1. Home
  2. Humans

Humans

Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis A Systematic Review and Meta-Analysis

Author/s: 
Isabella Faria, Ana Carolina Godinho Cintra, Luiz Gustavo Albuquerque Mello de Oliveira

Importance: Nonoperative management (NOM) has emerged as a potential alternative to surgery for acute uncomplicated appendicitis in children; however, while short-term outcomes are often favorable, concerns remain about treatment durability, complication rates, and long-term failure. An updated meta-analysis of randomized clinical trials (RCTs) may help clarify the comparative safety and effectiveness of NOM vs appendectomy.

Objective: To evaluate the safety and effectiveness of NOM compared with appendectomy for uncomplicated appendicitis in children using the highest level of available evidence.

Data sources: A systematic review of PubMed, Embase, Scopus, Cochrane, and Web of Science was conducted from inception through March 2025 to identify randomized clinical trials comparing NOM with surgical management in pediatric patients.

Study selection: RCTs comparing NOM vs surgical management in pediatric patients younger than 18 years were included. Nonrandomized and quasi-randomized studies were excluded.

Data extraction and synthesis: Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses were conducted using random-effects models. Risk of bias was assessed independently by multiple reviewers. Trial sequential analysis was performed to determine whether the evidence was sufficiently robust and conclusive.

Main outcomes and measures: The primary outcomes were treatment failure and treatment success in 1 year and major complications (Clavien-Dindo grade ≥IIIb). Secondary outcomes included time to return to school and time to return to normal activity.

Results: Of 1246 studies screened, 7 RCTs, including 1480 pediatric patients, met inclusion criteria. Treatment failure was significantly higher in the NOM group than in the appendectomy group at 1 year (risk ratio [RR], 4.97; 95% CI, 3.57-6.91; I2 = 0.0%). Treatment success was significantly lower in the NOM group at 1 year (RR, 0.67; 95% CI, 0.60-0.75; I2 = 31.1%). Major complications classified as Clavien-Dindo grade IIIb or worse were more frequent in the NOM group (RR, 33.37; 95% CI, 7.89-141.05; I2 = 9.5%). Appendicitis recurred at a rate of 18.47 events/100 observations (95% CI, 12.62-25.07 events/100 observations; I2 = 48.5%) among patients who received NOM. NOM, compared with appendectomy, was associated with a modestly faster return to school (mean difference, -1.36 days; 95% CI, -2.64 to -0.08 days; P = .04; I2 = 57.7%) and return to normal activities (-4.93 days; 95% CI, -8.68 to -1.19 days; P = .01; I2 = 87.2%), although this may be offset by subsequent readmissions or reintervention. Trial sequential analysis demonstrated the robustness and conclusiveness of primary outcomes.

Conclusions and relevance: In contrast to earlier studies, this meta-analysis found significantly higher treatment failure and major complication rates within a year with NOM among children and adolescents. The meta-analysis provides pediatricians and pediatric surgeons with up-to-date data to inform shared decision-making with families and encourage individualized, patient-centered treatment.

Keywords 
Humans Appendicitis Appendectomy Patient Readmission

Surgery versus corticosteroid injection for carpal tunnel syndrome (DISTRICTS): an open-label, multicentre, randomised controlled trial

Author/s: 
Wijnand A C Palmbergen, Roy Beekman, A Marijne Heeren, Bart F L van Nuenen, Tim W H Alleman, Esther Verstraete, Korné Jellema, Wim I M Verhagen, Leo H Visser, Godard C W de Ruiter, Diederik van de Beek, Corianne A J M de Borgie, Johannes A Bogaards, Rob M A de Bie, Camiel Verhamme, Dutch CTS study group

Background: Surgery and corticosteroid injections are established treatments for carpal tunnel syndrome, but the optimal treatment strategy remains unclear. This study aimed to compare starting treatment with surgery versus starting with a corticosteroid injection.

Methods: We conducted an open-label, randomised controlled trial across 31 hospitals in the Netherlands. Eligible patients, diagnosed with carpal tunnel syndrome for at least 6 weeks and confirmed by electrophysiological or sonographic testing, were randomly assigned (1:1) to start treatment with either surgery or an injection via a web-based system. Randomisation was stratified by unilateral or bilateral symptoms, carpal tunnel syndrome with or without concomitant disease as risk factor, and previous ipsilateral injections. If needed, additional treatments were allowed, such as additional injections or surgery. The primary outcome, assessed in the intention-to-treat population, was the proportion of patients who were recovered (defined as a score of less than eight points on the six-item carpal tunnel syndrome scale) at 18 months. The trial was preregistered with the ISRCTN Registry (ISRCTN13164336) and is now completed.

Findings: From Nov 7, 2017, to Nov 4, 2021, 934 participants (545 female and 389 male participants) were included. 468 were randomised to the surgery group and 466 to the injection group. At 18 months, 805 (86%) of 934 participants had primary outcome data. In the surgery group, 243 (61%) of 401 participants had recovered, significantly higher than the 180 (45%) of 404 participants recovered in the injection group (relative risk 1·36; 95% CI 1·19-1·56; p<0·0001). One or more adverse event occurred in 376 (86%) of 436 participants in the surgery group and in 384 (85%) of 453 participants in the injection group. One participant in the surgery group was hospitalised due to complications. No treatment-related deaths were reported.

Interpretation: In patients with carpal tunnel syndrome, initiating treatment with surgery offers a higher chance of recovery after 18 months compared with starting with a corticosteroid injection, even with the possibility of additional interventions.

Funding: The Netherlands Organization for Health Research and Development and Zorgverzekeraars Nederland.

Keywords 
Netherlands middle aged Humans Adrenal Cortex Hormones* / administration & dosage Adrenal Cortex Hormones* / therapeutic use Carpal Tunnel Syndrome* / drug therapy Carpal Tunnel Syndrome* / surgery Carpal Tunnel Syndrome* / therapy Decompression Surgical* / methods

Gold 2023: Highlights for Primary Care

Author/s: 
Alvar Agustí, Antoni Sisó-Almirall, Miguel Roman, Claus F. Vogelmeier

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has issued its 2023 annual report1. Compared with former versions, it has been significantly updated. Here, we summarize the most relevant changes for a Primary Care audience. The complete document can be downloaded for free from the GOLD web page (www.goldcopd.org), together with a “pocket guide” and a “teaching slide set”.

Keywords 
chronic obstructive pulmonary disease gold primary health care Humans

Parkinson disease primer, part 1: diagnosis

Author/s: 
Frank, C., Chiu, R., Lee, J.

Objective To provide family physicians an updated approach to the diagnosis of Parkinson disease (PD).

Sources of information Published guidelines on the diagnosis and management of PD were reviewed. Database searches were conducted to retrieve relevant research articles published between 2011 and 2021. Evidence levels ranged from I to III.

Main message Diagnosis of PD is predominantly clinical. Family physicians should evaluate patients for specific features of parkinsonism, then determine whether symptoms are attributable to PD. Levodopa trials can be used to help confirm the diagnosis and alleviate motor symptoms of PD. “Red flag” features and absence of response to levodopa may point to other causes of parkinsonism and prompt more urgent referral.

Conclusion Access to neurologists and specialized clinics varies, and Canadian family physicians can be important players in facilitating early and accurate diagnosis of PD. Applying an organized approach to diagnosis and considering motor and nonmotor symptoms can greatly benefit patients with PD. Part 2 in this series will review management of PD.

Parkinson disease (PD) is the fastest growing neurodegenerative condition, with prevalence predicted to double from more than 6 million globally in 2015 to more than 12 million by 2040.1 Recognizing parkinsonism and having knowledge of the presentation, diagnosis, and management of motor and nonmotor symptoms of PD are increasingly important, particularly as access to neurologists and specialized clinics is limited in many parts of Canada.2 Family physicians are well placed to identify symptoms, participate in diagnosis, and collaborate with specialty clinics in management of patients through the course of the disease.

Keywords 
Levodopa Parkinson's Disease diagnosis Parkinson Humans

Snake Envenomation

Author/s: 
Seifert, S. A., Armitage, J. O., Sanchez, E. E.

Snake envenomation represents an important health problem in much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms.1 However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma.2,3 In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago.4 For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.

Keywords 
Animals Humans Snake Bites Elapidae
Subscribe to Humans