Conservative Management Group Research Articles

High-grade carotid artery stenosis: A forgotten area in cardiovascular risk management.

Patients with high-grade (≥70%) carotid artery stenosis (CAS) rank in the highest risk category for future cardiovascular (CV) events, but the quality of cardiovascular risk management in this patient group is unknown. Cross-sectional retrospective study. Data were collected for all patients diagnosed with high-grade CAS in Östergötland county, Sweden between 1 January 2009 and 31 July 2012 regarding the quality of cardiovascular risk management, co-morbidity and outcomes during the 2-year follow-up period after a diagnosis of CAS with a carotid ultrasound scan. Patients were included regardless of whether they underwent carotid endarterectomy (CEA). A total of 393 patients with CAS were included in the study; 133 (33.8%) underwent CEA and 260 (66.2%) were assigned to a conservative management (CM) group. In both groups of patients the prescription of platelet inhibitors, statins and antihypertensive drugs increased significantly (p < 0.001) after diagnosis. However treatment targets were not met in the majority of patients and the low-density lipoprotein level was on target in only 13.5% of patients. During follow-up, low-density lipoprotein levels were not measured in 19.8% of patients who underwent CEA and 44.2% of patients in the CM group (p < 0.001); HbA1c was not measured in 24.4% of patients with diabetes in the CEA group and in 18.8% of patients in the CM group (p = 0.560). There was no documentation of counselling on diet, exercise, smoking cessation or adherence to medication. The combined clinical event rate (all-cause mortality, cardiovascular mortality and non-fatal cardiovascular events) was high in both groups (CEA 36.8% and CM 36.9%; p = 1.00) with no difference in the occurrence of ipsilateral ischaemic stroke. The clinical event rate was high in patients with high-grade CAS and the management of cardiovascular risk was deficient in all aspects.

Treatment strategies for upper tract urothelial carcinoma (UTUC) of a solitary kidney: a single-institutional analysis of 61 cases.

To explore the treatment strategies for patients with upper tract urothelial carcinoma (UTUC) of a solitary kidney. A retrospective analysis of 61 cases who underwent operation for UTUC of a solitary kidney from 2000 to 2012 was performed. Radical nephroureterectomy (RNU) or conservative management was performed. Patients were divided into three groups according to preoperative renal function: group A (eGFR≥60mL/min), group B (15mL/min≤eGFR<60mL/min) and group C (eGFR<15mL/min). We analyzed treatment outcomes of patients with different renal function and surgical approaches. No significant complications were observed, and short-time recovery after operation was satisfactory in all patients. The 5-year cancer-specific survival (CSS) rates for the groups A, B and C were 92.9, 75.3 and 63.7%, respectively (p=0.683). The 5-year overall survival (OS) and recurrence-free survival rates were 92.9 and 53% for group A, respectively, 75.3 and 64.8% for group B, respectively, and 63.7 and 29.5% for group C, respectively (all p>0.1). The conservative management arm was associated with older age (p=0.002), smaller tumor size (p=0.013), lack of renal replacement history (p=0.007) and better preoperative renal function (p=0.002). There were no significant differences in 5-year CSS, OS or recurrence-free survival between the RNU and conservative management groups. Long-term hemodialysis was required in only three patients in the conservative management arm. Long-term oncological outcomes after conservative management are comparable to RNU in selected cases, and conservative management should be considered an alternative treatment measure. Preoperative renal function and clinicopathological characteristics are important in surgery selection for patients with UTUC of a solitary kidney.

Comparison of duration of maternal hospital stay in conservative &amp; aggressive management of Preterm prelabor rupture of membranes(PPROM) in Indian women at 34-36 weeks gestation.

Aim:To compare the conservative and aggressive management of Preterm prelabor rupture of membranes (PPROM) in Indian women at 34-36 weeks gestation in terms of duration of their hospital stay. Materials & Method:194 pregnant women with PPROM at gestational age 34-36 weeks admitted in labour ward were included in the study conducted from 2009 -2010 in department of Obstetrics & Gynaecology, SMS Medical College, India. Random allocation to conservative & aggressive management group was done by offering Chit Box Method assigning 97 cases in each group. In conservative management cases were hospitalized& provided bed rest, Daily fetal monitoring, maternal vitals monitoring, Oral tab erythromycin 500 mg t.d.s for 7 days, Daily WBC count and C reactive protein estimation. Expectant management was abandoned if there was clinical evidence of labour, infection or fetal distress. In aggressive management induction of labour was done by Tab Misoprostol 25 g orally, at 4-6 hour intervals, for a maximum of 5 doses. Caesarean delivery was performed for standard obstetrical indication and for failed induction. After delivery neonatal care was provided by neonatologist Results:Out of total 97 cases, in aggressive management, majority 73 (75.26%) cases had duration  5 days, 19 (19.59%) up to 6-10 days and 5 (5.15%) cases up to 11+ days. Similarly out of total 97 cases in conservative management, majority 46 (47.42%) cases had duration  5 days, 33 (34.02%) up to 6-10 days and 18 (18.56%) cases up to 11+ days. The mean duration of hospital stay of mother in aggressive management were 4.10  3.10 days and in conservative management it is 7.21  3.36 days. Conclusion:Majority of cases in both aggressive and conservative management group had duration of hospital stay of  5 days. But the total duration of hospital stay of mother were much higher in conservative management group in present study. Thus mean duration of hospital stay of mother were much higher in conservative management group as compared to aggressive management. Keywords-PPROM, conservative, aggressive, hospital stay.

Surgical management and outcomes of type A dissection-the Mayo Clinic experience.

Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes. All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method. Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support post-operatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study. TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.

COMPARATIVE STUDY OF STANDARD COAGULATION PROFILE IN NON-DIALYZED AND POST-DIALYZED PATIENTS SUFFERING FROM CHRONIC KIDNEY DISEASE.

Aims and Objectives: This comparative cross sectional study assessed whether there was any subtle change in the standard coagulation profile of chronic kidney disease (CKD) patients who needed no dialysis or who were dialysis candidates but had not yet started dialysis. Aim of this study was to find out any correlation between patients’ coagulation parameters and their degree of uremia. Materials and Methods: A total 30 CKD patients were carefully selected and assigned to three groups after excluding patients who were predisposed to bleeding diathesis. Group A—10 CKD patients on the verge of hemodialysis (HD); Group B—10 CKD patients who were clinically and biochemically stable and on renal replacement therapy in the form of HD; and Group C—10 CKD patients who were in the early stages of standard medical treatment. A coagulation profile study was done for all three groups using nonparametric statistical analysis. Results and Discussion: Significant thrombocytopenia and prolongation of prothrombin time (PT) were present in (Group A), whereas no significant coagulation abnormality was noted in the other two groups. A significant correlation was found between uremia (creatinine clearance) and platelet count, P time, and APTT in Group B and Group C patients and with bleeding time in patients stable with conservative management (Group C). Conclusion: The study shows coagulation parameters are progressively affected with the progress of renal disease and that dialysis has an important impact on coagulopathy in CKD.  But the coagulation parameters showed no statistically significant correlation with degree of uremia

Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants\xa0vs conservative management

PurposeTo compare the safety and effectiveness of minimally invasive sacroiliac joint fusion (SIJF) using triangular titanium implants vs conservative management (CM) in patients with chronic sacroiliac joint (SIJ) pain.Methods103 adults with chronic SIJ pain at nine sites in four European countries were randomly assigned to and underwent either minimally invasive SIJF using triangular titanium implants (N = 52) or CM (N = 51). CM was performed according to the European guidelines for the diagnosis and management of pelvic girdle pain and consisted of optimization of medical therapy, individualized physical therapy (PT) and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated low back pain (LBP) at 6 months. Additional endpoints included quality of life using EQ-5D-3L, disability using Oswestry Disability Index (ODI), SIJ function using active straight leg raise (ASLR) test and adverse events. NCT01741025.ResultsAt 6 months, mean LBP improved by 43.3 points in the SIJF group and 5.7 points in the CM group (difference of 38.1 points, p < 0.0001). Mean ODI improved by 26 points in the SIJF group and 6 points in the CM group (p < 0.0001). ASLR, EQ-5D-3L, walking distance and satisfaction were statistically superior in the SIJF group. The frequency of adverse events did not differ between groups. One case of postoperative nerve impingement occurred in the surgical group.ConclusionsIn patients with chronic SIJ pain, minimally invasive SIJF using triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, improving patient function and quality of life.

Clinical outcome of neurofibromatosis type 2-related vestibular schwannoma: treatment strategies and challenges.

To discuss the appropriate treatment strategy for NF2-related vestibular schwannoma (VS) according to our experiences, we analyzed long-term clinical and radiological data focusing on NF2-related VS patients. Seventeen NF2-related VS patients were included. Based on their first management modality for VS, we classified these patients into the following four groups: microsurgery (MS), fractionated gamma knife radiosurgery (f-GKS), single session gamma knife radiosurgery (s-GKS), and conservative management (CM). Each patient was assessed for each separate ear. Changes of tumor volume and hearing status for 32 ears in 17 patients according to their first treatment modality were evaluated. The mean follow-up duration and tumor volume of the MS (4 ears, 4 patients), f-GKS (12 ears, 10 patients), s-GKS (8 ears, 7 patients), and CM (8 ears, 7 patients) groups were 3.9years and 1.6mL; 5.1years and 11.1mL; 8.4years and 5.6mL; and 6.1years and 1.6mL, respectively. Relatively lower local control rates were observed in the MS and the CM group (0 and 12.5%, respectively). On the other hand, better local control rates for follow-up periods of 5.1 and 8.4years were achieved in the f-GKS and the s-GKS groups (75 and 50%, respectively). However, hearing preservation in all treatment modalities could not be achieved effectively. Long-term preservation of hearing in at least one serviceable ear as well as tumor control should be considered for each patient. Therefore, a proper treatment option should be selected at the appropriate time according to clinical characteristics of individual patients.

Multicenter retrospective evaluation of the validity of the Thoracolumbar Injury Classification and Severity Score system in children.

OBJECTIVE The Thoracolumbar Injury Classification and Severity Score (TLICS) system was developed to streamline injury assessment and guide surgical decision making. To the best of the authors' knowledge, external validation in the pediatric age group has not been undertaken prior to this report. METHODS This study evaluated the use of the TLICS in a large retrospective series of children and adolescents treated at 4 pediatric medical centers (Texas Children's Hospital, Children's Healthcare of Atlanta, Riley Children's Hospital, and Doernbecher Children's Hospital). A total of 147 patients treated for traumatic thoracic or lumbar spine trauma between February 1, 2002, and September 1, 2015, were included in this study. Clinical and radiographic data were evaluated. Injuries were classified using American Spinal Injury Association (ASIA) status, Denis classification, and TLICS. RESULTS A total of 102 patients (69%) were treated conservatively, and 45 patients (31%) were treated surgically. All patients but one in the conservative group were classified as ASIA E. In this group, 86/102 patients (84%) had Denis type compression injuries. The TLICS in the conservative group ranged from 1 to 10 (mean 1.6). Overall, 93% of patients matched TLICS conservative treatment recommendations (score ≤ 3). No patients crossed over to the surgical group in delayed fashion. In the surgical group, 26/45 (58%) were ASIA E, whereas 19/45 (42%) had neurological deficits (ASIA A, B, C, or D). One of 45 (2%) patients was classified with Denis type compression injuries; 25/45 (56%) were classified with Denis type burst injuries; 14/45 (31%) were classified with Denis type seat belt injuries; and 5/45 (11%) were classified with Denis type fracture-dislocation injuries. The TLICS ranged from 2 to 10 (mean 6.4). Eighty-two percent of patients matched TLICS surgical treatment recommendations (score ≥ 5). No patients crossed over to the conservative management group. Eight patients (8/147, 5%) had a calculated TLICS of 4, which meant they were candidates for surgery or conservative therapy by TLICS criteria. Excluding these patients, the degree of agreement between TLICS and surgeon decision was deemed to be very good (κ = 0.878). CONCLUSIONS The TLICS results and recommendations matched treatment in 96% of conservative group cases. In the surgical group, TLICS recommendations matched treatment in 93% of cases. The TLICS recommendations and surgeon decision making displayed very good concordance. The TLICS appears to be effective in the classification of thoracic and lumbar spine injuries and in guiding treatment in the pediatric age group.

0253: Prognostic impact of interventional approach in non-ST segment elevation acute coronary syndrome in very elderly Algerian patients

In moderate or high risk non-ST segment elevation acute coronary syndrome, clinical practice guidelines recommend a coronary angiography with intent to revascularize. However, evidence to support this recommendation in very elderly patients is poor. All patients over 85 years old (military hospitals of Algeria) admitted between 2006 and 2014 with a diagnosis of non-ST segment elevation acute coronary syndrome were retrospectively included. Using a propensity score, patients undergoing the interventional approach and those undergoing conservative management were matched and compared for survival and survival without ischemic events. We included 167 consecutive patients with a mean age of 88 years (range: 85 to 101). Those in the interventional approach group (n=67) were younger, with a higher proportion of males and less comorbidity, less cognitive impairment and lower troponin I levels compared with patients in the conservative management group (n=100). We matched 60patients from the interventional approach group and 60 from the conservative management group using propensity score. In the matched patients, the interventional approach group exhibited better survival (log rank 4.24; P=0.039) and better survival free of ischemic events (log rank 8.63; P=0.003) at the 3-year follow-up. In the whole population, adjusted for propensity score quintiles, the interventional approach group had lower mortality (hazard ratio 0.52; 95% confidence interval: 0.32-0.85) and a better survival free of ischemic events (hazard ratio 0.48; 95% confidence interval: 0.32-0.74). Nearly all the very elderly patients admitted with non-ST segment elevation acute coronary syndrome were of moderate or high risk. In these patients, the interventional approach was associated with overall better survival and better survival free of ischemic events.

日本外傷学会腎損傷分類2008（JAST分類2008）に基づいた鈍的腎外傷207例の初期治療選択因子の検討

(Objective) We retrospectively investigated the applicability of the Japanese Association for the Surgery of Trauma (JAST) classification version 2008 for renal injuries as predictive factors of the initial treatment for 207 blunt renal injury cases. (Materials and methods) We reviewed 207 patients between 1982 and 2013 who were admitted to our institution with blunt renal trauma. Patients were classified as conservative management group, immediate transcatheter arterial embolization (TAE) group, and immediate nephrectomy group by initial treatment. We retrospectively assessed several parameters including JAST criteria version 2008 type of renal injury (type), severity of hematoma (H factor) and extravasation of urine (U factor), the shock on arrival, associated abdominal injuries, serum hemoglobin levels, and macrohematuria as predicting factors of initial treatment of blunt renal trauma. (Result) TypeIII and PV injuries, H2 factor and associated non-renal abdominal injuries were predictive factors of immediate nephrectomy (p=0.001, p=0.000, p=0.003). TypeIII and PV injuries and H2 factor were predictive factors of immediate TAE. Both of H2 and U2 factors were significant predictors of immediate nephrectomy in patients with typeIII injury. H factor was a significantly predictive factor of immediate TAE in patients with typeI/II injuries (p=0.040). The rate of immediate TAE has been increasing but the rate of partial nephrectomy except for nephrectomy has been decreasing since the year 2007 when TAE was immediately available in our hospital. (Conclusion) The type category and severity of hematoma of JAST classification version 2008 would be predictive factors of initial management of blunt renal injuries. Patients with typeIII injuries and both of H2 and U2 factors, can be adapted to immediate nephrectomy. Patients with typeI/II and H2 factors can be adapted to immediate TAE.

Clinico-pathological profile of liver abscess: a prospective study of 100 cases

Background: Liver abscess is a constant source of mortality and morbidity in general and tropical countries. India has second highest incidence of Liver abscess. This study were planned to identify the clinical profile of liver abscess in terms of demographic profile, clinical presentation, etiology, evaluation of different modalities of investigations, effectiveness of various treatment modalities and to study influence of alcohol and diabetes. Methods: This study was carried out in a tertiary care centre in Northern India between the period of January 2013 to June 2014. An attempt was made in this study to define the various symptoms complex, treatment options and complications occurring in cases of liver abscess. Results: In our study highest incidence occurred in 31-60 years age group (71%). Males were more commonly affected (92%). Abdominal pain (98%) was the most common symptom. Alcohol was the single most common etiological factor in 84% of cases of Liver abscess. Laboratory investigations were leucocytosis (72%), anaemia (23%), Raised B. Urea (21%), RBS >200mgm% (29%), raised alkaline phosphatase (83%), hypoalbuminemia (84%), PT >20sec (29%), raised SGOT (52%), SGPT (45%). Aspirated pus culture from liver abscess was sterile in 59.45% cases suggestive of amoebic etiology. Ultrasonography revaled solitary abscess in 78%. Isolated Right Lobe abscess was seen in 74%.72% of patients were subjected to percutaneous aspiration in abscess >100 ml or >3 cm; Recurrences were noted in 8% of cases in conservative management group. Conclusions: Amoebic abscess is much more common than pyogenic liver abscess. Lack of proper sanitary condition, DM and addiction to alcohol are the most important predisposing condition for liver abscess. Ultrasound is simple, inexpensive and quick to perform, with a diagnostic accuracy of 90%.

The effect of conservative fluid management on Toll-like receptor 4 signal pathway of peripheral blood mononuclear cells and cardiac function in patients with septic shock

Objective To evaluate the effect of different fluid resuscitation strategies on the cardiac function in patients with septic shock. Methods Forty-eight patients met diagnostic criteria of septic shock were enrolled prospectively between January 2014 and April 2015. Patients were divided into conservative late fluid management (CLFM) group (n=20) and liberal late fluid management (LLFM) group (n=28) after achieving early goal-directed therapy within 24 h. Haemodynamic parameters, mRNA levels in Toll-like receptor 4 (TLR4) signal pathway and serum levels of myocardial damage markers were compared. Student t-test was used to compare means between two groups. Quantitative data that were not normally distributed were compared by Mann-Whitney U test. Qualitative data were compared using χ2 test. Multivariable Logistic regression analysis was used to identify the independent predictors for prognosis. Results The cardiac function index (CFI) in CLFM group were (5.01±1.41)/min and (5.39±1.48)/min on day 3 and day 7, respectively, and the cardiac index (CI) were (3.43±0.50) and (3.73±0.76) mL·min-1·m-2 on day 3 and day 7, respectively. The CFI and CI in LLFM group were (4.28±1.22)/min, (4.22±1.63)/min and (3.31±1.24), (3.09±1.14) mL·min-1·m-2respectively on day 3 and day 7. The differences between two groups were statistically significant on day 7 (t=2.546, 2.185, both P<0.05). The TLR4 mRNA levels were 3.0±1.1 in CLFM group compared to 4.8±1.4 in LLFM group on day 3 (t=4.786, P<0.01) and 1.6±0.5 compared to 4.0±1.1 on day 7 (t=9.089, P<0.01). Nuclear factor (NF)-κB mRNA levels were 3.5±1.1 in CLFM group compared to 6.8±1.5 in LLFM group on day 3 (t=8.354, P<0.01) and 2.4±0.5 compared to 5.7±0.9 (t=14.820, P<0.01) on day 7. The levels of serum tumor necrosis factor (TNF)-α and interleukin (IL)-1β in CLFM group were lower than those in LLFM group on day 3 and day 7 (all P<0.01). Multivariable Logistic regression analysis showed that fluid balance (OR=1.236, 95%CI: 0.78-1.692, P=0.033), CFI (OR=3.263, 95%CI: 1.136-7.936, P=0.027) and acute physiology and chronic health evaluation Ⅱ(OR=2.064, 95%CI: 1.248-2.898, P=0.003) were the independent predictors for 28-day mortality. Conclusions CLFM may inhibit the product of myocardial depressant factors TNF-α and IL-1β through attenuating TLR4/NF-κB signal pathway activation and thus to improve myocardial function and decrease mortality. Key words: Fluid therapy; Shock, septic; Myocardial depressant factor; Toll-like receptor 4

Clinical Outcomes of Postoperative Upper Gastrointestinal Leakage According to Treatment Modality.

We evaluated the clinical outcomes according to treatment modality for gastrointestinal anastomotic leakage. Of the 19,207 patients who underwent gastrectomy for gastric cancer from March 2000 to April 2013, we retrospectively analyzed the 133 cases who developed anastomotic leakage. These patients were treated using endoscopic management, surgery, or conservative management (endoscopic treatment was introduced in 2009). To evaluate the efficacy of endoscopic treatment, we compared the clinical outcomes between the conservative management-only group before 2009 and the conservative or endoscopic management group from 2009; and between the surgical management-only group before 2009 and the surgical or endoscopic management group from 2009. Seventy-three were initially managed conservatively, 35 were treated surgically, and 25 were treated using endoscopic procedures. Chronologically comparing each treatment group as 'before 2009' (n = 54) and 'from 2009' (n = 79), there were differences in the length of hospital stay (median 32 versus 27, p = 0.048) and duration of antibiotic use (median 28 versus 20, p = 0.013). Patients who underwent conservative or endoscopic management from 2009 showed a shorter hospital stay, period of fasting, and duration of antibiotic use than patients who underwent only conservative management before 2009. Patients who received surgery or endoscopic management from 2009 showed a shorter hospital stay and duration of antibiotic use than patients who underwent only surgery before 2009. Endoscopic management for selected cases can reduce duration of hospital stay and antibiotic administration in the treatment of anastomotic leakage after gastrectomy.

The urologist's role in multidisciplinary management of placenta percreta.

To evaluate urological interventions in patients with placental adhesive disorders in our collaborative experience at a tertiary referral centre. We performed a retrospective analysis of a prospectively collected data set, consisting of all women that presented with placental adhesive disorders at the Royal Women's Hospital from August 2009 to September 2013. Patients who required urological intervention were identified and perioperative details were retrieved. Of the 49 women that presented with placental adhesive disorders, 36 (73.5%) underwent urological interventions. The patients were divided into three groups: planned hysterectomy (37 patients), planned conservative management (five) and undiagnosed placenta percreta (seven). In the planned hysterectomy group, 29 patients underwent preoperative cystoscopy and ureteric catheter placement. In 10 patients (34%), the placenta partially invaded the bladder and/or ureter, requiring urological repair. In the conservative management group, four underwent preoperative cystoscopy and ureteric catheter placement, and one case required closure of a cystotomy. Of the seven patients with undiagnosed percreta, two were noted to have bladder involvement requiring repair at the time of Caesarean hysterectomy. Patients with placental adhesive disorders frequently require urological intervention to prevent or repair injury to the urinary tract. These cases are best managed in specialist centres with multidisciplinary expertise including urologists and interventional radiologists.

Outcome in fetal lower urinary tract obstruction: a prospective registry study.

To describe influences on decision-making and prognostic variables in the prenatal management of fetal lower urinary tract obstruction (LUTO). This was a prospective registry study of pregnant women with a male fetus with LUTO from centers within the British Isles and The Netherlands. Women and/or their clinicians were given the treatment option of either conservative management or vesicoamniotic shunting (VAS). Baseline characteristics of women in the registry, reasons for entry to the registry and pregnancy outcomes were assessed. The main study outcomes were survival to 28 days after delivery, further survival to 2 years and renal function. Logistic regression analysis was used to examine prognostic variables that affected outcome. Results were compared with those of women in a randomized controlled trial (RCT) who were allocated randomly to a treatment option. Forty-five women were registered, of whom 78% (35/45) underwent conservative management. Twenty-seven women entered the registry owing to their clinician's preference for management and 18 because of their own preference. Compared to the conservative-management group of the RCT, a higher proportion of women in the registry opting for conservative management had a normal amniotic fluid volume at diagnosis (P = 0.05) and a diagnosis of LUTO ≥ 24 weeks' gestation (P = 0.003). On multivariable logistic regression analysis, these variables showed a significant association with perinatal survival (P < 0.001). Survival to 28 days after delivery was higher in the conservative-management group, at 69% (24/35), compared to 40% (4/10) in the VAS group (P = 0.02) but this difference had limited statistical significance owing to small study size (relative risk, 0.58 (95% CI, 0.26-1.29); P = 0.14). In our prospective registry, the majority of fetuses with LUTO received conservative management, which was associated with better short- and long-term outcomes. A significant proportion of these pregnancies had normal amniotic fluid volume and a gestational age at diagnosis of ≥ 24 weeks, characteristics shown to be associated with improved survival.

Management of duodenal perforation post-endoscopic retrograde cholangiopancreatography. When and whom to operate and what factors determine the outcome? A review article.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to primarily therapeutic procedure. With this, the complexity of the procedure and risk of complication including duodenal perforation have increased. In this article, the recent literature is reviewed to identify the optimal management and factors influencing the clinical outcome. Recent literature in English language from the year 2000 onwards, containing major studies of 9 or more cases on duodenal perforation post ERCP were analyzed. Literature review revealed a total of 251 cases of duodenal perforation reported in 10 major reports presenting 9 or more cases each. The mean age of these patients was 58.5 years with nearly two third (62.9%) being female patients. The predominant location of the perforation was: duodenal wall (34.5%), perivaterian (31.3%), common bile duct (23.0%), and unknown in 7.9%.Early diagnosis within 24 hours was made in 78.5%, with 55.8% of these being diagnosed during or immediately after ERCP. CT scan was the most useful investigations in detecting perforations missed during ERCP (44.6%). Conservative management was employed in 62.2%, which was successful in 92.9% of these cases. Ten of these who failed conservative management required salvage surgery (6.4%) and one died of pneumothorax (0.6%). The predominant surgical intervention was closure of perforation (49.0%) with or without other procedures, retroperitoneal drainage (39.0%), duodenal exclusion (24.0%) and common bile duct exploration and T tube insertion (13.0%). The overall mortality was 8.0% which appears to be better than previously reported (16-18%). Among the 20 patients who died, six (30.0%) had salvage surgery, five (25.0%) had delay in diagnosis/intervention beyond 3 days and 3 (15.0%) required multiple operations. While the patients with duodenal perforation invariably require surgical intervention, most of the patients with perivaterian injuries can be successfully managed conservatively. The most important factors for recent better outcome were early detection and prompt treatment. Delay in diagnosis and intervention, salvage surgery after failed conservative management, multiple operations, and older age group contributed significantly to the poor outcome.

The Gynecologic Management of Hemoperitoneum

INTRODUCTION: Rupture of a corpus luteum cyst is the major cause of gynecological hemoperitoneum. The diagnosis is based on clinical suspicion, laboratory data, and radiologic findings. Although mild cases require only observation and support, surgical intervention is necessary for severe cases. A standardized management is not defined. Our study compares the outcomes of patients undergoing conservative and surgical management of a ruptured corpus luteum cyst. METHODS: A retrospective chart review was performed, seeking data from Magee Women's Hospital patients with the diagnosis of hemoperitoneum, corpus luteum cyst, or follicular cyst of the ovary between September 2007 and January 2013. These women were hospitalized or underwent laparoscopy or laparotomy with the prior mentioned diagnoses including hemoperitoneum without proof of pregnancy. Statistical analyses were performed with SPSS 21. RESULTS: Our study included 30 patients in whom 17% underwent conservative management and 83% underwent surgical management including laparoscopy or laparotomy. Notably 63% of patients presented with rupture on the left side and 88% presented with abdominal or pelvic pain. We compared differences in radiologic findings (size of cyst, fluid volume, fluid location) between the conservative and surgical management groups and noted no significant differences. There were no significant differences in either short-term (hemoglobin drop, transfusion, infection, length of hospital stay, readmission within 3 months) or long-term outcomes (readmission with same diagnosis, future pregnancies) between the groups. CONCLUSIONS: Although our study size was small, there appears to be no significant adverse outcomes when managing stable hemoperitoneum with conservative management compared with surgical management.

Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion

Symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment remains a dismal disease when untreated. In this prospective, single-center, controlled study, we investigated the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic ICA occlusion. Forty patients with symptomatic chronically occluded ICA were assigned to receive endovascular recanalization (group A, n = 18) or conservative management (group B, n = 22). The primary end point was 100% complete recanalization of the primary occlusion at 60 minutes, and secondary end points were improvement in neurologic function and cognitive function. Patients in the 2 groups were comparable in demographic and baseline characteristics. Successful recanalization was achieved in 88.9% (16 of 18) of patients with the restoration of Thrombolysis in Myocardial Ischemia/Thrombolysis in Cerebral Ischemia 2 or 3 flow. There was no procedural or new cerebral ischemic event. Improvement in brain perfusion was observed in 12 (12 of 18, 75%) patients on single-photon emission computed tomography. Improvement in neurologic function defined as a reduction of ≥4 points on the National Institutes of Health Stroke Scale (NIHSS) at 6 months was observed in group A (baseline, 6.83 ± 3.01 vs 6 months, 2.61 ± 1.20; P < .01) and group B (baseline, 6.05 ± 2.75 vs 6 months, 4.77 ± 1.69; P < .05). A significant difference in NIHSS scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Improvement in cognitive function defined as an increase of ≥8 on the Montreal Cognitive Assessment (MoCA) was observed in group A at 3 and 6 months (baseline, 14.67 ± 3.56 vs 3 months, 24.17 ± 3.55 and 6 months, 24.72 ± 2.85; P < .01). Significant improvement in MoCA was also observed in group B (P < .01). Furthermore, a significant difference in MoCA scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Endovascular recanalization is feasible and safe for patients with symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization.

Clinical Outcome of Patients with T1 Micropapillary Urothelial Carcinoma of the Bladder

We report cancer specific outcomes of micropapillary nonmuscle invasive bladder cancer. We retrospectively reviewed the records of 36 cases restaged within 3 months of the initial diagnosis of micropapillary nonmuscle invasive bladder cancer. Early radical cystectomy within a 3-month landmark after restaging transurethral bladder tumor resection or conservative treatment with intravesical bacillus Calmette-Guérin, surveillance or deferred radical cystectomy was offered according to surgeon and patient preference. The cumulative incidence of cancer specific mortality and metastasis was estimated using the Kaplan-Meier method. Differences in the cumulative incidence of cancer specific mortality and metastasis between the groups were tested using the log rank test. Median patient age was 68 years (IQR 63-77). The male-to-female ratio was 3:1. At restaging all patients had cT1 disease or less. Early radical cystectomy was performed in 15 patients (42%) while 21 (58%) underwent conservative treatment. Median followup after landmark in cancer specific survivors was 3.1 years (IQR 1.1-5.9). The 5-year cumulative incidence of cancer specific mortality was 17% in the early radical cystectomy group and 25% in the conservative management group for an absolute difference of 7% (95% CI -26-41, p= 0.8). The 5-year cumulative incidence of metastasis was 21% and 34%, respectively, with an absolute difference of 13% (95% CI -23-49, p = 0.9). The extent of the micropapillary component was not significantly associated with cancer specific mortality (p = 0.4) or metastasis (p = 0.9). Using proper selection criteria, including patient and pathological factors, certain patients in whom cT1 micropapillary urothelial carcinoma was managed conservatively did not have significantly worse outcomes than patients treated with early radical cystectomy.

Drug holiday as a prognostic factor of medication-related osteonecrosis of the jaw.

ObjectivesTo identify post-treatment prognostic factors for medication-related osteonecrosis of the jaw (MRONJ).Materials and MethodsWe evaluated 54 MRONJ patients who visited the Department of Dentistry, Ajou University Hospital, from May 2007 to March 2014. Twenty-one patients were surgically managed with debridement or sequestrectomy and 33 patients were conservatively managed using antibiotics. Correlations of age, sex, stage, bisphosphonate duration and type, and drug holiday with the prognosis of MRONJ were investigated. Correlations were verified by logistic regression analysis and t-tests with a significance level of 0.05.ResultsClinical outcomes were evaluated on the basis of both clinical and radiographic findings. Twelve out of 21 surgically managed patients showed a favorable prognosis and nine patients relapsed. Thirty-one of the 33 conservatively managed patients showed no specific change in prognosis, and two patients worsened. Statistical analyses of the conservative management group did not reveal any correlation of the above factors with the prognosis of conservative management. Drug holiday was the only prognostic factor in the surgical management group (P=0.031 in logistic regression analysis, P=0.004 in t-test).ConclusionDrug holiday is a prognostic factor in the surgical management of MRONJ. Because the drug holiday in the patients of the poor prognosis group occurred 1.5 to 4 months prior to surgical management, we recommend a drug holiday more than 4 months before surgery.