Friday, June 24, 2016

Irrational fear of CT scans in appendicitis

By Skeptical Scalpel and Saurabh Jha*

Simple appendicitis cannot be distinguished from complicated appendicitis by clinical examination and laboratory findings say Finnish investigators. They looked at data from their randomized prospective trial of antibiotics vs. surgery for treatment of appendicitis and concluded that only CT scans could reliably differentiate the two entities.

The study involved adult patients from 18 to 60 years old; 368 of whom had uncomplicated acute appendicitis and 337 had complicated appendicitis—appendicolith, perforation, or abscess.

Duration of symptoms, C-reactive protein, white blood cell count, and temperature were significantly different between simple and complicated appendicitis patients. However substantial overlap of values meant they were not helpful in predicting the presence of complicated appendicitis.

Receiver operating curves for C-reactive protein and temperature areas under the curve do no exceed 0.77. Combining these parameters did not improve accuracy.

The paper concluded that CT scanning is essential in diagnosing acute appendicitis and identifying simple and complicated cases.

A companion study by many of the same authors looked at 1321 patients who presented with clinical and laboratory findings of possible appendicitis. Since their protocol called for confirmation of the diagnosis, all patients underwent CT scans, and 351 (27%) did not have appendicitis.

Thursday, June 23, 2016

Recording patient/doctor encounters: A modest proposal

This is a guest post by Dr. Drake Ramoray (A pseudonym. He is not affiliated with the actor, character, the show “Days of Our Lives,” or NBC.)

I have been assured by a very knowing American of my acquaintance in London, that a young healthy child well nursed is at a year old a most delicious, nourishing, and wholesome food, whether stewed, roasted, baked, or boiled ...—Jonathan Swift

I have A Modest Proposal. I suggest we just videotape all patient/physician encounters. Why rely on a possibly low quality audio recording where exterior noises or interruptions could interfere with the quality? Furthermore, perhaps my comment that may or not be taken out of context will make more sense if one can see my body language. Even better, lets just transmit the videos directly to CMS and your insurance carrier so we can add additional layers of bureaucracy and non-medical personnel to the mix whose pay has to come out of physician charges, taxes, or patients' premiums.

Tuesday, June 21, 2016

Guarded condition

For the last week or so, updates on the condition of the surviving victims of the Orlando mass shooting featured headlines like this:

“6 Orlando shooting victims remain ‘critically ill,’ another 5 patients in ‘guarded’ condition”

Even the trauma center, Orlando Health, tweeted this the other day:

“No surgeries on the victims are scheduled for today. 4 patients are in critical condition, 2 are guarded, and 12 are stable.”

I think we all have an idea of what critical and stable mean [more about this below], but what about guarded?

I’ve never known what guarded means and wondered if it was just me. To find out, I conducted an informal 24-hour Twitter poll.

Here are the results:


By a 2% margin, “I have no idea” was the most common response, but 35% thought guarded condition meant between serious and critical, and 21% thought guarded was better than serious.

Friday, June 17, 2016

How frequently do surgeons and anesthesiologists lie to each other?

More often than you might think.

Results of a survey published in the journal Patient Safety in Surgery found that 27% of anesthesiologists and 7% of surgeons admitted that they “misreported” information to each other at least once a month in the perioperative setting.

Surveys were mailed to 2260 anesthesiologists and surgeons. The response rate was only 11%, which the authors ascribed to the sensitive nature of the questions asked.

The demographics of the respondents in each group were similar regarding age, sex, years of practice, hospital type, and self-described involvement with religion.

The most commonly misreported events by anesthesiologists were actions that affected vital signs, and the misrepresentation of vital signs and amounts of fluid administered. Surgeons most commonly admitted to incorrectly estimating the expected length of a case and misstating the nature of intraoperative adverse events, degree of surgical risk, and how urgent a case was.

Wednesday, June 15, 2016

The checklist from hell

This one-page form illustrates much of what is wrong with medical care today.


































Just imagine the amount of time it would take to complete all 11 steps. Wouldn't you love to hear what goes on in a "post Fall Huddle"?

Thanks to @anish_koka for tweeting the form.

Thursday, June 9, 2016

Antibiotics vs. surgery for appendicitis: Critique of a meta-analysis

A meta-analysis can be useful when looking at a topic that has been studied by several different groups of investigators. The pooling of data from different published papers can sometimes bolster a conclusion about the effectiveness of a treatment.

However, a meta-analysis is only as good as the studies it includes, and the biases of those performing the meta-analysis can color the results.

Last month, a meta-analysis concerning antibiotics vs. surgery for the treatment of uncomplicated acute appendicitis by investigators from Nottingham University Hospitals was published in the World Journal of Surgery.

The authors concluded that “antibiotic therapy represents a safe, efficacious and viable treatment option for the treatment of uncomplicated acute appendicitis.” I disagree.

Five randomized trials involving 1430 subjects were included in the meta-analysis. After one year of follow-up, the efficacy of treatment for those receiving antibiotics was 62.2% compared with those undergoing appendectomy whose treatment efficacy was 88%. Depending on the inclusion or exclusion of a particularly weak study there was said to be a 39-52% risk reduction for complications in the antibiotic group.

This meta-analysis has so many problems that it is hard to know where to start.

Tuesday, June 7, 2016

Changing pre-med requirements and med school curricula

Ezekiel Emanuel, the University of Pennsylvania physician and ethicist, has written an opinion piece suggesting many changes in both pre-medical education and the medical school curriculum.

He would do away with many of our hallowed medical school prerequisites such as calculus, physics, and organic chemistry, feeling that those subjects are simply used to "weed out" certain students. I confess I once believed that such subjects were worthwhile. However, Emanuel makes a convincing argument that rigorous college courses in more relevant disciplines such as statistics, genetics, ethics, and psychology with a special focus on human behavior would suffice.

Regarding medical school, Emanuel points out he was taught the Krebs cycle on four different occasions in college and medical school and never used it once in practice or research. I have made a similar observation in a previous blog post.

He considers pathology, cytology, and pharmacology to be largely irrelevant to medical practice but concedes that some may disagree.