The Skeptics Guide to Emergency Medicine

Date: July 10, 2025 Guest Skeptics: Professor Timothy Caulfield is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization. This is another SGEM Xtra book review. Tim was our guest skeptic a few years ago, discussing his book called Relax, Dammit! A User’s Guide to the Age of Anxiety. He is back on the SGEM to discuss his latest book called The Certainty Illusion: What You Don't Know and Why It Matters. I asked Tim several questions about his book. Please listen to the podcast to hear his responses.  Questions for Professor Caulfield The book is structured into three main parts. In Part I: The Science Illusion, you examine how scientific language and imagery are co-opted to confer credibility on dubious claims. You discuss how quantum physics has been misappropriated by the wellness and alternative medicine industries. Why do you think "quantum" has become such a powerful marketing tool? The phrase "It’s Science!" is often used to shut down debate. What are the dangers of weaponizing the language of science? You talk about Zombie Science (ideas that refuse to die despite mountains of evidence). I’ve given a lecture for the Gateway Centre of Excellence in Rural Health on zombie ideas about hospital crowding. What is a good example of zombie science in health and wellness? At the end of Part I, you introduce ‘The Humility Fix" as a potential solution. Can you explain why intellectual humility is a necessary antidote to misinformation? In Part II: The Goodness Illusion, you unpack how concepts of health, sustainability, and morality are manipulated to create a false sense of certainty. You explore things like "health halos," in which terms like "clean," "organic," and "natural" are used to mislead consumers. Can you expand on that concept? You list 12 words in total that you call the "Devious Dozen". These are a set of misleading or overhyped health and wellness claims that exploit public perception and create a false sense of certainty. These terms and concepts are often used in marketing, politics, and public discourse to manipulate consumers and reinforce misinformation. Do you have a couple of favourites? You also talk about how virtue signalling and ideological narratives shape public opinion, often overriding evidence-based reasoning. The idea that our desire to do what’s "right" can be exploited through misleading claims about health, wellness, and even sustainability. What’s an example of this in the medical field, and how can healthcare professionals push back against it? You also discuss the White Hat Bias in this section of the book. It is a phenomenon where research findings are distorted in the service of what is perceived as a noble or righteous cause. This bias leads to the overrepresentation of certain findings, particularly in fields like public health, nutrition, and medicine, where there is strong societal motivation to support outcomes. Who coined the term White Hat Bias? Can you give an example of the White Hat Bias from the COVID-19 pandemic? In Part III of the book, you discuss The Opinion Illusion. This delves into how the digital age has fueled an economy of opinion, where ratings, reviews, and social media influence create misleading perceptions of truth and expertise. How has the “opinion economy” shaped modern decision-making? How has this shift impacted our ability to discern truth from misinformation? You highlight the influence of online reviews and rankings. Why do people trust anonymous reviews more than expert opinions or personal recommendations? What role do algorithms play in distorting our perception of consensus and credibility?  The book isn’t all doom and gloom. You do offer some solutions for navigating this chaotic information environ...

Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Date: July 28, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her wonderful PaperinaPic infographics.   Case: Your non-US emergency department (ED) has recently been shaken by the attendance of a teenager with a gunshot injury. Subsequent investigation has found he attended a different hospital in the region six weeks ago with a stab wound. The team wonders if that attendance was an opportunity to intervene. Background: Firearm injuries are now the leading cause of death in youth in the United States, surpassing motor vehicle collisions.[1] While the immediate clinical management of gunshot wounds is well covered in emergency medicine training, there is less clarity around what happens before and after that ED visit. Could we identify these high-risk youth earlier? Do patterns of ED use provide clues for intervention? The ED often serves as the primary healthcare contact point for youth exposed to community violence. Some youth injured by firearms may have prior ED visits for mental health crises or minor injuries, presenting opportunities for preventative strategies. But are we missing these cues? Additionally, once youth survive a firearm injury, they face elevated risk for repeat injury, psychological trauma, and even death. Understanding post-injury healthcare utilization may reveal missed chances for intervention, particularly in general EDs that may lack pediatric-specific resources. Clinical Question: Do youth with firearm injuries have increased emergency department utilization before and after their injury compared to their peers? Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Population: Youth aged 10 to 19 years who had an index ED visit for a firearm injury in 2019 across eight US states, identified from the Healthcare Cost and Utilization Project database. Exclusion: Youth who lacked the data to assess 90 days before or after the index injury, and those without longitudinal ED visit linkage, injuries from non-power firearms, and recurrent visits with firearm injury. Exposure: Having sustained a firearm injury as indexed by an ED visit. Comparison: ED utilization by the same patients in the 90 days before and after the firearm injury. Outcomes: Primary Outcome: Number and types of ED visits 90 days before and after the index firearm injury. Secondary Outcomes: Types of ED visits and recurrence of trauma. Type of Study: Retrospective cohort study using linked administrative claims data. Dr. Samaa Kemal This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Samaa Kemal is an early-career pediatric emergency medicine clinician-investigator at Ann & Robert H. Lurie Children's Hospital of Chicago. Her work is primarily focused on the intersection of violence and health equity in children. Her research priorities are focused on developing and implementing novel and effective solutions to prevent violent injuries and subsequent adverse outcomes in children.  Authors’ Conclusions: “Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes

Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Annals of Emergency Medicine. Feb 2025 Date: April 29, 2025 Guest Skeptic: Dr. Brad Sobolewski, is a pediatric emergency medicine physician at Cincinnati Children’s Hospital and Professor of Pediatrics at the University of Cincinnati College of Dr. Brad Sobolewski Medicine. He is the creator of the PEMBlog and host of PEM Currents: The Pediatric Emergency Medicine Podcast. Brad is passionate about using digital media to translate complex clinical concepts into engaging, accessible educational content. His work centers on advancing knowledge sharing through innovative, tech-forward approaches to medical education. Case: A 14-year-old girl with no known medical or psychiatric history presents to the emergency department (ED) with her family for aggression. Her parents tell you that they have been getting into arguments a lot recently. Today, she became so angry that she started punching and kicking the walls at home. You interview the girl and perform your physical examination, and determine that there are likely no medical diagnoses contributing to her aggression, nor that she has sustained any injuries requiring immediate management. After you leave the room and her parents enter, you hear them get into another argument, and she gets more agitated. The staff try a combination of de-escalation techniques, but she continues to be aggressive and starts threatening the staff. A nurse working with you asks, “I don’t think our de-escalation techniques are working. Do you want to give her something to help calm her down? We have olanzapine or diazepam here. Which one do you want to give?”  Background: Pediatric agitation can be defined as a clinical state characterized by heightened motor activity, emotional arousal, and often aggressive or disruptive behavior outside of expected developmental norms. It can be triggered by many things like underlying psychiatric disorders, medical conditions (like delirium, hypoxia, or metabolic disturbances), substance intoxication or withdrawal, and situational stressors, such as hospitalization or separation from caregivers​. In the ED setting, pediatric agitation presents unique challenges. Not only can it compromise the safety of the child, caregivers, and medical staff, but it can also delay care and exacerbate underlying conditions​. When a child presents with extreme agitation or aggression, the first step is to take a broad, thoughtful approach. We can’t just assume it’s a psychiatric issue. Medical causes like hypoglycemia, intoxication, or even something like new-onset diabetic ketoacidosis can present this way. Missing these diagnoses could be dangerous. Once we’ve ruled out organic causes, the focus shifts to early recognition and de-escalation. We try to identify the signs that a child is becoming more agitated before they escalate further. The goal is to intervene early and often with non-pharmacologic strategies. This can mean adjusting the environment: dimming the lights, reducing noise, giving the child space, or removing extra staff from the room. Sometimes something as simple as offering a snack, a drink, or a comfort item can make a big difference. Re-direction, distraction, and using calm, supportive language can also go a long way. Of course, there are times when those strategies aren’t enough, and we may need to use physical restraints or medications. But that should never be our starting point. The overarching goal is to approach these situations with empathy and respect. Support the child and their family while protecting everyone’s safety, including our own. There’s no perfect medication for agitation so it really depends on the situation. If the child is cooperative, start with an oral option. It gives the child a bit of control and helps avoid the trauma of restraint or an ...

Date: July 9, 2025 Guest Skeptics: Dr. Cindy Bitter is an Associate Professor in the Division of Emergency Medicine at Saint Louis University. She has a Master’s in Bioethics, and she is passionate about EM capacity building and physician resilience, especially improving wellness through time in nature.    Dr. Amy Bi is a graduate from the SSM Health Saint Louis University Emergency Medicine residency and the University of Missouri School of Medicine. She is interested in continuing medical education, orange theory, and travelling. This is an SGEM Xtra episode, which takes us back to the late '90s to explore the intersection of pop culture and professional practice through the lens of Buffy the Vampire Slayer. It's similar to the episodes we did about Star Trek, Top Gun, Dark Knight, Ted Lasso, and The Pitt. Cindy reached out to me about a presentation she made at the HumanisEM conference. It's an interdisciplinary conference that explores the intersections of the Health Humanities and Emergency Medicine, started in 2023. The presentation at the conference was inspired by a conversation with female residents about why Buffy remains a must-watch show for young professionals, especially in medicine. In the lecture, we explore lessons from the show that resonate with emergency physicians and healthcare professionals. Click on the LINK for a copy of the slides. There may be some people like me who are not familiar with the show. Buffy the Vampire Slayer premiered in 1997 and ran for seven seasons. Its central premise was that the seemingly dumb blonde chick who is the first to get killed in horror movies is trained to fight back. Ultimately, the monsters were symbols of the challenges we face on the way to growing up and creating a meaningful life. The show hid a healthy dose of existential philosophy under the quips, music, and 90s fashion, and continues to gain fans more than 20 years after it ended. Career Advice from Buffy the Vampire Slayer Honour Your Calling Quote: “You talk about slaying like it’s a job, it’s not. It’s who you are”. What’s My Line? Part 2; S2, ep 10. Writer: Marti Noxon Our path in medicine is somewhat different than the “one girl in all the world” who is destined to fight the forces of darkness, but there are analogies. Buffy sometimes struggles with her calling but ultimately accepts her path (Prophecy Girl). And she shows that this is not a single event, but something she chooses every day (What’s My Line, Anne, Amends). We come to medicine with our own set of strengths and skills, choose our path, and actively reaffirm it as we complete years of education and residency training. There are certainly challenges in our healthcare system, but there is also connection and sometimes even joy. Meeting Challenges Quote: “Bottom line is, even if you see 'em coming, you're not ready for the big moments. No one asks for their life to change, not really. But it does. So, what are we, helpless? Puppets? No. The big moments are gonna come. You can't help that. It's what you do afterwards that counts. That's when you find out who you are.” Becoming, part 1; S2, ep 22. Writer: Joss Whedon Quote: “From now on, we won’t just face our worst fears, we will seek them out. There’s only one thing in this world more powerful than evil, and that’s us.” Bring on the Night; S7, ep 10. Writer: Marti Noxon with Douglas Petrie Medical school, residency, and even attending life are filled with learning from students, residents, coworkers, nurses, colleagues, and administrators. We must incorporate new evidence into our practice, learn from mistakes, and improve for future encounters. New situations come at us all the time; it’s how we strategize and confront them that counts. That might mean reading up on disease presentations we do not see often or practicing high-acuity, low-occurrence procedures. Knowing we are prepared for the challenges we s...

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Date: May 7, 2025 Dr. Sandi Angus Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education. Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?” Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately. The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​. Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each  abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1]. To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule. These seven variables were: Evidence of abdominal wall trauma or seat belt sign GCS <14 and blunt abdominal trauma Abdominal tenderness Thoracic wall trauma Complaint of abdominal pain Decreased breath sounds Vomiting If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan. Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric t...

Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Date: June 24, 2025 Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. Case: A 24-year-old woman presents to the emergency department (ED) with a two-day history of dysuria, lower abdominal discomfort, and abnormal vaginal discharge. She is sexually active with multiple male partners and does not consistently use condoms. A urine nucleic acid amplification test (NAAT) is sent, and the patient is clinically diagnosed with a possible sexually transmitted infection (STI). She is not in acute distress, has no fever, and requests discharge after symptom control. Background: STIs such as chlamydia and gonorrhea remain significant public health concerns in the United States (US), particularly among young adults. EDs are increasingly serving as critical access points for STI screening and treatment. However, emerging evidence suggests that treatment practices may differ by patient sex, raising concerns about potential inequities in care delivery. Women are disproportionately affected by the long-term sequelae of untreated STIs, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Despite this, treatment disparities may exist. Men presenting with STI symptoms often receive expedited care, while women, even when symptomatic or diagnosed, may not receive timely or adequate treatment. Potential explanations include differing clinical presentations, provider bias, and system-level barriers such as follow-up challenges or diagnostic uncertainty. Chlamydia and gonorrhea can present with a range of symptoms or be asymptomatic, which complicates timely diagnosis and treatment. While the Centers for Disease Control and Prevention (CDC) guidelines recommend empiric treatment in cases of high clinical suspicion, especially when patients may be lost to follow-up, the extent to which these guidelines are equitably applied across sexes remains uncertain. Clinical Question: Are there sex-based disparities in the treatment of chlamydia and gonorrhea among adults presenting to US emergency departments? Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Population: Adults (≥18 years) presenting to US EDs with testing for chlamydia or gonorrhea. Exclusions: Pediatric patients, individuals with incomplete demographic or treatment data, and those not diagnosed in the ED. Exposure: Receipt of appropriate antibiotic treatment during the ED visit. Comparison: Male versus female patients. Outcomes: GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex. Type of Study: Systematic review and meta-analysis Dr. Rachel Solnick This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Rachel Solnick is an Assistant Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. Her research focuses on HIV prevention, STI care, and maternal health, with an emphasis on expanding access to high-quality reproductive and sexual healthcare for all emergency department patients. She is the PI of an NIH Career Development Award studying the implementation of HIV pre-exposure prophylaxis (PrEP) for ED patients diagnosed with STIs during telephone callbacks. Authors’ Conclusions: “Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially under-treated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy.

Dr. Aine Yore, an experienced Emergency Physician from Seattle and former ACEP president, dives into the critical topic of pre-oxygenation strategies for high-risk intubations. She highlights the superiority of high-flow nasal cannula in enhancing patient safety and reducing hypoxia. The discussion also critiques existing randomized controlled trials, emphasizing the importance of transparency in research. Yore engages listeners with intriguing insights from a network meta-analysis, wrapping it up with a fun musical trivia segment that blends entertainment with medical education.

Date: June 2, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. This is another SGEM Xtra that talks about what we can learn about being physicians from certain pop culture (TV and Movies). Past episodes include: Star Trek Made Me A Better Physician Lead Me On – What I Learned from Top Gun Holding Out for a Hero – Lessons from The Dark Knight Yeah, Might Be All that You Get – How Ted Lasso Made Us Better Doctor, Doctor – Paging Dr. Robby (The Pitt) Five EM Lessons from Mission Impossible Movies Precision Under Pressure: Ethan Hunt doesn’t get extra time or perfect conditions — and neither do we. Whether defusing a bomb or managing a crashing patient, calm execution under pressure saves lives. The Team is Everything: Hunt may be the face, but he’s nothing without Luther, Benji, and the crew. Medicine is no different: the best outcomes happen when we trust our team and play to each other’s strengths. Always Question the Intel: Just because it’s in the mission briefing doesn’t mean it’s true. Skeptical medicine is about challenging the “received wisdom” and verifying it before acting — just like a good IMF agent would Know Your Exit Strategy: Whether escaping a vault or de-escalating a high-stakes family discussion, always have a way out. Good clinicians plan for failure just as much as success — that’s what keeps patients (and careers) safe. Mission Fatigue is Real: Even Ethan looks wrecked sometimes. Adrenaline is not a sustainable fuel. We need to rest, recover, and recalibrate — especially if we want to perform at a high level over decades. The SGEM will return with a structured critical appraisal of a recent publication. We will continue to strive to reduce the Knowledge Translation (KT) window from over ten years to less than one year, leveraging the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Dr. Ross Prager, an Intensivist at the London Health Sciences Centre, shares ten crucial life lessons that are often missing from medical education. He highlights the importance of emotional connections with patients, focusing on how genuine care trumps clinical knowledge. Prager emphasizes that true character shines in tough moments and shows that passion is not a weakness in medicine. He also critiques reliance on standard evidence while advocating for accuracy in diagnoses and nurturing personal joy in healthcare. Authenticity and kindness remain central themes.

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Date: March 19, 2025 Dr. Camille Wu Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand. Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?” Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions. The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​. We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies. SGEM #115: Complicated-Non-operative Treatment of Appendicitis (NOTA) SGEM #180: The First Cut is the Deepest- N.O.T. for Paediatric Appendicitis SGEM #256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain- Should I have an Appendectomy? SGEM #345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis (APPAC II RCT) SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains: To cut or not to cut? Clinical Question: In children with acute uncomplicated appendicitis, is treatment with antibiotics non-inferior to appendicectomy? Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Population: Children aged 5-16 years with suspected non-perforated appendicitis based on clinical diagnosis +/- imaging Excluded: suspicion of perforated appendicitis, appendix mass/phlegmon, previous antibiotic treatment, positive pregnancy test, current treatment for malignancy, comorbid condition altering length of stay Intervention: Antibiotic therapy, initially with IV antibiotics followed by oral antibiotics after clinical improvement Comparison: Laparoscopic appendectomy Outcome: Primary Outcome: Treatment failure within 1 year. Secondary: Complications (adverse events that required interventions without general anesthesia), length of hospital stay,