A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We 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 (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: 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). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. 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 rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

Racial disparities exist among burn patients despite insurance coverage.

BACKGROUND: Age, total burn surface area (TBSA), and inhalation injury are proven predictors of mortality and morbidity following burn injury. Most previous studies have also found that African Americans and females with burns also fare worse. We sought to determine whether these disparities were reduced when burn victims were analyzed separately by categories of insurance coverage. METHODS: We evaluated records in the National Burn Registry (NBR) from 2002 to 2011. Multivariate logistic regression was performed to determine factors associated with inpatient mortality, including age, TBSA, inhalation injury, race, and sex, and allowing for clustering by hospital. Separate models were constructed for each category of insurance. 95% confidence intervals (CI) not including 1 for any odds ratio were considered evidence of statistical significance (designated by * in the table below). RESULTS: NBR included records from 172,640 patients (55.8% Caucasian, 18.1% African American, 14.2% Hispanic, 6.4% other minority groups, 5.4% unknown). Age, TBSA, and inhalation were strong predictors of mortality as expected. Non-African American males were the largest group for all insurance categories, and had the lowest mortality. Controlling for these factors, and compared with non-African American males, African American males had consistently increased odds of mortality regardless of insurance coverage. African American females had increased odds of mortality if they had Private, Medicare, or Medicaid insurance, and Non-African American females had increased odds of mortality if they had Private or Medicaid insurance. The association of Hispanic ethnicity with mortality was inconsistent or insignificant, and other minority groups had too few members to evaluate. Most patients were missing comorbidity data, and no other socioeconomic or hospital data were available in NBR. CONCLUSIONS: African American males with burn injury are at increased risk of mortality regardless of insurance coverage, and most females are at increased risk regardless of race. Analyzing the reasons for these disparities will require databases containing more complete comorbidity, socioeconomic, and/or hospital data.

New onset squamous cell carcinoma in previous split-thickness skin graft donor site.

INTRODUCTION: Marjolin' s ulcer, an aggressive ulcerating squamous cell carcinoma, is a well-known phenomenon that occurs in chronically inflamed or scarred tissue; however, squamous cell carcinoma arising in the acute setting after tissue trauma - specifically autograft donor harvest sites for burns - is a rare, but notable event. METHODS: This case series describes three instances of squamous cell carcinoma diagnosed in split-thickness skin graft donor sites in the immediate post-operative period. Charts were reviewed in detail after at least 9 months follow-up from identification of the tumor. Detailed descriptions of each case are included. A discussion of the literature on this rare entity is included as well. RESULTS: In the three cases discussed, all were characterized clinically as painful masses arising in a recently healed donor site. Two were managed surgically with adherence to oncologic principals. One lesion regressed or fell off spontaneously. With at least 9 months follow-up, there was no evidence of recurrence. CONCLUSIONS: Very few cases of acute neoplasm in donor sites have been described in the literature. Presently, there is no dominant theory as to how these lesions arise; however, this is an entity that burn care providers, world wide should be aware of, with a low threshold for oncologic evaluation if suspected.