Antibiotics for appendicitis No thanks

The long-awaited Finnish randomized controlled trial of antibiotics vs. surgery for appendicitis was just published in JAMA. Depending on your perspective, 73% of patients were successfully treated with antibiotics or 27% of patients failed antibiotics and needed surgery.

The good news is that it was a large multicenter study involving 273 patients randomized to surgery and 257 to antibiotics. Patients included in the study had uncomplicated appendicitis as diagnosed by CT scan.

The bad news is that the paper has many limitations.

Of the patients who underwent appendectomy as the primary treatment, only 15 (5.5%) had laparoscopic surgery. The authors state that open appendectomy was selected as the protocol operative technique because laparoscopic instruments may not be available worldwide and apparently many surgeons in Finland are not experienced in performing laparoscopic appendectomies.

In most Western countries, laparoscopic appendectomy is the procedure of choice. In the United States, at least 80% of all appendectomies (not just those done in patients with early or simple appendicitis) are done laparoscopically. Laparoscopic appendectomy has a much lower complication rate than open. This renders the comparison of complications of surgery (20.5%) and antibiotics (2.8%) in the Finnish randomized trial meaningless. The Finnish authors did not consider failure of antibiotic treatment a complication. Had they done so, the complication rate would have been higher for the antibiotic group.

The hospital length of stay for the surgery patients in the JAMA study was a median of three days. A paper from Texas published last year found that of 345 patients who had laparoscopic appendectomies for uncomplicated appendicitis, 88% were managed as outpatients. They spent a total of about eight hours in the hospital from admission to discharge and had a complication rate, including readmission, of 2.8%.

The antibiotic chosen for the in-hospital treatment in the JAMA study nonoperative group was ertapenem—a once-a-day drug that costs $80 per dose. How available is ertapenem in low- and middle-income countries?

The follow-up in the current paper was only one year. Is it realistic to expect that no more patients will have recurrences of appendicitis in the following years?

The inconvenience and costs of the extra hospitalization for the 27% of patients who failed antibiotic therapy were not addressed.

The stated goal of the trial was to prove the noninferiority of antibiotic therapy for appendicitis. By the authors own admission, the result failed to meet their prespecified criterion for noninferiority. In plain English, this means the trial showed antibiotic therapy is inferior to surgery for the treatment of uncomplicated acute appendicitis.

Early last year, I blogged about the potential problems with this study and said, "A randomized trial of antibiotics vs. surgery for uncomplicated appendicitis is underway in Finland. Judging from the wording of the abstract describing the trial, the authors are markedly biased toward the use of antibiotics. Despite this, lets hope it sheds some much needed light on this subject." Too bad that did not happen.

Other than Dr. Edward Livingston, a surgeon who wrote a favorable editorial accompanying the paper in JAMA, I do not know of any surgeons who would opt for antibiotics to treat appendicitis for themselves or their family members.

A more realistic randomized trial is planned by surgeons in Washington State. Until that study is published, I’ll stick with surgery for uncomplicated appendicitis.

Addendum: The spelling of ertapenem was corrected on 6/18/15.

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Externships or observerships Can they help an IMG get a surgical residency slot

A woman writes [some non-essential details have been changed to preserve anonymity. Permission to post this was obtained.]:

I am a non-US citizen medical graduate from The University of The West Indies in Trinidad and am currently an intern in a Caribbean nation. Although UWI has produced great students, you may not be familiar with it.

I would like to become a surgical resident in the US. I have no US clinical experience, but my USMLE Step 1 score was >235.

What do you think about my doing a post-intern year externship (hands on clinical) as opposed to an observership (just observing) in the US? I know that an externship carries more weight as far as applications go, and the only reason I would want to do either of these would be to get recommendation letters from surgeons in the US.

However, since I have already graduated from medical school, getting into an externship will be more difficult because this will no longer be a medical school rotation. I believe that observerships will be easier to get into but are they worth it?

Do you know of any IMG-friendly programs that facilitate this? Do you think that this is a good idea? Do you feel that I will be able to get an externship?

Other than this idea for externship/observership, I am blank for ways to improve my chances of matching to a US program in surgery. Do you have any suggestions?

Thank you for writing and for reading my blog.

Your USMLE Step 1 score is excellent, but as you stated, the lack of any clinical experience in the US might be a problem.

Im afraid your plan to do externships may not work out. I do not know of any hospital in this country that supports externships for people who have already finished medical school. The issue is that once you graduate from medical school, you no longer have status as a student. There are medicolegal, educational, and funding considerations that I do not think can be overcome.

I am not sure about the availability or value of observerships. My opinion, which may not be shared by others, is that I see no value in observing. How could anyone write a meaningful letter for you if all you did was watch other people take care of patients?

I am also unable to tell you what a letter from a surgeon who works at a hospital nobody knows is worth.

I hope my readers will have some thoughts for you.

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Applicants want to be a resident but don’t write good Here’s help

Thanks to a spammer trying to comment on some of my posts, I have been introduced to the world of online personal statement services.

On a website called internalmedicineresidency.biz, $54.09 (discounted to $43.27 if you order by June 30) will get you a 275-word personal statement. As the website points out, “Coming up with a personal statement internal medicine of this quality is far from easy, but it’s what our professional service is here to help you achieve.”

Under the heading “How to create a killer statement, item #2 is “Argue why you suit for the course.”

The site offers a sample personal statement that begins, “I’ve always admired those who work in the health care industry not only because my mother was one but the fact that these people are the ones who care for our well being.”

In case you are after bigger game, the same company offers similar services for obtaining a neurosurgical residency. This site says, “Getting a neurosurgery residency can give your career a boost which can have a positive effect at your future in this field.”

I must agree that if you want to become a neurosurgeon, failure to obtain a neurosurgical residency position is a definite disadvantage. In fact, I think it would pretty much preclude your becoming a neurosurgeon.

It may be more difficult to obtain a neurosurgical residency than one in internal medicine, but the price for a neurosurgery personal statement, at a mere $27.19, is much lower.

For some reason when you click on the Sample tab, the site displays a “Pre Med Personal Statement” followed by this paragraph:

Pre Med personal statement writing is nowadays proven as beneficial using online services. Nowadays, students are showing more interest for the pre-med programs because of its value and prospective value for the future medicine studies. There is a great competition every year for this program and thousands of students applying every year too. Here, it is indicating, how important it is to add your application with a personal statement. If you fail to satiate this factor, then admission success is hard to expect. Our service is definitely wise option here to come up with a neurosurgery residency personal statement and any winning personal statement.

If that doesn’t convince you to try this service, I don’t know what will.

A USMLE Forum lists 18 other websites that provide personal statement writing services. I wish I had time to check out all of them.

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Problem with my blog I need your help

I have a big problem.

For the last 10 days, Twitter has been blocking me from tweeting any links to my blog.

This is the message I get whenever I try to send a tweet with "skepticalscalpel.blogspot.com" in it.

I have tried to contact Twitter through @twitter and @support four times and have received no reply, nor have they replied to numerous ticket requests through the Twitter Help Center.

I discovered a site called virustotal.com which compiles reports from 63 different programs that detect viruses, worms, trojans, and malware.

Originally a site called BitDefender claimed my site was malicious. The next day, BitDefender declared my site was clean, but AutoShun, which previously had no problem with my site, said it was malicious. The following day, AutoShun said my site was unrated and Clean MX said "malicious." But the day after, AutoShun went back to calling it malicious and Clean MX said my blog was clean. At no time, did more than one of the 63 detection programs identify my blogsite is being malicious.

You would think that if my blog contained any suspicious programs, more than one of the 63 virus detection organizations would have come up with a positive result on the same day.

None of the programs saying my blog was malicious gave me any clue as to what part of my site was supposedly creating the problem.

I attempted to get some help from Blogger, which hosts my blog. Although one person on a forum responded with some advice, it wasnt enough for me to solve the problem.

My blog is averaging 1600 page views per day. Not one person has contacted me to complain that I am harboring viruses or any other malicious software. That is because, to the best of my knowledge, no such malicious software exists on my blog.

Maybe it would help if you would go to the results section of the virustotal website and cast your vote in favor of my site as not being malicious. In the upper right-hand corner of the site you will see this cartoon.



 Please click on the green face to support my blog.

Meanwhile, I have discovered an interesting workaround which enables me to tweet links to my blog, but visitors to the site will still be blocked by Twitter from tweeting links.

If you consider yourself computer-savvy, maybe you can figure out how I did it. If you think you know the answer, please submit a comment.

I also would welcome any comments or suggestions that could help to resolve my problem. If anyone knows a way to contact a human at Twitter, please let me know.

Thanks.

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