Appendectomy outcomes in the modern era

Finally we have some data on the current rate of complications of appendectomy for uncomplicated appendicitis. But that’s not all. This new paper, published online in the journal Surgery, reveals much about the diagnosis, technique, and outcomes of appendectomy in the United States.

Using data from 115 hospitals participating in the National Surgical Quality Improvement Program, researchers at UCLA analyzed the results of 7778 adult patients undergoing appendectomy for simple appendicitis in 2016.

Perforated appendix not seen on CT scan

From an email received two days ago. Posted with permission and edited for length and clarity.

I came across your blog while looking for information on something puzzling that happened to my sister. I read the blog on CT scans and appendicitis* and went through all of the comments section. I couldn't find a case like my sister’s.

She has been sick off and on for the last two months. It began with what seemed like a bad stomach virus, fever, throwing up, diarrhea, gas pain, bloating, and stomach cramps. She brushed it off as a 24 hour type thing, stayed home from work a few days, and felt better but never returned to normal. She would have intermittent stomach upset and began to have weight loss. About 3 weeks ago, she went to see her GP who ran some tests (antibody tests, no CBC, chem 7 or normal work up) and diagnosed her with gluten intolerance.

Aortic dissection leads to man's death in the ED: His wife's perspective

A woman wrote to me about the day her husband died. I have edited her email for length and clarity and changed some insignificant details to protect her anonymity as she requested.

Joe passed away outside in the parking lot while they were getting on a helicopter for transport to a hospital equipped to do his surgery.

He had presented to the ED in terrible pain with lots of thrashing and writhing. His right hand was very cold. His right arm tingled to the point of hurting bad. The vision in his right eye was cloudy, and his hearing was muffled on the right. This was in addition to being very pale and diaphoretic upon admission. This is when I felt a dissecting aorta should have been suspected.

I don’t recall the vitals in the beginning, but they were changing and his blood pressure was dropping very fast. As soon as they finished the EKG-in the first 5 minutes of the visit, I asked the doctor about John Ritter's death [the actor died of a dissecting thoracic aneurysm in 2003]. First I asked if he could check for the condition that caused John Ritter's death. I called it an abdominal aortic aneurysm. The doc corrected me and said that it wasn’t an AAA it was a dissected aorta. I said OK, then check for that. This was 1 hour before the CT scan that led to his diagnosis.

Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but it's true.

A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years.

The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion.

The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. The genrally accepted upper limit of normal is 200 mg/dL.

After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL.

Can hypocholesterolemia cause health problems? How low is too low? No one knows for sure, but cholesterol is a constituent of cell membranes and many hormones.

I've blogged before about the overuse of medical care, particularly Pap smears, in Florida.

Why does Medicare pay for all these unnecessary tests and drugs? Medicare probably has no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months?

It's probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012).

The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. There's potential for a lot of money to be wasted.

As one of its Choosing Wisely items, the Society of General Internal Medicine has recommended that routine general health exams not be done for asymptomatic adults.

A Cochrane Review of 14 studies comprising 182,880 patients came to the same conclusion and noted that important harmful outcomes of routine check-ups were often not studied or reported.

In June I wrote about the doctors who received seemingly excessive Medicare payments identified by various journalists and wondered why Medicare couldn't have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why can't Medicare do something?

PS: For all you fans of rating doctors according to patient satisfaction scores, the patient in the above anecdote really likes his doctor and is worried that, because he is fed up with everything about the practice of medicine, he may retire.

Uncertain diagnosis or CT scan radiation? Which would you choose?

It is so nice to be right.

To summarize what I wrote almost 4 years ago, here and here—based on my experience, patients and families will accept the theoretical risk of a future cancer if it means they'll get an accurate diagnosis.

A recent study validates that opinion.

MedPage Today reports that before receiving any recommendation for CT scanning, 742 parents of children who presented with head injuries were surveyed by researchers from Toronto's Hospital for Sick Children.

Parents, almost half of whom had previously known that CT scanning might cause a cancer to develop in the future, were told of the radiation risks of CT scanning in detail. The authors found that although the parents' willingness to go ahead with the CT scan fell from 90% before the explanation of risk to 70% after they were briefed about radiation, at crunch time only 42 (6%) of them refused to let their child be scanned.

And of the 42 who initially refused, 8 eventually went ahead with the scan after a physician recommended it.

So to put it another way, even after they were fully informed of the potential risk of CT scan radiation to their child (lifetime risk of cancer is about 1 in 10,000, according to the authors), nearly all parents opted for the scan.

Also of note are the following:

The median age of the children was 4.

12% of the children in the study had undergone at least one previous CT scan.

97% of the children were diagnosed with only concussions or mild head injuries.

An article in Scientific American puts some of the radiation risk into perspective. It is long, but worth reading as it explains how risk has been calculated, the best guess as to the true level of risk, and what radiologists are doing to lower the radiation exposure associated with CT scanning.

According to that article, "Any one person in the U.S. has a 20 percent chance of dying from cancer [of any type]. Therefore, a single CT scan increases the average patient's risk of developing a fatal tumor from 20 to 20.05 percent."

No one ever comments about weighing the potential harms that may have been prevented by a timely CT scan diagnosis against the radiation risk.

CT scans should be ordered judiciously. The area scanned and the amount of radiation should be limited as much as possible.

But if you need a CT scan to help diagnose your problem, go ahead and have it.

Bottom line. When it comes to accuracy in diagnosis vs. radiation-induced cancer risk, parents overwhelmingly chose the former.

Is ultrasonography overrated? A radiologist thinks so

In response to an article in the New England Journal of Medicine that discussed whether bedside ultrasonography (US) should be taught to medical students, radiologist Dr. Saurabh Jha recommended that clinicians do a proper history and physical instead of point-of-care ultrasound.

His post appeared on the KevinMD website.

As if a radiologist advising doctors to do an H&P wasn't shocking enough, Dr. Jha then confessed that he thinks "ultrasound images look like a satellite picture of a snow blizzard."

He worried that rather than finding hidden pathology, indiscriminate use of US by inexperienced physicians will simply lead to more and more testing.

Even seasoned radiologists tend to overcall abnormalities on US said Dr. Jha. This leads to increased use of other imaging studies, most of which turn out to be normal. Using US to avoid the risks of ionizing radiation often results in patients having CT scans anyway.

In the comments section of the post, Dr. Jha emphasized that he was talking about situations where the pretest probability of finding something wrong is very low. Directed US based on clinical indications is obviously of value.

Emergency medicine physicians who

Photo via Dr. Ryan Radecki (@emlitofnote)

commented listed several instances which bedside US can be useful such as in identifying pericardial effusions and fluid or blood in the abdomen of trauma patients.

Ultrasound is clearly the test of choice for right upper quadrant abdominal pain. There is nothing better for identifying gallstones, but thickening of the gallbladder wall and fluid surrounding the gallbladder are best seen with US done in the radiology department.

Probing all body cavities with a transducer for no specific indications is another matter.

Is there still a role for a good history and physical examination in modern medicine? Yes.

Is US a useful test? Yes, in the proper context, it can be very helpful.

Should every medical student be taught how to do bedside US? I don't think so. A course is just the beginning. Learning how to perform US requires a lot of repetitions. Many medical specialists will never use it.

I agree with Dr. Jha that the time should be used to "Teach them to organize their thoughts coherently."

What's your opinion?

Note: These folks also tweeted the photo.@EM_Educator @MDaware @EBMGoneWild @choo_ek

We order too many preop tests

As predictable as the leaves falling this time of year, another paper on the subject of unnecessary preoperative laboratory testing has appeared.

A group from the University of Texas Medical Branch looked at more than 73,000 elective hernia repairs in the National Surgical Quality Improvement Project (NSQIP) database. Almost 2/3 of the patients had preoperative laboratory tests. Of that group, 58.6% had a CBC, 53.5% had electrolytes, 23.7% had liver function studies, 18.7% had coagulation studies and 9.9% had all of the above. Even 54% of patients with no co-morbidities had at least one test.

An abnormal test was found in more than 60% of those tested, of the 7200 patients who had lab tests done on the day of surgery, 61.6% had at least one abnormal test including 23% with a coagulation abnormality, 41% with a chemical abnormality and 33% with an LFT abnormality. Despite these results, the scheduled surgery was done.

Tests did not predict complications in patients without co-morbidities. Obtaining a test (not necessarily an abnormal result) was associated with a higher risk of major complications (0.4% versus 0.2% p < 0.0001) but not wound complications. However, abnormal results did not predict complications.

The authors of the paper recommended that surgical societies establish guidelines for preop testing.

Hernia patients, particularly those without comorbidities, are similar to normal people. Obtaining lab studies on these patients is analogous to obtaining labs on the next 100 people who walk past the hospital. Few abnormal results will be found, and most of them will be false positives.

This fact has been known for at least 30 years, yet surgeons, who as shown by previous studies order 80% of preop tests, still continue to order them. Some question whether anesthesiologists insist on having the tests done. Is it defensive medicine? Force of habit?

When I was a department chairman and this subject came up for discussion, at least one person always said, "But if you miss one patient with (you fill in the blank), you will get sued." That type of comment is very difficult to refute because there is a grain of truth to it.

As far as I can tell, "I was following evidence-based guidelines" is not a foolproof defense against a malpractice suit. While there have been some attempts to legislate that following evidence-based guidelines should "immunize" doctors against malpractice suits, to my knowledge, no such laws exist. In 2004, an article in the AMA’s Virtual Mentor journal discusses this point very well as does a paper from the Journal of Law, Medicine & Ethics.

What then is a practicing physician to do? That unnecessary pre-op testing occurs has been understood for many years. The paper points out that the estimated cost of preoperative testing is anywhere from $3 billion to $18 billion. Several esteemed associations and societies have established guidelines which are not followed.

Meanwhile, extensive preoperative testing of ambulatory patients continues at the discretion of the surgeon, anesthesiologist and probably the patient’s primary care doctor too. And the tab mounts.

Radioactive man? Milford resident pulled over by state police

A few days ago, a 42-year-old man was stopped by a state policeman because radiation coming from his vehicle was detected by a device in the patrol car. Earlier that day, he had undergone a cardiac stress test which involved the injection of a small amount of radioactive isotope into his body. He was released when he produced a doctor’s note stating he had undergone the test. [Full story here.]

Two things make this story interesting.

One, the report reveals the fact that many police cars have radiation detectors that are so sensitive that a man emitting a small amount of radiation while driving could be fingered as a possible terrorist. Despite my being a news junkie, I did not know that such detectors were deployed. Did you?

Now the terrorists know too. What is to stop them from bringing a nuclear weapon into a city now that they are aware of the existence of these detectors and that a note from a doctor can get one off the hook?

The second interesting point involves the stress test. The story says the man had what seems to have been a transient hypertension. There was no mention of any cardiac symptoms or a family history of heart disease. The man is employed as a fireman, a strenuous occupation.

Why was a nuclear stress test ordered?

I am a mere, “non-cognitive” surgeon, but I believe that an asymptomatic 42-year-old fireman with hypertension, episodic or not, does not need a cardiac stress test.

Do you wonder why we spend so much on health care in the United States?

Clever New Diagnostic Test for Pancreatitis Fails to Measure Up

Today Eurekalert!, a science news service, featured a story about a new diagnostic test that at first glance seems interesting and possibly of value. Researchers at the University of Texas have developed a simple, inexpensive test for diagnosing acute pancreatitis using an LED sensor, aluminum foil, gelatin, milk and lye. Using about $1.00 worth of materials, the test identifies the presence of high levels of a pancreatic enzyme, trypsin, in the blood and takes only a few minutes to do.

According to the press release on the Texas Science website, “The sensor could help prevent damage from acute pancreatitis, which is a sudden inflammation of the pancreas that can lead to severe stomach pain, nausea, fever, shock and in some cases, death.”

Unfortunately, the breakthrough is not really all that dramatic.

Acute pancreatitis usually resolves in a few days. It is treated conservatively using bowel rest, intravenous fluids to maintain hydration and pain medication.

Pancreatitis is commonly diagnosed by history and physical examination and confirmed by elevated levels of one or two blood tests, serum amylase and lipase. Lipase, which rises more slowly but remains elevated in the blood longer than amylase, is the preferred test. Checking on line reveals that a serum lipase test can be obtained for as little as $39.00 retail. The actual cost of performing the test is under $6.00. In a hospital emergency department, the result is available within an hour of obtaining a blood sample, which negates the small speed advantage of the gelatin-based test. And let’s not forget that according to Joint Commission and other regulatory organizations, any point-of-care test must undergo frequent calibration to assure consistent quality. Technically, even a simple test for occult fecal blood cannot be performed at the bedside in the 21^st century.

It is not clear exactly how a diagnostic test that might save a few dollars and produces a result a little quicker than a standard blood test can prevent damage to the pancreas. Since the test is qualitative [elevated trypsin levels are present or not] rather than quantitative like the lipase test [a numerical value is reported], the gelatin test cannot be used to determine whether the level of pancreatic inflammation is increasing or not.

In fairness, the press release does point out that the gelatin test could be used in developing countries where automated blood analyzers might not exist or in situations where electrical power has failed. This of course is based on the assumption that aluminum foil, LED sensors gelatin etc are handy.

Bottom line. The test is ingenious but seems unlikely to replace standard blood tests for pancreatitis. Don’t believe everything you read in a press release.

[Note: Only 32 (7%) of the 451 words in this post were taken directly from the press release.]