A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

CODA Collaborative, Flum DR, Davidson GH, Monsell SE, et al. N Engl J Med. 2020 Oct 5. Epub ahead of print. [CrossRef] [PubMed]

Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. The authors conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days. In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The authors conclude that for the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients with Pneumonia

Freburger JK, Chou A, Euloth T, Matcho B. JAMA Netw Open. 2020;3(9):e2012979. Published 2020 Sep 1. [CrossRef] [PubMed] 

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Patients from 12 acute care hospitals in a large health care system in western Pennsylvania were analyzed for the number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6). Of 30,746 patients, the 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95%CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95%CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95%CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting. The authors conclude that the number of physical and occupational therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis

WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, Sterne JAC, Murthy S, et al. [published online ahead of print, 2020 Sep 2]. JAMA. 2020;10.1001/jama.2020.17023. [CrossRef] [PubMed]

JAMA published five papers concerning the use of steroids to treat people with severe COVID-19, including three new studies which can be found here, here, and here. There is also a well-written editorial and a meta-analysis which is summarized here.

Prospective meta-analysis from 7 randomized clinical trials evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The trials were conducted in 12 countries from February 26, 2020, to June 9, 2020, and the date of final follow-up was July 6, 2020. 28-day all-cause mortality was lower among patients who received corticosteroids compared with those who received usual care or placebo (summary odds ratio, 0.66). The authors conclude that administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality in critically ill patients with COVID-19. 

Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020

Yip L, Bixler D, Brooks DE, et al. MMWR Morb Mortal Wkly Rep. 2020;69(32):1070-1073. Published 2020 Aug 14. [CrossRef] [PubMed]

Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands and is an important part of the CDC recommendations to prevent spread of COVID-19. On June 30, 2020, the CDC received notification from Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. The later results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve. 62 poison center call records from May 1 through June 30, 2020 of alcohol-based hand sanitizer-associated methanol poisoning. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

Risk of COVID-19 Among Front-Line Health-Care Workers and The General Community: A Prospective Cohort Study

Nguyen LH, Drew DA, Graham MS, et al. Lancet Public Health. 2020. Published Online July 31, 2020 [CrossRef]

The authors sought to assess risk of COVID-19 among front-line health-care workers compared with the general community and the effect of personal protective equipment (PPE) on risk. They did a prospective, observational cohort study in the UK and the USA of the general community, including front-line health-care workers, using self-reported data from the COVID Symptom Study smartphone application (app) from March 24 (UK) and March 29 (USA) to April 23, 2020. Participants were voluntary users of the app and at first use provided information on demographic factors (including age, sex, race or ethnic background, height and weight, and occupation) and medical history, and subsequently reported any COVID-19 symptoms. Among 2,035,395 community individuals and 99,795 front-line health-care workers, 5545 reported a positive COVID-19 test over 34 435 272 person-days. Compared with the general community, front-line health-care workers were at increased risk for reporting a positive COVID-19 test (adjusted HR 11·61, 95% CI 10·93–12·33). Secondary and post-hoc analyses suggested adequacy of PPE, clinical setting, and ethnic background were important factors. The authors conclude that the health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds.