142. Covid, Appendicitis, COPD, Vitamin D

Sometime I wonder how the world will change post covid- or how the board questions will change?

And that is clearly seen in this article titled-

Yip L et al. Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol — Arizona and New Mexico, May–June 2020. MMWR Morb Mortal Wkly Rep 2020 Aug 14; 69:1070.

hand sanitizing gels and foams containing ≥60% alcohol (either ethanol or isopropyl alcohol) has been proven to be effective -- Methanol is not an acceptable substitute
in this paper they looked at 15 cases of methanol poisoning due to ingestion of methanol-containing hand sanitizers From May through June 2020

All patients had a history of ingesting alcohol-based hand sanitizer
presentation included visual disturbance, seizures, gastrointestinal involvement, altered mental status, and anion-gap acidosis with blood pH varying from 6.70 to 7.23.
in the end Four patients died and three others were discharged with new visual impairment.

I can see it now- beth comes into the office and has visual changes and slightly altered mentation – she is known to be a prepper and vary scared of covid and he husband said she recently read that if you swallow hand sanitizer it will kill covid19 just like it does when it is on your hands—what is the most likely diagnosis for this pt. and the answer will be methanol poisoning!

Next artciel

Are antibiotics as good as surgery for pediatric appendicitis? The answer depends on who is asking the question
In this trial
Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis
nonrandomized study of nonoperative treatment of 1068 pediatric patients with uncomplicated appendicitis.
Roughly 65% chose to undergo urgent laparoscopic appendectomy, while 35% chose nonoperative management with IV antibiotics in the hospital followed by oral antibiotics at home
The primary outcome was defined as not requiring appendectomy within 1 year of study enrollment. And in the end Two thirds of youth who received antibiotics to treat uncomplicated appendicitis avoided surgery, and
Nonoperative management was associated with a 67% success rate for avoiding surgery in the subsequent year
But the important thing here is how you power your study- you power it to find the minimal clinically important difference (MCID)—the MCID is a a mystery- you wont a number that is reasonable difference in practice for the reader but attainable for the study so we don’t have a million neg. trials and what this difference is completely determined by the authors. Sure they can look at other studies and see what they used but ultimately this is up to the authors—if in this trial they say I think the clinical meaningful difference is to avoid 25% of surgeries then they set that as the standard and BOOM in this trial about 65% of surgeries were avoided in those in the antibiotic arm. This trial would have been a smashing hit! But instead the authors chose a much hard outcome of 70% based on surgeons they work with! And when you asked parents they said ‘well I think 50% would have been good enough’--- HOWEVER since 70% of pts had to avoid going to surgery- this means it was a negative trial.
I think this is a great article that points to the shared decision making conversation because no article or paper is 100% if you do this then this will happen, bit if you say well if you do this then about 2/3 of the time you will prevent having to go to surgery that is a much different conversation than well if you do this then you wont have to go to surgery because the truth is they still do around 33% of the time which is good enough odds for me and my child or at least any child I would be babysitting since I don’t have children.
So I ask again is it ok to spare 2 out of every 3 children a surgery and invasive procedure, I guess it just depends who you are asking







https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769373?guestAccessKey=7518012e-17e8-48cd-8278-c3b68652db52&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=081720

Is an article that will leave you breathless- in jama internal medicine

Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health StatusA Randomized Clinical Trial

They asked the question- Does regular, low-dose, oral sustained-release morphine improve disease-specific health status or cause respiratory adverse effects in patients with moderate to very severe chronic breathlessness due to advanced chronic obstructive pulmonary disease?

and the results were = ---
In this randomized clinical trial of 111 patients with chronic obstructive pulmonary disease, morphine 10 mg twice daily for 4 weeks significantly improved CAT SCORES or the Chronic Obstructive Pulmonary Disease Assessment Test scores
. compared to placebo

This is good we think!! Except when you read the study you see in the sample size they say-

To detect a mean (SD) change in CAT of 3.8 (6.1) “62 participants per group needed to be included.

remember thiswas only 111 pts so no matter how you cut it they didnt achieve adequete power of their study.

The CAT questionnaire consists of eight questions, assessing the symptoms on a scale from 0 to 5. The total score ranges from 0 to 40, with higher scores representing worse health status.

And remember they wanted a difference of 3.8 but in the end there was only a 2.18 difference ---And the authors say but our finding of a 2.18 difference is important because there is previous data saying that the minimal clinical important difference (MCID) for the CAT is 2·0 to 3·0 points. YOU CANT DO THAT!! Its like saying I am going to do a triple back flip then after doing a double back flip saying well that is still really good and worth a blue ribbon!! NO NO NO not everyone gets a blue ribbon- sometimes negative trials are important or just as important as the positive trial!!

the authors are saying we understand we powered and ran our study to find a 3.8 difference in the cat scale and we understand that we barely found half of that but because of cherry picking study we found from 3 yrs ago we still think our trial is ‘positive’ and we will think that there should be “a larger and longer trial is warrented”

and I would say – it is not warrented---and incase you were wondering—yes this is absolutely another study where the authors were tainted by drug company conflicts of interest but am sure you already assumed that


next article



Effect of Long-term Vitamin D3 Supplementation vs Placebo on Risk of Depression or Clinically Relevant Depressive Symptoms and on Change in Mood ScoresA Randomized Clinical Trial Long-term vitamin D
https://jamanetwork.com/journals/jama/article-abstract/2768978
Roughly 18,000 adults (aged 50 and up for men, 55 and up for women) free of depression at baseline, including 1700 at risk for recurrence of depression but without treatment over the preceding 2 years, were randomized to receive either vitamin D3 (2000 IU per day of cholecalciferol) or placebo. After a median treatment duration of 5 years, rates of depression were similar between groups at about 13 per 1000 person-years. Mood scores were also similar.
The authors write: "The findings do not support a role for supplemental vitamin D3 in depression prevention among adults." Read Dr. Peter Roy-Byrne's take on this study in NEJM Journal Watch Psychiatry in the coming days.
Any benefit is seen in observational data!!! Confounders!!
We all want it to be but the evidence just doesn’t support vitamin d or at least not when we look at the evidence for the RCT