Dr K K Aggarwal: Practice changing

Monday, April 8, 2019

Practice changing: Advise interval appendectomy to all conservatively managed patients with perforated appendicitis

Should an interval appendectomy be done in patients with perforated appendicitis and who have been managed conservatively or nonoperatively with intravenous antibiotics and percutaneous drainage of an abscess, if present? Or, can these patients be followed-up with MRI scans?

The Peri–Appendicitis Acuta randomized clinical trial examined this question and found the answer. It recommends interval appendectomy for patients with perforated appendicitis managed conservatively at the time of presentation to exclude an appendiceal neoplasm.

In the trial, 60 patients were randomized either to interval appendectomy or follow-up with magnetic resonance imaging (MRI). All patients underwent colonoscopy. Data was analyzed from April 2016 to September 2017.

The incidence of appendiceal neoplasms was high. The overall neoplasm incidence was 20% with all neoplasms in patients older than 40 years.

The trial was terminated early because of ethical concerns due to a high incidence of appendiceal neoplasms. All patients were offered appendectomy.

The 1-year outcomes have been published in March 2019 issue of JAMA Surgery.

(Source: JAMA Surg. 2019;154(3):200-207)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Saturday, February 9, 2019

Practice changing: NIH study provides answer to long-held debate on blood sugar control after stroke

Hyperglycemia is common in patients with acute ischemic stroke and is associated with worse outcomes compared to normal glucose levels.

It has often been debated whether intensive glucose management, which requires the use of IV insulin to bring blood sugar levels down to 80-130 mg/dL, or standard glucose control using insulin shots, which aims to get glucose below 180 mg/dL, lead to better outcomes after stroke.

Primary results from the Stroke Hyperglycemia Insulin Network Effort (SHINE) study, a large, multisite clinical study presented at a plenary session at the International Stroke Conference in Honolulu on Feb. 6, 2019 provide a clear answer to that question.

The primary results show that intensive glucose management did not improve functional outcomes at 90 days after stroke compared to standard glucose therapy.

In addition, intense glucose therapy increased the risk of very low blood glucose (hypoglycemia) and required a higher level of care such as increased supervision from nursing staff, compared to standard treatment.

(Source: NIH, Feb. 6, 2019)