Conservative Treatment Group Research Articles

Induction of labor in cases of late preterm isolated oligohydramnios: is it justified?

Objectives: To analyze in a retrospective cohort study the outcomes of pregnancies with isolated oligohydramnios at the late preterm period (34–36.6 weeks of gestation).Study design: This retrospective cohort study included three groups of women: (1) Women with isolated oligohydramnios whose pregnancy was managed conservatively (n = 33 births); (2) women with isolated oligohydramnios who were managed actively (i.e. induction of labor) (n = 111 births); and (3) a control group including women with normal amount of amniotic fluid who had a spontaneous late preterm delivery (n = 10,445 births). Maternal and fetal characteristics and obstetrics outcomes were collected from a computerized database of all deliveries at Soroka University Medical Center during the study period.Results: Our cohort included 10,589 births. The rate of inducing labor was higher in the oligohydramnios groups compared to the controls (p < .001). There was an increase in the rate of cesarean section (CS) in the conservative treatment group (p < .001), compared with the other groups. Conservative management was associated with higher rates of maternal infection (p = .026), chorioamnionitis (p = .01), and transitory tachypnea of the newborn (p = .02). After controlling for confounding factors, mal presentation (OR = 19.9), and a prior CS (OR = 2.4) were independently associated with an increased risk for CS, while induction of labor was associated with a reduced risk for CS (OR = 0.28).Conclusions: Women with late preterm isolated oligohydramnios had a higher rate of induction of labor than women with a normal amount of amniotic fluid. Induction of labor seems to be beneficial to both the neonate and the mother as seen by a lower rate of CS conducted in this group, as well as lower maternal and neonatal morbidity in comparison to the conservative group. Therefore, women with oligohydramnios at late preterm may benefit from induction of labor.

Impact of Magnetic Resonance Imaging on Treatment-Related Decision Making for Osteoporotic Vertebral Compression Fracture: A Prospective Randomized Trial.

BackgroundThe aim of this study was to analyze the impact and usefulness of characteristic signal change of a linear black signal on magnetic resonance imaging (MRI) on treatment-related decision making.Material/MethodsForty-one patients with a linear black signal on MRI were enrolled in this prospective study. They were randomly divided into the percutaneous kyphoplasty (PKP) group (n=24) and the conservative treatment group (n=17). Clinical measures, including visual analog scale (VAS) and short-form 36 (SF-36) questionnaire, were analyzed. Radiographic measures, including anterior vertebral body height, kyphosis angle and rate of bone-union, were evaluated.ResultsVAS scores were significantly lower in the PKP group than in the conservative treatment group post-treatment and at one-year follow-up. After one year of treatment, the values for physical functioning, physical health, and body pain were significantly higher in the PKP group than in the conservative treatment group (p<0.05). The PKP group had a significantly higher anterior vertebral body height, rate of bone-union, and lower kyphosis angle than the conservative treatment group at one-year follow-up (p<0.05).ConclusionsIn patients with a linear black signal detected on MRI, the first-choice treatment should be PKP rather than conservative treatment.

Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty.

Introduction:Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs.Materials and Methods:A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA.Results:One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59).Discussion:Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist—a reduction in the increased mortality risk associated with PHFs.Conclusions:There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30-65 years old.

Objectives:Midshaft clavicular fractures are increasingly treated operatively rather than nonoperatively. Studies have shown mixed results for both types of treatment. The aim of this study was to compare the early-stage functional status associated with open reduction and internal fixation (ORIF) with plating and that associated with conservative treatment for displaced midshaft clavicular fractures.Materials and Methods:A single-center retrospective review of the results of 120 cases of displaced midshaft clavicular fractures in patients aged 30–65 years old was conducted. The primary outcome was fracture union status at 6 months. Other outcomes were subjective shoulder value (SSV) scores, visual analog scale (VAS) scores, and radiographic shortening at 6 weeks, 3 months, and 6 months. The complication rates in the operative and nonoperative groups were recorded.Results:The delayed union rate at 6-month postoperatively and VAS scores at 6 weeks, 3 months, and 6 months postinjury were significantly higher in the conservative treatment group than in the ORIF group. SSV scores were significantly improved at 6-month postinjury in the ORIF group.Conclusions:This is the first study to discuss the importance of early-stage functional restoration after ORIF with plating for displaced midshaft clavicular fractures. This surgery leads to lower pain complications in the earlier stages of bone healing and lower delayed union rates compared with conservative treatment, in patients aged 30–65 years old.

Acute Traumatic Primary Patella Dislocation in Children and Adolescents: A Detailed Evaluation of the Impact upon the Results

Background and Aim: Through accurate assessment of the risk factors and structural characteristics of children presenting with acute patella dislocation, this study aimed to evaluate the probability of recurrence and the effects on treatment. Materials and Methods: Demographic and radiological evaluation was made of each case. Contributory factors to patellofemoral instability were investigated. Surgical treatment was applied to 4 (15.39%) patients and conservative treatment to 22 (84.61%). Functional status before and after treatment was evaluated using the Kujala patellofemoral scoring system. Results: The patients comprised 8 (30.77%) males and 18 (69.23%) females with a mean age of 13.46 years. In 15 (57.69%) cases, there were patellofemoral complaints before the dislocation. The Kujala score was determined as mean 54.27 pre-treatment and 84.81 post-treatment in the conservative treatment group and mean 48.00 preoperatively and 75.25 postoperatively in the surgically treated group. No recurrence of patella dislocation was observed in any patient during the follow-up of both groups. Conclusions: Although it seems to be simple surgical intervention, as patella dislocation surgery can involve several complications, the surgical program must be very well planned and only applied to cases where necessary. With case-by-case assessment, the probability of recurrence of patella dislocation will be removed.

Conservative approach in drilling-cutting tool injuries

Objective: To prevent unnecessary laparotomies by evaluating the effectiveness of conservative approach in abdominal trauma cases due to drilling-cutting instruments. Methods: Demographic data, effected region of the body, additional findings of trauma, hemodynamic parameters, duration of admission, diagnostic methods and treatment modalities were retrospectively evaluated in 217 cases with abdominal injury (lower thoracic region, abdominal wall and back) among 1 128 victims with drilling-cutting instrument injuries between January 1, 2012 and December 31, 2017. The conservative approach was based on physical examination, hemogram follow-up and hemodynamic evaluation. Results: Totally 177 (81.6%) cases of 217 patients were followed conservatively while 25 cases were operated at early (1-8 hours) and 15 were operated at late (9-48 hours) periods. Two patients who underwent surgery in the early period and two patients who underwent surgery in the late period were accepted as negative laparotomy while 1 patient in the late operated group was regarded as non-therapeutic laparotomy. Diagnostic laparoscopy was performed in 81 cases. Complications developed in 7 patients who were operated in the early period and 10 patients who were operated in the late period. The mean hospital stay period was 5.3 days (1-33) in all cases, 4.5 days (2-20) in conservative treatment group and 8.4 days (3-33) in the operated patients; and the difference was statistically significant. Conclusions: Detailed physical examination, accurate assessment and effective use of different diagnostic methods reduce the frequency of negative and non- therapeutic laparotomies in abdominal stab wound injuries.

The management of low velocity transarticular gunshot injuries: A pilot study

Objectives: To prospectively evaluate the incidence of superficial and deep wound sepsis in a cohort of patients who sustained low velocity transarticular gunshot wounds. Methods: We performed a prospective, randomised, non-blinded pilot study of all adults presenting to a single institution between November 2011 and January 2015 that sustained a transarticular gunshot injury with no definite indication for surgery. We defined indications for surgery as: retained bullet or bullet fragments that warranted surgical removal or the presence of skeletal injuries that required surgical intervention. Patients were randomised into two treatment groups. The conservative treatment group received antitetanus toxoid and antibiotics alone, and the surgical treatment group received anti-tetanus toxoid and antibiotics, as well as formal arthrotomy, debridement and irrigation. Setting: Single Level 1 University Hospital Trauma Centre. Main outcome measurements: The two groups were assessed for development of septic arthritis or superficial wound infection. Results: We identified 30 transarticular gunshot wounds in 29 patients with an average age of 29.5 years (range 18–74). Sixteen (53%) were treated conservatively and 14 (47%) had a formal arthrotomy and washout. The median follow-up period was 20 days (range 5–84) for the conservative group and 30 days (range 8–84) for the operative group. No wound or intra-articular sepsis was observed for any of the 30 gunshot wounds. Conclusion: It can be concluded, with appropriate caution, that there may be a place for non-operative treatment of low-velocity transarticular gunshot injuries without a demonstrable increased risk of infection. Level of evidence: Level 2

Comparison of Arthroscopic and Conservative Treatments for Knee Osteoarthritis: A 5-Year Retrospective Comparative Study

To compare the effectiveness of arthroscopic and conservative treatments in patients with knee osteoarthritis (KOA) with 5years of follow-up. Patients diagnosed with Kellgren-Lawrence grade 2 to 4 KOA who underwent arthroscopic or conservative treatment from May 2005 to May 2012 were included. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score was collected 1, 2, 3, 4, and 5years after the initial treatment, and the number of patients who underwent total knee arthroplasty (TKA) at every time point was recorded. Three hundred eighty-two patients (168 in the conservative group and 214 in the arthroscopy group) were included. Five years after the initial treatment, 32 of the 214 patients who underwent arthroscopy (15.0%) compared with 30 of the 168 patients in the conservative treatment group (17.9%) ultimately underwent TKA, with no statistically significant difference between groups (P= .20). The WOMAC score was significantly lower in the arthroscopy group than in the conservative group at year 1 (24.33 ± 21.56 vs 36.43 ± 16.22, respectively) and year 2 (26.31 ± 17.84 vs 35.41 ± 19.21, respectively). There were no significant between-group differences at years 3, 4, and5. Compared with conservative treatment, arthroscopy provided no benefit in decreasing or delaying arthroplasty surgery. However, arthroscopy had a greater ability to relieve symptoms at 1 and 2years. Our results suggest that arthroscopy can relieve symptoms up to 2years without elevating the risk of arthroplasty. Level III, retrospective comparative study.

The efficacy and safety of conservative treatment versus surgery for traumatic flail chest in elderly patients

Objective To compare the clinical safety and efficacy of conservative treatment and surgery for traumatic flail chest in elderly patients. Methods From January 2013 to January 2017, 68 elderly patients with traumatic flail chest in the Department of Thoracic Surgery, Beijing Lu He Hospital were enrolled.Based on different treatment methods, patients were divided into a conservative treatment group (n=34) and a surgery group (n=34), and the clinical safety and efficacy were compared between the two different treatment groups. Results Patients in the surgery group were associated with significantly decreased mechanical ventilation time, and days stayed in ICU and hospital, compared with the conservative treatment group (all P 0.05). Rates of delayed or nonunion (2.9% vs.17.6%) and thoracic deformity (0.0% vs.11.8%) were significantly lower in the surgery group than those in the conservative treatment group (χ2=3.981 and 4.250, both P<0.05). Conclusions Surgery can safely and effectively reduce incidences of complications in elderly patients with traumatic flail chest disease and shorten the time of hospitalization.Therefore, the short-and long-term effects are promising and warrant further investigation. Key words: Flail chest; Surgical procedures, operative

Neutrophil to Lymphocyte Count Ratio Has a Close Association With Severe Acute Colonic Diverticulitis in Patients Undergoing Surgical Treatment

Objective: To investigate the diagnostic potential of neutrophil-to-lymphocyte count ratio (NLCR) for acute diverticulitis. Summary of Background Data: We evaluated NLCR in patients with acute colonic diverticulitis who were treated with conservative and surgical treatments. Methods: A total of 205 patients who underwent surgical treatment or conservative management of acute diverticulitis between 2012 and 2016 were reviewed. Patients' age; sex; hospital days; co-morbidity; complication; period of use of antibiotics; treatment method; body temperature; and initial laboratory results such as neutrophil count, lymphocyte count, NLCR, and serum levels of C-reactive protein (CRP) were assessed. Results: The median ages of the conservative and surgical treatment groups were 46 and 68 years, respectively. Median CRP and glucose levels were high in acute colonic diverticulitis patients who underwent surgical treatment (P &amp;lt; 0.001, P &amp;lt; 0.001). Albumin level was low in the surgical treatment group (P &amp;lt; 0.001). NLCR was significantly different in both groups (conservative management vs surgical treatment, 4.1 mg/L versus 8.5 mg/L; P &amp;lt; 0.001). Median white blood cells was 11.36 × 109/L in the conservative management group and 14.0 × 109/L in the surgical treatment group, with no significance (P = 0.071). Multivariate analysis revealed that NLCR &amp;gt;10.21 [odds ratio (OR) = 5.613, P = 0.022]; CRP &amp;gt;17.23 mg/L (OR = 4.241, P = 0.006); and albumin ≤3.5 (OR = 4.192, P = 0.036) were significant for acute colonic diverticulitis patients. Conclusion: NLCR, CRP, and albumin levels were significantly associated with acute colonic diverticulitis in the surgical treatment group, and NLCR was the most powerful predictive marker of severe acute colonic diverticulitis.

Prediction of Late Enophthalmos Using Preoperative Orbital Volume and Fracture Area Measurements in Blowout Fracture.

Enophthalmos caused by orbital volume expansion is the traditional indication for blowout fracture operation, but it may not appear immediately after orbital trauma due to periorbital swelling. The purpose of this study was to investigate the correlations of the orbital volume ratio (OVR) and, orbital fracture area (OFA) with the late enophthalmos measurement in unilateral pure blowout fracture. Seventy-two patients who had experienced a blowout fracture were divided into 2 groups, the conservative treatment group (n = 40) and the operative treatment group (n = 32). The authors measured the preoperative OVR and OFA using three-dimensional facial bone computed tomography and investigated their relationship with late enophthalmos that obtained 6 months after orbital trauma. In both conservative and operative groups, there were significant positive correlations between the OVR and OFA (P < 0.05). In the conservative group, both the OVR and OFA showed significant positive correlations with late enophthalmos, but the OVR (r = 0.777) was more closely correlated with enophthalmos than the OFA (r = 0.739). Quantitative measurements of OVR and OFA are useful parameters that can predict the extent of late enophthalmos and are useful in planning the treatment of blowout fracture.

Effectiveness of etilefrine regimen for chylothorax after esophagectomy with thoracic duct resection

BackgroundManagement of postoperative chylothorax generally involves nutritional regimens as well as pharmacological and surgical therapies, but a clear consensus has yet to be reached.MethodsRetrospective review of 371 patients who underwent esophagectomy for esophageal cancer was performed. They were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I/II tumor of the esophagogastric junction who underwent subtotal esophagectomy. Of these patients, 19 patients who were diagnosed with chylothorax as a postoperative complication were enrolled in this study.ResultsConservative treatment achieved cure in 16 patients among 19 patients. The duration of chylothorax tended to be longer in the no-etilefrine group (n = 5) than in the etilefrine group (n = 11) (27.8 vs. 11.6 days; p = 0.078). The 14 patients among 19 patients resected the thoracic duct. Etilefrine was used in 12 of these 14 patients. Among these 12 patients, 3 required surgical treatment and the remaining 9 patients were cured with conservative treatment. The duration of chylothorax was shorter in the conservative treatment group than in the surgical treatment group (11.9 vs. 36.3 days; p = 0.052). In addition, with the use of etilefrine as adjuvant therapy, cure was achieved in 9 patients (75%) without surgical intervention.ConclusionsThe findings of this study suggest that when used concurrently with conventional treatments, etilefrine facilitates early chest tube removal. In addition, post-thoracic duct resection chylothorax, which frequently requires surgical treatment because of the general less effectiveness of conservative treatments, showed high successful rate (75%) to etilefrine treatment.

Endothelial dysfunction in patients with Buerger disease.

We evaluated the endothelial function of patients with Buerger disease using peripheral arterial tonometry test, and examined the factors that are significantly correlated with the endothelial dysfunction in these patients. We performed the peripheral arterial tonometry test in 22 patients with Buerger disease. We recorded the patients’ characteristics, including ankle brachial pressure index and reactive hyperemia index, which reflect the endothelial dysfunction. We divided the patients with Buerger disease into the conservative treatment and lumbar sympathectomy group. While the reactive hyperemia index was not significantly different between these two groups, the ankle brachial pressure index was significantly different (1.12 versus 0.83, P=0.003). Furthermore, the reactive hyperemia index was significantly correlated with the ankle brachial pressure index value in the patients in the lumbar sympathectomy group (ρ=0.848, P=0.005). Given that patients with Buerger disease show impairment of the sympathetic nervous system, we should consider the after-effects of such an impaired system on the condition of these patients. The patients treated with lumbar sympathectomy might be more appropriate to evaluate their endothelial function by a peripheral arterial tonometry test.

Effectiveness of surgical revascularization for stroke prevention in pediatric patients with sickle cell disease and moyamoya syndrome

OBJECTIVE Sickle cell disease (SCD) in combination with moyamoya syndrome (MMS) represents a rare complication of SCD, with potentially devastating neurological outcomes. The effectiveness of surgical revascularization in this patient population is currently unclear. The authors' aim was to determine the effectiveness of surgical intervention in their series of SCD-MMS patients by comparing stroke recurrence in those undergoing revascularization and those undergoing conservative transfusion therapy. METHODS The authors performed a retrospective chart review of patients with MMS who were seen at the Johns Hopkins Medical Institution between 1990 and 2013. Pediatric patients (age < 18 years) with confirmed diagnoses of SCD and MMS were included. Intracranial stroke occurrence during the follow-up period was compared between surgically and conservatively managed patients. RESULTS A total of 15 pediatric SCD-MMS patients (28 affected hemispheres) were included in this study, and all were African American. Seven patients (12 hemispheres) were treated with indirect surgical revascularization. The average age at MMS diagnosis was 9.0 ± 4.0 years, and 9 patients (60.0%) were female. Fourteen patients (93.3%) had strokes before diagnosis of MMS, with an average age at first stroke of 6.6 ± 3.9 years. During an average follow-up period of 11.6 years, 4 patients in the conservative treatment group experienced strokes in 5 hemispheres, whereas no patient undergoing the revascularization procedure had any strokes at follow-up (p = 0.029). Three patients experienced immediate postoperative transient ischemic attacks, but all recovered without subsequent strokes. CONCLUSIONS Indirect revascularization is suggested as a safe and effective alternative to the best medical therapy alone in patients with SCD-MMS. High-risk patients managed on a regimen of chronic transfusion should be considered for indirect revascularization to maximize the effect of stroke prevention.

Benefits of Intraoperative Continuous Renal Replacement Therapy During Liver Transplantation in Patients With Renal Dysfunction

BackgroundComparative outcomes of continuous renal replacement therapy during liver transplantation have not been investigated. We retrospectively compared the outcomes of intraoperative continuous renal replacement therapy with those of non-dialytic conservative treatment in patients with pretransplant renal dysfunction. MethodsWe analyzed 240 transplantation patients with preoperative renal dysfunction (estimated glomerular filtration rate <60 mL/min/1.73 m2). ResultsCompared with the non-dialytic conservative treatment group (n = 98), the intraoperative continuous renal replacement therapy group (n = 142) experienced more severe critical illness (as indicated by Model for End-Stage Liver Disease score) and more severe preoperative renal dysfunction, as well as more frequent hepatic encephalopathy, ventilatory care, and intensive care unit admission (P < .005). There were also worse outcomes regarding patient survival, graft survival, recovery of renal function, and postoperative complications. However, the intraoperative continuous renal replacement therapy group significantly escaped volume overload (adjusted odds ratio, 0.396; 95% confidence interval, 0.223–0.703; P = .002) and unnecessary changes in serum sodium concentration ≥10 mmol/L during surgery (adjusted odds ratio, 0.208; 95% confidence interval, 0.065–0.665; P = .008). ConclusionsConsidering the more severe critical illness of the intraoperative continuous renal replacement therapy group but the low frequency of volume overload and serum sodium fluctuation, intraoperative continuous renal replacement therapy could be useful during liver transplantation in critically ill patients with renal dysfunction. Randomized, controlled studies that could demonstrate outcome benefits and indications of intraoperative continuous renal replacement therapy during liver transplantation are needed.

New Scoring System for Evaluating Patulous Eustachian Tube Patients

To assess the efficacy of patulous Eustachian tube handicap inventory (PHI) for patulous Eustachian tube (PET) patients. Prospective. Tertiary referral center. A prospective survey of medical records in Sen-En Hospital identified 31 ears of 31 patients with definite PET who received insertion of the silicone plug as surgical treatment group, 29 ears of 29 patients treated with self-instillation of physiological saline solution as conservative treatment group, and 29 ears of 29 patients of sensorineural hearing loss without findings of PET treated between June 2015 and December 2015. Diagnosis of definite PET was based on the proposal on PET diagnosis criteria announced by the Otological Society of Japan. The evaluation scale of PHI was modified from the Japanese version of the tinnitus handicap inventory-12 (THI-12). The classification for grading of severity is defined as follows: 1) no handicap (0-8), 2) mild handicap (10-16), 3) moderate handicap (18-24), and 4) severe handicap (26-40), matching the severity grades of tinnitus handicap inventory-25 (THI-25). The outcome measurement was modified from the previous scoring system and is defined as 1) complete relief, 2) significant improvement, 3) slight improvement, 4) unchanged, and 5) worse, and is applied according to the classification for grading of severity. The PHI was conducted at the first visit to our center for all patients in the three groups. For cases requiring surgery for plug insertion, patulous Eustachian tube handicap inventory 10 (PHI 10) was also conducted postsurgery after the treatment (postsurgery). The findings from questions 1 to 7 and 9 to 11 were significantly different between the surgical (presurgery) and conservative treatment groups (p < 0.05). Taking these results, we analyzed 10 questions excluding questions 8 and 12 (PHI 10). The total score of PHI 10 averaged 19.5 ± 9.3 (n = 31) and 30.6 ± 8.6 (n = 29) in the surgical treatment (presurgery) and conservative treatment groups, respectively, with a significant difference (p < 0.05). Internal consistency reliability testing of the PHI 10 yielded a Cronbach α of 0.887 for all questions. In the surgical treatment (presurgery) and conservative treatment groups, there were 0 (0%) and 3 cases (12%) of no handicap, 3 (10%) and 13 cases (50%) of mild handicap, 6 (19%) and 4 cases (15%) of moderate handicap, and 22 (71%) and 6 cases (23%) of severe handicap, respectively. There was a significant correlation between the PHI 10 and Likert scale (r = 0.796, p < 0.01). In the surgical group, the presurgery and postsurgery PHI 10 scores (n = 25) were 29.6 ± 8.5 and 7.8 ± 11.3, respectively. The PHI 10 is suitable for evaluating severity of PET if the patients have been diagnosed as definite PET. Furthermore, this scoring system could be suitable for surgical treatment assessment.

Treatment strategies and outcomes of spontaneous spinal epidural hematomas

Objective To investigate the treatment strategies and neurological outcomes of spontaneous spinal epidural hematomas (SSEH). Methods From June 2004 to March 2016, a total of 42 patients with SSEH were admitted to Department of Neurosurgery, Tianjin Medical University General Hospital and were retrospectively reviewed in this study. All patients were divided into the surgery group (24 cases) and conservative treatment group (18 cases). Based on the time interval from inital symptoms to surgery, the patients in surgery group were further separated into 24 h group. The neurological functions of patients were assessed by the Japanese Orthopedics Association (JOA) scale and American Spinal Injury Association(ASIA) impairment scale. The JOA scores were used to determine the recovery rate of neurological functions. The follow-up period ranged from 4 to 34 months, with an average of 18±6 months. Results There were significant differences in the recovery rate of neurological functions between patients with different ASIA scales either in the surgery group or conservative treatment group (all P 0.05). The neurological function recovery rate in 24 h group (20.0±21.3%) (both P<0.05). Conclusions For patients graded as ASIA scale A, B, C or those with progressive decline in ASIA scale, early surgical treatment should be recommended. For patients of ASIA scale D, E or those with tendency for neurological function recovery within a short term, conservative treatment might be considered. Patients undergoing operations with higher initial ASIA scale and shorter preoperative interval tend to demonstrate better outcomes. Patients undergoing conservative treatment with higher initial ASIA scale seem more likely to achieve good outcomes. Key words: Hematoma, epidural, spinal; Prognosis; Neurosurgical procedures; Conservative management

The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: a systematic review

Background: Instrument-assisted soft tissue mobilization (IASTM) is an emerging intervention in physical therapy. With the increasing prevalence of pain and disability associated with musculoskeletal impairments, it is essential to identify the most effective treatment strategies. Objective: To systematically examine evidence on the effectiveness of IASTM, compared to other interventions on patients with pain and disability resulting from musculoskeletal impairments. Methods: Numerous databases were searched using the terms Instrument Assisted Soft Tissue, Pain, Function, Graston, and soft tissue mobilization (STM). Inclusion criteria included: randomized clinical trials on patients with musculoskeletal impairments, STM had to be a treatment intervention, performed on human subjects, and had to capture a measure of pain or function. Articles were excluded if they were not published in English or if the subjects were of the pediatric or geriatric populations. Included articles were appraised using the Physiotherapy Evidence Database (PEDro) scale. Results: Seven studies met the inclusion criteria. All seven articles scored a minimum 4/10 on the PEDro scale. The studies involved treatment of numerous anatomical locations and the majority of the studies demonstrated significant improvements in pain and/or range of motion when compared to control or other conservative treatment groups. Conclusions: These outcomes support the idea that IASTM may have an impact on physiological changes by providing an increase in blood flow, reduction in tissue viscosity, myofascial release, interruption of pain receptors, and improvement of flexibility of underlying tissue. It is suggested that IASTM is an effective treatment intervention for reducing pain and improving function in less than a three-month period.

Anterior subcutaneous transposition for persistent ulnar neuropathy after neurolysis.

OBJECTIVE Little is known about optimal treatment if neurolysis for ulnar nerve entrapment at the elbow fails. The authors evaluated the clinical outcome of patients who underwent anterior subcutaneous transposition after failure of neurolysis of ulnar nerve entrapment (ASTAFNUE). METHODS A consecutive series of patients who underwent ASTAFNUE performed by a single surgeon between 2009 and 2014 was analyzed retrospectively. Preoperative and postoperative complaints in the following 3 clinical modalities were compared: pain and/or tingling, weakness, and numbness. Six-point satisfaction scores were determined on the basis of data from systematic telephonic surveys. RESULTS Twenty-six patients were included. The median age was 56 years (range 22-79 years). The median duration of complaints before ASTAFNUE was 23 months (range 8-78 months). The median interval between neurolysis and ASTAFNUE was 11 months (range 5-34 months). At presentation, 88% of the patients were experiencing pain and/or tingling, 46% had weakness, and 50% had numbness of the fourth and fifth fingers. Pain and/or tingling improved in 35%, motor function in 23%, and sensory disturbances in 19% of all the patients. Improvement in at least 1 of the 3 clinical modalities was found in 58%. However, a deterioration in 1 of the 3 modalities was noted in 46% of the patients. On the patient-satisfaction scale, 62% reported a good or excellent outcome. Patients with a good/excellent outcome were a median of 11 years younger than patients with a fair/poor outcome. No other factor was significantly related to satisfaction score. CONCLUSIONS A majority of the patients were satisfied after ASTAFNUE, even though their symptoms only partly resolved or even deteriorated. Older age is a risk factor for a poor outcome. Other factors that affect outcome might play a role, but they remain unidentified. One of these factors might be earlier surgical intervention. The modest results of ASTAFNUE should be mentioned when counseling patients after failure of neurolysis of ulnar nerve entrapment to manage their expectations. Patients, especially those who are elderly, might even consider not undergoing a secondary procedure. A randomized trial that includes a conservative treatment group and groups undergoing one of the several possible surgical procedures is needed to find the definitive answer for this clinical problem.

How Should We Lower Blood Pressure after Cerebral Hemorrhage? A Systematic Review and Meta-Analysis

Background: The optimal treatment of high blood pressure (BP) after acute intra-cerebral hemorrhage (ICH) is controversial. Summary: The aim of the study was to evaluate the safety and efficacy of early intensive vs. conservative BP lowering treatment in patients with ICH. Randomized controlled trials with active and control groups receiving intensive and conservative BP lowering treatments were identified. The following outcomes were assessed: 3-month mortality and combined death or major disability, 24-h hematoma growth, early neurological deterioration, occurrence of hypotension, severe hypotension, and serious treatment-emergent adverse events. Five trials were included involving 4,350 participants, 2,162 and 2,188 for intensive and conservative treatment groups, respectively. The pooled risk ratio of 3-month death or major disability was 0.96 (0.91-1.01) and the weighted mean difference in absolute hematoma growth was -1.53 (95% CI -2.94 to -0.12) mL in the intensive compared to conservative BP-lowering. There were no differences across the treatments in the incidence rates of 3-month mortality, early neurological deterioration, hypotension, and treatment-related adverse effects other than renal events. Key Messages: The early intensive anti-hypertensive treatment was overall safe and reduced the hematoma expansion in patients presenting with acute-onset spontaneous ICH and high BP levels.