Conservative Management Of Patients Research Articles

Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure

BackgroundThis study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure.MethodsIn this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed.ResultsThe conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22–85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001–0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001–0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72–0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008).ConclusionAmong patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

Iatrogenic pharyngo-esophageal diverticulum post-anterior cervical discectomy and fusion: A case report and review of literature.

The purpose of this study is to report a case of iatrogenic pharyngoesophageal diverticulum post-anterior cervical discectomy and fusion (ACDF) surgery, its management and management of postoperative complications. We also did a thorough review of literature about iatrogenic pharyngoesophageal diverticulum which is a rarely encountered complication occurring after a commonly performed surgery; ACDF. Here we describe a case of iatrogenic pharyngoesophageal diverticulum post-ACDF surgery. In this paper we also make comparisons to the 23 cases reported in the literature in terms of: presentations, clinical findings, management courses, and complications. This study was approved by the Institution Review Board of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. (Ref. no.: IRB-2023-01-473). The reported subject provided written informed consent before initiation of this study. Our case is a 45-year-old male with a history of ACDF surgery 8 years ago. He presented with dysphagia and regurgitations which started 1 year after ACDF. He was labeled as a case of Zenker's diverticulum and underwent multiple failed open and endoscopic surgeries prior to presenting to us. Upon presenting to our center, barium swallow showed the pharyngoesophageal diverticulum. Patient definitive diagnosis of iatrogenic rather than Zenker's diverticulum was established intra-operatively with esophagoscopy which revealed exposed hardware inside the diverticulum. He underwent open diverticulectomy and diverticulopexy. Postoperatively he developed pharyngocutanous fistula and right vocal fold palsy, both successfully managed conservatively. Iatrogenic Pharyngoesophageal diverticulum is a rare complication following ACDF, however prolonged dysphagia shall warrant further investigation by contrast studies. Open diverticulectomy with muscle reinforcement is a good management modality. Due to the complicated anatomy secondary to previous operations, we recommend conservative management for patients with postoperative pharyngocutaneous fistula.

Manual therapists’ appraisal of optimal non-pharmacological conservative management of patients with lumbar spinal stenosis. An international Delphi study

BackgroundLumbar Spinal Stenosis (LSS) is a slow progressive degenerative disorder associated with chronic pain and disability. Although consensus-based international guidelines for invasive treatment of patients with LSS exist, few consensus-based guidelines for optimal conservative management strategies have been published. ObjectiveTo achieve manual therapists’ consensus on optimal physiotherapeutic management strategies for LSS. MethodsThe study employed a three-round, email–based International Delphi survey. All qualified members of the International Maitland Teacher Association (IMTA) (n = 30) were invited to participate. ResultsTwelve IMTA teachers participated in the study. Eight essential physiotherapy management strategies were identified, as follows: 1. Detailed assessment with in-depth interview; 2. Recognition of red flags, contraindications and precautions; 3. Neurological examination; 4. Postural and movement analysis with related ergonomics; 5. Functional analysis; 6. Individualized treatment based on assessment findings and research evidence; 7. Aerobic training and 8. Patient education. ConclusionThis Delphi survey provides a foundation for physiotherapists to individualize and optimise management approaches for patients with LSS. With a growing elderly population, there is an increasing need for evidence-based conservative management guidelines based on high quality research.

Outcomes of conservative management in patients with nutcracker syndrome.

This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions. This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms. Sixteen patients (75% female and mean age 24.4 ± 3.5years) underwent conservative management. Over a mean follow-up of 27.3months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged. This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Non-pharmacological methods of treating chronic non-specific neck pain, possibilities of radiofrequency denervation: A review

Chronic non-specific neck pain (CNSNP), or cervicodynia, is a common pathology that significantly reduces the quality of life of patients. It is believed to be based on degenerative and dystrophic changes in the spine, as well as myofascial pain syndrome. Currently, a comprehensive approach is used in the treatment of CNSNP, including kinesitherapy, ergotherapy, manual therapy, and cognitive-behavioral therapy. In case of ineffectiveness of conservative patient management methods, radiofrequency denervation is used, which is an effective and safe procedure for reducing the severity of pain syndrome. The results of the use of radiofrequency denervation in CNSNP are discussed.

Nutritional therapy in Chronic Kidney Disease

Dietary-Nutritional Therapy (DNT) is an essential component of the conservative management of patients with chronic kidney disease (CKD) as it helps maintain optimal nutritional status, prevent and/or correct symptoms and complications of CKD. Moreover, it allows adherent patients to delay the onset of dialysis, leading to improved quality of life and cost savings for both patients and the community. Through a survey, we aimed to evaluate how personalized diets were assessed, administered, and experienced by CKD patients. A questionnaire was administered to 180 patients from 4 nephrology Centers in Lombardy, (Italy,) regarding their CKD and nutritional therapy. 73% of patients received dietary prescriptions. In 40% of cases, dietary prescriptions were administered in dedicated clinics and were valued as much as pharmacological ones. Most diets prescribed were low-protein (0.8g protein per kg of body weight), although some included very low protein diets supplemented with keto analogs. Unfortunately, post-initial prescription, monitoring adherence to nutritional therapy is not particularly frequent. In conclusion, our survey suggests that while patients in different Nephrology Centers receive proper dietary prescriptions and follow-ups, there are areas for improvement with positive implications for CKD progression and delaying dialysis therapy.

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.

How Does Resorption Differ Among Single-Level and Multilevel Lumbar Disc Herniations? A Prospective Multi-Imaging and Clinical Phenotype Study.

Prospective, case series. To identify and characterize any differences in specific patient factors, MRI findings, features of spontaneous disc resorption, and outcomes between patients with single-level and multilevel LDH. Lumbar disc herniation (LDH) is one of the most common spinal pathologies worldwide. Though many cases of LDH resolve by spontaneous resorption, the mechanism underlying this "self-healing" phenomenon remains poorly understood, particularly in the context of multilevel herniations. A one-year prospective study was conducted of patients presenting with acute symptomatic LDH between 2017 and 2019. Baseline demographics, herniation characteristics, and MRI phenotypes were recorded before treatment, which consisted of gabapentin, acupuncture, and the avoidance of inflammatory-modulating medications. MRIs were performed approximately every three months after the initial evaluation to determine any differences between patients with single-level and multilevel LDH. Ninety patients were included, 17 demonstrated multilevel LDH. Body mass index was higher among patients with multilevel LDH ( P <0.001). Patients with multilevel LDH were more likely to exhibit L3/L4 inferior endplate defects ( P =0.001), L4/L5 superior endplate defects ( P =0.012), and L4/L5 inferior endplate defects ( P =0.020) on MRI. No other differences in MRI phenotypes ( e.g. Modic changes, osteophytes, etc .) existed between groups. Resorption rate and time to resolution did not differ between those with single-level and multilevel LDH. Resorption rates were similar between single-level and multilevel LDH at various time points throughout one prospective assessment, providing insights that disc healing may have unique programmed signatures. Compared with those with single-level LDH, patients with multilevel herniations were more likely to have a higher BMI, lesser initial axial and sagittal disc measurements, and endplate defects at specific lumbar levels. In addition, our findings support the use of conservative management in patients with LDH, regardless of the number of levels affected. Level 3.

Prevalence and Correlation between MRI Findings and Outcome of Conservative Treatment in Primary Idiopathic Frozen Shoulder.

Primary idiopathic frozen shoulder (FS) causes pain and stiffness in the shoulder joint. Over time, this disease causes restriction of shoulder motion. We undertook this study to evaluate possible correlation of MRI findings with outcome of conservative management in FS. A total of 65 cases participated in prospective cohort study. The correlation of MRI findings obtained before commencing the treatment with outcome of non-operative management (Mean of ROM, VAS, SST and OSS) was evaluated. Anterior extracapsular edema significantly correlated with FF, EXR, VAS (a) and OSS. The effusion in humeral side of axillary recess significantly correlated with ROM restriction in ABD, EXR. Capsular thickness of glenoid portion showed good significance with FF, ABD, VAS (a) and OSS. Increased thickness of CHL showed negative correlation with improvement of EXR (P=0.049) (r=-0.617). Thickening of IGHL showed negative correlation with improvement of ABD (p=0.005 r=-0.862) and FF (p=0.007 r=-0.831). Mean Height of Axillary recess (HAR) was 7.2mm (3.5-11mm). HAR showed negative correlation with VAS pain scale (P=0.036) (r=-0.682) and OSS (P=0.038) (r=-0.668). Thickness of the joint capsule and effusion at the axillary fold are important factors for refractory frozen shoulder. We can recommend MRI for refractive cases and low threshold of expectation can be set for conservative management in patients with above findings.

Sexual Outcomes after Conservative Management for Patients with Localized Penile Cancer.

Men with localized invasive penile cancer (PC) can be treated with organ-sparing treatments with different functional and aesthetical outcomes. Thus, the aim of this study is to investigate sexual outcomes in patients with PC confined to the glans that underwent wide local excision (WLE) vs. glansectomy with urethral glanduloplasty. Complete data from 60 patients with PC were analyzed at our institution from 2017 to 2022. Patients were asked for personal habits and clinical features. PC was assessed with a clinical visit and imaging techniques. At the outpatient follow-up visit or phone call, all patients compiled the Changes in Sexual Function Questionnaire (CSFQ) and the International Index of Erectile Function in its short 5-item form (IIEF-5). Erectile function (EF) impairment was categorized using Cappelleri's criteria. Overall, 34 patients with PC confined to the glans (c ≤ T2N0) were included. Of those, 12 underwent WLE and 22 underwent glansectomy with urethral glanduloplasty. Using multivariable logistic regression, glansectomy (OR: 3.49) and diabetes (OR: 2.33) were associated with erectile disfunction (IEEF < 22). Meanwhile, using multivariable linear regression analysis, younger patients (Coeff: -2.41) and those that underwent glansectomy (Coeff: -7.5) had a higher risk of sexual function impairment, according to the CSFQ. Patients with PC ≤ T2N0 that underwent WLE have better outcomes in terms of sexual functioning than the patients who underwent glansectomy and uretheral gladuloplasty. Further research is needed to clarify the outcomes of penile-sparing surgery, to inform patients in pre-surgical counseling more comprehensively, and to meet their post-operative expectations more effectively.

Degenerative Cervical Myelopathy: An Overview.

Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.

Diagnosis and Management of Ectopic Pregnancy

Ectopic pregnancy (EP) is a serious obstetric complication that can be life-threatening. Age-adjusted incidence of ectopic pregnancy is roughly 15.8 pregnancies per 1000. Despite this seemingly low value, EP remains one of the largest contributors to maternal mortality in the first trimester. While some patients require urgent surgery, there is a role for medical and conservative management in patients who are hemodynamically stable. In cases where medical or conservative management is appropriate, family physicians can choose to manage this condition with collaboration from the patient’s obstetrician. Particularly for residents in the 50% of US counties with no obstetrician, it is imperative for family doctors to diagnose EP quickly and accurately

Management of foreign body ingestion in adults: Time to STOP and rethink endoscopy

Abstract Background and study aims Foreign body ingestion is a common cause for Emergency Department presentation. In adults, foreign body ingestion is more common in patients with underlying psychiatric comorbidity, the elderly, alcohol intoxication, and in prisoners. This study reviewed the management of patients presenting to a tertiary hospital with foreign body ingestion. Patients and methods A retrospective review of patients presenting with foreign body ingestion to a tertiary hospital in Melbourne, Victoria, was undertaken from January 2017 to December 2021. Data collected included patient demographics, type of foreign body, length of stay, imaging modalities, management strategies, and complications. High-risk ingestion was defined as sharp objects, length &gt;5 cm, diameter &gt;2.5 cm, button battery and/or magnet ingestion or esophageal as per international guidelines. Results A total of 157 presentations by 63 patients with foreign body ingestion occurred between 2017 and 2021 (50% male; median age 30 years). Of the patients, 56% had underlying psychiatric comorbidities. The majority of presentations occurred in prisoners (65%). The most commonly ingested objects were batteries (23%), alleged drug-containing balloons (17%), razor blades (16%), and miscellaneous (40%). High-risk ingestion occurred in approximately two-thirds of presentations. Conservative management was the most common approach in 55% of patients. Complications, defined as perforation, bowel obstruction or fistula formation, did not occur in this cohort despite more than half presenting with high-risk ingestions. Thirty-day re-presentation rates were high (31%) and that was most common in patients with intentional ingestion, underlying mental health disorders, and a documented history of self-harm. Conclusions Conservative management for patients presenting with recurrent high-risk foreign body ingestion was safe in appropriately selected cases. Re-presentation is common and poses significant challenges for health care providers.

Exploring the assessment, diagnosis and conservative management of patients with neurogenic thoracic outlet syndrome (NTOS): an online survey of UK medical and allied health professionals

Objective: Neurogenic thoracic outlet syndrome (NTOS) is challenging to diagnose and manage. While physiotherapy is widely recognised as the primary treatment for NTOS, treatment specifics and target populations are poorly described. The objective of this cross- sectional survey was to explore the experiences and opinions of UK therapy and medical professionals regarding the assessment, diagnosis and physiotherapy management of patients with NTOS. Methods: An online survey was distributed through a multimodal recruitment strategy employing snowball sampling. The survey remained active for 4 weeks and targeted healthcare professionals with experience of treating NTOS, ending May 2023. Results: 46/55 (83.6%) responses were deemed eligible for analysis. 84.7% (39/46) worked in the NHS, with 41% (16/39) specialising in multidisciplinary team nerve services and most (58.7%, 27/46) having &gt;10 years of experience treating NTOS. Key findings included: NTOS assessment (performed by &gt;91%) involved taking a subjective history, evaluating cervical and shoulder active range-of-motion, upper limb neurological screening and assessing the patient’s understanding of NTOS. Physiotherapy treatment (provided by &gt;94%) consisted of advice and education, range of motion exercises for the shoulder, cervical and thoracic regions, postural advice, activity modification and a home exercise plan. Three-quarters (76.1%, 35/46) of respondents reported an absence of treatment guidelines for NTOS, and 98% (45/46) expressed the need for further research into exercise and physiotherapy management for NTOS. Conclusion: While clinicians perceive NTOS as a complex condition lacking treatment guidelines, physiotherapy remains a mainstay in the current treatment pathways. Further research is warranted to enhance the understanding of NTOS and develop evidence-based management strategies.

Impact of patient-reported frailty on cardiovascular outcomes in elderly patients with non-ST-elevation myocardial infarction

Abstract Background Due to the increasing life expectancy, more older people will be affected by coronary artery disease (CAD). The evaluation of frailty and comorbidity is crucial when elderly patients with non–ST-segment elevation myocardial infarction (NSTEMI) are treated, as frailty can increase the risk of adverse clinical outcomes. Purpose The aim of this registry was to assess the predictive value of patient-reported frailty on the treatment and prognosis of elderly non-ST-elevation myocardial infarction (NSTEMI) patients. Methods A post-hoc analysis was performed in patients included in the POPular Age trial and POPular Age egistry, which both enrolled elderly patients with NSTEMI. Frailty was assessed within one month after admission using the Groningen Frailty Indicator (GFI), which is a widely-used questionnaire that includes both physical, cognitive, social and psychological domains. Missing data was imputed by predictive mean matching when at least one item for the questionnaire was registered. Patients with a GFI score of 4 or higher were defined as frail. We evaluated the impact of frailty on both major adverse cardiovascular events (MACE, consisting of cardiovascular mortality, myocardial infarction and stroke) and major or clinically-relevant non-major bleeding (BARC 2, 3 or 5) at one year. Outcomes were then evaluated by stratifying the population in invasively managed patients, who underwent coronary angiography (CAG), versus conservatively-managed patients. Results The total included population consisted of 2229 patients ≥70 years presenting with NSTEMI. The GFI score was available in 1320 patients (mean age 79 years, 51% women), of whom 712 were considered frail (54%, mean GFI score 4.3 ± 2.8). In total, 1027 patients (78%) were invasively-managed. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.05-2.51), but not for major or clinically-relevant non-major bleeding (12.5% vs. 14.5%, HR 0.93, 95% CI 0.69-1.28). In frail patients, invasive management was strongly associated with a lower incidence of MACE (6.7% vs. 17.0%, adjusted HR 0.40, 95% CI: 0.24-0.66, p &amp;lt; 0.001). Yet, in non-frail patients, invasive management was not associated with a lower risk for MACE (4.8% vs. 6.9%, adjusted HR 0.81, 95% CI: 0.32-2.06, p = 0.66). This difference in outcomes could not be primarily explained by frailty status (p-value for interaction = 0.19). Conclusions Patient-reported frailty was independently associated with higher risk for MACE but not for major or clinically relevant nonmajor bleeding in elderly patients presenting with NSTEMI. The results may consolidate the importance of frailty screening in risk stratification in elderly patients presenting with NSTEMI.Figure 1.KM MACE in frail vs. nonfrailFigure 2.Forest plot inv vs. consv

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty.

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty. Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management. A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n=70; 59.3%) followed by review or expert opinion articles (n=35; 29.7%). Most references were of level IV evidence (n=60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty. The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease.

The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.

Factors associated with quality of life in patients with kidney failure managed conservatively and with dialysis: a cross-sectional study

BackgroundLater stage chronic kidney disease (CKD) is associated with poorer self-perceived health-related quality of life (HRQOL), a major consideration for many patients. Psychological factors such as depression and anxiety have been linked with poorer HRQOL. We aimed to determine if anxiety or depressive symptoms are significantly associated with self-perceived health-related quality of life, in patients with CKD Stage 5. The secondary aim was to determine which patient-associated factors are associated with HRQOL in patients with CKD Stage 5.MethodsThis retrospective cross-sectional study included patients that attended the St George Hospital Kidney Supportive Care (KSC) clinic between 1 and 2015 and 30 June 2022 with CKD Stage 5 (either conservatively-managed or receiving dialysis). Patients completed surveys of their functional ‘domains’ and quality of life (EQ-5D-5L) and symptom surveys (IPOS-Renal) at their first visit. We performed multivariable linear regression analysis with the outcome of interest being HRQOL, measured using the EQ-VAS, a continuous 100-point scale, for patients undergoing conservative management or dialysis. Pre-specified variables included age, sex, eGFR (for those conservatively-managed), “feeling depressed” (IPOS-Renal), “feeling anxious” (IPOS-Renal) and “anxiety/depression” (EQ-5D-5L).ResultsWe included 339 patients. 216 patients received conservative kidney management (CKM) and 123 patients received dialysis. Patients receiving CKM were significantly older than those on dialysis, (median age 83 years vs. 73 years, p < 0.001). For conservatively-managed patients, variables independently associated with poorer EQ-VAS were difficulty performing usual activities (EQ-5D-5L), drowsiness (IPOS-Renal) and shortness of breath (IPOS-Renal). For patients receiving dialysis, variables that were independently associated with poorer EQ-VAS were reduced ability to perform self-care (EQ-5D-5L) and lack of energy (IPOS-Renal). Anxiety and depressive symptoms were not significantly associated with poorer EQ-VAS for either group of patients.ConclusionsSymptoms associated with reduced HRQOL include shortness of breath, drowsiness and impaired functional ability. Optimization of multidisciplinary teams focusing on these issues are likely to be of benefit.

Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review

BackgroundSeveral studies reported the efficacy of exercise therapy in hand and wrist tendinopathy. However, no systematic review synthesized the effect of exercise therapy on these patients. PurposeThis study aimed to perform a systematic review to summarize evidence if exercise therapy may be considered an effective treatment in conservative management for patients with hand and wrist tendinopathy. Study DesignThis was a systematic review. MethodsA literature search in MEDLINE, Cochrane Library, PEDro, and Embase was conducted from their inception until April 10, 2022. Two independent reviewers included the studies administering exercise therapy in patients with hand and/or wrist tendinopathy in the review and extrapolated the data. Methodological quality was assessed using the framework developed by Murad et al for case reports and case series and the PEDro score for clinical trials. ResultsSeven case reports, 3 case series, and 2 randomized controlled studies were included and methodologically evaluated, obtaining a low score for all the analyzed studies. The total number of included patients in the analyzed studies was 106, of which 54 were female, 13 were male, and 39 were not specified. The type of exercise was widespread and often not really well described: it varies from eccentric forearm training to mobilization with movement, passing through strengthening exercises, grip proprioception training, and self-management exercises according to the McKenzie method. The dosage was often not precise, making it difficult to reproduce the therapeutic proposals. Exercise therapy was always administered together with different treatments; therefore, its efficacy alone is difficult to distinguish, although in some cases, the patients improved pain and functionality. ConclusionsEvidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. Future research is strongly recommended to determine the appropriate dosage of the exercise therapy to determine clinical changes in these patients.

Outcome of surgical versus conservative management in patients with mild autonomous cortisol secretion

Outcome of surgical versus conservative management in patients with mild autonomous cortisol secretion