Can a positive attitude keep appendicitis patients from going under the knife?

Appendicitis patients who were treated with antibiotics and expressed full confidence in the healing power of therapy beforehand had a reduced risk of undergoing an appendectomy and coping with persistent symptoms, a secondary analysis of the CODA study found, although one expert questioned the feasibility of the results.

Of the more than 400 antibiotic patients in the randomized study who completed a baseline survey, those who believed the treatment would be fully successful had a 13 percentage point lower risk of having an appendectomy at 30 days than those who did believed that antibiotics would not work or who were uncertain (14% vs. 26%, adjusted risk difference [aRD] -13.49, 95% CI -24.57 to -2.40) reported David Flum, MD, MPH, of the University of Washington in Seattle and colleagues.

registered mail JAMA surgerythe group said there was “a clear effect within the first 48 hours,” noting that beliefs may have driven differences in antibiotic adherence.

Fewer patients with completely or moderately positive beliefs about antibiotics’ likelihood of success had persistent symptoms at 30 days (30% and 29%, respectively) compared to patients who thought antibiotics were unsuccessful or who were unsure (47%) , although this difference was significant only for the middle group (aRD -16.0, 95% CI -30.0 to -1.7).

“The magnitude of some of these associations was large,” the authors wrote, concluding that “this information is likely to improve shared decision-making, although we acknowledge that beliefs can affect outcomes in ways that are not yet fully understood.”

High decision regret or dissatisfaction with antibiotic treatment after 30 days, observed in 17% of patients, was not associated with belief in treatment success.

The primary analysis of the CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) study showed that antibiotics were not inferior to appendectomy, although many antibiotic patients still required appendectomy later, analyzes showed. In the current study of antibiotic patients in the CODA study who completed the baseline survey, 20% ultimately required a subsequent appendectomy.

“Appendicitis, traditionally characterized as a mechanical obstruction of the lumen causing infection, is now considered biological (or microbiological) because in select cases it can be successfully treated with antibiotics,” wrote John Alverdy, MD, of the University of Chicago, in an accompanying editorial. “Under this new framework, it is reasonable to assume that mind-body connections can affect the infection process based on new evidence in this area.”

However, he stated, “Readers must be aware that rigorous molecular-based studies are required to transform such observations at the descriptive level”—as seen in the present analysis—”from a probabilistic fate to a more deterministic one”.

“This includes the attitudes of doctors, nurses, family members, etc., the pheromones they emit and share with one another, how those transmitted signals are received and acted upon, and how this giant ‘interactome’ affects the outcome mechanistically,” he noted Alverdy.

“Without this information, we are left with associations that can neither be classified as causal nor as actionable,” the editorialist concluded. “Unless we insist on complementary biological-level measurements and hard mechanistic evidence to support our clinical observations, we seem no better than homeopathic claims declaring, ‘If you think you’re better, then you’re better .'”

For their study, Flum and colleagues examined data from a subgroup of 415 patients with acute appendicitis who had been randomized to receive antibiotics in 25 centers for the CODA study from 2016 to 2020. All patients had completed a baseline survey of how successful they perceived antibiotics to be before knowing their assigned treatment group.

The mean age of the patients in the analysis was 38.5 years, 65% were males and almost two-thirds were white. More than half had some education beyond high school, and the majority said they had rarely or never sought health literacy assistance.

Based on the survey results, 27% believed antibiotics would be completely successful, 51% had a moderate response, and 22% believed they would not be successful or were unsure.

Persistent signs and symptoms, observed in a total of 33%, included fever, abdominal pain, chills and tenderness. Almost three quarters had symptoms for at least 1 day.

Analyzes adjusted for sociodemographics, body mass index, appendix diameter, average pain over the past week, and health literacy.

Limitations of the study included the fact that beliefs were assessed after everyone had received an informational brochure or watched a video detailing the risks/benefits of treating appendicitis with antibiotics.