Conservative Therapy Research Articles

Growth Factor Concentrate (GFC) for the Management of Osteoarthritis of the Knee: A Systematic Review.

The knee is the most commonly affected joint in osteoarthritis (OA), affecting millions of people worldwide. Knee OA significantly impacts the activities of daily living (ADL) along with affecting overall quality of life of patients (QoL), thereby leading to substantial socio-economic burden. Conservative therapies are prioritized, resorting to surgery only when needed. However, these traditional approaches have limitations. Regenerative medicine, involving the use of orthobiologics, including autologous peripheral blood-derived orthobiologics such as growth factor concentrate (GFC), has evolved and shown potential for managing knee OA. The primary goal of this review is to summarize the results of in vitro, preclinical and clinical studies involving GFC for the management of knee OA. Multiple databases (PubMed, Scopus, Google Scholar, Web of Science and Embase) were searched applying terms for the intervention 'GFC' and treatment 'knee OA' for the studies published in the English language to March 10, 2024. Only three clinical studies met our pre-defined criteria and were included in this review. Intra-articular administration of GFC is safe and potentially efficacious to manage OA of the knee. More, adequately powered, multi-center, prospective, RCTs are warranted to demonstrate the long-term effectiveness of GFC in patients suffering from mild-to-moderate knee OA and to justify its routine clinical use. Further studies evaluating the efficacy of GFC compared to other orthobiologics are also required to allow physicians/surgeons to choose the optimal orthobiologic for the treatment of OA of the knee.

Chinese guidelines on the management of endometrial hyperplasia

• Endometrial hyperplasia can be classified as either hyperplasia without atypia or atypical hyperplasia.• Abnormal uterine bleeding is the most common symptom of endometrial hyperplasia. Transvaginal ultrasound is recommended for initial imaging to evaluate endometrial hyperplasia (evidence level 2+), while transrectal ultrasound is recommended for virgo patients (evidence level 3).• Endometrial biopsy should be used to confirm diagnosis in patients where endometrial lesions are suspected. Effective histological approaches to make definite diagnoses include diagnostic curettage (evidence level 2++), hysteroscopic-guided biopsy (evidence level 2+) and endometrial aspiration biopsy (evidence level 2-).• Progesterone is the preferred medication for the treatment of endometrial hyperplasia without atypia. Compared to oral progestins, placement of a levonorgestrel-releasing intrauterine system (LNG-IUS) has been associated with higher regression rates, lower recurrence rates and fewer adverse events which can be the initial treatment method. (Meta evidence level 1-, RCT evidence level 2+). Ultrasound and endometrial biopsies should be performed every 6 months during treatment to evaluate its effect and treatment should continue until no pathological changes are observed in two consecutive endometrial biopsies. Hysterectomy is not the preferred choice of treatment for patients with endometrial hyperplasia without atypia.• Minimally invasive hysterectomy is indicated for patients with endometrial atypical hyperplasia (evidence level 1+), bilateral fallopian tubes should also be removed (evidence level 2+). In cases where surgery cannot be tolerated, fertility is desired or the patient is younger than 45 years old, medical therapy is recommended (evidence level 3). LNG-IUS is the preferred medical therapy method (evidence level 2+). Endometrial pathologic evaluation should be performed every 3 months during conservative treatments, with adjustments made to dosages or approaches based on observed response to medication. Treatment should continue until no pathological changes are detected in two consecutive endometrial biopsies (evidence level 2++). There is no indication of sentinel lymph nodes biopsy and/or lymphadenectomy for hyperplasia with or without atypia.• Total hysterectomy is recommended to treat patients with recurrent endometrial atypical hyperplasia (evidence level 3); however, medical conservative therapy may be considered for patients hoping to become pregnant in the future.• Patients with fully regressed disease who would like to become pregnant should be advised to seek assistance through assisted reproductive technologies (evidence level 3).• Long-term follow-up is suggested for patients after endometrial hyperplasia treatment (evidence level 2+). Patient education is imperative for improving medication adherence, increasing regression rates and lowering recurrence rates (evidence level 3).

Rare recurrence pattern after complete response to chemotherapy in a patient with rectal cancer: a case report

BackgroundColorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease.Case presentationA 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis.ConclusionsThis case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.

"Peace of Mind" After Mastectomy: A Scoping Review.

Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire for "peace of mind." This study aimed to characterize how peace of mind is defined and measured and how it relates to surgical choice. Nine databases were searched for relevant articles through 8 October 2023, and data were extracted from articles meeting the inclusion criteria. The inclusion criteria were met by 20 studies.Most were prospective cohort studies (65%, 13/20). In the majority of the studies (72%, 13/18), Non-Hispanic white/Caucasian women comprised 80 % or more of the study's sample. Almost half of the studies used the phrase "peace of mind" in their publication (45%, 9/20), and few directly defined the construct (15%, 3/20). Instead, words representing an absence of peace of mind were common, specifically, "anxiety" (85%, 17/20), "fear" (75%, 15/20), and "concern" (75%, 15/20). Most of the studies (90%, 18/20) measured peace of mind indirectly using questionnaires validated for anxiety, fear, worry, distress, or concern, which were administered at multiple postoperative time points (55%, 11/20). Most of the studies (95%, 18/19) reported at least one statistically significant result showing no difference in peace of mind between BCT, UM, and/or CPM at their latest time of assessment. Peace of mind is largely framed around concepts that suggest its absence, namely, anxiety, fear, and concern. Existing literature suggests that peace of mind does not differ among average-risk women undergoing BCT, UM, or CPM. Shared surgical decisions should emphasize at least comparable emotional and/or psychosocial well-being between CPM and breast conservation.

Comprehensive comparison between conservative therapy and surgical management for completely displaced and comminuted mid-shaft clavicle fractures

PurposeIt is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective study aims to compare clinical outcomes of two treatment protocols.Materials and methods105 patients with displaced and comminuted mid-shaft clavicle fractures were included in this study, among which 55 patients were treated conservatively and 50 patients accepted surgical fixation and were followed up for over 20 months on average. Rate of union, malunion, time taken for union, functional outcome, self-reported satisfaction and complications were compared.ResultsUnion rate of operative group (n=49, 98.0%) was higher than the non-operative group (n=48, 87.3%). Time taken for union in operative group (2.37±1.06 months) was shorter than the non-operative group (3.69±1.01 months). Malunion and asymmetric were only seen in the conservative group. Numbness of the shoulder was only reported in the operative group (n=23, 46.0%). Most of patients in the operative group (n=45, 90%) accepted a second operation to remove the implant. No statistically difference was found in self-reported satisfaction, Quick-DASH and Constant-Murley score. The operative group returned to work faster (1.47±0.89 to 3.34±1.37 months), regained full range of motion earlier (1.66±0.78 to 3.83±1.24 months) and regained strength faster (3.86±2.45 to 8.03±2.78 months) than the non-operative group.ConclusionComplete displaced and comminuted mid-shaft clavicle fractures treated surgically have more reliable union and faster recovery when compared to conservatively treated fractures.

Prımary External Audıtory Canal Cholesteatoma

Abstract External auditory canal (EAC) cholesteatoma is characterized by a bony defect in the auditory canal with a cystic structure lined by keratinizing stratified squamous epithelium and retention of keratin debris. Clinically, patients present with chronic dull pain, otorrhea, or conductive hearing loss. Lamellar keratin debris in a bony defect in the case of an intact tympanic membrane is highly suggestive of external ear canal cholesteatoma. It must be differentiated from keratosis obturans. The locally erosive and indolent nature of cholesteatoma in the bony external ear canal may result in complications due to erosion into adjacent structures such as mastoid cells, semicircular canals, fallopian canal, and temporomandibular joint. The treatment options include conservative therapy and surgery. In this case report, we presented a 75-year-old male with a primary left EAC cholesteatoma underlining the diagnostic and therapeutic features of this rare disease.

Sacral neuromodulation in children and adolescents with defecation disorders.

Even if understanding of neuronal enteropathies, such as Hirschsprung's disease and functional constipation, has been improved, specialized therapies are still missing. Sacral neuromodulation (SNM) has been established in the treatment of defecation disorders in adults. The aim of the study was to investigate effects of SNM in children and adolescents with refractory symptoms of chronic constipation. A two-centered, prospective trial has been conducted between 2019 and 2022. SNM was applied continuously at individually set stimulation intensity. Evaluation of clinical outcomes was conducted at 3, 6, and 12 months after surgery based on the developed questionnaires and quality of life analysis (KINDLR). Primary outcome was assessed based on predefined variables of fecal incontinence and defecation frequency. Fifteen patients enrolled in the study and underwent SNM (median age 8.0 years (range 4-17 years)): eight patients were diagnosed with Hirschsprung's disease (53%). Improvement of defecation frequency was seen in 8/15 participants (53%) and an improvement of fecal incontinence in 9/12 patients (75%). We observed stable outcome after 1 year of treatment. Surgical revision was necessary in one patient after electrode breakage. Urinary incontinence was observed as singular side effect of treatment in two patients (13%), which was manageable with the reduction of stimulation intensity. SNM shows promising clinical results in children and adolescents presenting with chronic constipation refractory to conservative therapy. Indications for patients with enteral neuropathies deserve further confirmation.

Decellularized Descemet Membrane Anterior Keratoplasty With Allogeneic Simple Limbal Epithelial Transplantation for Partial Limbal Stem Cell Deficiency Following Partial Keratolimbal Allograft Failure.

The purpose of this study was to describe the use of Descemet membrane anterior keratoplasty (DMAK) with modified allogeneic simple limbal epithelial transplantation to treat a case of partial limbal stem cell deficiency (LSCD) following keratolimbal allograft failure. Case report. A 21-year-old woman with autoimmune polyglandular syndrome-related LSCD presented with pain and decreased vision. There was partial failure and recurrence of LSCD after a severe/acute keratolimbal allograft rejection that led to persistent epithelial defects refractory to conservative therapy. This was treated with a superficial keratectomy and placement of a DMAK. A modified allogeneic simple limbal epithelial transplantation was performed with an overlying amniotic membrane and temporary tarsorrhaphy. There was epithelialization of the corneal surface by 3 to 4 weeks with an improved ocular surface. Despite partial recurrence of late staining, the cornea has remained epithelized, vision has improved, and the patient has remained pain-free more than 1.5 years following the procedure. DMAK may be a long-term substrate to help improve and maintain epithelization of the cornea up to 1.5 years. DMAK may be a viable alternative to using amniotic membrane as a scaffold in allogeneic simple limbal epithelial transplantation for treatment of partial LSCD. While late epithelial staining recurred in our patient, DMAK appears to prevent recurrent epithelial defects and reduce ocular surface pain, conveying an improvement in quality of life in patients at high risk of rejection/failure.

Abstract PO2-18-07: Ultrasound – guided Interstitial Laser therapy for Stage I Breast Cancer: a phase 2 trial

Abstract Background: Screening programs are changing the scope of breast cancer, with a growing number of patients diagnosed at a nearly stage. The current standard treatment (breast conservation and radiation therapy) offers an excellent prognosis for these patients. Besides tumor removal, other techniques can be used to destroy a mass in place. A range of minimally invasive techniques holds promise on local breast tumor ablation (i.e. thermotherapy, cryotherapy, and irreversible electroporation). Previous studies with Interstitial laser thermotherapy (ILT) for breast cancer report mean ablation rates between 33% to 87%. Most common cited causes for failure are equivocal tumor size estimation, inadequate technique and the learning curve. Objective: Improve the ILT technique and achieve better ablation rates through the evaluated procedure. Methods: A prospective study with 15 patients with Stage I invasive breast cancer, presented as a unique lesion as inclusion criteria was conducted. MRI and US were used to estimate the primary tumor volume and rule out multicentric/multifocal disease. ILT ablation was performed using an Echolaser unit (Elesta) through percutaneous laser optical fibers with a US-guided insertion in the lesion center. All procedures were performed under local anesthesia and sedation. The post procedure image reevaluation included an immediate US after the ablation and a new MRI about 3 hours after the procedure. The definitive proposed surgical treatment was carried out 8-13 days after the ILT ablation. Results: Eighteen patients were included in the study, of whom 14 (with 15 lesions) completed the protocol. The mean tumor size measured by MRI was 13.7 (4-20) mm. The mean treatment time was 10.1 minutes and all patients went home the same day, reporting only mild (78%) or moderate (22%) pain, controlled with analgesics. The mean ablation index, evaluated by H&E and CK8/18, was 61,5% (0 -93%) and when only tumors under 15 mm were considered the mean ablation index was 75% (30%-93%). The MRI performed after ablation procedure showed a large area of edema around the clip in all cases. The sensitivity and specificity to detect residual tumors were 1.0 and 0.84, respectively, when the residual tumors were larger than 15% of the original tumor size . Conclusions: These preliminary results suggest that laser therapy can eliminate viable neoplastic tissue in vivo. To achieve better results, standardization in patient selection, power and energy applied, should be considered. There are several advantages of ILT for breast cancer treatment, including preserving the structure and function of breast, no bleeding, no scaring and no radiation. More studies refining the technique should be conducted to allow the implementation of ILT as an alternative to surgical treatment in early breast cancer. Citation Format: Danielle Matsumoto, Silvio Bromberg, Marcus Corpa, Rodrigo Garcia, Guilherme Mariotti, Monica Rudner, Angela Waitzberg, Afonso Nazário, Gil Facina. Ultrasound – guided Interstitial Laser therapy for Stage I Breast Cancer: a phase 2 trial [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-18-07.

Usefulness of the Clinical Frailty Scale in patients with end-stage kidney disease.

The frailty index (FI) is commonly used to estimate frailty in end-stage kidney disease (ESKD) patients. The Clinical Frailty Scale (CFS) is a less time-consuming alternative. We aimed to determine the test performance of the CFS for pre-dialysis and dialysis patients and patients receiving conservative therapy from the Dialysis Centre Apeldoorn. In this cross-sectional study, haemodialysis, peritoneal dialysis, pre-dialysis patients and patients receiving conservative therapy from the Dialysis Centre Apeldoorn were included and subjected to frailty assessment. Nephrologists not familiar with the CFS completed the frailty score after medical consultation. The sensitivity, specificity and area under the curve (AUC) of the CFS were determined. The FI was used as the gold standard. Included were 144 patients, of whom 60 (41.7%) were considered frail according to the FI. The mean age was 67.4±13.5years and 56 (38.9%) were female. The cut-off point of the CFS for 'vulnerable' (CFS ≥4) had a sensitivity of 63.3%, a specificity of 81.0% and an AUC of 0.72. The cut-off point of the CFS for 'frail' (CFS ≥5) had a sensitivity of 50.0%, a specificity of 91.7% and an AUC of 0.71. The CFS is a quick and easy-to-use tool for the determination of frailty in ESKD patients with a high prevalence of frailty. Nevertheless, the sensitivity of the CFS in the present study was considered too low to implement into daily clinical practice. The sensitivity might be increased by training nephrologists in the use of the CFS.

Diagnosis dan Tata Laksana Varises Tungkai

Varicose veins are characterized by the elongation, widening, and twisting of the venous system, accompanied by impaired blood circulation. It usually occurs in lower extremities, with a prevalence of 10%-30%. It affects mainly women, and the prevalence rate increases with age. The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification allows for a more precise diagnosis and provides better results. Treatment includes conservative therapy and intervention. With appropriate management, postoperative care, and rehabilitation, the prognosis of varicose veins is generally good.

Abstract PO3-20-05: Phase II Study of Genomically Guided Radiation Dose Personalization in the Management of Triple Negative Breast Cancer

Abstract Background: Our group has previously developed the radiosensitivity index (RSI) using a multigene expression model that is directly proportional to tumor radioresistance (high RSI = increased radioresistance). RSI has been previously validated in two datasets of patients with triple negative breast cancer (TNBC). In this study, we will run a selective dose personalization study in TNBC patients undergoing breast conservation therapy (BCT). Based on patients RSI scores, they will either receive a radiation therapy (RT) boost of 10 Gy to the tumor cavity or not. Given our data in two independent datasets, the current study will reveal the feasibility and benefit of selective genomic dose personalization in TNBC following BCT. Trial Design: The study is designed as a prospective, nonrandomized, phase II trial of genomically guided RT in the management of TNBC undergoing BCT. Patients will be allocated to one of two groups based on their RSI determination from fresh frozen tissue collected by biopsy or at the time of BCT. These groups will be Group A, RSI optimized whole breast radiotherapy alone or with a 10 Gy boost or Group B, RSI not optimized whole breast radiotherapy with a boost of 10 Gy to tumor cavity. Patients will receive standard of care chemotherapy, neoadjuvant or adjuvant. Eligibility: TNBC patients undergoing BCT. Specific Aims: To determine the three-year local control following genomically guided dose personalization in the management of TNBC following BCT. Secondary objectives include determination of overall survival (OS), progression free survival (PFS), and quality of life (QOL) following genomically guided dose personalization. Statistical Methods: The primary hypothesis is the three-year local control rates differ for groups A and B, against the null hypothesis that the two rates are identical. Patients will allocate approximately 78% in group A and 22% in group B and local control rates are expected to be 96% and 75%, respectively. Assuming 80% power and 10% type I error for a log-rank test, 86 patients are needed. An interim analysis will be completed when 4 disease progression events are observed. There will be approximately 43 patients at the time of interim analysis. Patient Accrual: This study is open with 1 patient enrolled at the time of submission. A total of 86 patients will be enrolled. Contact Information: Kamran A. Ahmed MD, Moffitt Cancer Center, email: kamran.ahmed@moffitt.org, Clinical trial information: NCT05115474. Funding: Moffitt and Morton Plant Mease Foundations. Citation Format: Kamran Ahmed, Iman Washington, Matthew Mills, Michelle DeJesus, Youngchul Kim, Ronica Nanda, Javier Torres-Roca, Steven Eschrich, Janis De La Iglesia, John Puskas, Marilin Rosa, Jason Wilson, Paula Lundgren, Negar Golesorkhi, Nazanin Khakpour, Susan Hoover, Marie Lee, John Kiluk, Melissa Mallory, Christine Laronga, Laura Kruper, Brian Czerniecki, Roberto Diaz. Phase II Study of Genomically Guided Radiation Dose Personalization in the Management of Triple Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-20-05.

Abstract PO5-20-08: A Case of Multifocal Ductal Breast Carcinoma with Extension into Lobules and Concurrent Primary Colon Adenocarcinoma

Abstract Background Multifocal (MF) multicentric breast cancer is a form of breast cancer that consists of disease independently developing at various locations due to a tumor clone spreading within the ductal complex. Multifocal breast cancer is associated with increased local recurrence. Our case highlights an example of multifocal breast cancer and addresses treatment challenges. Case presentation The patient is a 52-year-old African American female with a history of HCV cirrhosis, diabetes mellitus, and hypertension who presented with a palpable 4 cm right breast mass, without adenopathy, clinically Stage II, T2N0. Mammogram revealed a 2.5 cm right breast mass and three right level 1 axillary nodes with biopsy confirming invasive ductal carcinoma with extension into the lobules, ER positive (3%)/PR-/HER2-, Ki-67 95%. Neoadjuvant paclitaxel, carboplatin, and pembrolizumab was initiated but she incurred complications of decompensated liver cirrhosis after the second cycle and treatment was held. After 2 cycles her tumor was not palpable, and surgery was recommended, but due to COVID infection and concurrent decompensated liver failure surgery management was delayed. She underwent staged surgery with partial mastectomy without lymph node exploration. Histopathology showed DCIS grade 3 with extension into lobules and invasive ductal carcinoma with no lymphovascular invasion and all margins were negative, pathological stage ypT3NxM0. Immunohistochemistry demonstrated partial ER+ (50%)/PR-/HER2-, Ki-67 80%. She was given 4 cycles of adjuvant cyclophosphamide, adriamycin, pembrolizumab and continued on maintenance pembrolizumab. The patient was found with anemia out of proportion to chemotherapy and underwent colonoscopy that showed a colonic mass. Biopsy showed a primary moderately differentiated colonic adenocarcinoma. Her re-excision with new margins for partial mastectomy had negative margins, and 2 negative sentinel lymph nodes for ypN0. Genetic testing was negative. She continued on adjuvant immunotherapy with pembrolizumab for breast cancer. She is planned to start on adjuvant anastrozole. Patient has completed adjuvant radiation treatment and has no new complaints. She is pending curative intent completion colectomy for colon cancer. Discussion This case of MF breast cancer is significant, as one foci was ER negative, which responded to neoadjuvant chemoimmunotherapy and other ER positive that did not respond to treatment and was surgically excised. The pathology report from the surgical specimen revealed DCIS with extension into the lobules. Due to her tenuous clinical condition, she had staged surgeries for breast cancer, and now colon cancer. Genetic testing is negative. Currently, there is insufficient data to suggest which surgical approach is preferred in MF breast cancer. Based on the literature, breast conservation therapy (BCT) is a feasible option and is oncologically safe. Due to the patients’ medical condition and infections, it was felt a less invasive surgery could offer cure and minimize complications. Our patient underwent neoadjuvant chemoimmunotherapy, followed by partial mastectomy, adjuvant chemoimmunotherapy, second staged completion breast surgery, radiation therapy, and anti-estrogen therapy. MF breast cancer is associated with increased lymph node involvement. A 2022 meta-analysis found that multifocal and multicentric breast cancer has a slightly increased risk of death as compared to unifocal tumors. Lastly, our patient is African American, and multifocal tumors occur with a higher incidence in African Americans (43.4%) and Asian patients (37%) as compared to whites (28.9%). This case of breast cancer highlights treatment challenges in a case of multifocal multicentric breast cancer occurring concurrently with a secondary primary colonic cancer. Citation Format: Rabab Jafry, Hina Khan, Jessica Jones. A Case of Multifocal Ductal Breast Carcinoma with Extension into Lobules and Concurrent Primary Colon Adenocarcinoma [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-08.

Risk Factors Associated with Pressure Ulcers among Home Health Care Patients; Riyadh, Saudi Arabia

Background: Patients, professionals, and health care systems are faced with a serious problem of pressure ulcers. They represent a significant occurrence and prevalence throughout the world. Their character iatrogenic states that its appearance is preventable, and its incidence is an indicator of scientific and technical quality both in primary care and specialized care. Surgery may be necessary to accelerate the healing process, although most pressure ulcers are usually treated with debridement and conservative therapy. Their reported incidence and prevalence are significant worldwide. Objectives: The study's objectives are to identify the pressure ulcer risk factors in patients getting home health care, as well as to look at the quantity, type, and characteristics of pressure ulcers as well as patient comorbidities. Methods: Cross-sectional study, Home Care Nursing personnel questionnaire to determine the Risk Factors of Pressure Ulcers, patient comorbidities, and the number, and characteristics of pressure ulcers among patients receiving home care in Riyadh, Saudi Arabia. Results: PU is prevalent among the studied participants in Saudi Arabia, about 55% of these ulcers showed noticeable distraction of skin and/or deeper soft tissue against a bony prominence. We have also found a significant relationship between PU and gender, diabetes mellitus, hypertension, incontinence issues, nutritional status, and physical status, cerebrovascular accidents, trauma, and chronic kidney disease. Conclusion: Different risk factors are associated with PU such as diabetes mellitus, hypertension, and nutritional, and physical status. To monitor and promote best practices in skin care for highly dependent patients, continued measurement and evaluation of PU incidence, it is recommended more research of risk factors of PU development be assessed at home Health care Centers.

Variation of practice in the treatment of pyogenic spondylodiscitis: a European Association of Neurosurgical Societies Spine Section study.

The incidence of spondylodiscitis is rising across Europe, but the ideal treatment approach remains controversial. The choice between conservative and surgical therapies is ambiguous due to a lack of consensus. This European survey aimed to explore prevailing treatment paradigms for primary spondylodiscitis. Spine neurosurgeons were invited through the European Association of Neurosurgical Societies Spine Section's mailing list to participate in an online survey featuring 7 spondylodiscitis case vignettes. Along with general management queries, specific patient treatment questions were posed. Data analysis was performed using R software (version 4.0.4). The index of qualitative variation (IQV) was calculated to quantify the variability in responses. A total of 130 responses were collected, comprising 86.9% board-certified neurosurgeons and 13.1% neurosurgeons in training, with an average of 11 years of practice. Most respondents performed 50-100 spine surgeries annually, with 66.7% specializing in spine surgery. An epidural empyema causing pronounced neurological deficits influenced 95.4% toward a surgical intervention, and mild neurological deficits and challenges in pathogen identification prompted 72.3% and 80%, respectively, to consider a surgical approach. Vertebral body destruction and spinal deformity directed 60% and 66.2%, respectively, toward surgery, whereas advanced age and comorbidities had a much smaller impact-5.4% and 9.2%, respectively. Clinical vignettes highlighted a predominant preference for conservative treatment in specific cases, with statistical significance (p < 0.05). The IQV values evaluated for each question ranged from 0.88 to 0.99, indicating low agreement across all questions among respondents. When examining the average IQV by country, intercountry variations in IQV were substantial, as illustrated by the diverse range of overall mean IQV values (0.15-0.85). The findings reveal a significant variability in the treatment of spondylodiscitis among European neurosurgeons, with most neurosurgeons opting for conservative treatment. These diverse strategies, both between and within countries, highlight an imperative for evidence-backed guidelines and consensus statements for this grave condition.

Stimuli-Responsive Delivery Systems for Intervertebral Disc Degeneration.

As a major cause of low back pain, intervertebral disc degeneration is an increasingly prevalent chronic disease worldwide that leads to huge annual financial losses. The intervertebral disc consists of the inner nucleus pulposus, outer annulus fibrosus, and sandwiched cartilage endplates. All these factors collectively participate in maintaining the structure and physiological functions of the disc. During the unavoidable degeneration stage, the degenerated discs are surrounded by a harsh microenvironment characterized by acidic, oxidative, inflammatory, and chaotic cytokine expression. Loss of stem cell markers, imbalance of the extracellular matrix, increase in inflammation, sensory hyperinnervation, and vascularization have been considered as the reasons for the progression of intervertebral disc degeneration. The current treatment approaches include conservative therapy and surgery, both of which have drawbacks. Novel stimuli-responsive delivery systems are more promising future therapeutic options than traditional treatments. By combining bioactive agents with specially designed hydrogels, scaffolds, microspheres, and nanoparticles, novel stimuli-responsive delivery systems can realize the targeted and sustained release of drugs, which can both reduce systematic adverse effects and maximize therapeutic efficacy. Trigger factors are categorized into internal (pH, reactive oxygen species, enzymes, etc.) and external stimuli (photo, ultrasound, magnetic, etc.) based on their intrinsic properties. This review systematically summarizes novel stimuli-responsive delivery systems for intervertebral disc degeneration, shedding new light on intervertebral disc therapy.

Denervation procedure of the lateral epicondyle for refractory lateral epicondylitis

BackgroundLateral epicondylitis is the most common cause of lateral elbow pain in adults, and non-operative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving ECRB débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. MethodsThis investigation was an IRB-approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale (VAS) pain and Single Assessment Numerical Evaluation (SANE) scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. ResultsCompared to the preoperative average, the cohort’s mean VAS pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean SANE score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. ConclusionsThe PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.

ECAP-controlled closed-loop versus open-loop SCS for the treatment of chronic pain: 36-month results of the EVOKE blinded randomized clinical trial

IntroductionThe evidence for spinal cord stimulation (SCS) has been criticized for the absence of blinded, parallel randomized controlled trials (RCTs) and limited evaluations of the long-term effects of SCS in...

Comparison of Radiofrequency Ablation and Steroid Injection in the Treatment of Plantar Fasciitis; Short and Medium Term Results

Objective: Plantar fasciitis, commonly found in orthopaedic practice, may restrict daily life activities and lead to loss of workforce. We aimed to evaluate the short- and medium-term outcomes of radiofrequency ablation (RFA) and steroid injection treatments in patients with plantar fasciitis who did not benefit from conservative therapies through pain and function scores. Material and Method: Patients studied at the Hakkari State Hospital for at least six months of conservative treatment due to plantar fasciitis between 01.07.2021-01.01.2023. The patients were divided into two groups: those who received RFA and those who were given steroid injections. Demographic information of the patients, the Visual Analog Scale (VAS) and the American Orthopedic Foot Ankle Society (AOFAS) score were studied, and both gups were compared. Results: No significant difference was observed when comparing preop VAS and AOFAS values for both groups (p=0.469 p=0.244). No significant difference was observed when comparing the VAS and AOFAS values of the two groups for the first month (p=0.764 p=0.466 respectively). A significant difference was observed when comparing the VAS and AOFAS values in the post-6 month (p=0,001 p=0.001). Significant differences were observed between VAS and AOFAS values in patients receiving RFA in preop and 6 months (p=0.001 p=0.001). No significant difference was observed in preop and 6 month VAS and AOFAS values in steroid injections (p=0.512 p=0.844 respectively).No complications were observed in both groups during the follow-up period. Conclusion: In patients who have received conservative treatment but have not benefited, radiofrequency ablation has been found to be an effective, safe and minimally invasive method of reducing the severity of pain in the short to medium term and improving daily activities.

Risk factors for reoperation after discectomy of lumbar herniated intervertebral disc disease.

Discectomy is the most common surgery for lumbar herniated intervertebral disc (HIVD) disease. However, 5%-24% of patients undergo a second surgery due to recurrent disc herniation. This study was aimed to identify the risk factors for reoperation after discectomy of lumbar HIVD and recommend treatment for patients with a high risk of reoperation. We recruited patients diagnosed as having single-level lumbar HIVD who underwent open discectomy from January 1, 2000, to December 31, 2012 in our hospital. We used a survival curve to inspect the survival time and reoperation rate after surgery. We discussed the correlation of reoperation rate with discectomy level, body mass index, heavy lifting after surgery, sex, and age. Furthermore, we investigated the correlation between the experience of a surgeon and the reoperation rate. A total of 619 patients were enrolled in our study. Most patients were 40-60 years old (48.8%), and most of them had herniation at L4/5 level (48.9%). The 8-year survival rate was 92%. Weight lifting after surgery may increase the reoperation rate by 115 and 18 times for those >60 years and <40 years, respectively. In addition, less experience of the surgeon and female sex had a high reoperation rate. Postoperative working modification may be very important for preventing patients from recurrent HIVD. For elderly people with HIVD, a more conservative therapy could be selected. If patients with lumbar spine hypermobility or severe degeneration require wide laminectomy, primary fusion should be considered.