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Comment & Response |

Management of Acute Appendicitis, Comparative Effectiveness Research, and the Nuances of Study Design—Reply

Peter C. Minneci, MD, MHSc1,2; Katherine J. Deans, MD, MHSc1,2
[+] Author Affiliations
1Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
2Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio
JAMA Surg. 2016;151(8):784-785. doi:10.1001/jamasurg.2016.0478.
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In Reply We thank Dr Drake for his insightful comments. As pointed out, our intent was to study the effectiveness of nonoperative management in clinical practice because we believe that the safety and efficacy of antibiotics to treat acute appendicitis are now well established in recent trials and reports.13

We appreciate the concern that differences in the rate of complicated appendicitis between the 2 groups in our study may be due to selection bias. It is difficult to determine how to best report the overall incidence of a given finding in a sample of patients for whom you cannot actually measure the finding in all patients. Our reported rate of complicated appendicitis in the nonoperative group (2.7%) represents the rate of complicated appendicitis in the whole group (1 of 37 children). However, in the nonoperative group, we could only truly identify whether patients had complicated appendicitis if antibiotic therapy failed and they subsequently underwent an appendectomy. Of 9 patients whose treatment failed, 1 (11.1%) had complicated appendicitis at the time of laparoscopy, similar to what was found in the surgery group (8 of 65 children [12.3%]). Among the surgery patients with complicated appendicitis, 4 had gangrenous/necrotizing appendicitis, and 4 had a rupture (2 with a “microperforation” only and 2 with an early periappendiceal abscess formation).

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August 1, 2016
Frederick Thurston Drake, MD, MPH
1Division of Endocrine Surgery, Department of Surgery, University of California–San Francisco, San Francisco
JAMA Surg. 2016;151(8):783-784. doi:10.1001/jamasurg.2016.0477.
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