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CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT) , Hall, Crawley et al, 2021

Discussion in 'Other health news and research' started by Andy, Feb 21, 2021.

  1. Andy

    Andy Committee Member

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    Open access, https://adc.bmj.com/content/early/2021/01/12/archdischild-2020-320746
     
  2. Cheshire

    Cheshire Moderator Staff Member

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    4,675
    Is she at least leaving the CFS field?

    (Still enjoying acronyms, though...)
     
    Lidia, Shinygleamy, Sarah94 and 11 others like this.
  3. Adrian

    Adrian Administrator Staff Member

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    I wonder if she is still trying to play tricks with the ethics committees in doing a feasibility study that will suddenly become a full study
     
  4. Hutan

    Hutan Moderator Staff Member

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    She may be playing tricks, but with 'more participants having perforated appendicitis than anticipated', I expect this feasibility trial will be put to one side and there will be another roll of the dice for the main trial.

    Cheaper for the health system/insurers than an operation no doubt, but at least the children in the study get antibiotics and monitoring - rather than thinking happy thoughts about healthy appendices and an investigation of what past trauma or personality failing has caused the problem.

    I suppose a pandemic is a perfect time to investigate non-operative alternatives to surgeries - as people have a good incentive to not go into hospital. Possibly it won't be so easy to recruit with everyone vaccinated.
     
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  5. Snowdrop

    Snowdrop Senior Member (Voting Rights)

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    Question for anyone who knows: Is there no obligation to say where the funding comes from for a study?
     
  6. Mithriel

    Mithriel Senior Member (Voting Rights)

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    I am shocked speechless. Perforated appendicitis is no joke. My Mother in Law died at age 75 due to adhesions on the bowel caused by a perforated appendix operation when she was 7 causing torsion and tissue death.

    It tells you the quality of the doctor when they publish results that are said to be "be safe and adverse event profiles acceptable" despite the number of perforated appendicitis being higher than anticipated.

    It is proof that this is not patient centred research.
     
    Lidia, Wonko, lunarainbows and 11 others like this.
  7. Amw66

    Amw66 Senior Member (Voting Rights)

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    Perhaps of interest as the appendix functions as part of the immune system ( and is not something left over from its fetal role)
     
  8. Milo

    Milo Senior Member (Voting Rights)

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    Right, the study is feasible, but more patients risk death as a side effect of not getting the surgery. Will parents be informed of that?
     
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  9. MSEsperanza

    MSEsperanza Senior Member (Voting Rights)

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    I'm afraid she's just showing that children's wellbeing is not what she primarily cares for also in other illnesses than ME.
    Are their beliefs good reasons why not to wait for the results of these other studies first?

    But look how generous they are:

    Discharge assessment and follow-up
     
    Last edited: Feb 22, 2021
  10. MSEsperanza

    MSEsperanza Senior Member (Voting Rights)

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    It's in the footnotes:

    Funding
     
  11. Trish

    Trish Moderator Staff Member

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    I did a quick google search and found this paper from April 2020:
    Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines
    https://wjes.biomedcentral.com/articles/10.1186/s13017-020-00306-3
    which has a section on treatment with antibiotics in non complicated acute appendicitis, including in children. It's not a new idea, and seems to be recommended in some cases.
     
  12. Midnattsol

    Midnattsol Moderator Staff Member

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    Recently there was a short debate in "Dagens Medisin" (a health journal in Norway) about antibiotic treatment vs an operation for appendicitis. One proponent started it and got a reply from a surgeon. I'm pretty sure that was about adult patients, though.
     
  13. Andy

    Andy Committee Member

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    A bit confused by this, but it seems like it's a NIHR report on this study.

    Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

    This study suggested that a multicentre trial comparing the effectiveness of broad-spectrum antibiotics and active observation to appendicectomy is feasible.

    Open access, https://www.journalslibrary.nihr.ac.uk/hta/hta25100#/abstract
     
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  14. Sid

    Sid Senior Member (Voting Rights)

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    It's amazing what these people are willing to do to patients just to save the NHS some money.
     
  15. MEMarge

    MEMarge Senior Member (Voting Rights)

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    So, only 50% of suitable patients were willing to enter the trial, not surprising.

    In their future work:
    "Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved."

    So, a few more hoops to go through before a larger trial, which will hopefully reduce the numbers with perforated appendices.
     
  16. MEMarge

    MEMarge Senior Member (Voting Rights)

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    From the full HTA report, Results:

    "Of the 28 participants randomised to appendicectomy, 27 received the intervention. Seventeen were found to have uncomplicated acute appendicitis, but eight had perforated appendicitis and two had a histologically normal appendix. The median length of stay in hospital was 65 (range 20–196) hours after randomisation. Three children (11%) were re-admitted to hospital, following initial discharge, for investigation and/or treatment of potential complications related to appendicectomy. All were treated with intravenous antibiotics and one received percutaneous abscess drainage. Two further children received oral antibiotics for a wound infection.

    Of the 29 participants randomised to non-operative treatment, 27 received the intervention. Nineteen (70%) of these participants responded to initial non-operative treatment and were discharged home a median of 61 (range 34–125) hours following randomisation. The remaining eight underwent appendicectomy during initial hospital admission because of parental choice (withdrawal from treatment allocation, n = 1), clinical deterioration (n = 6) and no improvement at 48 hours (n = 1). Among these eight, four had simple acute appendicitis and four had perforated appendicitis. Among the 19 participants who initially responded to non-operative treatment, seven developed recurrent appendicitis after hospital discharge and underwent appendicectomy.
     
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  17. MEMarge

    MEMarge Senior Member (Voting Rights)

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    So, for the ones who were originally allocated to antibiotics, 28
    • 8 had the operation (4 perforated, 4 acute appendicitis)
    • 19 were discharged after 61 hrs (34-125)
    • Of the 19 discharged, 7 were readmitted at a later date and had appendectomies then.
    For those who had appendectomies initially, 27
    • 8 perforated
    • 17 uncomplicated acute appendicitis
    • 2 normal histology
    Average hospital stay 65 hrs (20-196), 3 were readmitted for iv antibiotics
     
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  18. Invisible Woman

    Invisible Woman Senior Member (Voting Rights)

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    Curious.

    For someone whose measure of function seemed to be purely bums on the school seat approach this seems to be the opposite.

    A sibling of mine had "grumbling appendicitis" as they became a teen. Several episodes of time off school - not all requiring hospitalization, several hospital stays & eventually an appendectomy.

    A fair bit of school time lost, high cost to my parents who both worked at the time and general family upheaval.

    Quite a few rounds of antibiotics and several hospital stays that all ended in an appendectomy anyway. It can't have saved the health authority money in the long run.

    I thought "individualised, patient centred care" was the latest BPS catchphrase. In which case why not let the surgeon crack on and do that, based on his experience and knowledge of each individual case?
     
  19. Amw66

    Amw66 Senior Member (Voting Rights)

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    Antibiotic resistance implications ?
    Gut integrity ?
     
  20. Daisybell

    Daisybell Senior Member (Voting Rights)

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    N=1 but my partner had an undiagnosed perforated appendix. I insisted he needed antibiotics and then insisted he needed more. The hole in his appendix was discovered some months later. He still has problems years later due to suspected adhesions.
    I’m suspicious that this is simply a money-saving exercise.
     

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