CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial

Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy

BACKGROUND

Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children.

OBJECTIVE

to determine the safety and efficacy of NOM for paediatric simple appendicitis.

METHODS

A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471).

RESULTS

From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications.

CONCLUSIONS

While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study

BACKGROUND

The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy.

OBJECTIVE

To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children.

METHODS

Design: Cross-sectional study in a single medical centre.

SETTINGS

Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France.

PATIENTS

Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included.

INTERVENTIONS

NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days.

MAIN OUTCOME MEASURE

Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years.

RESULTS

The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess.

CONCLUSION

Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.

Assessing micro- vs macro-costing approaches for treating appendicitis in children with appendicectomy or non-operatively

OBJECTIVES

We conducted a health economic sub-study within a feasibility RCT comparing a non-operative treatment pathway as an alternative to appendicectomy for the treatment of uncomplicated acute appendicitis in children. The objectives were to understand and assess data collection tools and methods and to determine indicative costs and benefits assessing the feasibility of conducting a full economic evaluation within the definitive trial.

METHODS

We compared different methods of estimating treatment costs including micro-costing, hospital administrative data (PLICS) and health system (NHS) reference costs. We compared two different HRQoL instruments (CHU-9D and EQ-5D-5L) in terms of data completeness and sensitivity to change over time, including potential ceiling effects. We also explored how the timing of data collection and duration of the analysis could affect QALYs (Quality Adjusted Life Years) and the results of the cost-utility analysis (CUA) within the future RCT.

RESULTS

Using a micro-costing approach, the total per treatment costs were in alignment with hospital administrative data (PLICS). Average health system reference cost data (macro-costing using NHS costs) could potentially underestimate these treatment costs, particularly for non-operative treatment. Costs incurred following hospital discharge in the primary care setting were minimal, and limited family borne costs were reported by parents/carers. While both HRQoL instruments performed relatively well, our results highlight the problem of ceiling effect and the importance of the timing of data collection and the duration of the analysis in any future assessment using QALYs and CUA.

CONCLUSIONS

We highlighted the importance of obtaining accurate individual-patient cost data when conducting economic evaluations. Our results suggest that timing of data collection and duration of the assessment are important considerations when evaluating cost-effectiveness and reporting cost per QALY.

CLINICAL TRIAL REGISTRATION

Current Controlled Trials ISRCTN15830435.

Parental Knowledge of Appendicitis and Its Management Options Among Children of Makkah Region, Saudi Arabia

BACKGROUND

Despite decades of studies, appendicitis in children still presents several uncertainties regarding optimal treatment.

OBJECTIVES

To assess parental understanding of appendicitis, along with its risks and treatment, and to determine attitudes to operative and non-operative treatment of uncomplicated appendicitis.

METHODS

This is a cross-sectional study. The current study has targeted all parents who visited the pediatric outpatient departments or clinics at three different hospitals in Makkah and Jeddah City, including Maternity and Children Hospital (MCH) in Makkah, King Fahad Armed Force Hospital (KFAFH), and Saudi German Private Hospital (SGH) in Jeddah. Data was collected via an online Google form and was analyzed by using SPSS.

RESULTS

A total of 408 subjects were involved in this study. The majority of them were females (74.5%); 25.5% were males. Most of the study participants aged between 25 and 34 years. Our results found that the average knowledge score of the study population was 4.1±1.81 out of 11. Only 23.5% of them had good knowledge about appendicitis. More than half of the respondents identified the appendix as a part of the digestive system and most of the study population were aware of the current treatment for appendicitis, which is surgery (80.9%). Female participants and respondents who knew someone that has been treated for appendicitis were significantly associated with a better level of knowledge about appendicitis (P-values: 0.011 and 0.033, respectively). Moreover, we found that educational level significantly influenced preference for treatment with antibiotics and surgery if appendicitis happened again (P-value: 0.049).

CONCLUSION

The study population had poor knowledge of appendicitis and its management options. The highlighted criteria of self-reported relevance to parents should be addressed in all appendicitis counseling and consent. We advocate for the establishment of national public awareness campaigns, as well as increased research and clinical trials. Understanding lay views of treatment alternatives and efficacy will influence future approaches to appendicitis therapy by analyzing the community's preference for emerging treatment modalities and identifying future directions for patient-centered clinical trials.

Feasibility of nonoperative treatment of acute appendicitis in children: a prospective cohort study

Introduction

The management of acute appendicitis is a matter of debate even in contemporary era. Non-operative management is proposed as a valid treatment option for acute appendicitis in children.

Methods

A prospective cohort study was conducted from April 2020 to September 2021 at the National Institute of Child Health, Jinnah Sindh Medical University, Karachi, Pakistan, in children aged ≤ 12 years who were suspected of having acute appendicitis. Children with diffuse peritonitis and complex mass on ultrasonography were excluded. All children were kept nil per oral and started on intravenous fluid hydration and antibiotics. Statistical analyses were performed using IBM SPSS version 20. Chi-square test and Fisher's exact test were applied to determine the statistical significance.

Results

A total of 190 patients were admitted with a diagnosis of acute appendicitis. Thirty-two children with advanced disease underwent surgery. The remaining 158 patients were managed with nonoperative treatment. In 138 (87.3%) patients, resolution of symptoms occurred. Twenty (12.7%) patients underwent operation during the same admission (non-responders). Thirteen (9.4%) patients had recurrence of symptoms and underwent appendectomy. A total of 33 (20.9%) patients had appendectomy either at the primary admission or after discharge. Non-operative treatment was more likely to be successful in patients with symptoms of ≤ 24 h duration (P = 0.02), total leucocyte count of <12 × 109 cells/L (P = 0.005) and smaller size of the appendix on ultrasound (P = 0.001).

Conclusion

Among children with uncomplicated acute appendicitis, a non-operative approach resulted in resolution of symptoms in 87.3% of patients at the initial admission. Failure of non-operative treatment and recurrence of disease after discharge from the hospital occurred in 9.4% of patients after successful initial treatment. Thus, the overall success rate at a mean follow-up of 3 months was about 78%.

Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study

BACKGROUND

There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis.

MATERIALS AND METHODS

Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses.

RESULTS

Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005).

CONCLUSIONS

CFP and NLR are accurate biomarkers of UA and complicated appendicitis.

Parental Knowledge of Appendicitis and Preference for Operative or Non-Operative Treatment at a United Kingdom Children’s Hospital

Appendicitis is a common cause of abdominal pain in children, and is the most common reason for children to undergo emergency abdominal surgery. To guide our research program in this field, we aimed to determine parental understanding with regard to appendicitis and its treatment. We also wished to assess parental preference for non-operative or surgical treatment of children with uncomplicated appendicitis. We asked parents attending a children’s outpatient clinic to complete a brief questionnaire that was interspersed with educational content to rectify any knowledge gaps. A total of 396 parents (of 414 approached) agreed to participate. There were gaps in parental knowledge, including not knowing where the appendix is located (one-third of respondents), not knowing what appendicitis is (40% of respondents), and underestimating the incidence of appendicitis. Parents typically overestimated the risks of complications and dying from both uncomplicated and complicated appendicitis. There was no influence of gender, age, or previous experience of appendicitis on these findings. When presented with the scenario of equal effectiveness of non-operative treatment and surgery for uncomplicated appendicitis, 59% of respondents expressed a preference for non-operative treatment over surgery, while 21% expressed a preference for surgery (20% expressed no preference). These findings are important for clinicians and researchers when discussing appendicitis and treatment options with families, and justify ongoing research into the comparative effectiveness of non-operative treatment and surgery.

Nonoperative management of appendicitis in children

Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT)

OBJECTIVE

To establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.

DESIGN

Feasibility randomised controlled trial with embedded qualitative study to inform recruiter training to optimise recruitment and the design of a future definitive trial.

SETTING

Three specialist paediatric surgery centres in the UK.

PATIENTS

Children (aged 4-15 years) with a clinical diagnosis of uncomplicated acute appendicitis.

INTERVENTIONS

Appendicectomy or a non-operative treatment pathway (comprising broad-spectrum antibiotics and active observation).

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of eligible patients recruited. Secondary outcomes evaluated adherence to interventions, data collection during follow-up, safety of treatment pathways and clinical course.

RESULTS

Fifty per cent of eligible participants (95% CI 40 to 59) approached about the trial agreed to participate and were randomised. Repeated bespoke recruiter training was associated with an increase in recruitment rate over the course of the trial from 38% to 72%. There was high acceptance of randomisation, good patient and surgeon adherence to trial procedures and satisfactory completion of follow-up. Although more participants had perforated appendicitis than had been anticipated, treatment pathways were found to be safe and adverse event profiles acceptable.

CONCLUSION

Recruitment to a randomised controlled trial examining the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy for the treatment of uncomplicated acute appendicitis in children is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN15830435.

Circumcision versus preputioplasty for balanitis xerotica obliterans: a randomised controlled feasibility trial

OBJECTIVES

To determine: (i) feasibility for a randomised controlled trial (RCT) comparing circumcision to preputioplasty and intralesional triamcinolone (PIT) to treat balanitis xerotica obliterans (BXO) and (ii) patient outcomes to inform future study design.

PATIENTS AND METHODS

Approval was obtained from the UK Health Research Authority and local Research Ethics Committee (Reference 16/NW/0364) and the trial protocol registered with ClinicalTrials.gov (NCT02854995). A total of 20 boys (aged 2-16 years) with BXO were randomised to either circumcision or PIT (online parallel group 1:1 allocation, non-blinded). Exclusion criteria were: (i) previous penile surgery and (ii) contraindication for either treatment. Follow-up (including satisfaction questionnaire) was at 6 weeks, 3 and 12 months. Data are presented as median (interquartile range [IQR]), continuous variables were compared by t-test.

RESULTS

A total of 54 boys were approached over 18 months: 23 (45%) were recruited and randomised. The commonest reason for non-entry was treatment preference: 12 preferred circumcision, 18 preferred PIT. Four patients withdrew after randomisation, three did not want circumcision and one did not want PIT. The groups were similar in terms of age (median [IQR] 11 [6-12] vs 8 [7-10] years, P = 0.53) and duration of symptoms (median [IQR] 6 [6-15] vs 6 [2-24] months, P = 0.77). There were no protocol breaches, serious adverse events or postoperative meatal stenosis. There was one self-resolving haematoma after PIT and one suture granuloma after circumcision. Two boys went on to have a circumcision after PIT. Overall, satisfaction levels were high for both groups.

CONCLUSION

A definitive RCT of circumcision vs PIT for BXO appears feasible, with 39% of those approached completing the trial. More families preferred PIT. A robust comparison in the form of a multicentred RCT is required.

Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19.

METHODS

This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

RESULTS

The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy.

CONCLUSIONS

COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.

Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children

INTRODUCTION

 During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA.

MATERIALS AND METHODS

 Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason.

RESULTS

 A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group.

CONCLUSION

 Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.

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

BACKGROUND

Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking.

OBJECTIVES

The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children.

DESIGN

This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set.

SETTING

This study was set in three specialist NHS paediatric surgical units in England.

PARTICIPANTS

Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set.

INTERVENTIONS

Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial.

DATA SOURCES

Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews.

RESULTS

Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol.

LIMITATIONS

Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time.

CONCLUSIONS

A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres.

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.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15830435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

Enhancing communication, informed consent and recruitment in a paediatric urgent care surgical trial: a qualitative study

Background

Recruiting patients to paediatric trials can be challenging, especially in trials that compare markedly different management pathways and are conducted in acute settings. We aimed to enhance informed consent and recruitment in the CONTRACT trial (CONservative TReatment of Appendicitis in Children a randomised controlled Trial; ISRCTN15830435) – a feasibility trial that compared non-operative treatment (antibiotics) versus appendicectomy for uncomplicated acute appendicitis.

Methods

Qualitative study embedded within CONTRACT and conducted across three UK children’s hospitals. Data were transcribed audio-recordings of 85 CONTRACT recruitment consultations with 58 families; and semi-structured interviews with 35 health professionals and 28 families (34 parents, 14 children) invited to participate in CONTRACT. Data analysis drew on thematic approaches. Throughout CONTRACT, we used findings from the ongoing qualitative analysis to inform bespoke communication training for health professionals recruiting to CONTRACT. Before and after training we also examined qualitative changes in communication during consultations and quantitative changes in recruitment rates.

Results

Bespoke communication training focussed on presenting the trial arms in a balanced way, emphasising clinical equipoise, exploring family treatment preferences and managing families’ expectations about the trial’s treatment pathways. Analysis of recruitment consultations indicated that health professionals’ presentation of treatment arms became increasingly balanced following training, (e.g. avoiding imbalanced terminology) and recruitment rose from 38 to 62%. However, they remained reluctant to explore families’ treatment preferences and respond with further information to balance these preferences. Analyses of interviews identified the time constraints of the urgent care setting, concerns about coercion, and reservations about exposing children to conversations about treatment risks as reasons for this reluctance. Interviews with families indicated the importance of clear explanations of trial treatment timings and sensitive communication of treatment allocation for both recruitment and retention.

Conclusions

Following bespoke training based on the qualitative analyses, health professionals presented CONTRACT to families in clearer and more balanced ways and this was associated with an increase in the recruitment rate. Despite training, health professionals remained reluctant to explore families’ treatment preferences. We provide several recommendations to enhance communication, informed consent, recruitment and retention in future trials in urgent care settings.

Core outcome set for uncomplicated acute appendicitis in children and young people

Background

Research studies to inform clinical practice and policy in children and young people with appendicitis are hampered by inconsistent selection and reporting of outcomes. The aim of this study was to develop a core outcome set for reporting all studies of uncomplicated acute appendicitis in children and young people.

Methods

Systematic literature reviews, qualitative interviews with parents and patients treated for uncomplicated acute appendicitis, and a Study‐Specific Advisory Group informed a long list of outcomes. Outcomes were then prioritized by stakeholders based in the UK (patients, parents, and paediatric and general surgeons) in an online three‐round Delphi consensus process, followed by face‐to‐face consensus meetings.

Results

A long list of 40 items was scored by 147 key stakeholders in the first Delphi round, of whom 90 completed the two subsequent Delphi rounds. The final core outcome set comprises 14 outcomes: intra‐abdominal abscess, reoperation (including interventional radiology procedure), readmission to hospital, bowel obstruction, wound infection, antibiotic failure, wound complication, negative appendicectomy, recurrent appendicitis, death, patient stress/psychological distress, length of hospital stay, time away from full activity and child's quality of life.

Conclusion

A core outcome set comprising 14 outcomes across five key domains has been developed for reporting studies in children and young people with uncomplicated acute appendicitis. Further work is required to determine how and when to measure these outcomes.

Challenges Conveying Clinical Equipoise and Exploring Patient Treatment Preferences in an Oncology Trial Comparing Active Monitoring with Radiotherapy (ROAM/EORTC 1308)

INTRODUCTION

Providing balanced information that emphasizes clinical equipoise (i.e., uncertainty regarding the relative merits of trial interventions) and exploring patient treatment preferences can improve informed consent and trial recruitment. Within a trial comparing adjuvant radiotherapy versus active monitoring following surgical resection for an atypical meningioma (ROAM/EORTC-1308), we explored patterns in communication and reasons why health practitioners may find it challenging to convey equipoise and explore treatment preferences.

MATERIALS AND METHODS

Qualitative study embedded within ROAM/EORTC-1308. Data were collected on 40 patients and 18 practitioners from 13 U.K. sites, including audio recordings of 39 patients' trial consultations, 23 patient interviews, and 18 practitioner interviews. Qualitative analysis drew on argumentation theory.

RESULTS

Practitioners acknowledged the importance of the research question that the trial aimed to answer. However, they often demonstrated a lack of equipoise in consultations, particularly with eligible patients who practitioners believed to be susceptible to side effects (e.g., cognitive impairment) or inconvenienced by radiotherapy. Practitioners elicited but rarely explored patient treatment preferences, especially if a patient expressed an initial preference for active monitoring. Concerns about coercing patients, loss of practitioner agency, and time constraints influenced communication in ways that were loaded against trial participation.

CONCLUSIONS

We identified several challenges that practitioners face in conveying equipoise and exploring patient treatment preferences in oncology, and particularly neuro-oncology, trials with distinct management pathways. The findings informed communication about ROAM/EORTC-1308 and will be relevant to enhancing trial communication in future oncology trials. Qualitative studies embedded within trials can address difficulties with communication, thus improving informed consent and recruitment. ROAM/EORTC-1308 RCT: ISRCTN71502099.

IMPLICATIONS FOR PRACTICE

Oncology trials can be challenging to recruit to, especially those that compare treatment versus monitoring. Conveying clinical equipoise and exploring patient treatment preferences can enhance recruitment and patient understanding. This study focused on the challenges that practitioners encounter in trying to use such communication strategies and how practitioners may inadvertently impede patient recruitment and informed decision making. This article provides recommendations to support practitioners in balancing the content and presentation of trial management pathways. The results can inform training to optimize communication, especially for neuro-oncology trials and trials comparing markedly different management pathways.

Indications for Nonoperative Management of Uncomplicated Appendicitis in Children: A Prospective Analysis at a Single Institution

Aim: To assess nonoperative management (NOM) of uncomplicated appendicitis (UC-appy) in children to determine factors influencing prognosis and review the literature. Materials and Methods: All UC-appy cases presenting younger than 16 years between 2015 and 2018 who had NOM (one dose of intravenous analgesia and intravenous piperacillin/tazobactam 112.5 mg/kg 8 hourly) and were followed up for at least 3 months were reviewed prospectively (n = 146). Perceived pain and fever were assessed 12 hourly, biochemistry daily. If predetermined cutoff results were not achieved at each assessment, NOM was abandoned and urgent laparoscopic appendectomy (ULA) performed. Results: NOM succeeded in 48.6% (S-NOM; n = 71) and failed in 51.4% (F-NOM; n = 75). Mean age at presentation (10.7 ± 2.5 versus 8.6 ± 3.7 years old; P < .0001) and duration of preadmission fever (1.0 ± 0.9 versus 2.1 ± 1.2 days; P < .0001) were the only significantly different criteria between S-NOM and F-NOM. Optimal cutoff values using receiver operating characteristic curve analysis were 7.0 years old (32% sensitivity and 93% specificity) and 1.0 day (95% sensitivity and 25% specificity), respectively. NOM was abandoned for persistent pain, prolonged fever, or raised white blood count at 12 hours in 20/75 (26.7%), 24 hours in 31/75 (41.3%), 36 hours in 14/75 (18.7%), and 48-72 hours in 10/75 (13.3%). At ULA, perforation was identified in 14/75 (18.7%). Complications arising within 3 months of ULA were residual abscess (n = 7/75; 9.3%) and transient ileus (n = 1/75; 1.3%). Conclusion: It would appear that surgery may be more appropriate for children with UC-appy when they are younger and febrile before admission for longer.

Conservative treatment of acute appendicitis

Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.

Conservative therapy for appendicitis in children

Question A 10-year-old girl who was seen in my office last week with acute-onset abdominal pain and fever was referred to an emergency department, was diagnosed with appendicitis, and was treated conservatively with antibiotics, without surgery. Has the paradigm for treating appendicitis changed, and which is the preferred treatment of appendicitis in children: antibiotics or appendectomy?Answer For more than 100 years, surgical management was the principal treatment of acute appendicitis. Potential adverse events associated with appendectomy include bleeding, surgical site infection, and ileus, as well as stress for children and their parents. The option of treating appendicitis with antibiotics has been known for decades, which has led to consideration of antibiotics alone as a therapeutic alternative to surgery for uncomplicated appendicitis. While there is a reasonable body of evidence in support of this practice in adults, the accumulation of evidence of the safety and effectiveness of non-operative management in children is ongoing. Large studies are still needed, and those are being conducted at this time, with results expected in the next few years.

Health economics and quality of life in a feasibility RCT of paediatric acute appendicitis: a protocol study

BACKGROUND

Acute appendicitis is one of the most common acute surgical emergencies in children and accounts for an annual cost of approximately £50 million to the National Health Service. Investigating alternative treatment options offers the best prospect of enhancing the quality of care for patients and potential opportunities for cost savings through better allocative efficiency. A feasibility randomised controlled trial (RCT) comparing a non-operative treatment pathway with appendicectomy for children with acute uncomplicated appendicitis is underway (CONTRACT feasibility RCT).

AIMS

The prime objective of this economic substudy conducted alongside the CONTRACT feasibility RCT is to better understand and assess: (1) cost data collection tools and cost drivers by identifying patients' pathways and (2) patient quality of life by assessing alternative paediatric health-related quality of life (HRQoL) instruments. Outcomes from this study will inform a future efficacy RCT assessing the effectiveness and cost-effectiveness of non-operative treatment pathway for the treatment of acute uncomplicated appendicitis in children.

METHODS

The economic substudy will use individual-level data and will be conducted from the health system perspective over the study's 6-month follow-up period. Microcosting will include health resource and service use, while potential benefits acquired will be measured using the HRQoL measures, Child Health Utility 9D (CHU-9D) and Euroqol-5 dimensions and 5 levels (EQ-5D-5L). We will assess the appropriateness of using the cost per quality-adjusted life year framework in the future RCT, as well as testing and identifying the most suitable HRQoL instrument.

CONCLUSIONS

The outcomes of the investigational economic substudy will be used to inform the design of our future definitive RCT. However, the result from this economic study will also provide a detailed description and account of the issues inherent in paediatric Economic Evaluations Alongside Clinical Trials with an emphasis on costing methods of interventions taking place in secondary care settings.

TRIAL REGISTRATION NUMBER

ISRCTN1583043.