human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: METHODS We r and omly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever , leukocytosis , and ileus , with a maximum of 10 days of therapy ( control group ) , or to receive a fixed course of antibiotics ( experimental group ) for 4±1 calendar days . The primary outcome was a composite of surgical-site infection , recurrent intraabdominal infection , or death within 30 days after the index source -control procedure , according to treatment group . Secondary outcomes included the duration of therapy and rates of subsequent infections Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options Background Antibiotic treatment of acute appendicitis has gained interest and inquiries . Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis , but information on long-term results is required . Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis . Methods Patients with favourable response to antibiotics in earlier r and omized ( RCT , n = 97 ) and population -based ( PBT , n = 342 ) studies as well as subsequently treated non-r and omized ( Non-R , n = 271 ) patients are evaluated for long-term risk to relapse dem and ing surgical appendectomy ; altogether 710 patients . Results Clinical characteristics among r and omized and non-r and omized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation ( CRP , WCC ) when antibiotic treatment started . Females and males showed the same results . The median follow-up time was 2162 days ( 5.92 years ) , and the range across highest and lowest follow-up was 3495 days ( range 2–3497 ) for the entire group , without significant differences among subgroups ( RCT , PBT , Non-R ) . The cumulative probability for relapse of appendicitis dem and ing appendectomy was : 0.09 , 0.12 , 0.12 and 0.13 at 1- , 2- , 3- and 5-year follow-up , with a probability of 0.86 ± 0.013 without appendectomy after 8 years . This may imply an overall benefit of 60–70 % by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10–23 % in our published reports . Conclusion Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15 % for long-term relapse following favourable initial treatment response Background Appendectomy has been the treatment for acute appendicitis for over 120 years . Antibiotic treatment has occasionally been used in small uncontrolled studies , instead of operation , but this alternative has never before been tried in a multicenter r and omized trial . Patients and Methods Male patients , 18–50 years of age , admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study . No women were enrolled by decision of the local ethics committee . If appendectomy was planned , patients were asked to participate , and those who agreed were r and omized either to surgery or to antibiotic therapy . Patients r and omized to surgery were operated on with open surgery or laparoscopically . Those r and omized to antibiotic therapy were treated intravenously for 2 days , followed by oral treatment for 10 days . If symptoms did not resolve within 24 hours , an appendectomy was performed . Participants were monitored at the end of 1 week , 6 weeks , and 1 year . Results During the study period 252 men participated , 124 in the surgery group and 128 in the antibiotic group .  The frequency of appendicitis was 97 % in the surgery group and 5 % had a perforated appendix . The complication rate was 14 % in the surgery group . In the antibiotic group 86 % improved without surgery ; 18 patients were operated on within 24 hours , and the diagnosis of acute appendicitis was confirmed in all but one patient , and he was suffering from terminal ileitis . There were seven patients ( 5 % ) with a perforated appendix in this group . The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14 % during the 1-year follow-up . Conclusions Acute nonperforated appendicitis can be treated successfully with antibiotics . However , there is a risk of recurrence in cases of acute appendicitis , and this risk should be compared with the risk of complications after appendectomy Although antibiotic therapy seemed to be a safe treatment option for acute appendicitis , indications of this treatment have not been fully evaluated . We hypothesized that clinical and radiologic mild appendicitis may be a c and i date for short-term antibiotic therapy . The purpose of present study was to examine the efficacy and the recurrence rate of short-term antibiotic therapy for consecutive patients with mild appendicitis . A prospect i ve observational study was conducted over 3 years . The mild appendicitis was defined as the intermediate Alvarado score ( 4 - 8 ) and dilated appendix from 6 mm to 10 mm in radiologic study . All patients received initial antibiotics administration with clinical observation during 48 hours . The failure to respond to therapy and the incidence of recurrence were assessed . There were 107 enrolled patients with the mean Alvarado score of 6 ± 1 and the mean appendiceal diameter of 7.4 ± 1 mm . Of these , 97 ( 91 % ) exhibited improved symptoms and were discharged . The remaining 10 patients underwent surgery because of clinical aggravation , and pathology revealed true appendicitis in six of them . Of the 97 patients in whom the initial treatment was successful , five patients ( 5 % ) exhibited recurrent symptoms during a median follow-up period of 18 months . Of these five patients , three were treated with surgery ( all true appendicitis ) , and the remaining two were once again treated with antibiotics . Patients with suspected appendicitis , those in whom mild appendicitis was diagnosed after clinical and radiologic evaluations , were found to benefit from short-term antibiotic therapy BACKGROUND Carefully selected children with early appendicitis may be managed nonoperatively . However , it is unknown whether nonoperative management ( NOM 
    Output:
    
agent
Although pain was a common criterion for nonresponse and appendectomy , analgesic regimens were poorly described .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: METHODS We r and omly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever , leukocytosis , and ileus , with a maximum of 10 days of therapy ( control group ) , or to receive a fixed course of antibiotics ( experimental group ) for 4±1 calendar days . The primary outcome was a composite of surgical-site infection , recurrent intraabdominal infection , or death within 30 days after the index source -control procedure , according to treatment group . Secondary outcomes included the duration of therapy and rates of subsequent infections Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options Background Antibiotic treatment of acute appendicitis has gained interest and inquiries . Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis , but information on long-term results is required . Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis . Methods Patients with favourable response to antibiotics in earlier r and omized ( RCT , n = 97 ) and population -based ( PBT , n = 342 ) studies as well as subsequently treated non-r and omized ( Non-R , n = 271 ) patients are evaluated for long-term risk to relapse dem and ing surgical appendectomy ; altogether 710 patients . Results Clinical characteristics among r and omized and non-r and omized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation ( CRP , WCC ) when antibiotic treatment started . Females and males showed the same results . The median follow-up time was 2162 days ( 5.92 years ) , and the range across highest and lowest follow-up was 3495 days ( range 2–3497 ) for the entire group , without significant differences among subgroups ( RCT , PBT , Non-R ) . The cumulative probability for relapse of appendicitis dem and ing appendectomy was : 0.09 , 0.12 , 0.12 and 0.13 at 1- , 2- , 3- and 5-year follow-up , with a probability of 0.86 ± 0.013 without appendectomy after 8 years . This may imply an overall benefit of 60–70 % by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10–23 % in our published reports . Conclusion Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15 % for long-term relapse following favourable initial treatment response Background Appendectomy has been the treatment for acute appendicitis for over 120 years . Antibiotic treatment has occasionally been used in small uncontrolled studies , instead of operation , but this alternative has never before been tried in a multicenter r and omized trial . Patients and Methods Male patients , 18–50 years of age , admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study . No women were enrolled by decision of the local ethics committee . If appendectomy was planned , patients were asked to participate , and those who agreed were r and omized either to surgery or to antibiotic therapy . Patients r and omized to surgery were operated on with open surgery or laparoscopically . Those r and omized to antibiotic therapy were treated intravenously for 2 days , followed by oral treatment for 10 days . If symptoms did not resolve within 24 hours , an appendectomy was performed . Participants were monitored at the end of 1 week , 6 weeks , and 1 year . Results During the study period 252 men participated , 124 in the surgery group and 128 in the antibiotic group .  The frequency of appendicitis was 97 % in the surgery group and 5 % had a perforated appendix . The complication rate was 14 % in the surgery group . In the antibiotic group 86 % improved without surgery ; 18 patients were operated on within 24 hours , and the diagnosis of acute appendicitis was confirmed in all but one patient , and he was suffering from terminal ileitis . There were seven patients ( 5 % ) with a perforated appendix in this group . The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14 % during the 1-year follow-up . Conclusions Acute nonperforated appendicitis can be treated successfully with antibiotics . However , there is a risk of recurrence in cases of acute appendicitis , and this risk should be compared with the risk of complications after appendectomy Although antibiotic therapy seemed to be a safe treatment option for acute appendicitis , indications of this treatment have not been fully evaluated . We hypothesized that clinical and radiologic mild appendicitis may be a c and i date for short-term antibiotic therapy . The purpose of present study was to examine the efficacy and the recurrence rate of short-term antibiotic therapy for consecutive patients with mild appendicitis . A prospect i ve observational study was conducted over 3 years . The mild appendicitis was defined as the intermediate Alvarado score ( 4 - 8 ) and dilated appendix from 6 mm to 10 mm in radiologic study . All patients received initial antibiotics administration with clinical observation during 48 hours . The failure to respond to therapy and the incidence of recurrence were assessed . There were 107 enrolled patients with the mean Alvarado score of 6 ± 1 and the mean appendiceal diameter of 7.4 ± 1 mm . Of these , 97 ( 91 % ) exhibited improved symptoms and were discharged . The remaining 10 patients underwent surgery because of clinical aggravation , and pathology revealed true appendicitis in six of them . Of the 97 patients in whom the initial treatment was successful , five patients ( 5 % ) exhibited recurrent symptoms during a median follow-up period of 18 months . Of these five patients , three were treated with surgery ( all true appendicitis ) , and the remaining two were once again treated with antibiotics . Patients with suspected appendicitis , those in whom mild appendicitis was diagnosed after clinical and radiologic evaluations , were found to benefit from short-term antibiotic therapy BACKGROUND Carefully selected children with early appendicitis may be managed nonoperatively . However , it is unknown whether nonoperative management ( NOM 
    Output:
    