Expectant Management Research Articles

Do all traumatic hemothorax require a tube thoracostomy: A retrospective review

Abstract Background: Blunt thoracic trauma accounts for a majority of trauma-related admissions. The Eastern Association for the Surgery of Trauma guidelines recommend placement of a tube thoracostomy for all patients with a hemothorax. Our study was conducted to look at those managed without an intercostal drain (ICD) and the factors that could predict a failure in conservative management. Materials and Methods: A retrospective study was conducted from January 2020 to June 2022 at a level-one trauma center in South India to account for patients who required a tube thoracostomy after planned expectant management for hemothorax. All adult patients above 16 years, with traumatic hemothorax were included. Those who had ICD inserted in the emergency department before computed tomography (CT) and those who did not have a CT Thorax were excluded. A retrospective review of patient records was conducted and analyzed using Stata (ver. 16). Results: Eighty-eight patients were included in the study, of whom 11 patients required a tube thoracostomy after an initial trial of conservative/expectant management (i.e., not inserting an ICD). The most common reason for failure was an increase in the size of the hemothorax. Among all the predictors we looked at, only a systolic blood pressure of <90 mm Hg on presentation was statistically significant for predicting failure of expectant management. Conclusion: Our study suggests not all patients with a traumatic hemothorax require a tube thoracostomy and can be managed expectantly provided close monitoring is possible. An increase in the size of the hemothorax was the main indication for a tube thoracostomy.

Revealing patient characteristics and treatment outcomes in ultra-long biologic users for psoriasis.

Biologics are effective for psoriasis, but little is known regarding patients treated with one biologic for an "ultra-long" duration. To explore the prevalence, patient and treatment characteristics and treatment outcomes of "ultra-long users" of biologics for psoriasis. From the prospective, multicenter BioCAPTURE cohort, patients with psoriasis who received continuous treatment with the same biologic for ≥10 years were included. Baseline characteristics of these "ultra-long users" were determined and compared to the total BioCAPTURE population. Additionally, the frequency of concomitant systemic treatment use and dose adjustments administered, the trajectory of Psoriasis Area and Severity Index (PASI) scores, and drug survival rates beyond 10 years were analysed. In BioCAPTURE, 30.5% of the patients with the potential to reach a treatment episode of ≥10 years achieved this treatment duration. These patients were treated with ustekinumab, etanercept, adalimumab and infliximab. The proportion of ultra-long users was highest for ustekinumab (37%). The ultra-long user cohort had a slightly longer disease duration at registry entry, and higher proportion of males and patients diagnosed with PsA, compared to the total BioCAPTURE population. A large percentage of ultra-long users (69.5%) had ≥1 comorbidities and 66% used no additional systemic antipsoriatic therapy. Dose adjustments were often applied, varying from dose escalation (30%), dose reduction (41%), or both (14%); only 16% consistently used the standard dose. The median PASI course for ultra-long users from month 6 onwards was continuously <3, with only a small proportion achieving complete clearance of their psoriasis (3.9-13.7% at the various time points). Drug survival beyond 10 years showed >60% was still treated with the same biologic after 15 years. Ultra-long use of the same biologic in patients with psoriasis was common in real-world practice, but varied between biologics. The median PASI was around 2.5 throughout the 10-year treatment course; complete clearance was often not reached. Remarkably, ultra-long use was reached also in patients having multiple comorbidities (including PsA) and a variety of dose adjustments of the biologics was applied. These results provide clinicians with important evidence on ultra-long biological treatment, thereby improving psoriasis care and management of treatment expectations.

Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial

BackgroundOutcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits. MethodsThirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization. ResultsThe groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01). ConclusionsOur results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies.

Impact of the ARRIVE Trial on Stillbirth Rates in Nulliparous Individuals.

We aim to examine the population-level rates of induction, stillbirth, perinatal mortality, and neonatal death before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial. This study was a cross-sectional analysis of publicly available U.S. Live Birth data linked with Infant Death and Fetal Death certificate data from National Vital Statistics Online. We limited analyses to nulliparous individuals with singleton pregnancy and cephalic presentation who delivered at 39 weeks or greater. The pre- and post-ARRIVE periods spanned from August 2016 to July 2018, and from January 2019 to December 2020, respectively. Our primary outcome was a stillbirth. Secondary outcomes included induction of labor, perinatal mortality, and neonatal death. Outcomes were compared between the pre- and post-ARRIVE periods. Modified Poisson regression was used to calculate adjusted relative risks (aRRs). Of 2,817,071 births, there were 1,454,346 births in the pre-ARRIVE period and 1,362,725 in the post-ARRIVE period; there were 1,196 and 1,062 stillbirths in the pre- and post-ARRIVE periods, respectively. Compared to the pre-ARRIVE period, the post-ARRIVE period was not associated with a significant decrease in the risk of stillbirth at 39 weeks or greater (aRR 0.92 [95% confidence interval {95% CI} 0.85-1.00]) and stillbirth at 40 weeks or greater (aRR 0.92 [95% CI 0.82-1.04]). Compared to the pre-ARRIVE trial period, the post-ARRIVE trial was associated with increased rates of induction of labor at 39 weeks (aRR 1.37 [95% CI 1.37-1.38]) and 40 weeks (aRR 1.24 [95% CI 1.24-1.25]. Similar to stillbirth, there was no significant decrease in the risk of perinatal mortality at 39 weeks or greater or 40 weeks or greater. There was also no statistically significant change in neonatal death rates at 39 weeks or greater or at 40 weeks or greater. The increase in induction of labor at 39 weeks was not large enough to impact the stillbirth rate at 39 weeks or greater. · Post-ARRIVE trial, rate of induction of labor increased at 39 and 40 weeks.. · Post-ARRIVE trial, stillbirth and perinatal mortality rates remained unchanged.. · Induction rate rise post-ARRIVE trial did not impact neonatal death rates..

Predictors of successful expectant and medical management of miscarriage: A systematic review.

15.3% of pregnancies result in miscarriage, management options include expectant, medical, or surgical. However, each patient has a range of variables, which makes navigating the available literature challenging when supporting individual patient decision-making. This systematic review aims to investigate whether there are any specific predictors for miscarriage management outcome. The following databases were searched, from the start of each database up to April 2023: PubMed, Medline, and Google Scholar. Inclusion criteria were studies interrogating defined predictors for expectant or medical management of miscarriage success. Exclusion criteria were poor quality, review articles, trial protocols, and congress abstracts. Data collection was carried as per PRISMA guidelines. Quality assessment for each study was assessed using the QUIPS proforma. Relevant predictors include demographics, ultrasound features, presenting symptoms, and biochemical markers. Across the 24 studies there is heterogeneity in miscarriage definition, predictors reported, and management outcomes used. Associations with certain variables and miscarriage management outcomes are described. Ten studies assessed the impact of miscarriage type on expectant and/or medical management. The majority found that a diagnosis of incomplete miscarriage had a higher success rate following expectant or medical management compared to missed miscarriage or anembryonic pregnancy. We conclude that there is evidence supporting the possibility to offer personalized miscarriage management advice with case specific predictors. Further larger studies with consistent definitions of predictors, management, and outcomes are needed in order to better support women through the decision-making of miscarriage management.

Balancing key stakeholder priorities and ethical principles to design a trial comparing intervention or expectant management for early-onset selective fetal growth restriction in monochorionic twin pregnancy: FERN qualitative study

ObjectivesAs part of the FERN feasibility study, this qualitative research aimed to explore parents’ and clinicians’ views on the acceptability, feasibility and design of a randomised controlled trial (RCT) of...

Prevalence of and risk factors for endometrial polyps among asymptomatic postmenopausal women with uterovaginal prolapse

The prevalence of endometrial polyps among asymptomatic, postmenopausal women is not well defined. There is no clear clinical consensus on how to manage endometrial polyps in this population and whether these polyps truly are cause for clinical concern. To estimate the prevalence of endometrial polyps among asymptomatic (without bleeding), postmenopausal women, and evaluate risk factors associated with their presence. This cross-sectional study assessed the prevalence of endometrial polyps among asymptomatic, postmenopausal women undergoing hysterectomy for uterovaginal prolapse. Patients were excluded if undergoing hysterectomy for other indications including postmenopausal bleeding. Chart review included eligible patients who received care at a single-site in Washington state from 2009 to 2018. The primary outcome was presence of endometrial polyps on pathology. Risk factors associated with polyp prevalence were subsequently assessed using univariate analysis and multivariate regression. Of the 317 eligible women identified, endometrial polyps were identified in 106 women (33.4%). The average polyp size and endometrial thickness was 13 +/- 10mm and 1.4 +/- 1.5mm. Most cases, 78%, had solitary polyps. Premalignant and malignant lesions were found in 2 cases (1.89%); one had endometrial carcinoma and one had endometrial intraepithelial neoplasia. Baseline clinical and demographic characteristics were similar between patients with and without endometrial polyps, including the presence of fibroids, endometriosis and adenomyosis. Multivariate logistic regression showed that presence of polyps was independently associated with high body mass index (OR 1.06, 95%-CI 1.01-1.12, p-value 0.02) and use of menopausal hormone therapy (OR 1.67, 95%-CI 1.02 - 2.72, p-value 0.04). Asymptomatic postmenopausal women undergoing hysterectomy for uterovaginal prolapse exhibit a high prevalence of endometrial polyps. Those with use of menopausal hormone therapy and high body mass index are at a higher risk of developing endometrial polyps. While the malignant risk seems to be low, more investigation is warranted to truly quantify the lifetime risk. For now, expectant management may be a reasonable approach for incidentally found, asymptomatic polyps.

The role of VEGF and TGF-β blood levels for fibroid shrinkage, menorrhagia score, and quality of life improvement after uterine artery embolization for uterine fibroids: a study protocol.

Uterine leiomyoma is a common condition affecting women that occurs in more than 70% of females. Women with leiomyomas overall have lower quality of life and deficiency in many specific spheres of life including work-related productivity, sexuality, relationships, social-emotional health, and physical well-being that might be present even in pre-and extended throughout early postmenopausal life. Choices for symptomatic fibroid management include medical, interventional radiology procedures, surgical, and expectant management. The uterine artery embolization (UAE) procedure has gained justified popularity for myoma management. Growth factors, vascular endothelial growth factor (VEGF) and tumor growth factor β (TGF-β), hold an important role in leiomyoma progression. However, blood levels of VEGF and TGF-β in patients before and after UAE are not fully investigated and the possible relationship with myoma shrinkage has not been evaluated. Therefore, this study aims to assess menorrhagia score and quality of life improvement after UAE for uterine fibroids and compare blood levels of VEGF and TGF-β in patients with uterine leiomyoma before and after UAE. This cross-sectional study will be performed at the University Medical Center, Astana, Kazakhstan. Women undergoing the UAE procedure for uterine leiomyoma will be involved in the study following the precisely defined inclusion/exclusion criteria. Uterine leiomyoma nodules' structural changes after UAE will be assessed along with the blood levels of growth factors (VEGF and TGF-β), menorrhagia score, and quality of life. An important outcome of this project will be an investigation of the blood levels of growth factors (VEGF and TGF-β) before and after the procedure and their association with leiomyoma shrinkage in correlation with the menorrhagia score and quality of life alterations among patients undergoing UAE.

Risk of hypertensive disorders of pregnancy in electively induced or expectantly managed full-term IVF pregnancies

Research questionAre there differences in the rates of hypertensive disorders of pregnancy among in vitro fertilization (IVF) patients who underwent induction of labor at 39 weeks compared to those who were managed expectantly? DesignThis is a retrospective cohort study of 1,176 low-risk singleton pregnancies conceived following IVF with no contraindications to vaginal delivery. Two groups were constructed: elective induction of labor from 39 weeks 0 days to 39 weeks 6 days (n=234) versus expectant management (n=942). Main outcome measure was the incidence of hypertensive disorders of pregnancy. Secondary outcome was the rate of cesarean delivery. Sub-analyses were performed within fresh and frozen embryo transfer groups. ResultsHypertensive disorders of pregnancy developed in 8.1% of patients in the induction of labor group and in 12.4% in the expectant management group (P=.06). This difference was attenuated after controlling for potential confounders (P=.28). For frozen embryo transfers, the unadjusted odds of hypertensive disorders of pregnancy were significantly lower with induction of labor compared to expectant management (P=.02) and after adjusting for confounders, the odds ratio neared significance (P=.09). For fresh transfers, there was no difference in the odds of hypertensive disorders of pregnancy between the two groups. The odds of delivering via cesarean section were higher in the induction of labor group, in the total population and in sub-analyses. ConclusionOverall, in IVF conceived pregnancies, induction of labor when compared to expectant management was not associated with a lower incidence of hypertensive disorders of pregnancy, it was however, associated with a higher rate of cesarean delivery.

Ten Myths in Nerve Surgery.

Surgical innovation has provided new options for the management of complex peripheral nerve injuries, generating renewed interest in this field. Historic literature may be misinterpreted or misquoted, or create dogma, which is perpetuated in teaching, research publications, and clinical practice. The management of peripheral nerve injuries is based on complex decision-making, with potential lifelong ramifications for patients incorrectly receiving an expectant or surgical management plan. This article includes opinion from expert leaders in the field of peripheral nerve surgery and questions some of the current assumptions and preconceptions around nerve surgery based on clinical evidence. There was extensive debate regarding the contents of the final article, and the different opinions expressed represent the uncertainty in this field and the differing levels of confidence in available published evidence. Individual practices vary and, therefore, absolute consensus is impossible to achieve. The work is presented as 10 myths which are assessed using both historical and emerging evidence, and areas of uncertainty are discussed. It is important to learn lessons from the past, and scholars of history bear the task of ensuring references are accurately quoted. Expunging myths will enhance care for patients, focus research efforts, and expand on the surgical possibilities within this specialty.

Upper Extremity Ballistic Nerve Injury

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal.

Pre- and Periviable PPROM after Fetoscopic Laser Surgery: Are Survival Outcomes Better than We Think?

Limited data exist regarding outcomes when pre- and periviable PPROM (PPROM ≤26 weeks of gestation) occurs as a complication of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). This is a retrospective cohort study of FLS cases performed at a single institution between January 2015 and May 2021. Study inclusion was limited to patients with monochorionic-diamniotic twin pregnancies complicated by TTTS who underwent FLS. Patients were grouped by pPPROM status, and further stratified to those continuing with expectant management, and outcomes were compared between groups. The primary outcome was survival to live birth of at least one twin. During the study period, 171 patients underwent FLS and a total of 96 (56.1%) subjects satisfied inclusion criteria. Among included subjects, 18 (18.8%) experienced pPPROM after FLS and 78 (81.2%) did not. Baseline characteristics were similar between groups. Among patients with pPPROM, 11 (61.1%) pursued expectant management and 7 (38.9%) opted for pregnancy termination. Among expectantly managed subjects, median pPPROM-to-delivery interval was 47.0 days (6.0-66.0 IQR) with a median gestational age at delivery of 29+1 weeks (24 + 4-33 + 6 IQR). Rates of survival to live birth of at least one twin (90.9% vs. 96.2% p = 0.42) were similar between those with pPPROM undergoing expectant management and those without pPPROM. Dual survivorship (45.5% vs. 78.2%, p = 0.03), perinatal survival to live birth (68.2% vs. 87.2%, p = 0.05), and perinatal survival to newborn hospital discharge (59.1% vs. 85.9%, p = &lt;0.01) were all significantly lower among those with pPPROM. Gestational age at delivery was lower among those continuing with pregnancies complicated by pPPROM (29 + 1 vs. 32+5 weeks, p = &lt;0.01). Survival of at least one twin to live birth remained high among those pursing expectant management after experiencing post-FLS pPPROM, suggesting that the outlook after this complication is not necessarily poor. However, this complication was associated with lower chances of dual survival and greater prematurity.

Case report of rare cause of small bowel obstruction: distal migration of metal biliary stent requiring enterotomy

Endoscopic biliary stent placement is a mainstay in the management of biliary strictures both malignant and benign. Distal stent migration is a known complication of metal biliary stents, however small bowel obstruction or perforation are rare. In this report from a tertiary referral centre, we detail a mid-small bowel obstruction caused by covered metal stent migration requiring a laparotomy and enterotomy for definitive management. A 69-year-old male was admitted to the Sunshine Coast University Hospital with obstructive jaundice on a background of previous metal biliary stent placement. On day 3 of his admission, he developed worsening abdominal pain. Cross-sectional imaging demonstrated distal migration of his stent to his mid-jejunum, causing a high-grade small bowel obstruction. He underwent laparotomy to retrieve the stent. He recovered well and underwent a percutaneous transhepatic cholangiogram with stent replacement. In this case, distal biliary stent migration causes a small bowel obstruction. Whilst uncommon, risk factors including previous intra-abdominal operation can be used to identify patients unlikely to achieve successful expectant management of distal migration.

Genetic Heterogeneity, Craniofacial Surgical Burden, and Surgical Techniques in Patients With Saethre-Chotzen Syndrome.

While genotype correlates with phenotype in patients with many forms of syndromic craniosynostosis, the relationship between molecular diagnosis and craniofacial surgical history in patients with Saethre-Chotzen syndrome (SCS) is more variable. This manuscript characterizes that relationship and evaluates operative trends in these patients over the past 3 decades. Demographic information, molecular diagnosis, and craniofacial surgical history in patients born with SCS between 1989 and 2023 were compared with appropriate statistics, including t tests and analysis of variance. Thirty-five patients with SCS were included, and there was no difference in total craniofacial procedures among those with TWIST1 substitutions (2.1 ± 1.6), duplications (3.0 ± 4.2), insertions (3.5 ± 0.7), or deletions (2.4 ± 1.9; P = 0.97). Cranial expansion rates were also similar across all genetic diagnoses (P>0.05), and surgical incidence was similar across patients with unicoronal, bicoronal, and multisuture involvement (P > 0.05). Those with an initial fronto-orbital advancement had a lower incidence of secondary cranial vault procedures compared with those with an initial posterior vault distraction osteogenesis (29% versus 71%, P < 0.05), though this did not control for phenotypic severity. On average, total cranial vault surgical burden (1.35 ± 0.67 versus 1.75 ± 0.46) and cranial expansion surgical burden (1.40 ± 0.68 versus 1.88 ± 0.64) between the fronto-orbital advancement-first and posterior vault distraction osteogenesis-first cohorts were similar (P = 0.11, P = 0.17, respectively). While SCS is molecularly and phenotypically heterogeneous, genetic diagnosis does not appear associated with rates of craniofacial surgery. Additional prospective study of correlations between genotype, severity of craniofacial manifestations, and treatment algorithms is warranted; but, in the end, it may be that this highly variable form of syndromic craniosynostosis warrants tailored, expectant management.

Pearls of Wisdom: Expert Insights for Communicating With Aesthetic Patients.

Good communication with patients is essential in aesthetic surgery. In particular, the challenge of expectation management is crucial to optimise patient satisfaction, which may be irrespective of objective outcomes. Experienced plastic surgeons inevitably refine their consultation process and hone their communication skills throughout their years of practice. The invaluable "pearls" that expert surgeons develop would be beneficial to all surgeons and particularly those early in their practice. This concept prompted the authors to explore whether the communication skills acquired by a selected group of highly regarded plastic surgeons could be condensed and categorised in a way that others could benefit from. The purpose of this Special Topic is to demonstrate that there are a select number of core messages that many plastic surgeons desire to communicate, particularly during the pre-operative consultation process. Various phrases and aphorisms have been formulated within these sub-topics that we hope will be positively incorporated into colleagues' practices in order to improve the patient experience, and ultimately patients' understanding and satisfaction with their outcomes.

A Meta-Analysis Approach on Medical, Surgical and Expectant Management on Abortion of First Trimester

A Meta-Analysis Approach on Medical, Surgical and Expectant Management on Abortion of First Trimester

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Understanding and Setting Treatment Expectations for Patients With Metastatic Spine Tumors.

Literature review with clinical recommendation. A concise curation of the latest spine literature exploring the relationship between expectations and satisfaction for patients with metastatic spinal disease (MSD). Deliver recommendations to practicing clinicians regarding interpretation and utilisation of this evidence. The latest spine literature in the topic of factors affecting the expectations of patients with MSD was reviewed and clinical recommendations were formulated. Recommendations are graded as strong or Conditional. 5 articles were selected. Article 1: risk factors for the development of dissatisfaction from a cohort of 362 MSD patients. Strong recommendation to incorporate risk factor assessment when considering treatment. Article 2: systematic review assessing the relationship between pre-operative patient expectations and subsequent satisfaction in allied disciplines. Conditional recommendation to optimize patient expectation to positively modify patient satisfaction. Article 3: qualitative study of how clinicians, from different specialties, counsel patients with MSD pre-treatment. Strong recommendation to use a multidisciplinary approach. Article 4 qualitative study of how MSD patients experience their pre-treatment counselling and how that affected their appreciation of treatment success. Conditional recommendation to furnish patients with tailored, expected outcomes in the context of systemic progression. Article 5 Design and validation of a pre-treatment questionnaire specific to MSD. A conditional recommendation to incorporate this questionnaire in clinical and research MSD practice. Patients with MSD are approaching end of life care and high levels of treatment satisfaction are crucial at this juncture. The role of expectation management and comprehensive counselling is critical.

Visual performance, safety, and patient satisfaction after binocular clear lens extraction and trifocal intraocular lens implantation in Chinese presbyopic patients

BackgroundAddressing presbyopia in the aging population, particularly in non-cataractous patients, remains a challenge. This study evaluates the outcomes of refractive lens exchange (RLE) with AT LISA tri 839MP trifocal intraocular lens (IOL) implantation in a Chinese presbyopic population without cataracts.MethodsThe study included 164 eyes from 82 patients undergoing bilateral RLE at Peking Union Medical College Hospital. Comprehensive evaluations encompassed visual acuities, refraction, ocular aberrometry, and subjective outcomes via the VF-14 questionnaire. The focus was on postoperative visual performance, refractive outcomes, safety, objective optical quality, and patient satisfaction.Results100%, 90.2%, and 89.0% of patients achieved binocular UDVA, UNVA, and UIVA of logMAR 0.1 or better at 6 months postoperatively. 97.6% of eyes were within ± 1.00 D of emmetropia postoperatively. Optical quality assessments showed increases in modulation transfer function and Strehl ratios (p < 0.05). High-order aberrations decreased significantly (p < 0.05). Despite the high incidence of posterior capsule opacification (83.2%), managed with early Nd: YAG capsulotomy, no other severe complications were reported. Patient-reported outcomes indicated high satisfaction, with an average VF-14 score of 94.3 ± 10.2 and 93.5% achieving complete spectacle independence. Halo (66.2%) was the most commonly reported optical phenomena, followed by glare (18.2%), and starburst (7.8%) after surgery.ConclusionsBilateral RLE with trifocal IOLs in presbyopic patients without cataracts significantly improves visual acuity and reduces ocular aberrations in presbyopic patients. The procedure offers high patient satisfaction and spectacle independence, though it requires careful patient selection and management of expectations regarding potential photic phenomena.

The utility of axial imaging among selected patients in the early postoperative period after pancreatectomy

BackgroundPostoperative computed tomography imaging has been shown to play an important role in avoiding failure-to-rescue. We sought to examine the impact of the timing of such imaging studies on outcomes after pancreatectomy. MethodsPatients who underwent pancreatic resection at our institution from 2017 to 2022 were reviewed retrospectively to identify those undergoing computed tomography for any indication before discharge. Patients were subdivided by the postoperative day that the first computed tomography scan was obtained: immediate (postoperative day <3), early (postoperative day 3–7), and delayed (postoperative day >7). ResultsOf 370 patients, 110 (30%) had a computed tomography during the initial surgical stay. The 3 timing groups were similar in age, comorbidities, pathology, operative time, and number of scans. When comparing the early with the delayed group, we found that antibiotic usage, percutaneous drainage, and overall invasive interventions during surgical stay were all similar. However, those patients who were scanned in the early period had significantly shorter length of stay (17.05 vs 22.82, P = .0008) and fewer composite days hospitalized (20.1 vs 24.9, P = .01) relative to the delayed group. Importantly, early computed tomography imaging was found to be the only independent predictor of a postoperative length of stay ≤15 days on multivariate analysis. Surgical stay mortality rates were significantly lower in the early compared with delayed group (0% vs 11%, P = .02). A change in treatment was observed in 59% after computed tomography, with 15% undergoing invasive interventions, 27% treated medically, and 16% with expectant management. ConclusionIn our cohort, patients imaged early after pancreatectomy experienced shorter hospital stays and lower inpatient mortality relative to those scanned after the first postoperative week.

Challenges for the management of Johne’s disease in the UK: Expectation management, space, ‘free riding’, and vet-farmer communication

Johne’s disease in cattle is a significant global animal health challenge. Johne’s disease is chronic, affecting the gastrointestinal tract of cattle and other ruminants and is caused by the bacteria Mycobacterium avium ssp. Paratuberculosis. Many countries have introduced schemes and programmes to try and control the spread of Johne’s disease, including the UK. Despite efforts to control it, however, Johne’s disease remains consistently ranked by UK producers as the top ranked disease negatively affecting productivity, indicating that schemes are not perceived to have solved the problem fully. Building on a global systematic review of the literature on barriers and solutions for Johne’s disease control on-farm, we conducted an empirical study with over 400 farmers and 150 veterinary professionals across the UK. The study used workshops and semi-structured interviews to understand better the challenges dairy farmers and veterinarians face in implementing on-farm Johne’s disease management schemes with the aim of identifying solutions. The study found that four main challenges are faced in the on-farm control of Johne’s – (1) Management of farmer expectations around Johne’s disease, with eradication near impossible, (2) Issues regarding space for segregation and the related economics of control (3) A ‘free-riding’ problem which can be influenced by the voluntary nature of control plans and (4) Challenges in vet-farmer communication, including levels of knowledge. Our findings have relevance for the control of Johne’s disease in the UK and other countries, including for regions with voluntary and compulsory control programmes.