Conservative Medical Management Research Articles

Intradural Small Bowel Herniation.

Online supplemental material is available for this article.

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms.

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.

A case of post-splenectomy posterior reversible encephalopathy syndrome: a reversible event

Posterior reversible encephalopathy syndrome (PRES) is a disease characterized by features of clinical and neuroimaging findings. The basics of recognizing the entity include a combination of clinical features and radiological findings in the presence of triggering factors. Clinically the patient can have various presentations like nausea, vomiting, blurring of vision, seizures, altered consciousness, transient motor deficits, or cortical blindness. Radiologically the findings can be picked up by computed tomography (CT), magnetic resonance imaging (MRI), or diffusion-weighted imaging. The usual factors that can trigger the PRES include blood pressure fluctuations, eclampsia/preeclampsia, renal failure, cytotoxic agents, and autoimmune conditions. With vigilant suspicion and prompt treatment, patients can be saved from serious complications. Here we wish to report a case of a 22-year male patient who developed PRES syndrome after undergoing an emergency splenectomy and recovered with conservative medical management for the condition. This syndrome can be managed well with an early diagnosis which needs keen suspicion and prompt treatment.

Carotid artery dissection in Hutchinson-Gilford Progeria: a case report

BackgroundStrokes in the paediatric age group have their own epidemiology and aetiology and are frequently misdiagnosed. As in the adult population, they present some risk factors that must be identified. Cerebral arteriopathies as a cause of paediatric ischaemic stroke present a very diverse aetiology and morphology.In this article we report a paediatric stroke in a patient who was diagnosed during his first months of life of Hutchinson-Gilford´s Progeria (HGP). This is a rare genetic condition caused by mutations in the LMNA gene, producing an aberrant lamin A protein. The disease leads to premature aging, and cardiovascular complications are the first cause of morbidity and mortality in these patients.Case presentationWe report the case of a 5-year-old patient with HGP (missense mutation—de novo—c.1822G > A in heterozygosis, LMNA gene). The patient was diagnosed during his first year of life and presented distinct phenotypical features. No other relevant comorbidities were present.He was admitted to the emergency department for right hemiparesis with at least 4 h of evolution, with inability to open the hand and slight decrease in the level of consciousness (pedNIHSS 5–6). Cranial-CT and angio-CT showed findings indicative of left carotid dissection. Consensus was reached on conservative medical management with anticoagulation and antiplatelet therapy. In the first few days, the patient had a favourable evolution with resolution of the right lower limb hemiparesis and, one month after discharge, of the hand paresis.ConclusionsThe clinical manifestations, the vascular phenotype of the genetic mutation and the location of the radiological signs on a specific vascular morphology are indicative of carotid dissection. Spontaneous dissections occur under a predisposing risk factor or disease and are an exceptional finding in patients with HGP.

Persistent aneurysmal vitelline vein with thrombus successfully managed with anticoagulation

Failure of the vitelline veins to regress as expected during embryonic development may lead to long-term consequences for neonatal patients. This case report describes a full-term infant born with a persistent vitelline vein, after prenatal ultrasound at 32 weeks suggested the presence of multiple venous system malformations. Postnatal imaging, including ultrasound and contrast computerized tomography (CT), confirmed a thrombus within the persistent vitelline vein, in addition to several hepatic embolic infarcts. Persistent aneurysmal vitelline vein with a thrombus is a rare diagnosis that has been previously managed with surgical interventions. This case demonstrates the multi-disciplinary decision to proceed with conservative medical management, and the subsequent resolution of both the thrombus and persistent vitelline vein with anticoagulation alone. • Previous case reports of persistent vitelline vein with thrombus suggest prompt surgical management • Our case showed resolution of vitelline vein thrombus and hepatic infarcts with anticoagulation alone. • Our case suggests the possiblity of conservative medical management in place of surgical management.

Prevalence and Co-Morbidities of Adult-Onset Otitis Media With Effusion.

Background:Adult-onset otitis media with effusion (AO-OME) is relatively difficult to characterize, because of its associated co-morbidities.Objectives:To quantify the burden, assess co-existing diseases, and management of patients with AO-OME.Design of the Study:A descriptive observational prospective study.Setting:Clinical department in a tertiary hospital.Materials and Methods:Adult patients with conductive hearing impairment without ear discharge (excluding other pathologies) nor external ear pathology were eligible. The patients also had tympanometry with type B tracings (tympanograms).Interventions:Clinico-demographic characteristics, history of otologic symptoms, affected ear, and hearing impairment were obtained. Pure-tone audiometry (PTA), tympanometry, and radiological investigations were performed. Other existing diseases (co-morbidities) were noted. The main outcome measure was audiologically confirmed AO-OME.Results:Prevalence of AO-OME was (110/3452) 3.2%. Young adults (age group 18–30 years) constituted 33.7% (28/83), mean age was 37.3 ± 11.5 years, and 46/83 (55.4%) were males and 37/83 (44.6%) were females. The common otologic symptoms were feeling of fullness in the ear in 27.7% (23/83), hearing loss in 24.1% (20/83), and bilateral ear involvement in 32.5% (27/83). PTA revealed 8.2% (9/110) had normal hearing, whereas 62.7% (69/110) ears had conductive hearing loss. Patients had radiological investigations, namely plain X rays in 67.5% (56/83) and computerized tomography scan of sinuses in 10.8% (9/83). Three (3/83) patients (3.6%) each had nasoendoscopy, and nasal and nasopharyngeal examination under anaesthesia and biopsy. The major associated diseases (co-morbidities) were allergy in 38.6% (32/83), infective rhinosinusitis in 24.1% (20/83), and upper respiratory tract infection in 14.5% (12/83).Conclusion:Prevalence of AO-OME was 3.2%. AO-OME co-existed commonly with allergy and other inflammatory diseases of the upper respiratory tract. The management was conservative medical management.

Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center.

Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI. Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery. Forty-two patients were identified. Within 30days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5days (95% CI: 3-7days). In univariable and multivariable analyses, only steroid use in the prior 30days was significantly associated with a faster TTR of PI (HR=2.27 [95% CI: 1.17-4.41], p=.02). This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

Office-Based Procedures for BPH.

Benign prostatic hyperplasia (BPH) is a common disease in men. A rapidly rising demand for safe and effective therapy for BPH has generated novel minimally invasive surgical treatments (MISTs). With multiple procedural options in the urology armamentarium for BPH therapy, we describe the current therapies and outcomes for office-based procedures for BPH including quality of life, voiding symptoms, and sexual function. There are three FDA-approved MISTs (Rezūm, Urolift, and iTind) and three emerging MISTs for BPH. Preliminary data suggest improvement in voiding symptoms and quality of life while minimizing unwanted sexual side effects. Long term data is required on the durability and safety of MISTs for BPH. MISTs mark a paradigm shift in BPH management. Sandwiched between conservative medical management and conventional transurethral surgery, these novel technologies promise to combine efficacy approaching that of TURP while sparing the negative side effects. We envision a future where BPH can be diagnosed and treated in an office-based setting with a standard cystoscope in one procedure.

Cornual Pregnancy

A true cornual pregnancy is one in the rudimentary horn of a unicornuate uterus. The term is often used interchangeably in the medical literature with interstitial pregnancy but the 2 are distinct entities [ 1 Chetty M Elson J. Treating non-tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol. 2009; 23: 529-538 Google Scholar ]. With recent diagnostic advances, early detection is possible [ 2 Afifi Y Mahmud A Fatma A. Hemostatic techniques for laparoscopic management of cornual pregnancy: double-impact devascularization technique. J Minim Invasive Gynecol. 2016; 23: 274-280 Google Scholar ] The ultrasonographic criteria are an empty uterine cavity, a gestational sac located eccentrically and 1 cm from the most lateral wall of the uterine cavity, and a thin (less than 5 mm) myometrial layer surrounding the gestational sac. Treatment of cornual pregnancy has been surgical and may include hysterectomy or cornual resection by laparotomy or laparoscopy. However, increasingly, more conservative approaches are being used such as cornuostomy instead of cornual resection, as well as laparoscopy instead of laparotomy. Although patients with milder symptoms may be considered for medical therapy (methotrexate), those with serious signs and symptoms of ruptured ectopic pregnancy are likely to receive immediate surgical intervention [ 3 Dagar M Srivastava M Ganguli I Bhardwaj P Sharma N Chawla D. Interstitial and cornual ectopic pregnancy: conservative surgical and medical management. J Obstet Gynaecol India. 2018; 68: 471-476 Google Scholar ]. The treatment goal of cornual pregnancy conservative management is to remove the gestational sac without damaging the myometrium, an accident that causes massive bleeding and requires immediate, urgent, laparotomy [ 4 Tinelli R Stomati M Surico D Cicinelli E Trojano G Angioni S. Laparoscopic management of a cornual pregnancy following failed methotrexate treatment: case report and review of literature. Gynecol Endocrinol. 2020; 36: 743-745 Google Scholar , 5 Damiani GR Landi S Tartagni M Bettocchi S Loverro G Pellegrino A. Cornual pregnancy after surgical treatment of an incarcerated fallopian tube: a case report. J Reprod Med. 2013; 58: 550-552 Google Scholar ]. Different authors have reported many types of suture to reduce intraoperative blood loss and gain optimal myometrial reconstruction: •Square suture: carried through the posterior and anterior cornual walls and then carried back through the anterior and posterior wall at a point 2 cm lateral to the initial knot. The knot is tied intracorporeally, achieving hemostasis by compression. •Encircling suture: around the base of the cornual ectopic, acts like a tourniquet •Endoloop device •Electrocoagulation (high risk of damaging myometrium) •Automatic staplers •Endo GIA (Covidien) stapler simultaneously excises and stitches the uterine cornua.

Abstract 8918: Nstemi in a Patient With Anomalous Coronary Artery Origin

Introduction: Anomalous origin of the coronary arteries is a rare condition that can be life threatening. We present the case of a patient with anomalous right coronary artery (RCA) origin who presented with atypical chest pain. Case Presentation: A 34-year old man with no medical history presented with atypical chest pain. Initial vital signs were within normal limits and physical examination was unremarkable. Laboratory results revealed a peak troponin of 16.56 Ng/ml and EKG did not show ischemic changes. Echocardiogram demonstrated mildly impaired right ventricular systolic function. Cardiac catheterization showed patent coronaries and anomalous RCA arising from the left coronary cusp (LCC). Cardiac CT showed anomalous origin of the RCA extending from the LCC and coursing between the aorta and the pulmonary artery. Patient remained asymptomatic and was referred for surgical evaluation Discussion: Anomalous RCA originating from the LCC occurs in 0.05%-0.1% of the general population. It may run posterior to the aorta, anterior to the pulmonary trunk, septal or between the pulmonary artery and the aorta itself, like in the case of our patient. Diagnosis of these anomalies can be done by cardiac MRI, cardiac coronary CT, or coronary angiography. Management depends on the nature of the anomalies and remains controversial. Options include coronary angioplasty, conservative medical management, or surgical correction. In patients with intramural course and symptoms of myocardial ischemia, most literature recommends surgical intervention. Conclusions: This case illustrates a unique case of a patient with an anomalous coronary artery origin presenting with NSTEMI. Management can be challenging, and it must be individualized.

S1549 An Ominous Connection Causing Recurrent Pleural Effusions

Introduction: Fistulation is a rare complication of chronic pancreatitis. Pancreaticopleural fistula (PPF) typically presents with thoracic symptoms. Pathogenesis is related to pancreatic duct obstruction causing leakage of pancreatic fluid, and if persistent can lead to fistula formation. Due to its predominant thoracic over abdominal symptoms, the diagnosis and treatment of PPF are usually delayed. The following case is an example of the potential need for repeat testing to confirm the diagnosis of PPF as well as a multidisciplinary approach to treatment. Case Description/Methods: A 66-year-old white woman presented to the emergency department with 10 days history of worsening dyspnea, orthopnea, and chest tightness. Her medical history was notable for alcohol-induced chronic pancreatitis. On physical examination, she was tachycardic with diminished breath sounds bilaterally. Chest CT angiogram revealed bilateral pleural effusions. Diagnostic right sided thoracentesis revealed exudative fluid pattern, but negative for infection and malignancy. Symptoms initially improved after therapeutic thoracentesis, but pleural effusions shortly recurred requiring repeat thoracenteses. Pleural effusions laboratory findings on thoracenteses are listed in Tables 1 and 2. MRCP showed an irregular tubular tract extending cephalad from the pancreas toward the right diaphragmatic crus and appeared to communicate with the right hydropneumothorax (Figure 1). ERCP was performed which showed diffuse dilatation of the pancreatic duct (Figure 2). Patient underwent therapeutic stenting to the ventral pancreatic duct (Figure 3). She had complete resolution of symptoms and pleural effusions on 2 months follow-up chest CT. Discussion: Pancreatic pleural fistula is a rare complication of chronic pancreatitis and can be a challenging diagnosis as symptoms tend to overlap with other causes of dyspnea, hypoxia and pleural effusions. MRCP is the most sensitive imaging modality, followed by ERCP and CT to visualize pancreatic duct anatomy and guide further therapeutic management. Conservative medical management with bowel rest and somatostatin analog are shown to be effective in patients without pancreatic ductal obstructions. In cases with recurrent pleural effusions despite conservative management, ERCP with therapeutic stenting to alleviate pancreatic ductal obstructions is strongly indicated with high success rate. Owing to its rarity and complexity, a multidisciplinary approach to PPF is warranted to provide the best care possible.Figure 1.: Tables and Figures.

Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial.

IntroductionAn anal fissure is defined as a longitudinal split in the distal anoderm which extends from the anal verge to the dentate line. Fissures can be of primary or secondary type. The posterior midline is the most common location for primary fissures, while, anterior primary fissures, though rare, are more common in females. The cause of primary fissure is idiopathic. But secondary fissures are associated with other systemic diseases and can occur at an abnormal position anywhere in the anoderm. A high percentage of acute fissures heal spontaneously within three weeks with conservative medical management comprising of a high fiber diet, warm sitz bath, and topical analgesic with steroids. Secondary anal fissures will not heal in any form of treatment until the primary cause is addressed. These fissures often need surgical treatment. The lateral internal sphincterotomy (LIS) is one of the most practiced treatments for chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is one of the options among those techniques which address the issues with LIS. Some studies showed that patients with chronic fissures who are refractory to medical treatment responded well to fissurectomy. Hence, this study was conducted to compare the outcomes of fissurectomy and lateral internal sphincterotomy in the treatment of chronic anal fissure and compare recurrence and postoperative complications among both the procedures.MethodsAll consecutive patients attending the department of surgery with chronic fissure and age above 18 years were included in the study. All the included patients were randomized into two groups (fissurectomy and LIS) using the serially numbered opaque-sealed envelope (SNOSE) technique. The patients were discharged on the third day. The first visit was scheduled after two weeks and subsequent visits on the first and second months. Then the patients were followed up by telephonic conversation for the next six months. At the end of the follow-up, post-surgical complications were enquired, recorded, and interpreted.ResultsIn the present study, out of a total of 87 patients, 80 patients were included in the study. Among all the patients, 16 patients (20%) developed retention of urine. Four patients in the LIS group showed retention of urine whereas in the fissurectomy group it was twelve. The difference was not statistically significant (p-value: 0.025). A total of 10 patients required catheterization postoperatively. More patients in the fissurectomy group developed incontinence to flatus (p-value: 0.02). Incontinence to liquid and solid was significantly higher in the fissurectomy group (p-value: 0.03 and 0.002, respectively).ConclusionIn the present study, it was found that LIS was a better treatment option for chronic anal fissure than Fissurectomy. The postoperative complications were less in LIS than in fissurectomy. But the recurrence was higher in the LIS group while there was no recurrence in the fissurectomy group.

Spontaneous Coronary Artery Dissection in Multiple Gestation Peripartum Period

Background: Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic and non-iatrogenic separation of the coronary arterial wall. SCAD is a highly uncommon cause of myocardial infarction (0.1 to 0.4 %).
 Case presentation: 40-year-old African American woman, G1T1P0A0L2, with a past medical history of tobacco abuse and obesity who had uncomplicated cesarean section delivery for healthy twins two weeks prior presented with substernal, sudden onset chest pain. The pain radiated to left arm and back, pressure-like, and is associated with nausea, vomiting, and dyspnea.
 On examination she was within normal limits except for a well-healed C-section wound. An electrocardiogram showed normal sinus rhythm with Nonspecific ST Abnormality. The first set of troponins less than 0.03, the second set shows troponins 0.18 and D-dimer 2340. The chest x-ray was unremarkable. An echocardiogram showed only mild to moderate mitral valve regurgitation. CT angiography of the chest showed no evidence of pulmonary embolism. She was started on a heparin drip and catheterization the next day showed no atherosclerotic coronary artery disease, but SCAD of inferior diagonal first branch noted. No intervention was done, heparin was stopped. The patient was started on aspirin, statin, Clopidogrel, Metoprolol, and Lisinopril per cardiology recommendation.
 Conclusions: As an internist and primary care provider, we should keep Non-atherosclerotic SCAD in mind when a young female patient presents with acute chest pain. More studies are needed to find out the optimal management.
 Current recommended conservative medical management includes long-term aspirin, beta blocker, and one year of clopidogrel, with the addition of a statin in patients with dyslipidemia.

The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain.

Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.

Clinical Presentation and Operative Findings of Ectopic Pregnancy

Objective: In this study our main goal is to evaluate the clinical and operative findings of ectopic pregnancy. Method: This descriptive study was carried out at tertiary medical college and hospital from January to December 2018-2019. Where 80 Patients who were clinically suspected but laparotomy findings ruled out ectopic pregnancy. Results: During the study, history of pelvic infection (26.25%), induced abortion (17.5%), previous MR (16.25%) and sub fertility (11.25%) constitute the main bulk of risk factors. Most of the patients (61.25%) presented with amenorrhoea (6-8 weeks) and 21.25%. cases had no history of amenorrhoea. Fallopian tube was affected 92.5% of cases & ampullary ectopic was most common (53.75%). Also, all cases were managed surgically. Salpingectomy with or without contralateral tubal ligation (85%) was the most common operation. Conclusion: Although ectopic can never be eliminated completely but some risk factors, responsible for ectopic pregnancy can be prevented by educational efforts. And early diagnosis and prompt conservative surgical or medical management will help in reducing maternal mortality and morbidity.

Subacute vision loss after microvascular decompression for trigeminal neuralgia

Microvascular decompression is the surgery of choice for typical trigeminal neuralgia (TN) that fails conservative medical management. Visual loss after MVD is a rare complication that has not been reported. In this article, we present a patient who developed delayed visual loss and papilledema from transverse sinus stenosis resulting from bone wax compression after MVD for TN. While waxing the edges of a retrosigmoid craniotomy may seem mundane, meticulous care should be taken to ensure that there is no compression of the venous sinuses, as this could lead to intracranial hypertension.

Diagnosis and Management of Patent Ductus Arteriosus in Newborn: An Update

Patent ductus arteriosus is one of the common congenital acyanotic heart disease in neonates, especially in preterm. Patent ductus arteriosus (PDA) is a congenital condition, characterized by a persistent connection between the aorta and the pulmonary artery. Patency of Ductus Arteriosus is essential for fetal survival. Patent ductus arteriosus is one of the most common clinical findings and most frequent source of complications in premature infant. After birth, in term infants, the ductus usually closes within the first day of life, starting with functional closure followed by anatomical closure with vascular remodeling. The persistence of the PDA in preterm infant is inversely related to gestational age and birth weight. The incidence of Patent Ductus Arteriosus is 31% in preterm infant weighing 501 to 1500 gm and gestational age 29 weeks. The treatment options available are conservative medical management, pharmacological therapy or surgical ligation. Conservative medical management involves fluid restriction; watchful waiting and ventilator support.
 DS (Child) H J 2020; 36(1) : 61-66

Partial Thickness Sclerectomy for Uveal Effusion Syndrome in nanophthalmic eyes

Introduction: Nanophthalmos characterized by short axial length, high lens-to-eye ratio and thick sclera, is more prone to develop uveal effusion syndrome (UES). This rare entity can result in idiopathic exudative detachment of the choroid, ciliary body and retina. Abnormality in the scleral thickness with resultant obstruction of the vortex veins and reduced trans-scleral drainage of fluid is responsible for exudative retinal detachment (ERD).
 Methods: A retrospective study of UES in nanophthalmic patients treated with partial thickness sclerectomy in tertiary eye care centre from January 2015 to June 2019. Five eyes of five patients (four males and one female) with a diagnosis of nanophthalmos suffered from angle closure glaucoma associated with ERD. Raised intra-ocular pressure (IOP) not amenable to conservative medical management were subjected to surgery. Lamellar sclerectomy was performed in two or more quadrants without drainage which was judged on the basis of maximum amount of exudative fluid present in the subsequent quadrants.
 Results: The average age at surgery was 39.2 years and the mean follow-up duration was 9.2 months (6 to 18 months). Revision sclerectomy was required in 2/5 (60%) eyes. The serous fluid gradually resolved and retina remained reattached at the end of final follow up. The useful vision was preserved and IOP was normalized.
 Conclusion: Nanophthalmic UES remains a challenging clinical entity. Partial thickness sclerectomy may be an effective option in the treatment of nanophthalmic UES, not amenable to the conventional medical management in a low resource setup.

Evaluation of Clinical Outcome in Traumatic Facial Nerve Paralysis.

Introduction The facial nerve is the most commonly paralyzed nerve in the human body, resulting in far-reaching functional, aesthetic and emotional concerns to the patient. Objective Evaluation of the clinical outcome of 47 patients with traumatic facial nerve paralyses, with respect to clinical recovery and audiological sequelae. Methods A descriptive longitudinal study was conducted over 24 months between January 2017 and December 2018 at a tertiary center with detailed clinical, topodiagnostic, audiometric and radiological evaluation and regular follow-up after discharge. Results Road traffic accidents constituted 82.98% of the trauma cases, out of which 76.60% were found to be under the influence of alcohol. Delayed facial paralysis was observed in 76.60% cases. Temporal bone fracture was reported in 89.36%, with otic capsule (OC) sparing fractures forming 91.49% of the cases. Topologically, the injury was mostly at the suprachordal region around the second genu. The majority of the patients (65%) attained full recovery of facial nerve function with conservative medical management. Audiometrically, 77.27% of the patients had hearing loss at the time of presentation, of which 64.71% were conductive in nature; 51.22% attained normal hearing at follow-up visits.Conclusion Early initiation of steroid therapy, concurrent eye care and physiotherapy are the cornerstones in the management of traumatic facial nerve paralysis.

A systematic review and meta-analysis of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain.

Studies have reported relief of chronic shoulder pain with non-ablative pulsed neuromodulatory (pRF) or ablative radiofrequency (aRF) procedures on innervation of the shoulder joint but interpretation of these reports is hampered by inconsistent indications, anatomic targets and follow-up. This systematic review was conducted to synthesize the existing literature on procedures employing pRF or aRF for treating chronic shoulder pain. MEDLINE and other medical literature databases were reviewed up to 31 December 2019 for publications on pRF or aRF procedures on shoulder joint innervation to relieve chronic pain. Data on analgesic and functional outcomes measured at any time point following the interventions were extracted. Existing knowledge on innervation of the shoulder joint with relevance to RF procedures was also synthesized. In all, 42 publications, 7 randomized controlled trials (RCTs) and 35 observational studies, case series or reports were identified. Thirty-six of these publications were on pRF procedure and 29 of these reported procedures exclusively targeting the suprascapular nerve. A meta-analysis of the seven RCTs evaluating pRF indicated no analgesic benefit or functional improvement with this treatment over conventional medical management. Case series and reports on aRF indicate a potential for analgesic benefit but the quality of this evidence was low. RF treatments targeting the sensory innervation of the shoulder joint affected by degenerative conditions have the potential to reduce pain but the current evidence does not suggest analgesic or functional benefit (GRADE certainty of evidence-low). Studies of high methodological quality are required to further investigate the role of these interventions. This is a comprehensive review of literature on pulsed (non-ablative) and ablative radiofrequency (RF) procedures for chronic shoulder pain. The systematic review and meta-analysis of 7 trials found that pulsed RF for chronic shoulder pain provided similar analgesia and functional improvement as conservative medical management at three months after the procedures. The case series and reports on ablative RF for shoulder pain indicate possible analgesic benefit but their quality was low. This review highlights the need for studies of a high quality on ablative RF treatments for chronic shoulder pain.