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.).

Hypokalemia in diabetic ketoacidosis is less common than previously reported.

[K+] < 3.5 mmol/L is reported to occur in approximately 4 % of patients with diabetic ketoacidosis (DKA.) Therefore, the American Diabetes Association (ADA) and Joint British Diabetes Societies (JBDS) recommend the assessment of [K+] before the initiation of insulin treatment to avoid the precipitation of morbid hypokalemia. The purpose of this study was to assess the incidence of hypokalemia in patients presenting to the emergency department (ED) with DKA. This was a multicenter retrospective, cross-sectional study at EDs with a combined annual adult census of 155,000. Adult patients diagnosed with DKA in the ED, or who were admitted from the ED and subsequently diagnosed with DKA as determined from the hospital electronic database between January 2008 and December 2008, were included for analysis if they had the following initial laboratory values: (1) serum glucose >13.9 mmol/L (250 mg/dL), (2) serum bicarbonate <18 mmol/L (18 mEq/L) or anion gap >15, and (3) evidence of ketonaemia or ketonuria. 537 patients were diagnosed with DKA in the ED at the participating institutions during the reference period. The median [K+] was 4.9 mmol/L (IQR 4.3, 5.5). There were a total of seven patients with an initial 3.3 < [K+] < 3.5 mmol/L, but none with a [K+] < 3.3 mmol/L. Thus, no patients in our study sample required potassium supplementation before the initiation of insulin treatment. The incidence of hypokalemia in our sample of patients with DKA was much less than previously reported, with no cases requiring potassium supplementation before insulin administration.