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Journal club 10/10/19 (Thread closed)

Journal Club
5

 

 

xenia sara
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Good evening everyone and welcome to the 2019/20 Journal Club. Today we will be discussing the paper "Five-Year Follow Up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomised Clinical Trial" with Dr Kirolos Michael

 

xenia sara
6:28 pm
Let's wait until 18:35 for everyone to login before starting.

 

xenia sara
6:30 pm
Could everyone please put their names and email addresses down here so that I can send portfolio certificate

 

ahmedadil1
6:31 pm
Ahmed Adil-  ahmxdadilx@gmail.com

 

aaminwaquar
6:31 pm
Good evening my name is Aamin Waqar and my email address is aaminwaqar@gmail.com

 

mahammalik
6:31 pm
Good evening,  Maham Malik @mahammalik027@gmail.com

 

OA
6:32 pm
Evening, Oliver Arscott: oliver.arscott@gmail.com

 

Sarah Michael
6:32 pm
Can everyone also say if they're a medical student or sixth-former?

 

aaminwaquar
6:32 pm
I am a sixth former

 

ahmedadil1
6:33 pm
i am a sixth former!

 

mahammalik
6:33 pm
I am also a sixth former

 

OA
6:33 pm
5th year medical student, hello sixth formers!!

 

Sarah Michael
6:33 pm
Kirolos is ready so once everyone else is we can start!

 

Sarah Michael
6:37 pm
Welcome to our first journal club of the year! I'm Sarah a 4th year medical student and Scalpel President! Let me know if you have any trouble! We have a nice mixture of sixth formers and medical students today! Leading our first session will be Dr Kirolos Michael, a current FY2 at Stepping Hill

 

kmichael
6:38 pm
Welcome everybody. It's great to see so many sixth formers today.

 

kmichael
6:38 pm
Did everybody get a chance to read the paper that I chose for this week?

 

kmichael
6:39 pm
I thought we'd kick things off with a general surgery paper looking treatment of appendicitis

 

OA
6:40 pm
I've managed to have a fairly quick skim through, oriel applications were this week so apologies

 

kmichael
6:40 pm
Does anybody want to give a brief summary of the article, what they understood from the paper?

 

kmichael
6:42 pm
Anyone?

 

mahammalik
6:42 pm
It focuses on using antibiotics to treat acute appendicitis rather than an appendectomy and found that it was a suitable alternative at the end of 5 years of.monitoring those on the antibiotic group as many did not have to get the appendectomy after the treatment
 

OA
6:42 pm
My understanding was that the paper presented a prospective observational study looking at the long-term recurrence of uncomplicated appendicitis over 5 years

 

mahammalik
6:43 pm
Also forgot to mention they had 2 groups of equal sizes between ages 18-60 for each treatment, appendectomy and antibiotics

 

kmichael
6:44 pm
Great Maham & Oliver

 

kmichael
6:45 pm
So this was actually a randomised control trial consisting of 530 patients in total in Finland between the ages of 18-60 years who had uncomplicated acute appendicitis

 

kmichael
6:45 pm
Does everyone know what uncomplicated acute appendicitis is?

 

kmichael
6:46 pm
(It essentially just means that your appendix is inflamed, but it hasn't burst, formed an abscess or caused wider inflammation)

 

aaminwaquar
6:46 pm
Swelling and infection of the appendix

 

OA
6:46 pm
Uncomplicated acute appendicitis is appendicitis that does not present with any "complicating" features (i.e. perforation, abscess formation, presence of tumor etc)

 

kmichael
6:46 pm
Absolutely

 

kmichael
6:47 pm
So what was the aim of this trial?

 

mahammalik
6:47 pm
Was it to see if antibiotics were a suitable alternative to surgery?

 

kmichael
6:48 pm
That's right. Currently the gold standard treatment for appendicitis is to take the appendix out

 

kmichael
6:48 pm
The question is, can we get away with treating simple cases of appendicitis with just antibiotics and avoid surgery?

 

kmichael
6:49 pm
To answer that question, the authors had a few hypotheses or they looked at different things to assess whether antibiotics were suitable. Can anybody list some of the factors they measured to help answer that question?

 

ahmedadil1
6:53 pm
incidence of complications post-surgery vs post-antibiotic use?

 

Sarah Michael
6:53 pm
the pain score, the complication rates, length of hospital stay

 

OA
6:53 pm
They measured primary outcome (i.e. resolution of the appendicitis) at one year follow up for both groups. They also assessed recurrence rates over 1-5 years, length of stay, sick leave and pain scoring (postintervention)

 

OA
6:53 pm
+ complications

 

kmichael
6:54 pm
That's right, all of you are correct

 

kmichael
6:55 pm
They looked at recurrence of appendicitis for up to 5 years. The also compared surgery vs. antibiotics in terms of complications, hosi

 

kmichael
6:55 pm
*hospital stay & sick leave

 

kmichael
6:56 pm
Something else they looked at which I found a little bit more tricky to pick up was the pain score after 2 months from the episode of appendicitis to see if that predicted recurrence.

 

kmichael
6:56 pm
What did everyone make of the study design? What kind of study was it?

 

ahmedadil1
6:58 pm
randomised repeated measures design?

 

kmichael
6:58 pm
I don't know if the sixth formers among us have come across different study designs and the way we group them

 

aaminwaquar
6:59 pm
I’m only aware of independent and repeated measures design so I don’t know any other study designs

 

OA
6:59 pm
Prospective observational study - a randomised control trial? Although not sure if the division of groups counts as the presence of a "control"

 

ahmedadil1
7:00 pm
Same as aamin^

 

kmichael
7:00 pm
That's okay. I'll briefly mention the types of study designs

 

ahmedadil1
7:00 pm
that would be great, thank you

 

aaminwaquar
7:00 pm
Thanks

 

kmichael
7:01 pm
So to keep things simple, when we have a clinical question that we want to answer, we can essentially do 2 things:

 

kmichael
7:01 pm
1) Observe

 

kmichael
7:01 pm
2) Intervene

 

kmichael
7:01 pm
So the 2 groups of studies generally are (1) Observational studies (2) Interventional studies

 

aaminwaquar
7:02 pm
that makes much more sense thanks

 

ahmedadil1
7:03 pm
what is the main difference between the two, sorry

 

kmichael
7:03 pm
If we wanted to look at whether smoking increased the risk of developing lung cancer, we could look at a group of smokers and a group of non-smokers, follow them for let's say 10 years and see how may in each group developed lung cancer and compare the 2. If we found that more people developed lung cancer in the smoking group (and this was statistically significant), we can say smoking likely increases the risk fo lung cancer etc.

 

kmichael
7:04 pm
that is an example of an observational study

 

kmichael
7:04 pm
We can also do the reverse where we can take a group of people with lung cancers and see how may of them were smokers & how many of them were non-smokers in the past.

 

kmichael
7:05 pm
that's another example of an observational study where essentially all we are doing is looking at relationships between diseases and risk factors

 

kmichael
7:05 pm
Interventional studies are different in that they are "experimental"

 

kmichael
7:07 pm
For example, if you wanted to find out whether a cholesterol lowering drug (a statin) reduced your risk of developing heart disease. You can get a group of patients with high cholesterol. Randomly allocate half to take the drug and give the other half a placebo (sugar pill). Ideally neither the patients nor the doctors would know who gets which one. You would then follow them up for a few years and see if there is a difference in how many in each group develop heart disease

 

kmichael
7:08 pm
If the group that had the drug had lower rates of heart disease (and this was statistically significant), then you could conclude that the drug in question reduces your risk of heart disease

 

mahammalik
7:08 pm
Thank you so.much for explaining the difference
 

aaminwaquar
7:08 pm
Thanks

 

kmichael
7:08 pm
Now the example I just gave would be a double-blinded randomised control trial

 

aaminwaquar
7:08 pm
I understand it now

 

kmichael
7:09 pm
Double-blinded: because both the patients and the doctors don't know who is getting the intervention & who is getting the placebo

 

kmichael
7:09 pm
randomised, becomes people are assigned completely at random to either the treatment or placebo group (usually using a computer)

 

kmichael
7:10 pm
Control trial: because the control is the placebo group, the sugar pill that you compare the intervention (the drug) to

 

kmichael
7:10 pm
Is everyone with me so far? Any questions at this stage?

 

ahmedadil1
7:10 pm
ahh that makes more sense, thank you

 

kmichael
7:11 pm
In the title, it says its a randomised clinical trial

 

kmichael
7:11 pm
But like Oliver mentioned, it's a little bit more complicated because actually it is essentially an interventional study & observational study all in one

 

kmichael
7:12 pm
Oliver, could you tell us which parts of it make it a randomised control trial & which parts make it an observational trial?

 

OA
7:14 pm
So the interventional portions make up the Randomised control trial elements. Those are where we "intervene" with using antibiotics instead of appendicectomy to manage the appendicitis. The observational portion is the follow-up and "observing" of patients over the 5 year period to assess the outcomes we've already discussed

 

kmichael
7:15 pm
Great

 

kmichael
7:16 pm
So essentially the first part is a prospective observational trial (a cohort trial), which means we look at the patients who were treated with antibiotics and follow them to see how many of them go on to develop another episode of appendicitis

 

kmichael
7:16 pm
the second part is a randomised control trial because we are comparing surgery vs. antibiotics in terms of complications, hospital stay & sick leave. That makes this part an interventional trial, a randomised control trial

 

kmichael
7:17 pm
Shall we talk about the results really quickly?

 

kmichael
7:18 pm
Then we can open up the discussion about the implications

 

kmichael
7:19 pm
I'm going to list the results so we can go ahead and discuss them.

 

kmichael
7:20 pm
In the antibiotic group, the recurrence rate of appendicitis was 27.3% at 1yr and 39.1% at 5yrs. 70% of those who had recurrence, had recurrence in the 1st year.

 

kmichael
7:21 pm
Having pain 2 months after appendicitis made recurrence more likely

 

kmichael
7:21 pm
Patients receiving antibiotics had fewer surgical complications (infections, hernas, pain or bowel obstruction) compared to those who had surgery

 

kmichael
7:22 pm
The hospital stay was the same in both groups (3 days)

 

kmichael
7:22 pm
However, those who had surgery had 11 days more sick leave than those who had antibiotics

 

kmichael
7:23 pm
What did everyone think about the results? Do you think we can safely conclude that antibiotics are effective?

 

mahammalik
7:23 pm
I think that 39.1 percent is still quite a lot

 

ahmedadil1
7:23 pm
definitely!

 

kmichael
7:24 pm
I think so too

 

kmichael
7:24 pm
so 2 out 5 people treated with antibiotics needed to have surgery anyway in the following 5 years

 

mahammalik
7:24 pm
However they did use broad spectrum antibiotics so further research could be done to formulate a more exact treatment

 

kmichael
7:25 pm
I'm glad you picked up on the antibiotic

 

kmichael
7:25 pm
they used an antibiotic called Ertapenem. This is something we don't use first line here. It's broad spectrum which means it covers a whole host of bugs and is very effective

 

kmichael
7:25 pm
which is why we only use it as 2nd and 3rd line

 

kmichael
7:26 pm
does anybody know of any problems with using such hard hitting antibiotics?

 

mahammalik
7:26 pm
Antibiotics resistance

 

kmichael
7:26 pm
Very good

 

kmichael
7:26 pm
That's a real problem with using these antibiotics

 

kmichael
7:27 pm
Normally if we take the appendix out and it hasn't burst or caused a lot of inflammation in the surrounding areas or caused contamination, we wouldn't start any antibiotics

 

kmichael
7:28 pm
What does everyone think about the difference in sick leave?

 

kmichael
7:28 pm
So it was 22 days off if you had an appendicectomy compared to 11 days off if you have had antibiotics

 

ahmedadil1
7:28 pm
they still had the same hospital stay?

 

ahmedadil1
7:29 pm
but then again, overall those who had the antibiotics has less complications

 

kmichael
7:29 pm
That's true, but this is sick leave after they go home. So time off of work

 

OA
7:30 pm
I think the difference in sick leave is interesting from a health economics point of view. However I would argue, similarly to the complications results, it is a weighted outcome to measure. People on Abx won't be getting incisional hernias so the assessment seems somewhat skewed. There is for example no record of those who suffered side effects or anaphylaxis from the antibiotics.

 

kmichael
7:30 pm
I guess, what I'm trying to get at is how do we do appendicectomies? There are 2 techniques which you may have heard of

 

mahammalik
7:30 pm
It was significant statistically but I'm not sure if It compares to having more complications later down the line by getting appendicitis again

 

OA
7:30 pm
Open vs laparoscopic

 

kmichael
7:30 pm
That's right

 

ahmedadil1
7:31 pm
Pararectus incision?

 

kmichael
7:31 pm
The majority of surgeries were open in this study

 

kmichael
7:31 pm
Very few were laparoscopic

 

kmichael
7:32 pm
Open appendicectomies are bigger operations than key hole (laparoscopic) appendicetomies

 

kmichael
7:32 pm
You usually need to take 2 weeks off work after open appendicetomy. However with key hole surgery, you can get back to work much quicker. You can also leave hospital the next day.

 

kmichael
7:33 pm
In the UK, virtually all uncomplicated acute appendicitis in this age group is usually laparoscopic (there are some reasons why you would have to do an open appendectomy, but we won't go into that here)

 

kmichael
7:33 pm
but perhaps if they compared the number of sick day leaves for keyhole appendicectomies vs. antibiotics, the differences may not be as marked

 

kmichael
7:34 pm
and just quickly before we wrap up

 

kmichael
7:34 pm
somebody mentioned about complication rates

 

ahmedadil1
7:34 pm
yes

 

kmichael
7:34 pm
So 24.4% in the appendectomy group vs. 6.5% in the antibiotic group

 

kmichael
7:34 pm
Would that sway you guys to the antibiotic group more?

 

ahmedadil1
7:35 pm
definitely!

 

mahammalik
7:35 pm
No

 

kmichael
7:35 pm
why not?

 

mahammalik
7:36 pm
It may still reoccur then appendectomy will be required anyways, especially since no targeted treatment has been formulated yet and current day appendectomies are quite safe even with complications

 

kmichael
7:37 pm
That's true

 

kmichael
7:37 pm
Most of the complications were infections

 

kmichael
7:37 pm
only 2 people in the whole study actually had severe complications that need a second operation

 

kmichael
7:37 pm
that's not too bad

 

kmichael
7:38 pm
and with laparoscopic surgery, there is a reduced risk of infection because it is keyhole and reduced risk of bowel obstruction because you don't muck about as much by handling the bowel and causing adhesions

 

kmichael
7:38 pm
Any questions or other thoughts before we finish?

 

mahammalik
7:39 pm
Also you mentioned that antibiotics would only be used if inflamed or contamination occurs, so less antibiotics used and hopefully less antibiotic resistance?

 

kmichael
7:39 pm
We didn't really dig deep into the statistical analysis today, but I thought since we went through study designs, we probably wouldn't have had enough time

 

Sarah Michael
7:40 pm
Ok everyone shall we begin wrapping up?

 

kmichael
7:40 pm
That's right Maham. If we take someone to theatre of uncomplicated acute appendicitis and it doesn't look to much, the appendix hasn't burst and we haven't made a mess of things inside, we don't generally give antibiotics.

 

mahammalik
7:41 pm
Thank you for clearing that up!

 

OA
7:41 pm
Thanks very much for running things Sarah and Dr Michael!

 

kmichael
7:41 pm
So we would end up comparing broad-spectrum antibiotics vs. no antibioitcs at all. You could see why the first group are at risk of resistance.

 

kmichael
7:41 pm
Thanks very much guys, it's been an engaging first journal club.

 

aaminwaquar
7:42 pm
Thank you so much for organising it!

 

ahmedadil1
7:42 pm
thank you, I learnt a lot!

 

kmichael
7:42 pm
I hope next time more people can join in. Scientific articles are very difficult to read, let alone undsertand what's going on, but hopefully this will give you guys a flavour of how to read and interpret scientific articles

 

mahammalik
7:43 pm
Thank you for giving us so much information and helping us understand the importance of the study!

 

Sarah Michael
7:43 pm
Thank you everyone for attending!

 

ahmedadil1
7:44 pm
Thank you!