Conservative Treatment Strategies Research Articles

Outcomes during the first year following spontaneous coronary artery dissection: A systematic timeframe pooled analysis.

We aimed to compare the incidence and timing of major adverse cardiovascular events (MACE) within the first year after spontaneous coronary artery dissection (SCAD) according to the management strategy: conservative versus invasive. Treatment of SCAD remains controversial. A pooled analysis of studies providing separate individual clinical outcomes for conservative and invasive treatment strategies within 1 year after SCAD was performed. The primary outcome measure was MACE incidence within three predefined study periods after SCAD, namely "in-hospital", "discharge-to-6-months" and "6-to-12-months". MACE was defined as a composite of all-cause death, myocardial infarction, target vessel revascularization, heart failure and SCAD recurrence. A total of 16 studies (444 patients) were included; 277 (62%) patients were treated conservatively and 167 (38%) invasively. Within 1-year follow-up, 39 (67%) MACE occurred during the in-hospital period compared to 10 (17%) in the "discharge-to-6months" period and 9 (16%) in the "6-to-12-months" period (p <0.0001 for the overall comparison). MACE incidence was also significantly different between the three study periods in the conservatively-treated group (23 [78%] vs. 7 [23%] vs. 0 [0%], respectively; p <0.0001) and the invasively-treated group (12 [66%] vs. 3 [17%] vs. 3 [17%], respectively; p <0.0001), although no significant difference was found regarding MACE incidence in the intra-period comparisons between conservative and invasive treatment strategies. This pooled analysis showed that most MACE following SCAD occurred during the in-hospital period compared to the following two semesters, regardless of the treatment strategy. No difference regarding MACE incidence was found between conservative and invasive strategies in each study period.

Detection of impending perfusion deficits by intraoperative computed tomography (iCT) in aneurysm surgery of the anterior circulation

BackgroundThe aim of our study was to evaluate the additional benefit of intraoperative computed tomography (iCT), intraoperative computed tomography angiography (iCTA), and intraoperative computed tomography perfusion (iCTP) in the intraoperative detection of impending ischemia to established methods (indocyanine green videoangiography (ICGVA), microDoppler, intraoperative neuromonitoring (IONM)) for initiating timely therapeutic measures.MethodsPatients with primary aneurysms of the anterior circulation between October 2016 and December 2019 were included. Data of iCT modalities compared to other techniques (ICGVA, microDoppler, IONM) was recorded with emphasis on resulting operative conclusions leading to inspection of clip position, repositioning, or immediate initiation of conservative treatment strategies. Additional variables analyzed included patient demographics, aneurysm-specific characteristics, and clinical outcome.ResultsOf 194 consecutive patients, 93 patients with 100 aneurysms received iCT imaging. While IONM and ICGVA were normal, an altered vessel patency in iCTA was detected in 5 (5.4%) and a mismatch in iCTP in 7 patients (7.5%). Repositioning was considered appropriate in 2 patients (2.2%), where immediate improvement in iCTP could be documented. In a further 5 cases (5.4%), intensified conservative therapy was immediately initiated treating the reduced CBP as clip repositioning was not considered causal. In terms of clinical outcome at last FU, mRS0 was achieved in 85 (91.4%) and mRS1-2 in 7 (7.5%) and remained mRS4 in one patient with SAH (1.1%).ConclusionsEspecially iCTP can reveal signs of impending ischemia in selected cases and enable the surgeon to promptly initiate therapeutic measures such as clip repositioning or intraoperative onset of maximum conservative treatment, while established tools might fail to detect those intraoperative pathologic changes.

Efficacy of intra-articular injection of combined platelet-rich plasma and hyaluronic acid in knee degenerative joint disease (182)

Objectives:Osteoarthritis (OA) of the knee is a debilitating disease whose prevalence has increased across the world with aging population. Platelet-Rich Plasma (PRP) and Hyaluronic Acid (HA) injections appear to be two of the main strategies for conservative treatment of early knee OA. The effectiveness of both treatments, however, is still under debate because contrasting results have been described in the current literature. Some pre-clinical studies evaluated the association of PRP and HA with encouraging results, highlighting the possibility of a synergistic effect between the two compounds and suggesting a possible use through combined intra-articular injections. The aim of this prospective randomized controlled double-blind clinical trial is to evaluate the efficacy of intra-articular injections of PRP and HA for the treatment of early stages of knee degenerative joint disease in improving joint function and reducing pain, compared to the intra-articular injections of PRP and HA alone.Methods:Patients with knee early OA were prospectively enrolled and then double-blinded randomly divided into three groups of fifty-eight subjects each: HA alone, PRP alone and PRP+HA group. Patients received three intra-articular injections with two-week interval period among each dose. Patients clinical outcome was evaluated through five questionnaires [The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner Activity, Visual Analogue Scale (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Subjective Knee Form] before the treatment (T0) and after 3, 6 and 12 months from the first injection. Patients’use of paracetamol and supplementary analgesia for knee pain during the study was collected.Results:One hundred and seventy-four patients were enrolled in this study (age, 30-80 years; 108 females and 66 males) and 162 completed the 12-month follow-up. All patients showed significant clinical improvement after treatment. The analysis of covariance (ANCOVA) did not show statistically significant differences among the three groups for all the variables analysed at 6 and 12 months of follow-up (p>0.05).No significant differences were found in terms of adverse events (p=0.49) among the three groups of patients (p=0.92).The demand for paracetamol and supplementary analgesics was generally low and there were no significant differences among the groups (p=0.23 and p=0.56, respectively).Conclusions:Injections treatments for early knee OA are an important conservative therapeutic strategy. To date, the current literature presents many contrasting studies about the effectiveness of PRP or HA, but only a few consider the combined use of PRP and HA as attractive therapeutic option. Our study has not shown any significant difference in clinical and functional outcomes among the three experimental groups, suggesting a substantial equivalence of these three treatments. Thus, cost-effectiveness is in favor of HA injections in the conservative treatment of early OA.

Effects of initial invasive vs. initial conservative treatment strategies on recurrent and total cardiovascular events in the ISCHEMIA trial

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial prespecified an analysis to determine whether accounting for recurrent cardiovascular events in addition to first events modified understanding of the treatment effects. Patients with stable coronary artery disease (CAD) and moderate or severe ischaemia on stress testing were randomized to either initial invasive (INV) or initial conservative (CON) management. The primary outcome was a composite of cardiovascular death, myocardial infarction (MI), and hospitalization for unstable angina, heart failure, or cardiac arrest. The Ghosh-Lin method was used to estimate mean cumulative incidence of total events with death as a competing risk. The 5179 ISCHEMIA patients experienced 670 index events (318 INV, 352 CON) and 203 recurrent events (102 INV, 101 CON). A single primary event was observed in 9.8% of INV and 10.8% of CON patients while ≥2 primary events were observed in 2.5% and 2.8%, respectively. Patients with recurrent events were older; had more frequent hypertension, diabetes, prior MI, or cerebrovascular disease; and had more multivessel CAD. The average number of primary endpoint events per 100 patients over 4 years was 18.2 in INV [95% confidence interval (CI) 15.8-20.9] and 19.7 in CON (95% CI 17.5-22.2), difference -1.5 (95% CI -5.0 to 2.0, P = 0.398). Comparable results were obtained when all-cause death was substituted for cardiovascular death and when stroke was added as an event. In stable CAD patients with moderate or severe myocardial ischaemia enrolled in ISCHEMIA, an initial INV treatment strategy did not prevent either net recurrent events or net total events more effectively than an initial CON strategy. ISCHEMIA ClinicalTrials.gov number, NCT01471522, https://clinicaltrials.gov/ct2/show/NCT01471522.

Update on primary spontaneous pneumothorax - conservative or primarily surgical therapy?

Spontaneous pneumothorax is a potentially life-threatening situation. Therefore, it is mandatory to treat it safely. The incidence is approximately 10 out of 100 000 residents per year. It occurs through an immediate disruption of the visceral pleura that results in an accumulation of air in the pleural space. According to its etiology, spontaneous pneumothorax is divided into 2 groups. Whereas primary spontaneous pneumothorax occurs in healthy individuals without any detectable lung disease, secondary spontaneous pneumothorax occurs in patients with preexisting. Diagnosis of pneumothorax is typically made by chest x-ray. After diagnosis pneumothorax is traditionally treated by an insertion of a thoracic tube.Recently, thoracic ultrasound gained influence in diagnosis of pneumothorax and primarily conservative treatment strategies have been shown to be safe and equally effective in particular groups of patients. This article aims to present and discuss these upcoming strategies.

Intravoxel incoherent motion imaging predicts exercise-based rehabilitation response in individuals with low back pain.

Exercises to strengthen and stabilize the trunk musculature are a common conservative treatment strategy for low back pain (LBP), despite the possible presence of impairments in muscle activation in this population. Intravoxel incoherent motion (IVIM) MRI permits evaluation of activation-induced blood flow through diffusion-weighted images that are sensitized to microvascular blood flow. In the current study we aimed to evaluate IVIM signal changes after exercise in patients with LBP compared with pain-free healthy controls and determine if these changes were related to reductions in disability with a 12-week rehabilitation program. We hypothesize that the magnitude of changes in IVIM parameters in the lumbar extensor muscles will be smaller in patients with LBP compared with those without LBP, and that these magnitudes will be correlated with responsiveness to a 12-week, resistance-based exercise program. IVIM MR data for molecular diffusion (D), blood flow pseudodiffusion (D*) and perfusion fraction (f) were collected before and immediately after an ~ 3-min session of high-intensity lumbar extension resistance exercise in 16 healthy participants and 17 participants with LBP. Improvements in LBP-related disability after the 12-week, machine-based, high-intensity exercise rehabilitation program were measured in the LBP group. We observed a significant increase in all IVIM parameters (f, D*, D) in response to exercise (p < 0.0001) and an interaction of group-by-time for D (p = 0.016). Thresholds were identified using receiver operating characteristic (ROC) curves for diffusion and pseudodiffusion coefficients, which predicted a reduction in LBP-related disability in response to the 12-week, exercise-based rehabilitation program. Exercise was associated with an increase in (f), capillary blood flow-based pseudodiffusion (D*) and diffusion coefficient (D), regardless of the presence of LBP. Additionally, subgroup analysis identified patients who were not responsive to the acute exercise session, for whom, based on ROC analysis, there was no clinically significant change in disability following the 12-week program.

Hand Erosive Osteoarthritis and Distal Interphalangeal Involvement in Psoriatic Arthritis: The Place of Conservative Therapy.

Hand erosive osteoarthritis (HEOA) and Psoriatic Arthritis (PsA) with DIP involvement are common diseases affecting the hand. Both of them evolve with a progressive limitation in grip due to limited range of motion of the affected joints and stenosing tenosynovitis. Pharmacological options currently available (corticosteroids and clodronate or Idrossicloroquine) for the treatment of EHOA are mostly symptomatic and currently there are no effective drugs able to modify the course of the disease. In addition, data on drug effectiveness of PsA with DIP involvement are lacking. Conservative therapy should be considered in order to reduce pain and improve hand functionality. There are many studies debating a wide range of non-pharmacological intervention in the management of HEOA: joint protection program, range of motion and strengthening exercise, hand exercise with electromagnetic therapy, application of heat with paraffin wax or balneotherapy, occupational therapy and education. Concerning conservative treatment strategies to treat PsA, on the contrary, current evidence is still weak. Further research is needed to find the correct place of physical therapy to prevent stiffness and ankylosis due to the vicious circle of inflammation-pain-immobility-rigidity.

Clinicopathological study of periapical scars

Background/purposePeriapical scar (PS) is an alternative healing process with the formation of scar tissue after appropriate endodontic treatments/retreatments with or without periapical surgeries. This retrospective study evaluated the clinical, radiographic, and histopathological features of 7 PSs. Materials and methodsThe clinical, radiographic, and histopathological data of 7 PSs were collected and analyzed. ResultsThe 7 PSs were taken from the maxilla (3 cases) and mandible (4 cases) of 3 men and 4 women. The most frequently involved teeth were maxillary or mandibular incisors (4 cases) and first or second molars (3 cases). Of 7 PS patients, 6 had none of symptoms, 5 had previous nonsurgical endodontic treatments/retreatments, and 2 had previous endodontic treatments/retreatments plus periapical surgery. Radiographically, all 7 PS cases presented as a persistent and well-defined periapical radiolucent lesion for a long period of time. Microscopically, all 7 surgical specimens of PS showed dense fibrous collagenous tissues with one having amalgam particles in the scar tissue. ConclusionPSs do have their common clinical and radiographic features. When the periapical radiolucent lesion is well-defined, persistent without a significant change of its size, and free from symptoms and signs after a long-term follow-up; the involved tooth has no evidence of root fracture and healthy periodontium except the periapical radiolucency; and the previous endodontic treatment/retreatment or periapical surgery is well performed with an adequate root canal or retrograde filling, then the PS may be a possible diagnosis and a close follow-up may be a more conservative treatment strategy for this condition.

Knowledge, Perception, and Attitude on Conservative and Endodontic Practice on COVID Pandemic Situation: A Qualitative Research.

Aim:The purpose of our study was to analyze the knowledge and attitude of conservative as well as endodontic practice among dental professionals during coronavirus pandemic situation.Methodology:A cross-sectional study was conducted over a period of 3 months among 1256 dental surgeons, which included 400 MDS and 856 BDS dentists. Questionnaire assessed knowledge of the participants about COVID-19, risk assessment about the pandemic, preparedness of the participants, as well as specific precautions in cases which require conservative and endodontic treatment strategies against COVID-19.Results:It was observed that around 83% of the study participants felt that rubber dams are a useful tool to prevent cross-infections, even COVID-19. However, COVID-19 prevention techniques such as use of low-speed handpiece and chemicomechanical techniques were preferred by a smaller number of participants: 25% of participants by former, only 12% for the latter. To prevent aerosol splatter, use of high-volume suction was preferred by 49% of dental surgeons.Conclusion:In our study, we concluded that dental surgeons, who come under high risk category; had good basic knowledge about COVID-19 disease process as well as transmission. However, it is imperative that these clinicians need to be extra cautious in handling cases during this pandemic time and limit the disease spread as well.

Therapeutic options in female stress urinary incontinence

Stress urinary incontinence in female patients is characterised by loss of urine without the need to urinate. Causes are manifold and require a good knowledge of the pelvic floor structures and the functionality of the bladder's occlusion system. Before any treatment can be initiated, differentiated diagnostic investigation must uncover the causes in order to be able to show incontinent women the ideal therapeutic options. In addition to conservative treatment strategies, there are several surgical alternatives available that can be used depending on the functional and/or anatomical deficit. Surgical correction produces good results, although a minor rate of possible complications must be accepted.

Conditioned medium from mesenchymal stem cells improves condylar resorption induced by mandibular distraction osteogenesis in a rat model

Condylar resorption (CR) after surgical orthognathic treatment is defined as dysfunctional remodeling of the temporomandibular joint manifested by morphological changes with decreased condylar head volume that cause occlusal and esthetic changes. Although both conservative and surgical treatment strategies have been employed for the treatment of CR, effective procedures have not been established till date. In this study, the effects of MSC-CM on CR were investigated. Bone marrow-derived MSCs of rats (rMSCs) were cultured until 80% confluent, cultured in serum-free conditioned medium for 48 h; the collected medium was defined as MSC-CM. Osteogenesis, chondrogenesis, and angiogenesis-related gene expression in rMSCs cultured with MSC-CM was evaluated by quantitative real-time polymerase chain reaction. A rat CR model was used for animal studies, in which CR occurred after mandibular distraction osteogenesis for 10 days. MSC-CM was injected via the tail vein and quantitative and qualitative evaluations were performed by micro-computed tomography (micro-CT) and histology.MSC-CM enhanced osteogenesis-, chondrogenesis-, and angiogenesis-related gene expression in rMSCs. Micro-CT showed CR in control groups; however, it was observed to be improved in the MSC-CM group. Histologically, an enlarged cartilage layer was seen in the MSC-CM group, while cartilage layers had almost thinned or disappeared in control groups. These results indicate that MSC-CM improved CR.

Into Clinical Practice: Diagnosis and Therapy of Retroperitoneal Fibrosis.

We aim to review the most relevant diagnostic features and treatment options of retroperitoneal fibrosis, in order to provide a useful guide for clinical practice. The recent literature highlights the role of imaging studies such as computed tomography, magnetic resonance imaging and positron emission tomography as useful tools for the diagnosis of retroperitoneal fibrosis, with retroperitoneal biopsy being reserved to atypical cases. The treatment approach is mainly conservative and is based on the use of medical therapies plus urological interventions. Medical therapies essentially comprise glucocorticoids and immunosuppressants-either traditional or biological agents such as rituximab. Surgical ureterolysis is only left for refractory cases. Recent findings in retroperitoneal fibrosis highlight the possibility of a non-invasive diagnostic approach and a conservative treatment strategy.

Akute Pankreatitis

Acute pancreatitis is one of the most common gastrointestinal diseases requiring acute hospitalization and its incidence is increasing. A particular challenge is the prediction and treatment of severe cases, which only affect a minority of patients, but are associated with mortality rates of up to 30 percent. In this review, we consider the diagnostic evaluation of the disease and provide an overview of current conservative and interventional treatment strategies.

Managing Patients with ST – Elevation Myocardial Infarction at the Epicenter of the COVID-19 Pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, strained acute care resources, the potential for rapid clinical decompensation, and concerns about staff safety has prompted a conservative management approach for acute coronary syndrome patients. We present our experience of COVID-19 patients at Elmhurst Hospital Center presenting with ST-Elevation Myocardial Infarction and compared outcomes of invasive vs conservative treatment strategies.

Transition zone prostate cancer is associated with better clinical outcomes than peripheral zone cancer.

ObjectivesTo determine the biological significance of zonal origins in prostate cancer.Patients and methodsAltogether, 270 consecutive radical prostatectomy cases from 2009 to 2012 were adopted. Cases were divided into those having transition zone (TZ) cancer or peripheral zone (PZ) cancer. Cases with indeterminate tumor location and central zone cancers were excluded from the analyses. Prognosis and clinicopathological features were compared between the two tumor locations. Biochemical recurrence (BCR) and clinical progression (CP) were adopted as prognostic outcome measures. Immunohistochemical features of the v‐ets avian erythroblastosis virus E26 oncogene homolog (ERG)/serine peptidase inhibitor, Kazal‐type 1 (SPINK1) status, and loss of phosphatase and tensin homolog (PTEN‐loss), as well as conventional preoperative and postoperative characteristics, were analyzed.ResultsThis cohort comprised 93 cases of TZ cancer and 160 cases of PZ cancer. TZ cancer cases showed significantly higher BCR and CP‐free survival rate than PZ cancer cases. Notably, no TZ cancer cases developed CP during the 7.8 years of median follow‐up time. Tumor location was an independent predictive factor for BCR in the multivariate analysis. Additionally, TZ cancer cases showed a significantly lower prevalence of ERG‐overexpression and PTEN‐loss than PZ cancer cases (3.2% vs 20.1% and 2.2% vs 18.2%, respectively).ConclusionTZ cancer cases showed a better prognosis and different immunohistochemical features. Conservative treatment strategies could be considered for TZ cancer cases.

Desmoid tumors: To treat or not to treat, That is the question.

Desmoid tumors (DTs) are a rare disease of intermediate malignancy characterized histologically by a locally aggressive, monoclonal, fibroblastic proliferation and clinically by a variable and often unpredictable course. For decades, surgical resection has been the standard initial treatment approach; however, more recently, a paradigm shift toward a more conservative treatment strategy has been introduced. More than 5 years ago, The Desmoid Tumor Working Group started a consensus initiative in Europe with the aim of harmonizing the strategy among clinicians and setting up treatment recommendations for patients with DTs. This review summarizes the latest joint, global, evidence-based guideline approach to DT management. Moreover, a number of gray areas in the treatment recommendations are discussed, and possible future perspectives on the treatment armamentarium for patients with DTs are presented.

MARSUPIALIZATION AS A TREATMENT STRATEGY BEFORE ENUCLEATION OF A LARGE CALCIFYING ODONTOGENIC CYST

This report describes a case of a large lesion occupying the posterior region of mandible in an 11-year-old male patient. This lesion had a slow and asymptomatic growth, with evolution of 4 months. In this period, odontogenic infection was suspected. In the extraoral examination, the presence of facial asymmetry and volume increase were observed involving the right mandibular angle and cortical basal bone to the full extent. Complementary diagnostic tests were requested, such as imaging examinations and incisional biopsy of the mandibular vestibule region. The anatomopathologic result was calcifying odontogenic cyst. The marsupialization prior to surgical enucleation was performed as a conservative treatment strategy together with a peripheral ostectomy. The lesion regressed after marsupialization, and a new bone formation was observed. This patient was followed for 1 year after surgery, and there were no signs of recurrence or functional deficits. This report describes a case of a large lesion occupying the posterior region of mandible in an 11-year-old male patient. This lesion had a slow and asymptomatic growth, with evolution of 4 months. In this period, odontogenic infection was suspected. In the extraoral examination, the presence of facial asymmetry and volume increase were observed involving the right mandibular angle and cortical basal bone to the full extent. Complementary diagnostic tests were requested, such as imaging examinations and incisional biopsy of the mandibular vestibule region. The anatomopathologic result was calcifying odontogenic cyst. The marsupialization prior to surgical enucleation was performed as a conservative treatment strategy together with a peripheral ostectomy. The lesion regressed after marsupialization, and a new bone formation was observed. This patient was followed for 1 year after surgery, and there were no signs of recurrence or functional deficits.

Conservative Intervention Strategies for Adult Cancer-Related Lymphedema: A Systematic Review and Network Meta-Analysis.

The comparative effectiveness of available management options for cancer-related secondary lymphedema is unknown. CINAHL®, Embase®, and MEDLINE® were searched for randomized trials comparing conservative treatment strategies. A network meta-analysis was conducted for lymphedema volume, along with pairwise meta-analyses for remaining outcomes. Evidence certainty was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Overall, 36 studies with a total of 1,651 participants were included. Compared to standard care, conservative treatments did not significantly reduce lymphedema volume. There was low to very low certainty evidence of benefit for several treatments on secondary outcomes. There is insufficient evidence to suggest important differences between standard care and conservative treatment strategies for reducing lymphedema volume and improving lymphedema-related symptoms. //onf.ons.org/supplementary-material-conservative-intervention-strategies-adult-cancer-related-lymphedema.

Left-sided omental infarction without torsion: report of a case with radiologic-pathologic correlation

BackgroundOmental infarction is a rare disease that affects the entire omentum or a segment of the greater omentum. It presents as acute abdominal pain mainly in the right lower quadrant or right flank. Left-sided omental torsion is infrequent and it is rarely preoperatively diagnosed.Omental infarction is a differential diagnosis in the acute abdomen. As most cases of omental infarction can be adequately diagnosed via computed tomography, a conservative treatment strategy for patients without complications should be considered in order to avoid any unnecessary surgical intervention.Case presentationWe herein report a case of a surgically proved left-sided infarction of the greater omentum presenting with abdominal pain, tenderness of the left flank. Specifically, we describe the ultrasound (US) and computed tomography (CT) findings of this rare disease providing a radiological-pathological correlation of them. To date, there are few similar correlation reports in literature.ConclusionsAlthough the classical treatment of omental infarction is surgery, more recently the conservative management has been suggested. Thus, we believe that the knowledge of the characteristic imaging findings is essential for establish a correct preoperative diagnosis, which can avoid unnecessary surgical intervention.

Pharmacological treatment strategies for patients with monogenic obesity.

The leptin melanocortin signaling pathway is playing a pivotal role for body weight regulation. Genetic defects within this cascade are leading to severe hyperphagia and early onset obesity. In most cases, due to persistent hyperphagia the affected patients are not able to stabilize body weight for a longer period of time with conservative treatment strategies based on lifestyle interventions. Therefore, it is of importance to implement alternative treatment options for these patients. This review provides an overview about the published pharmacological treatment attempts in respect to monogenic forms of obesity and summarizes recent research progress about the role of MC4R signaling and POMC derivatives for body weight regulation.