
After century of removing appendixes, doctors find antibiotics can be enough - YeGoblynQueenne
https://arstechnica.com/science/2018/09/after-century-of-removing-appendixes-docs-find-antibiotics-can-be-enough/
======
ransom1538
I found this conversation unnerving at 13 years old:

Doctor: "Does all this make sense? We need to remove your appendix.. now."

Me: "Doctor, ok, so you need to remove my appendix cause if you don't I could
get really sick. "

Doctor: "Yes."

Me: "What does the appendix do?"

Doctor: "We don't know."

~~~
jawns
About 10 years ago, one study set forth an interesting hypothesis: The
appendix is a place where "good" bacteria can safely hide during infection.
I'm not sure if there's been any work since then to confirm the hypothesis,
but it sure is an interesting idea.

Source:
[https://www.nytimes.com/2008/06/17/health/research/17appe.ht...](https://www.nytimes.com/2008/06/17/health/research/17appe.html)

~~~
smaddox
I think I remember reading at some point that another hypothesis is that it
acts as a repository for bad bacteria, so that your immune system doesn't
forget how to make antibodies for those bacteria. I think I remember the
sinuses being posited as serving the same role.

~~~
pazimzadeh
What if the appendix is an attempt to "tame" bad bacteria into being good?
Does giving bacteria access to nutrients from our food and mucus remove the
selective pressure to evolve virulence factors?

------
algorias
That's great to hear. However, keep in mind that appendicitis is still an
extremely serious condition that __will __kill you if left untreated. The fact
that you can avoid surgery in some cases doesn 't mean that surgery is not an
adequate treatment.

It's amazing how medicine has advanced: We can now cure illnesses with very
minimal amount of invasiveness required in most cases. Even before this news,
open surgery was already mostly supplanted by laparoscopy, which involves only
a few tiny cuts.

~~~
fredsanford
Appendicitis will kill you! And the surgery in most cases will save you. :) At
least in my case.

I technically died from a ruptured appendix and spent 9 days in ICU. The
doctors delayed surgery to see if the antibiotics would work. This was ~10 or
so years ago.

~~~
da02
Can you give more details of "technically died"? Any after-life experience?

~~~
SEJeff
Technically died likely means cardiopulmonary arrest aka a heartrate of zero.
Medical personnel refer to this as "a code" or "code blue"

I drowned as a kid in a friend's pool when I was 7 or 8. I was "technically
dead" as well. No afterlife experience, but as I was thrashing underwater, my
entire body felt like you feel when your leg goes to sleep, and before I went
"to sleep" I got really calm and everything was peaceful. The only thing I
could feel other than whole body numbness was a strong warmth. I took one last
look up at the sun sparkling on the ripples of water above and closed my eyes.

A few minutes later, I awoke puking water and choking with my best friend
shrieking hysterically as her mother frantically performed CPR on me. For some
reason, my parents never ever let me swim in her pool again or go to her house
unsupervised.

~~~
diminoten
You're crazy lucky, CPR isn't supposed to bring you back from anything or
flush water out of your lungs, it's supposed to keep your blood flowing to
your brain until paramedics can get to you.

~~~
SEJeff
Lucky indeed! I was terrified of water until I was about 12 and only then
learned to swim.

------
sureaboutthis
This reminds me of when tonsils were removed at the first sign of trouble.

When I was in my early 20s, in the 1970s, I went to my doctor about a bad sore
throat. He advised me to see an ENT who barely bothered to look down my throat
for more than a second and automatically declared I needed mine removed. That
bothered me but I very much respected my personal doctor who said he respected
this ENT. When I mention this to doctors nowadays, most nod their heads that,
today, it's not likely mine would have been removed.

~~~
Cthulhu_
Growing up, I felt like getting tonsils removed was as common as changing
teeth, it must've happened to a third or so of my classmates at the time.

It seemed harmless enough from a distance, they pull out some stuff from your
throat and you get ice cream.

~~~
pjc50
I had mine out as an adult and it was a pretty painful week of recovery.

~~~
sureaboutthis
Yes but Allison visited me in the hospital! TIL: Alisson liked me!!

------
bookofjoe
Somewhat OT but interesting: "When [Kurt] Semm introduced laparoscopic surgery
at the University of Kiel, he had to undergo a brain scan at the request of
coworkers as 'only a person with brain damage would perform such laparoscopic
surgery.' On September 13, 1980, Semm performed the first laparoscopic
appendectomy, opening up the path for a much wider application of minimally
invasive surgery. At first, his operation was severely criticized. Initial
attempts to publish it were rejected, and the American Journal of Obstetrics
and Gynecology stated that his technique was 'unethical.' The president of the
German Surgical Society demanded that Semm be suspended from medical
practice."—Wikipedia

~~~
krylon
It's weird in retrospect.

When my grandfather had his gall bladder removed (late 1960s, I think), he
spent about 4-6 weeks in hospital and another couple of weeks at home
recovering; last year, I had my gall bladder removed, they sent me home after
three days. Now that's progress!

~~~
christinamltn
My gallbladder removal 5 years ago was outpatient surgery. I went in around
7am and was home on the couch by mid afternoon. Gave up the serious pain meds
the next day since the side effects (zero attention span) were more annoying
than the bit of pain. It's amazing how far we've come for some medical
treatments.

~~~
hospes
>> Gave up the serious pain meds the next day since the side effects (zero
attention span) were more annoying than the bit of pain.

Next time you can try Ibuprofen + Tylenol, to avoid mentioned side effects.

Ibuprofen Plus Acetaminophen Equals Opioid Plus Acetaminophen for Acute Severe
Extremity Pain:
[https://www.aafp.org/afp/2018/0301/p348.html](https://www.aafp.org/afp/2018/0301/p348.html)

------
crazygringo
I'm so confused. From Wikipedia:

> _Appendicitis is caused by a blockage of the hollow portion of the appendix.
> This is most commonly due to a calcified "stone" made of feces. Inflamed
> lymphoid tissue from a viral infection, parasites, gallstone, or tumors may
> also cause the blockage... The combination of inflammation, reduced blood
> flow to the appendix and distention of the appendix causes tissue injury and
> tissue death. If this process is left untreated, the appendix may burst,
> releasing bacteria into the abdominal cavity, leading to increased
> complications... Acute appendicitis is typically managed by surgery. While
> antibiotics are safe and effective for treating uncomplicated appendicitis,
> 26% of people had a recurrence within a year and required an eventual
> appendectomy._

Given that bacteria are not even listed as a cause of appendicitis above, how
do antibiotics help at all? Is there anything they can do to prevent "tissue
death" in the appendix itself, and how? What about that "stone"?

Or are the antibiotics for dealing with an actual ruptured appendix (to kill
leaking bacteria from the gut into the rest of the body), while the appendix
presumably eventually resolves its blockage and heals itself on its own? Which
sounds... scary, but of course I'm no MD.

Would love if anyone here knows how to explain what the article doesn't.

~~~
gwbas1c
> Or are the antibiotics for dealing with an actual ruptured appendix

If your appendix ruptures, it is _life threatening_ and has to come out.

Most appendix removals happen _before_ the appendix ruptures. The conclusion
of the study is that high doses of antibiotics is an effective way to prevent
the appendix from rupturing without surgery.

~~~
JoeAltmaier
I still have the question: what about the 'stone'? Do antibiotics cure that
somehow? Or is that the reason that 30% of those treated with antibiotics
ultimately have the surgery?

~~~
robterrell
One of my kids had his appendix out last year, and I asked a similar question.
My recollection was: Blockages can form and resolve on their own -- it's
possible he'd had blockages before, felt pain, but they resolved before an
infection could occur. You could be having this happen right now, but it could
resolve later in the day and you never notice anything. Or the blockage could
be too severe and never resolve on its own.

------
colordrops
I recall reading sometime in the past that appendectomies are the perfect cash
crop at hospitals. Most are not needed but it's not worth the risk so everyone
gets them, they are a low risk easy surgery, and they can charge a lot for
them. I also recall that the cost for the surgery varies widely across
hospitals.

~~~
russdill
What's interesting is that you'd think the switch over to a laparoscopic
technique would save money, but it actually costs more.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653254/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653254/)

------
ectospheno
Article says sick leave on antibiotics was 11 days compared to 22 with the
invasive surgery.

The non invasive surgery only has you taking it easy for 7 days with no
lifting anything over 10 pounds for a bit after that. They send you home from
the hospital after 2 days. Most people resume work during the initial week.

~~~
rsynnott
Study was in Finland. How much time people take off presumably depends heavily
on national laws and norms around sick leave. Some countries have very
generous laws around paid sick leave; others, like the US, don’t have
mandatory paid sick leave at all.

Finland seems to be a special case; 10 days paid sick leave for a given
incident, but in practice this is improved on by collective bargaining
agreements in many trades.

------
jaggederest
It's interesting, an acquaintance of mine had this happen. Hospitalized, with
antibiotics, but just fine, no knife.

Definitely surprising to hear about, but I'm glad we're still learning about
these kinds of things. Imagine all the things we take for granted that are
simply superstition when examined closely.

~~~
jazoom
In Australia, where public hospitals provide a free service, antibiotics are
first line for uncomplicated appendicitis. Most people recover just fine.

It's amazing how things are different when a surgeon doesn't want to do a
procedure since it means more work for them, compared to where a surgeon wants
to do a procedure since that's how they get paid.

Obviously, it's much better for the patients if they avoid unnecessary
surgery.

~~~
sonnyblarney
Even in socialized medicine systems, doctors who do more stuff get paid more.
'Single Payer' usually means the government runs insurance not the doctors
office. So the doctor bills more in both cases.

Both of those inscentives are maligned though - the doctor should do 'what's
right'.

What's also nutbars is that there isn't a standard playbook for this stuff.

There should be specific procedural research on all of this stuff with the
'best practices' updated all the time.

There should be ongoing debate and churn around the practice, but once it's
published, the doctors should all be in sync.

Doctors, like judges, have too much leeway. I think they feel that 'every case
is special' and they are to some extent, however, I feel that they are playing
against a statistical game and that their 'gut' is not right.

Just like airline pilots go through massive 'checklists' ... so should
doctors.

I've been misdiagnosed for heart burn (doc thought it was heart palpitation)
and for wound infection (was not infected, just a little red) - which is
tragic because those are very common things.

~~~
seszett
Actually, at least in the medicine systems I know (France and Belgium) doctors
can either be independent or employed. It's about 50% each in both countries.

Independents are paid more when they do more stuff, but employed doctors are
usually paid a fixed salary depending on fixed work hours. Depending on the
system, the practice either bills patients directly per consultation, or the
social security organization, or gets a fixed income from social security or
from the ministry of health that does not directly depend from how many
patients they see. All three systems exist.

Best practices and procedures are usually handled at the hospital or...
"medical house" ( _maison médicale_ or _wijkgezondheidscentrum_ , the place
where several non-independent doctors work as a team) level. It is indeed not
something that really gets standardised at a higher level, although doctors
also have a number of mandatory meetings that get conducted with attendees
from different practices and that help with diffusing procedures, best
practices and knowledge.

They don't all get in sync at the same time, but knowledges and best practices
do diffuse through all doctors. Although independents usually try to attend
the bare minimum because meetings directly translate to missed income for
them.

I don't think the current model is wrong, although I think independent doctors
are ill equipped to stay up to date, and not enough incentivised to do so.

------
pbhjpbhj
A friend (in UK) had a similar condition called diverticulitis wherein the
intestine makes a new pouch and it gets infected.

They were treated only with IV antibiotics (and pain killers) but spent almost
a week in hospital vs people attending for surgeries who were out again in a
couple of days.

I imagine _if_ it requires a longer hospital stay that will override the
medical necessity.

Perhaps samples could be taken, eg of stool, in order to select bacteria with
which to reseed the intestine? I suppose that's quite labour intensive.

~~~
rincebrain
There's also some evidence that the bacteria in your stool is even less well-
correlated to the bacteria further up your intestines than we thought (and we
already thought it wasn't great). [1]

[1] -
[https://www.theguardian.com/science/2018/sep/06/probiotics-n...](https://www.theguardian.com/science/2018/sep/06/probiotics-
not-as-beneficial-for-gut-health-as-previously-thought)

------
cbdumas
There is currently a very similar study being conducted in the US. I am a
subject in this study after I got appendicitis last summer. I chose to be
treated with antibiotics and have been symptom free for the last ~14 months. I
could also have opted to participate in the randomized controlled trial (where
a treatment would have been randomly assigned to me) but surgery isn't really
something I'm comfortable leaving up to chance.

------
DoreenMichele
I had a cousin who delayed being seen for their stomach ache and the appendix
burst. They ended up hospitalized for like 6 weeks with one end of the
surgical opening left open so the wound could be drained or repeatedly cleaned
out or something.

I'm glad they are doing studies here. Please note the phrasing in the article
concerning "uncomplicated" cases. I have plenty of criticisms of modern
medicine, but let's not throw the baby out with the bathwater here.

------
geff82
This is no new news. When I was 17, I had all the signs of an appendicitis.
But I really feared to go to the hospital. I read through some medical books
where they mentioned that after 72 hours of pain things can get real
dangerous. I found some old antibiotics in the house (well beyond their date),
took them and after 48 hours the apendicitis was gone.

When I was 34, appendicitid struck again. I new instantly that I had it, and
this time I did not fear the hospital. This time, I wanted to avoid hospital
because we were just a few weeks from moving to a new house. So I took
antibiotics again, measured the fever, noted every measurement point in Excel
but after 36 hours I found that it was not getting any better. So finally I
took advantage of my wonderful German health insurance and got the appendix
brilliantly removed...

Just want to state: there are times when antibiotics work and times when they
do not.

------
ParanoidShroom
Is this really news ? I've gotten it removed, and before had antibiotics to
cure an infection. They misread the echo and though it was too infected to
start antibiotics. It hurt like hell. After the operation, he said they
removed it but could have been fixed by antibiotics earlier. They decided
during the operation is was safer in the future to remove it (as I had more
problems with it). They really don't want to remove it here, so I'm surprised
this is news ...

------
medicalhistory
I had an appendectomy a few years ago (in my late 20s) and I really wish the
doctors had given me the option of just antibiotics. I was in severe pain and
had spent the entire day vomiting, but from the CT scan my appendix wasn't at
risk of rupturing at that point. They basically told me they were going to
take it out as it was faster for them to manage it that way.

It's anecdotal, but ever since I had my appendix out I've struggled with
digestion issues. I've tried so many things: elimination diets to discover
food allergies, probiotics, a switch to vegetarianism, tons of fiber
supplements, no fiber supplements, intermittent fasting, acupuncture,
traditional Chinese medicine. I tried out uBiome to see if I could discover
anything with that. Nothing really has worked.

On top of that, the surgery cost $25k.

Certainly there are instances where the surgery is absolutely needed, as a
rupture will kill you. I'd really like to see more research on the theory that
the appendix holds a backup copy of good bacteria, because at this point I'm
willing to believe the appendix isn't just vestigial and actually plays a role
in intestinal health that we just don't understand.

------
saiya-jin
So no need to have appendixes removed prior to being stationed in Antarctica
anymore?

~~~
xbmcuser
Wait is that a requirement?

~~~
TheSpiceIsLife
From the Australian Government - Department of the Environment and Energy,
Australian Antarctic Division:

 _The answer is no, however doctors who are wintering at Australian Antarctic
stations are required to have their appendix removed. This is because there is
usually only one doctor on station during winter, and evacuation back to
medical care in Australia is impossible for at least part of the year. The
requirement dates from the 1950s, when an Australian Antarctic doctor
developed appendicitis on Heard Island and required a very challenging
evacuation back to Australia.

In 1961 a Russian doctor successfully removed his own appendix at
Novolazarevskaya station in Antarctica. With no outside help possible, he used
local anaesthetic and had two expeditioners assist with surgical retractors
and a mirror so that he could see what he was doing. The operation was a
success and the doctor was back on duty within two weeks. It's not a situation
that Australian Antarctic doctors would like to find themselves in!

As part of their overall medical review, all expeditioners are required to
have a dental check before they depart for Antarctica within six months of
their departure date. There is no requirement for expeditioners to have their
wisdom teeth removed unless the dentist identifies that they may cause a
problem over winter. The station doctor has eight days of training in
emergency dentistry as part of their preparation, but this does not include
wisdom teeth extraction._

[http://www.antarctica.gov.au/about-antarctica/people-in-
anta...](http://www.antarctica.gov.au/about-antarctica/people-in-
antarctica/health)

~~~
chippy
Evacuation in winter is possible, the Americans do it if there is a real
emergency - it's just that it's very very expensive (even for the US). Because
it's possible but expensive, all the non-US bases treat it as prohibitive and
effectively not to be counted on.

~~~
seszett
It's only possible in some places, for example Kerguelen island has no
airstrip, the closest airstrip being on Réunion island 3000km away (Davis
station on the Antarctic continent is closer, 2000km, but does not have a
permanent airstrip).

No helicopter in the world has such a range, so the only means of evacuating
is by ship, with the fastest ships in the area taking minimum 3 days to make
the trip. If a navy ship is around, it could probably treat the emergency on
board but most others will have to get back to Réunion first.

In the likely event that no ship from the French navy is around, the fastest
means of evacuating will be requisitioning a nearby fishing ship but those
will probably not make it to Réunion until at least one week.

Fortunately, the relative emergencies (but not life threatening) I have
witnessed have always happened when a ship was already on its way for other
reasons, but US or not there are real technical impossibilities in these
places.

~~~
fulafel
Could you parachute fuel down for helicopter refuelings along the way?

Edit: it seems that aetial refueling for helicopters is a thing as well.

~~~
seszett
There is only the ocean along the way though, I don't think it would be
possible to drop resupply fuel that way.

Aerial refueling though I guess could work, although I suspect that no
suitable tanker airplane is to be found within range anyway most of the time
(and no suitable helicopter either) as the military base on Réunion is not a
major air force base and there is no other country than France with decent
forces in the area. Australia has tankers but they're on the wrong side of
their country, nowhere near Perth.

I think we're getting beyond _very, very expensive_ here and into the
territory of things no country would do outside of extraordinary
circumstances, the kind of circumstances in which the country operating the
base would not matter anyway as most others would cooperate in any way they
could.

------
montenegrohugo
So what is the biological mechanism at work here? Take boatloads of
antibiotics and kill most of your intestinal flora, so that inflammation on
the appendix is reduced? (If I'm completely of the mark please correct me,
it's been years since I had any biology related coursework)

With all the recent studies of the evolving antibiotic-resistant properties of
bacteria and the importance of mantaining a healthy intestinal flora and how
much the gut influences the brain, I am not sure that this treatment is
necessarily preferable to modern appendix removal surgery. That said, if given
the option, I'd probably prefer this than getting cut open (even if the
incision with modern techniques is very very small).

~~~
alFReD-NSH
I'm guessing you still have to take antibiotics when you have any surgery to
reduce chance of getting an infection.

------
arkades
A few notes of interest:

1) Europe has been doing abx before surgery for a while now. Unfortunately,
their data has largely been lacking (thus the need for this trial), creating
the impression that this was pushed by their national health services as a
cost-saving measure rather than a patient-oriented one. The culture among
surgeons in the US, regarding abx for appendicitis, is largely "we don't kill
patients just to save a few bucks." The irony that the bucks being saved go
directly into their pockets usually goes un-mentioned, but they _are_ in
earnest. It's just a win/win that their earnest desire to do the best for
patients also pays their bills. It feels nice to get paid for doing the right
thing. However, that creates a cultural bulwark against a change in
expectations on appendicitis management.

2) There is often a feeling that "if we have to end up doing surgery anyway,
we should just do the surgery. There's no value in making the patient go
through two such episodes when we have definitive treatment." It's going to be
highly subjective whether you think a 1/3 chance of two appendicitis episodes
and inevitable surgery vs. a 2/3 chance of avoiding surgery means "it's
obvious you should get abx" vs. "it's obvious you should get surgery." I think
this study doesn't make anything obvious, but does pave the way to giving
patients a reasonable alternative course of action.

3) This is not tantamount to saying "well, we've just been rash all these
years in just going straight to appendectomy." Previous trials on this have
been, methodologically, poor. Even this trial is a five-year follow-up to what
was initially a one-year trial that wasn't adequately persuasive. The initial
trial showed a 27% rate of return appendicitis. You can imagine that if the
five-year results showed "80%" vs. "36/39%" we'd be having a different
discussion. If it showed that having an appendicitis pop up a few years later
had more adverse effects, we'd be having a different discussion. So this data
was needed, and the fact that docs didn't jump on previously heavily flawed
data is... well, docs doing what they're supposed to. You don't want your doc
jumping after every poorly-supported shadow.

4) Appendicitis isn't diverticulitis. There's often a layman's shorthand that
diverticulitis is just left-sided appendicitis, but it's not. The pathogenesis
and appropriate treatments vary quite a bit: conservative treatment of a piece
of normal anatomy is quite different from conservative treatment of a piece of
herniated, pathologic anatomy. Don't confuse this study for meaning anything
regarding the appropriate management of diverticulitis. That's not to say that
abx management for diverticulitis is inappropriate, per se, but just saying
these are different diseases and not to be confused here.

5) One shouldn't expect this to result in cultural change too quickly. There
remains the fact that the primary protection against a malpractice suit is
"local standard" \- if all the local docs are doing the same thing, it's not
malpractice to follow suit. The first doc to go out on a ledge with this is
going to be minced meat the moment there's a bad outcome and someone sues. A
study is beside the point - if you point to a new study during a suit, the
plaintiff's attorney says, "Oh? You have a PhD in study design? No? Then what
qualifies you to analyze this study better than every other doctor in your
community?" This really won't go anywhere until an entire medical department
agrees to go in on this simultaneously - most likely an emergency medicine
department. Politically, though, they'd probably have to go to war with their
hospital's surgery department to push it through, or otherwise have the surg
folk on-side. It'll happen eventually, but it's not going to happen overnight.

------
sandworm101
Do we need more reasons to soak ourselves in antibiotics? Appendectomies on
otherwise healthy people are extraordinarily safe procedures. And while some
research has indeed shown the appendix as a useful organ, having it out
doesn't have lasting side effects. Given the coming tide of antibiotic
resistance, perhaps this is an area where physical intervention via surgery
can reduce the need for antibiotics.

(I know antibiotics are normally prescribed after an appendectomy anyway, but
I presume that would be less than the dose needed to kill the primary
infection outright.)

------
arwhatever
It would be interesting if someone were to compile a list of surgical
procedures that have been performed too proactively throughout history.
Uteruses, molars, tonsils, breasts, I think some cases of prostate cancer, now
appendixes. My list might contain huge errors - I am not a medical
professional, but even as a medical layperson, it's really remarkable how
common this general type of situation occurs.

------
SketchySeaBeast
For myself appendicitis was a condition that recurred - I didn't realize what
I was having at the time until one night when I put the symptoms together and
went "uh oh", when I'd probably experienced those symptoms a half dozen time
in my adult life. I wonder what antibiotics mean for re-occurrence, do you end
up treating it like an ear infection, and take em when you get a flare up?

------
0xcafecafe
I wonder if this would eventually be extended to wisdom teeth, something
dentists are too trigger happy to remove.

~~~
SECProto
Not quite sure I understand - give antibiotics instead of pulling wisdom
teeth? They pull them because wisdom teeth often grow in at an angle to a
mouth of fully developed and settled adult teeth. Sort of a "why mess with a
good thing" (the teeth there already) approach. I certainly see an issue with
the rampant pulling of wisdom teeth for cosmetic reasons, but don't see how
it's relevant to a new treatment method for a life threatening illness.

~~~
0xcafecafe
I meant the overall principle of maintain rather than remove.

~~~
eigenstuff
So... braces? It's cheaper just to pull them. You really have to if you're
someone like me whose mouth was too small for them to even come in.

My wisdom tooth extraction was a shit show for that reason, but I've had all
my 12 year molars removed since then, the last one a couple of weeks ago, and
the recovery is pretty easy. (They wanted to root canal it and crown it... I
was like bro just pull it because otherwise we're just gonna have this same
conversation again in 10 years.)

~~~
rsynnott
Fillings. For people who have reasonably well aligned wisdom teeth (not
impacted, functional teeth), some dentists are inclined to remove them anyway;
others to treat any decay which shows up but otherwise leave them alone.
Again, this is something where norms differ by country.

Edit: Wait, you’ve had all your _second_ molars removed? That seems very
unusual. I’m a little surprised the dentis was willing to do it, unless there
was a big problem that couldn’t be dealt with otherwise.

------
dalbasal
This is a tangent but... Medical Science is an interesting institution. It's a
huge, formalized truth-values finding process...

A half sibling of Law (the other formal truth finding institution) and Science
(the abstract unformalized institution).

~~~
rscho
Yeah, so unfortunately regarding medical science "formalized truth-values
finding process" is actually about as far from reality as you could be.
"Politicized agenda-propelled random search" would be closer. However, we
still slowly are making progress thanks to new technologies, so all is not
lost...

~~~
arkades
I understand that, looking at individual scientific problems, it's easy to get
cynical. It's even fashionable to be so.

Deaths attributable to heart disease in 1970 were just shy of 800k per annum.
As of 2010, it was about 600k. A 25% drop in the leading cause of death, in
less than a generation. Life expectancy was 70.8 years in 1970, and 78.7 in
2010 - an increase of more than 10% in a single generation.

Science isn't a process that moves along by weeks, months, or even years. It's
something that moves generationally, and our society has made impressive
strides.

You're welcome to be skeptical - science would die without that. But be the
"loyal opposition," not a casual cynic: help the process improve, don't
discard it as some political shell-game. Lives are in the balance.

~~~
rscho
I have both feet in the game, being a clinical researcher. So, cynic but not
casual.

~~~
carapace
"Politicized agenda-propelled random search" Lol!

I think you and arkades _both_ have it right. It's a "politicized agenda-
propelled random search" on a large enough scale and over a rich enough search
space that it "has made impressive strides" despite its flaws and
inefficiencies.

I have a friend who works as a Healer. People come to him and pay him good
money and he gets results. He doesn't advertise, he gets referrals by word-of-
mouth alone. My point is _he gets results_.[1] He can do things that are
totally off the map of conventional medicine. However, he's uninterested in
science and scientists (in general) are uninterested in him. "It's something
that moves generationally" indeed, if paradigm shifts really require the dying
out of the old guard.

If we think of inefficiencies in the search due to e.g. politics and
superstition as a kind of malady, then it seems we are witnessing a phase of
"Physician heal thyself", what with the advent of mass medical monitoring and
big data correlation, eh?

[1] Have you heard the joke, "If alternative medicine works it's just called
medicine."? Well, yes and no. Some things _that work_ are too far outside the
belief structures and will be ignored or ridiculed.

------
bookofjoe
"Sulfonamide drugs were the first antibiotics to be used systemically, and
paved the way for the antibiotic revolution in medicine."—Wikipedia. These
drugs came into widespread use in the late 1930s.

------
shoo
this qualifier is interesting:

> researchers led by Paulina Salminen randomly assigned 530 patients that
> showed up in the hospital with an acute, uncomplicated appendicitis to get
> either a standard, open surgery to remove their inflamed organ or a course
> of antibiotics. (By “uncomplicated,” the authors mean there weren’t other
> issues like perforation, abscess, or suspicion of a tumor.)

although if your appendix is already perforated then it's a bit late to try to
prevent it from perforating by cutting it out, so fair enough.

~~~
arkades
You've made the correct conclusion. Management of a perforated appendix is
vastly different from management of the (much more common) uncomplicated appy.
There isn't much controversy about the management of the perforated appy: it's
going to be surgery _and_ antibiotics. Removal at that point isn't in
question, because the perforation is due to an increase in intra-appendiceal
pressure compressing its vasculature, causing a focal necrosis. The
perforation happens when a piece of the appendix dies, and thus loses its
integrity. Dead tissue has to go.

And of course surgical clean-up of the abdomen must follow, along with a big
pile of abx.

------
teekert
I also know 3 people that went to the doctor after some time of belly aches
and the doctor telling them: "You probably had an inflamed appendix but it's
ok now."

~~~
bwldrbst
As a kid in the mid-80's I once woke up with a bit of a belly ache and thought
"I can milk this for a day off school to play with Lego"

Ended up having an emergency appendectomy that night.

------
arisAlexis
many people will die from this article because they wil not believe their
doctor and go to another one with a broken appendix that kills you in a few
days from septic shock.

------
mscasts
The removed mine while I had another surgery just in case.

~~~
deskamess
Just in case of ...? I do not usually think of surgeons having the mentality
of 'I was in the neighborhood... so.... yeah, why not!'.

~~~
mscasts
Well, they were fiddling around with my intestines, moving them around (I have
/ had intestinal malrotation) and they told me that it could be an issue if
they didn't remove it.

Although they told me afterwards, but the surgeons were extremely competent so
I don't question their judgement.

------
httpsterio
Finally a thread where I can contribute!

I was part in the Finnish APPAC trial (published on JAMA/2015).

In April 2012 I was in an out of the hospital for four or five times with
intensive stomach pains, but as they weren't localised in the mcburney area
and my white cell counts weren't elevated, I just got sent home with
painkillers.

The last time my white cell counts were slightly elevated (around 36 when
under 14 is considered to be normal) and the stomach pains were worsening
while jumping and the pain localising in the lower right of my stomach I was
personally sure about what I had. Doctors still disagreed.

I was then told that there's an experimental trial and if I sign up for it,
they'll do a CT scan (I had begged for this the previous visits). Lo and
behold, the scan showed inflammation not caused by a stone.

I got ertapenem intravenously for three days and 7 days of metronidazole and
levofloxacin. For about a year everything was fine, but I started to get
occasional localised pains again, but they came and went and never really
worsened. I think between 2013 and 2017 I've been to the hospital about 6 or 7
times because of the pains but they've always resolved by itself.

Two months ago it came back again and it was worse than the first time I got
diagnosed. Spent two nights in the ER waiting for surgery. Again, ct scanned
and blood levels show inflammation. I get sent home with pain killers and
metronidazole and floxacin. ER nurses and surgery doctors were baffled by the
case, said they've never seen an inflammated appendix been put on the non-
urgent surgery waiting list.

Got told today that it's going to be removed this year, lol. After six years
and asking every time to have it removed.

Approximately 80% of the appendicitis cases are not at risk of bursting
anytime soon so an immediate surgery is not necessary. The rest are
complicated and need urgent surgery.

I've been told that about 74% are fine after the antibiotics for the first
year but a majority in the trial have ended up with it removed within a 5 year
window. So, while having an appendix would be ideal and it's cheaper to throw
a ct and some medicine at the patient, a surgery is still almost always
needed.

In my personal experience, I have a strong gut feeling that a low carb diet
might've affected how many times my appendix has shown slight signs of
inflammation. Up until 2016 I was in ketosis for a four years and that was
when I had issues most often (although the latest has been the worst overall).
The sample size of this idea is just n=1 so take it with a grain of salt.

Oh, a sidenote, latest hospital ordeal put me in bed rest for almost a month
because metronidazole did not play nicely with my ankles and I lost my job
during that time so I'm also going through talks with my lawyer about a suit
for unlawful termination. Fun times.

Please do ask questions if I can clarify anything or you want to hear about
something specific!

~~~
sah2ed
I'm surprised to hear you lost your job because of health issues in ...
Finland?

That kind of wrongful termination sounds like something that would happen in
the States not Europe. Correct me if I'm wrong.

------
srik
.

~~~
Retric
Waiting cures a wide range of problems, that don't end up killing you.

It's really hard to separate 'doing a rain dance' and 'just waiting' when you
have a sample size of 1.

~~~
D-Coder
And the ones who _do_ die, don't post here to let us know how it turned out.

------
saadsg
a little too late perhaps?

------
cabalistik_
Got confused there for a moment, thought it was about PDF files...

------
qwerty456127
Great news! Seems like I (not a doctor but probably the most medically-
qualified person in any group of random people that doesn't include anybody
with actual medical education) probably won't end up doing an appendectomy on
anybody after I move to a deep rural area...

~~~
PakG1
An appendectomy might be easier than procuring the necessary antibiotics in a
deep rural area, depending on how rural....

~~~
qwerty456127
Being a person fairly interested in medical science and lacking insurance I
always take care to have some antibiotics for just a case (I ask friends from
Russia to get them for me, you can buy antibiotics without prescriptions
there) although I hardly ever use any actually. Needless to say, I'm going to
take quite a selection with me when I travel to some place where they're hard
to get and there are no doctors around. By the way one should better have
antibiotics ready when performing this kind of surgery or chances are their
patient is going to die of sepsis.

~~~
peteretep
> I ask friends from Russia to get them for me

[http://www.chicagotribune.com/news/ct-
xpm-2002-09-01-0209010...](http://www.chicagotribune.com/news/ct-
xpm-2002-09-01-0209010411-story.html)

~~~
qwerty456127
Would you mind telling what's there? It says "Unfortunately, our website is
currently unavailable in most European countries..." as I open it directly and
shows no article body as I open it through us.ixquick-proxy.com.

~~~
fredsanford
A tl;dr summary...

> A US Special Forces soldier bought fish antibiotics at a pet store to treat
> his sinusitis. It did not work out.

\--

I grew up in an area with 6 to 8 different military bases and it is fairly
common knowledge in military areas that you can sometimes get away with using
fish antibiotics to treat human infections. And in a lot of cases the pills
are exactly the same. But sometimes not.

~~~
logfromblammo
Article also states that aquarium antibiotics are more expensive than
prescription antibiotics, while conveniently omitting the copay and time cost
required for the doctor's office visit, which was needed to obtain the
prescription.

As such, it is also an uncommon practice to lie about symptoms during an
office visit that was required for some other reason, to get a prescription
for antibiotics that is not immediately needed. I don't actually know anyone
who has done this, so it may be just rumor. I do know people who have used
aquarium antibiotics, because their copay for a $150 office visit is $150
until their $8000 annual deductible is met. US health care is bananas.

~~~
qwerty456127
> As such, it is also an uncommon practice to lie about symptoms during an
> office visit that was required for some other reason, to get a prescription
> for antibiotics that is not immediately needed.

Wait, do doctors actually prescribe antibiotics given just invisible symptoms
and no actual flora analysis? What's the point of the prescription system
them? Isn't a doctor meant to find out what specific bacteria causes the
problem and choose the right antibiotic to target these?

