Society of Cardiology (ESC) guidelines state beta-blockers are a class I indication (with dose titration based on heart rate) in patients with established coronary artery disease or ischemia on a preoperative stress test or in patients undergoing high-risk surgery[2]. They are a class IIa indication in patients undergoing intermediate-risk surgery.

The ESC guidelines, along with the 2009 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) class IIa indication for patients undergoing vascular surgery[3], are based, in part, on data from the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo(DECREASE) studies. Dr Don Poldermans, formerly of Erasmus Medical Center, was best known for his work in using beta-blockers in surgery patients and published the first DECREASE paper in 1999 on the use ofbisoprolol. He also authored subsequent DECREASE studies, includingDECREASE IV , which addressed the perioperative use of beta-blockers.

As has been reported extensively byheartwire and other media outlets,Poldermans was fired for violations of academic integrity and resigned from the ESC Committee for Practice Guidelines . Subsequent investigations into his research have questioned the validity of his findings, particularly the DECREASE studies. Complicating the whole matter further, Poldermans chaired the 2009 ESC guidelines for perioperative management in noncardiac surgery.

To heartwire , Dr Sripal Bangalore (New York University School of Medicine) said the newest meta-analysis raises important concerns about the safety and efficacy of perioperative beta-blockers, especially given the controversy surrounding the research by Poldermans. Irrespective of the DECREASE fiasco, Bangalore said his group already showed that the risk/benefit trade-off of perioperative beta-blocker use was unfavorable back in 2008 when they published a meta-analysis in the Lancet. In addition, the Perioperative Ischemic Evaluation (POISE) trial highlighted these same concerns.

"In our meta-analysis, we found that the benefits, if any, were driven by trials with high risk for bias, including the DECREASE trial," Bangalore commented.

As a result of the 2008 meta-analysis, the ACCF/AHA downgraded the recommendations from class I to IIa, but it is "surprising that the ESC guidelines still have a class I recommendation for perioperative beta-blockade," he added. Bangalore believes that neither now nor before the 2009 ESC guidelines were published did any solid evidence exist for beta-blocker use in this setting.

Excluding the DECREASE Studies

In the newest meta-analysis, with first authorDr Sonia Bouri (Imperial College London), the researchers included nine randomized controlled trials of beta-blockers given prior to noncardiac surgery. The nine trials, which involved 10 529 patients, excluded the DECREASE studies. The largest trial included in the meta-analysis was POISE, a study reported by heartwire , which first suggested beta-blockers may do more harm than good.

After exclusion of DECREASE I and DECREASE IV, given questions about the integrity of these trials, perioperative treatment of noncardiac surgical patients with a beta-blocker increased the risk of death by 27%. Similarly, perioperative beta-blockade also increased the risk of stroke and hypotension.

End Points: Secure Trials Only (Excludes DECREASE I and DECREASE IV)

End point	Risk ratio (95% CI)
Mortality	1.27 (1.01–1.60)
Nonfatal MI	0.73 (0.61–0.88)
Nonfatal stroke	1.73 (1.00–2.99)
Hypotension	1.51 (1.37–1.67)

To heartwire , Francis said the ESC guidelines recommending beta-blockade in noncardiac-surgery patients are based on analyses that include the now-discredited DECREASE studies. When these trials are included in the meta-analysis, the risk of mortality with beta-blockers is not statistically significant.

"The trouble is that DECREASE messed it all up," said Francis. "Once DECREASE is added to the mix, you could argue that the mortality risk is inconclusive, that there is no significant increased risk. So, what do you do next? You look at the risk of myocardial infarction, and here there is no controversy. Even I think myocardial infarction is reduced with beta-blockers. That is clear from the POISE trial. So we are right to think that it protects the heart, but it also does some other bad stuff, which unfortunately, is more important for the average patient."

He added that although cardiologists can sometimes have tunnel vision, a lot of other organs can go wrong after an operation. "Remember all those times we fought the anesthetists on the intensive care unit? They wanted to tweak up the inotropes and stop the beta-blocker, and we argued for the opposite? We may both have been right, we for the heart, and they for the rest of the body. In many perioperative situations, we may need to let the rest of the body take priority, in the interests of survival."

A Fictitious Adjudication Committee

Francis said the investigation into Poldermans and the DECREASE studies found that the DECREASE IV study included a "fictitious adjudication committee" of a cardiologist, anesthesiologist, and surgeon, but the adjudications were made by the surgeon alone. Most important, documented clinical events, including MI, did not match hospital records or clinical discharge reports. However, the paper was never officially retracted and as a result the guidelines have remained in place.

He has been waiting since the Poldermans's investigation for updated ESC guidelines.

"Every day, as a cardiologist, I am called to advise on patients in a dire state in need of surgery but with a major cardiovascular concern," said Francis. "They ask what can be done. We can't take them to the cardiac cath lab for a stent because they'll be out of action for a minimum of four weeks because of clopidogrel. It was lovely to recommend beta-blockers because we thought we'd reduce their mortality and then we'd sort out their heart afterward. Unfortunately, it looks as though we may have been killing them. It's an ugly thought, but remember, we are quick to boast of saving lives if our trials indicate this. We should be just as quick to recognize the opposite side of the coin."

heartwire reached out to members of the ESC guidelines writing committee but had not heard back at the time of publication.

Francis is supported by the British Heart Foundation; the authors had no conflicts of interest.

 

• References

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Heartwire © 2013 

Cite this article: Perioperative Beta-Blocker Controversy Begins Again With New Meta-analysis. Medscape. Aug 01, 2013.

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