by Nancy Humphrey

Antibiotics instead of surgery may be a good choice for some, but not all, patients with appendicitis, according to results from a study reported today in the New England Journal of Medicine.

The study compared immediate surgery for appendicitis against an alternative approach that used antibiotics initially to treat it, then only moved to surgery if the antibiotics strategy wasn’t working.

Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) is the largest randomized controlled clinical trial of appendicitis to date. It included 1,552 participants from 25 participating sites in 14 states and included Vanderbilt University Medical Center.

In the study, after three months, 7 of 10 participants (70%) randomized to the antibiotics strategy avoided an operation and 30% underwent surgery due to the perception that the antibiotics were not working. The authors concluded that treating appendicitis is definitely not a one-size-fits-all approach.

Surgical removal of the appendix, an appendectomy, has been the standard of care for treatment of appendicitis for more than 120 years, but treatment with antibiotics is often proposed as an alternative.

Wesley Self, MD, MPH

The participants were randomized to receive either appendectomy or antibiotics first for uncomplicated appendicitis.

“The results of this trial are very useful as doctors talk to patients about treatment options for appendicitis,” said Wesley Self, MD, MPH, vice chair for Research in the Department of Emergency Medicine at VUMC and an author of the study. “It appears that an antibiotics-first approach can lead to some patients recovering from appendicitis without surgery, but that approach certainly doesn’t work for everyone. For example, patients who have appendicitis with an appendicolith, a firm stone-like material inside the appendix, appear to frequently fail the antibiotics treatment approach.”

The results of this study can be important for individuals with appendicitis as they, with their physician, determine the best treatment option, the study shows.

“The best treatment option may depend on patient preference; some patients may want to have immediate surgery to definitively take care of the problem, knowing it may take them some time to recover after the surgery. On the other hand, other patients may choose the antibiotics strategy to see if they can avoid surgery, realizing the antibiotics approach may not work and they would need to come back to the hospital for surgery.” Self said.

While nearly half of the antibiotics group avoided hospitalization for their initial treatment, overall, the time spent in the hospital was similar between groups and patients treated with either surgery or antibiotics experienced symptoms for about the same length of time. Patients treated with immediate surgery missed more days of work on average than those treated with the antibiotics approach. But a lower proportion of patients treated with immediate surgery came back to the hospital after the initial treatment course,” Self said.

The trial was completed one month before the first cases of COVID-19 were identified in the United States. With the COVID-19 pandemic, health systems and professional societies such as the American College of Surgeons have been reconsidering many aspects of health care delivery, including the treatment of appendicitis.

The trial was funded by Patient-Centered Outcomes Research Institute (PCORI). The CODA Collaborative is composed of clinicians (surgeons and emergency physicians) at each of the 25 trial sites, patient advisors and other stakeholders.

“It’s essential to have both surgeons and emergency physicians working together because both specialties are central to diagnosing and treating patients with appendicitis. Successful collaboration across specialties was essential to make this trial a success,” Self said.

90,000 Appendicitis is treated with antibiotics, and octopuses on ecstasy want to cuddle. Science News

• Nikolai Voronin
• Science and Technology Correspondent

September 30, 2018

Subscribe to our newsletter “Context”: it will help you understand the events.

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In another compilation of the most interesting, most important and just the most unusual and funny scientific news of the week:

• Did you have your appendix removed? Probably in vain
• Under the influence of ecstasy, octopuses become more sociable
• A huge dust storm was noticed on Saturn’s moon Titan
• Animals can count, but do not know numbers. And that’s why
• Men and women cope with several tasks at the same time equally badly

Surgery is not needed for appendicitis

For more than a hundred years, the only treatment option for appendicitis was considered to be the removal of an inflamed organ. And only now the surgeons have found out that the operation is not at all necessary – in most cases it is enough for the patient to prescribe a course of antibiotics.

Scientists from the University of Turku made a sensational statement. Previous studies have already cautiously indicated the possibility of treating appendicitis with antibiotics, but so far such recommendations have been avoided. Doctors could not rule out the option that antibiotics only relieve an acute form of inflammation – and the operation will still be needed later, only it will turn out to be much more complicated.

In a large-scale experiment, Finnish scientists followed 300 patients aged 18 to 60 for five years who were asked to treat uncomplicated appendicitis without surgery with antibiotics.

They were given medication intravenously in the hospital for three days, and then for another week they took antibiotics at home, in the form of tablets.

As a result, almost two-thirds of the patients did very well without surgery. And for those who still needed it, the removal of the appendix went without any complications.

So, uncomplicated acute appendicitis should first of all be treated with antibiotics, the authors of the study conclude. This will not worsen the patient’s condition in any way, but with a high degree of probability it can save him from unnecessary surgery and the associated risks of infections getting into the wound.

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Ecstasy octopuses want to cuddle

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Humans and octopuses are separated by roughly 500 million years of evolution, but we have more in common than meets the eye. For example, as scientists have found out, the narcotic substance ecstasy has about the same effect on these animals as it does on humans.

In humans, ecstasy reacts with one of the proteins in the nerve endings, causing the brain to actively produce the hormone serotonin.

The SLC6A4 gene, which codes for this protein in human DNA, is also present in the octopus genome – and the scientists wanted to find out if the drug has the same effect on them.

First, the animals were placed in a solution with a small amount of ecstasy, and then moved to a three-chamber aquarium: in one of the compartments there was nothing, in another there was a plastic toy, and in the third – a male or female of the same species of octopus, only in a cage.

Octopuses are not usually social unless they are in mating season. However, under the influence of the drug, all animals spent most of their time in the company of a “buddy” in the third compartment.

Moreover, they pushed their tentacles through the bars of the cage, trying to touch and hug their relative – such behavior, again, they usually demonstrate only during the mating season.

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Dust storm on Titan

The Cassini space probe seems to have captured a giant dust storm on Titan, Saturn’s largest moon. The wind picked up huge clouds of dust from the dunes – approximately in the equator region – and carried them over a considerable distance.

Photos taken by the spacecraft published on the NASA website and in the journal Nature Geoscience. The discovery delighted scientists: previously, dust storms could only be observed on Earth and Mars.

Titan has a lot in common with the Earth. This is the only satellite of the planets in our solar system, where there is a dense atmosphere, and the only celestial body known to us, besides our planet itself, on the surface of which there are reservoirs full of liquids.

However, there is an important difference: the lakes, rivers and seas on Titan are filled not with water, but with liquid methane and ethane. However, these hydrocarbons evaporate from the surface of the satellite in the same way, condense in the atmosphere, form clouds – and fall back in the form of precipitation.

Titan also has a change of seasons. In particular, at the equinox – when the Sun crosses its equator – huge arrays of clouds can gather in tropical regions, forming powerful methane hurricanes.

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Animals can count but don’t know numbers. And that’s why

There are many kinds of animals that can count (think of circus performances), but only people can use abstract numbers like “2” or “5”. And now scientists have figured out why.

It turns out that completely different brain cells are involved in determining and recognizing numbers. And they managed to find out by studying the encephalograms of nine patients with epilepsy.

Scientists tested the origin of the signals that provoke an epileptic seizure by recording the data of electrodes implanted in the brains of patients – 585 individual nerve cells were examined in each. The neurons were located in the medial temporal lobe, which is responsible for the processing of sound and visual signals, as well as for memory and mental activity.

Each patient was asked to perform 320 simple arithmetic calculations (it was necessary to add or subtract numbers from 1 to 5) – while scientists wrote down exactly which cells were involved in this process.

At the same time, sometimes the subjects were shown numbers (1, 2, 3, 4 or 5), and sometimes – a set of circles that had to be counted before making calculations.

It was then that scientists discovered that the demonstration of numbers causes a certain neural reaction in patients – a kind of imprint, unique for each number. Circles also cause a similar “neural imprint” – but completely different cells were involved. For example, the reaction of the brain to the number “4” was not at all the same as the reaction to the image of four circles – and in the latter case, the combination of neurons was simpler.

“This may explain why, while some animals show amazing numeracy, only humans can tell numbers from their names and appearances,” says one of the study’s authors, Cristian Agrillo of the University of Padua.

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Men and women multitask in the same way. Equally bad

It is widely believed that women are much better than men at multitasking. This view is supported by several studies – for example, in one of them, women performed better than men on IQ tests, if at the same time they both walked on a treadmill.

However, it is also widely known that there are tasks where men always outperform women. For example, men, on average, have a much better idea of ​​what a three-dimensional figure will look like when rotated.

Women, in turn, remember a list of a dozen words much better than men.

However, now scientists have decided to approach this issue more comprehensively and compare not the ability of the sexes to perform certain tasks in the laboratory, but the ability to multitask in general, in the real world.

For this, University College London has developed a special computer test with two types of multitasking: simultaneous (for example, when you are talking on the phone while driving a car) and sequential (when you constantly switch from one to another – writing a letter, being distracted by a conversation with colleague or interrupted by reading social networks).

The experiment involved about 150 people – men and women aged 18 to 60 years. When they all passed the test, the scientists compared several parameters: how well the participants completed the tasks and whether all the tasks were completed, how long it took them to complete the test, and so on.

Scientists could not find any significant difference between men and women. And – moreover – they came to the conclusion that both of them cope with several tasks at the same time worse than expected.

Conservative treatment of acute appendicitis (translation)

Journal of Gastrointestinal Surgery (2009) 13:966-970 DOI 10.1007/s11605-009-0835-5
Conservative Management of Acute Appendicitis
Ajaz A. Malik Shams-ul Bari

Summary

Acute appendicitis is the most common disease in emergency surgery. Primary treatment consists traditionally in appendectomy. Antibiotics are administered before surgery and will continue after it, as needed.

Methods. A study was performed at the Medical Institute, Srinagar, Kashmir, India to determine the role of antibiotics as the sole treatment for acute appendicitis (AA) in combination with analgesics, as needed. A total of 80 patients with abdominal pain lasting less than 72 hours were examined. Of these, 40 patients were treated with intravenous antibiotics for two days, followed by oral continuation for 7 days. The remaining 40 patients, the control group, underwent appendectomy.

Results. Patients after conservative therapy were discharged after 3 days, except for two who underwent surgery 12 and 24 hours after admission, respectively, due to signs of peritonitis on the background of perforated appendicitis. The diagnostic accuracy in the operated group was 90%. Two patients had perforated appendicitis at surgery.

Conclusion. Our opinion is that the conservative treatment of OA with antibiotics is very effective, in general, they can do without surgery. Patients treated exclusively with antibiotics suffer less pain, require fewer painkillers, but have a high relapse rate of 10%.

Introduction

McBurney first reported 8 patients with acute appendicitis treated with early appendectomy in 1889 [1]. Coldrey in 1959 treated 471 unselected patients conservatively with low mortality and few complications [2], but the idea is controversial today. Anonymous of 500 patients with suspected acute appendicitis, 425 were treated conservatively with traditional Chinese medicine and antibiotics [3]. However, 7 out of 100 examined later had a recurrence of OA. In all cases, the clinic of the disease and its history were evaluated. Treatment was evaluated without standardization and follow-up examination. Preoperative antibiotics have been used as a means of delaying surgery at night. At the same time, the frequency of perforations, complications and duration of hospitalization in patients operated on up to 6 hours is similar to those who were operated on within 6 to 18 hours after admission [4].

Conservative treatment of OA was successfully defended by many authors [5-11]. Although some have recommended a “delayed” appendectomy [5–9] for suspected caecal tumor or recurrent appendicitis. Conservative treatment was recommended on American submarines [12] and Soviet ships at sea – 247 patients [13]. Only a few prospective randomized studies have been performed.

Materials and methods

Patients

80 people were examined between August 2003 and July 2005 followed by a year of follow-up. 56 men and 24 women aged 17-64 were observed. Detailed information about is presented in Tables 1 and 2. Patients were assessed using the Alvarado scoring system, which included various data, symptoms, laboratory results associated with acute appendicitis [15].

Table 1. Symptoms and their significance in acute appendicitis

Table 2. Sum of scores and probability of acute appendicitis

Ultrasound, laboratory tests like white blood cells, protein levels have been used as a diagnostic tool to identify AO [16,17]. Plus a typical history and clinical findings, including Alvarado scoring, positive ultrasound, leukocytosis, and C-reactive protein (Table 3). Ultrasound was positive in 64 (80%) cases. CT was not performed due to its high cost in this part of the world.

Table 3. Characteristics of patients with acute appendicitis.

Conservative therapy

Ciprofloxacin was administered at 500 mg every 12 hours and metronidazole at 500 mg every 8 hours for 2 days. The drug was administered only intravenously. Pain was recorded every 6 hours, thermometry was performed twice a day. Patients were discharged no later than the 3rd day. Ciprofloxacin 500 mg 2 times a day and tinidazole 600 mg 2 times a day were administered orally, for a total of 7 days.

Surgery

The operated patients were prescribed antibiotics only in case of process perforation or colonization of the abdominal cavity for 48 hours. Discharged from the hospital immediately after the normalization of the condition. The removed process was sent for histology.

Follow-up

Patients were examined on the 7th, 12th, 30th day after hospitalization.

Methods

Pain was recorded using visual analogues every 6 hours of hospital stay – from 0 points to 100, pain was relieved with intramuscular diclofenac, and after discharge – with paracetamol.

Ultrasound was performed on days 12 and 30. At the same time, in 38 patients treated conservatively with antibiotics, the process was visualized in 15 patients on the 12th day. A month later, in 15 patients, the appendix was visualized in 9. Of these 9, 4 had a recurrence of appendicitis after one year. All conservatively treated patients with OA recurrence underwent surgery.

Results

Conservatively treated group

Significantly fewer analgesics were required in patients treated conservatively (p<0. 001). Their pain 12 hours after the start of therapy was significantly less (p<0.001). Leukocytosis subsided much faster, and the temperature was significantly lower on days 1 and 2 after hospitalization. However, C-reactive protein was similar in both groups.

Surgery group

In 36, the diagnosis was confirmed histologically (Table 4). In 4, the appendix was not changed: in 2, a ruptured ovarian cyst was observed, in 1 man – Meckel’s diverticulitis and in 1 woman – pelvioperitonitis.

Consequences

Pain was significantly less on days 7 and 12 in patients treated with antibiotics. Leukocytosis also continued to decline by day 7, but there was no statistical difference. Three patients after removal of the gangrenous appendix in a week were rehospitalized due to wound infection, they were treated with antibiotics for 5 days.

Four patients treated with antibiotics were rehospitalized due to OA recurrence, they were operated on. Interventions were performed on average 8 (4-12) months after conservative treatment.

Tab. 4. Histological picture in operated patients.

Discussion

The basis of the pathogenesis of OA is the obstruction of its lumen with the development of infection. In 60% of cases, blockage of the lumen occurs as a result of hyperplasia of the submucosal layer. This form is more often observed in children, which leads to the development of catarrhal OA. In phlegmonous OA, inflammation spreads to the tissues surrounding the process. At first, it is only inflammation and hyperemia of the appendix. Further, inflammation and swelling increase, which leads to gangrene.

Traditionally, the diagnosis of OA is based on history, physical examination, and leukocytosis. In atypical cases, in patients with prolonged symptoms, an unusual history, or misleading physical findings, ultrasound or CT is helpful in diagnosing. The reliability of CT in OA is 95-100%, which allows us to recommend it as a routine examination in OA. A study by Horton et al. reports 100% specificity and 97% sensitivity for CT and 90% specificity and 76% sensitivity for US in OA [20]. In our study, ultrasound was positive in 80% of cases. We did not use CT because of its high cost in our country.

Patients with suspected OA require high diagnostic accuracy, since negative appendectomy carries with it a significant risk of complications from wound sepsis, AIO, pneumonia, and infertility due to fimbriae damage. The diagnostic screening system reduces the number of negative appendectomies, as has been reported previously [15,23]. There is a high risk of developing an adhesive process in the abdominal cavity when an unchanged process is removed, in comparison with OA. Leukocytosis, C-reactive protein and ultrasound can significantly help in accurate diagnosis [17, 28, 29].

Probably, a clinical examination 30 days after antibiotic therapy is sufficient. Our experience, as well as the experience of others [14], shows that 10 days of antibiotic therapy is sufficient. Conservative treatment initiated within 6 hours of the onset of abdominal pain is no less effective than other reports [13].

The number of relapses according to our data correlates with other reports [2,3]. Conservative treatment of OA is especially useful in peripheral centers, in developing countries, with a low level of medicine. And also in other situations when the operation is impossible. Further research is needed into the possibilities of conservative treatment of OA with antibiotics.

Translated by prof. Fedorov I.V.

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Comment by Yuri Viktorovich Shapiro.

(Experience 57 years, operating emergency surgeon, Moscow)

Everything new is the well-forgotten old. During the three years of my work in the Neksikansky district hospital of the Magadan region, the tactics for acute appendicitis were as follows. If more than 48 hours have passed since the moment of the disease and there were no signs of peritonitis, the patient was treated conservatively: cold, rest, antibiotics of the first generation – there were no others at that time.