Failure Of Medical Management Research Articles

Mifepristone Combination Therapy Versus Misoprostol Monotherapy for Early Pregnancy Loss: A Cost Analysis [17F

INTRODUCTION: For years, mifepristone combined with misoprostol was considered standard treatment for first-trimester abortions. In 2018, ACOG finally updated its recommendations to include mifepristone for management of early pregnancy loss (EPL). Adoption of this has met resistance. One perceived barrier to the provision of mifepristone is cost. Our aim is to determine if mifepristone pretreatment adversely affects cost of medical management of EPL. METHODS: Decision tree analyses were constructed comparing costs of combination therapy versus monotherapy in multiple scenarios weighing provider practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from recent randomized controlled trials. RESULTS: In nearly every scenario, combination therapy was favored over monotherapy. When surgical costs were higher, combined therapy was highly favored ($254.90 vs $391.60 per patient, 54% greater for monotherapy). Only when office manual vacuum aspiration was exclusively used and the patient population received minimum Federal wages was monotherapy minimally favored ($149.91 vs $152.54 per patient, 2% less for monotherapy). For equality of cost to occur in the various scenarios, the difference in completion rates between combination therapy and monotherapy needed to be between 5.6% and 15.2% - levels significantly less than that found in the literature (14.7% to 30.9%). CONCLUSION: Mifepristone combined with misoprostol is overall more cost effective than monotherapy and therefore cost should not be a deterrent to its adoption.

Extensive Genital Warts in Man Hampering Conjugal Life: A Case Report

Genital warts, commonly known as condyloma acuminata, caused by the proliferation of squamous epithelial cells in the presence of sexually transmission of human papilloma Virus (HPV) infection. In human, HPV infection results in simple condyloma acuminatum, giant condyloma or Buschke-LÖwenstein tumour, and seldom penile carcinoma. There are several modalities of treatment options available for genital warts- medical and surgical, alone or in combination. Sometimes extensive genital warts represent a district entity resulting from HPV infection and require surgical management. We present the case of a 42-year-old male; rickshaw puller had multiple professional female sexual partners, who presented with extensive genital warts in penoscrotal region. Lesions were treated due to failure of medical management, by wide electrosurgical excision and rotation scrotal skin flaps
 Anwer Khan Modern Medical College Journal Vol. 11, No. 1: Jan 2020, P 82-85

2566 Timing of Surgical Intervention Following Failed Medical Management of Ectopic Pregnancy

Study Objective To assess the timing at which patients received surgical management after receiving methotrexate (MTX) for management of ectopic pregnancy (EP). Design Retrospective cohort study at a single academic institution of patients treated for EP between January 2000 and December 2017. Medical records were reviewed for demographic and clinical information as well as approach to management. Setting N/A Patients or Participants 896 patients treated for EP were included. 220 (24.6%) of these patients were lost to follow up and their final outcomes were not available. Interventions N/A Measurements and Main Results Of the 676 patients with final outcomes available, 139 ultimately underwent surgical excision of EP (20.5%). Progression of ultrasound findings and significant worsening of pelvic pain accounted for the decision to proceed with surgery in all but 8 patients (94%). These 8 patients were operated on due to inappropriate hcg trend following multiple doses of MTX. Progression of ultrasound findings was noted in 82.5% of patients. Significant worsening of pelvic pain was present in 46.2% of patients. The median number of days from MTX administration to surgery was 7. Fifteen patients (10.8%) underwent surgery within 24 hours following MTX administration. Of those requiring surgery, only 8 patients (5.8%) had hcg values below 200. The indication for surgery in a majority of these cases was plateauing hcg values. Conclusion Despite the high success rate of medical management of EP, loss to follow up is significant in an urban population. A majority (74%) of patients that fail MTX do so within the first 10 days of treatment. Very few patients require surgical management after their hcg values decrease below 200. Given that pain is a reliable motivator to present for evaluation, it may be reasonable to limit follow up after hcg levels fall below 200.

2860 Safety of Esophageal Dilation in Patients With Eosinophilic Esophagitis in a Single Center Cohort

INTRODUCTION: Eosinophilic esophagitis (EoE), a chronic immune-mediated disorder, is a leading cause of food impaction due to fibrotic formation of rings, narrowing, and strictures. Historically, esophageal dilation (ED) was reserved as second-line therapy for EoE after failure of medical management, due to concern of complications, mainly perforation. Now, ED is recognized as an effective treatment for symptomatic relief. The aim of this study is to assess the safety of ED in a large cohort of EoE cases in a single center. METHODS: A retrospective review of patients with biopsy confirmed EoE at University of Iowa Hospitals and Clinics between the years 2006 – 2018 was conducted. All subjects met diagnostic criteria for EoE; presence of esophageal dysfunction and mucosal eosinophilic infiltration (≥15 eos/hpf). Histologic and clinical features, ED characteristics and related complications, and self-reported symptomatic improvement were extracted via chart review. Descriptive statistic with univariate analysis was performed. RESULTS: A total of 160 patients were dilated 295 times, ranging from 1-12 dilations per patient, with an average of 1.91 dilations per patient. 67 patients (41.88%) required >1 dilation. Procedures were generally tolerated well, with no major bleeds or perforations. The overall complication rate was 6.1%, primarily due to post-procedural chest pain (4.8%). Three patients had sedation related complications: one aspiration pneumonia and two ICU admissions for respiratory distress. Clinical improvement was documented in 87% of dilations on follow up. Table 1 and Figure 1 and 2. CONCLUSION: The prevalence of EoE is increasing with rates of 0.5 – 1 cases per 1000 individuals, with 25-35% of these patients requiring ED for symptomatic management. In the early 2000s, many reports suggested an increased procedure-related risk, including esophageal perforation. Recent systematic review and meta-analysis have shown otherwise. Present published rate of perforation in dilation in EoE occurs in < 0.3% of procedures, which approximates that of dilation for other benign esophageal indications. Our study is consistent with current data. Taking the above safety data of ED into account along with the rising incidence of EoE, lends evidence to the acceptance of ED as a safe and effective treatment. ED should therefore be considered a safe procedure in EoE patients for symptomatic management in addition to dietary and pharmacological interventions.

P074 Review of patients with inflammatory bowel disease at the university hospital of the West Indies between 1980-June 2018

BACKGROUND: There are limited data on the incidence and prevalence of Inflammatory bowel disease (IBD) in Jamaica and other Caribbean countries. The aim of this study is to determine the clinical features, course and outcomes of patients with IBD in Jamaica. METHODS: A retrospective chart review of patients who were diagnosed with IBD and seen at the University Hospital of the West Indies between the period January 1980 to June 2018 was conducted. Data collected included: demographic characteristics and symptoms, endoscopic disease activity at last endoscopy, treatment and response to therapy, and surgical requirement. Descriptive statistics was computed using Stata 14 statistical software. RESULTS: We identified 115 patients with IBD during the study period. Mean age was 48.2 ± 17.7 years, 61.7% were females and mean disease duration was 12.5 ± 10.2 years. Forty-three patients (37.4%) had Crohn's disease (CD) and 72 (62.6%) had ulcerative colitis (UC). The most common presenting symptom was diarrhea (86 patients, 78.2%) and was more common in females (88% vs 62%; P value 0.001). Most patients with UC had pancolitis (54.2%), 19.4% left sided colitis and 18.1% had proctitis/proctosigmoiditis. Disease distribution in CD was mainly ileal in 37.2%, ileo-colonic in 34.9% and colonic in 23.3%. CD phenotype was inflammatory in 37.2% of patients, stricturing in 25.6% and penetrating in 32.6%. The majority of patients had moderate/high risk disease (66.1%). Eighty-nine patients (78.1%) were treated with 5-aminosalicylates, 37 (32.2%) with immunomodulators, 1 (0.9%) with a biologic agent, 48 (41.7%) were on chronic steroids and 7 (6.1%) were not on any medications. Chronic steroid use was associated with side effects in 36.4% of patients with steroid induced diabetes mellitus being the most frequent side effect occurring in 9 patients, all of whom were females (16.4% vs 0%; P value 0.007). Twenty six patients required surgical therapy for IBD. The most common indication for surgery in patients with CD was bowel obstruction (45.8%) whereas 2 patients with UC had surgery for failed medical management and spontaneous perforation respectively. Over the last 2 years patients with CD required more frequent hospital admissions for disease flares than patients with UC (0.9 ± 1.3 vs 0.3 ± 0.7; P value 0.005). Clinical remission was achieved by 75% of patients at their last clinic visit. CONCLUSION(S): Only 115 patients with IBD were identified over a 38 year period at a single referral center in Jamaica. UC was more commonly diagnosed than CD. The most common presenting symptom was diarrhea. Most patients with UC had pancolitis whereas most patients with CD had inflammatory ileal disease. A third of patients were maintained on chronic steroids. Most patients achieved clinical remission at their last clinic visit.

Role of inferior turbinate reduction in the quality of life of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis.

The impact on quality of life (QoL) of bilateral inferior turbinate reduction (BITR) performed in the setting of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) has been a point of controversy. The aim of this study was to determine whether addition of BITR to ESS is associated with improved QoL when compared with ESS alone. This study presented findings a multi-institutional, retrospective analysis of a prospective open cohort of patients electing ESS for failed medical management of CRS. QoL parameters were compared between patients who underwent ESS alone vs those who underwent ESS with BITR. A total of 571 patients with CRS who elected to undergo ESS were identified. Sixty-one of these patients also underwent concurrent BITR, whereas 510 patients underwent ESS without BITR. Mean length of follow-up was 15.1 months. Comparison between baseline and last postoperative QoL, olfaction, and endoscopic scores revealed significant improvement in both groups. Overall, BITR surgery was not significantly associated with clinically significant incremental improvement in QoL in either the polyp or non-polyp group. Nevertheless, statistically significant improvement was noted for the nasal congestion/blockage symptom in polyp patients (p = 0.006) and in primary surgery patients (p = 0.027) who underwent BITR. BITR in the setting of ESS for CRS is not associated with significant incremental improvement in overall QoL vs ESS alone. However, BITR in polyp and primary surgery patients undergoing ESS appears to offer a significant incremental improvement in nasal congestion/blockage symptoms compared with ESS alone. Future studies are warranted to better corroborate these findings.

What Factors Predict Failure of Nonsurgical Management of a Lumbar Surgical Site Infection?

One of the most frequent complications of invasive lumbar spine surgery is postoperative surgical site infections (SSIs). Although there are absolute criteria for surgical intervention (progressive neurologic deficit, sepsis, failure of medical management), the treatment of routine, uncomplicated SSIs remains somewhat unclear. The purpose of this study was to evaluate the outcome of a series of patients with postoperative surgical site infections who were treated with or without surgical intervention. The primary clinical outcome was the assessment of whether medical management alone would be sufficient to eradicate the infection. A retrospective review of consecutive patients who underwent lumbar surgery complicated by spine infection between 2011 and 2017 was performed in order to determine what factors, if any, resulted in the need for additional surgical management. Medical records were reviewed for various demographic (e.g., age), clinical (e.g., organism), and surgical (e.g., presence of instrumentation) factors. A regression analysis was performed to identify what variables significantly increased the risk for SSI. During the 6-year period studied, a total of 74 patients met the inclusion criteria and were included in the study. There were 13 patients who failed medical management and required additional surgical management, which included irrigation and debridement. Thus, overall, medical management alone was effective in 82% of patients. In the final multivariate logistic regression analysis model, revision primary surgery had the strongest association with SSI that would require a washout. In addition, diabetes had a strong association with the occurrence of an infection. Identification of risk factors associated with the need for additional surgical management may benefit from aggressive antibiotic therapy to reduce the likelihood of reoperation. Clinicians should be aware of the identified risk factors, which may help with postoperative management in at-risk individuals.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Aided by Transcervical Instrumental Uterine Manipulation

Study ObjectiveTo describe the technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the aid of transcervical instrumental uterine manipulation. DesignVideo with step by step description of technique. SettingMinimally Invasive Gynaecological Surgery Department, Naval Multi Speciality Hospital, Jalgaon, India. PatientA 47-year-old woman. InterventionvNOTES hysterectomy. Measurements and Main ResultsA 47-year-old patient presented with history of menorrhagia since 4 years as well as a history of failed medical management for menorrhagia. Ultrasonography showed an enlarged uterus with findings suggestive of adenomyosis. Body mass index of the patient was 27. She had a history of 2 normal vaginal deliveries and had undergone laparoscopic tubal sterilization in the past. During vNOTES hysterectomy, an instrument was placed transcervically into the uterus for manipulation, providing leverage that helped gain good exposure of all uterine attachments. It also prevented unintentional rotation of uterus and its attachments. Therefore, the surgeon did not need to use a second hand for retraction of the uterus during surgery, allowing that second hand for retraction of bowel and adnexa. Hysterectomy was completed without any complications. Total estimated blood loss was 55 mL, and the patient was discharged on the third day. ConclusionBecause the tip of instrument is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures, thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique for vNOTES hysterectomy.

Favorable Outcomes with Ventricular Assist Device Exchange

Left ventricular assist device (LVAD) therapy remains a vital therapeutic option for patients with end-stage heart failure. Unfortunately, adverse events can occur and progress to require consideration for device exchange once the failure of medical management becomes evident, especially when heart transplantation is not possible in a timely manner. The aim of this analysis is to describe the incidence and outcomes of LVAD exchanges at our institution. Between April 2008 and May 2017, 397 patients underwent LVAD implantation, with 32 of those patients subsequently receiving exchange upon the recommendation of our multidisciplinary team due to refractory infection (n=12), device malfunction (n=5), hemolysis (n=9) and pump thrombosis (n=6). The average time from index implant to exchange was 580.6 days, with an average length of stay of 18.2 days. Survival at 3 months was 84.4%, 75.0% at 1 year and median at 8.3 years after exchange. The most common adverse events, occurring in less than 1/3 of the population, included bleeding, infection and stroke. This study suggests that LVAD exchange can be an effective and definitive mechanism for the treatment of otherwise potential fatal pump complications in highly select patients.

Management of cervical spine epidural abscess: a systematic review.

Background:Cervical spinal epidural abscess (CSEA) is a localized infection between the thecal sac and cervical spinal column which may result in neurological deficit and death if inadequately treated. Two treatment options exist: medical management and surgical intervention. Our objective was to analyze CSEA patient outcomes in order to determine the optimal method of treatment.Methods:An electronic literature search for relevant case series and retrospective reviews was conducted through June 2016. Data abstraction and study quality assessment were performed by two independent reviewers. A lack of available data led to a post hoc decision not to perform meta-analysis of the results; study findings were synthesized qualitatively.Results:927 studies were identified, of which 11 were included. Four studies were ranked as good quality, and seven ranked as fair quality. In total, data from 173 patients were included. Mean age was 55 years; 61.3% were male. Intravenous drug use was the most common risk factor for CSEA development. Staphylococcus aureus was the most commonly cultured pathogen. 140 patients underwent initial surgery, an additional 18 patients were surgically treated upon failure of medical management, and 15 patients were treated with antibiotics alone.Conclusion:The rates of medical management failure described in our review were much higher than those reported in the literature for thoracolumbar spinal epidural abscess patients, suggesting that CSEA patients may be at a greater risk for poor outcomes following nonoperative treatment. Thus, early surgery appears most viable for optimizing CSEA patient outcomes. Further research is needed in order to corroborate these recommendations.

Urethral stricture after bipolar transurethral resection of prostate - truth vs hype: A randomized controlled trial.

Introduction:Bipolar transurethral resection of prostate (B-TURP) was introduced as an alternative procedure to minimize the surgical complications of monopolar TURP (M-TURP). However, there are concerns about increased incidence of stricture urethra (SU) post B-TURP. This study was designed to analyze the incidence of SU among patients undergoing M-TURP versus B-TURP.Materials and Methods:This is a randomized controlled, single-blinded study; randomization was performed using a stratified permuted randomization algorithm (1:1 ratio) and only the patients were blinded. Both M-TURP and B-TURP were performed with a 26 Fr resectoscope; the electrosurgical generators were Karl Storz Autocon II 400 and Olympus UES-40 SurgMaster (TUR in saline [TURIS] method), respectively. Follow-up visits were scheduled at 3, 6, and 12 months post surgery and patients with lower urinary tract symptoms and a maximum urinary flow rate of <10 ml/sec on uroflowmetry underwent retrograde urethrography to assess for development of SU.Results:Forty patients were randomised to each arm. None developed SU in the monopolar group, whereas there were three cases in the bipolar group (P = 0.2). Among these three patients, two belonged to the failed medical management subgroup and one to the refractory urinary retention subgroup (P = 1.0).Conclusion:The incidence of SU following B-TURP using the TURIS system was comparable to the conventional M-TURP. Moreover, the incidence of SU was same for both the techniques when sub-grouped according to the indication for surgery that is failed medical management versus refractory urinary retention.

Lumbar Epidural Abscesses: A Systematic Review.

Study Design:Systematic review.Objectives:Spinal epidural abscesses (SEAs) are rare, but when missed or when diagnosis is delayed, SEA can lead to permanent neurological impairment or death. Limited information exists on the optimal treatment modalities for SEA, especially in the lumbar spine. We synthesize the current literature to identify the clinical features, diagnosis, management, and outcomes of lumbar SEA.Methods:Queries in 4 databases—EMBASE, MEDLINE, Scopus, and Web of Science—were performed using comprehensive search terms to locate published literature on lumbar SEA.Results:Ten articles reporting results for 600 cases of lumbar SEA were included, published between 2000 and 2017. Negative prognostic factors included diabetes, older age, methicillin-resistant Staphylococcus aureus, immune compromise, and more severe disease at presentation. Early first-line surgically treated patients responded better, specifically in terms of motor recovery, than those undergoing medical management or failing medical treatment, despite generally worse initial presentation. Elevated C-reactive protein, leukocytosis, and positive blood cultures predicted medical management failure.Conclusions:This systematic review provides guidance to neurological and orthopedic spine surgeons seeking the best treatment for lumbar-localized SEA. This study is limited by a dearth of high-quality publications to support evidenced-based management recommendations. Surgical treatment appears to provide better outcomes than medical treatment alone, especially in those who present with a motor deficit. Further investigation is needed to confirm this finding. What is clear is that early recognition and treatment remains crucial to minimizing morbidity and mortality of SEA.

Fibrocalculous pancreatic diabetes with hemorrhagic pericardial effusion in a female—a rare case report

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes due to non-alcoholic chronic pancreatitis peculiar to tropical countries. The hallmark features are younger age of onset pain abdomen and presence of pancreatic calculi. Though etiology remains unclear but on long-term follow-up, patient may develop microvascular and macrovascular complication. Chances of progression to malignancy are also high which carries poor prognosis. We present a case of a 36-year-old female presenting with recurrent abdominal pain, diabetes and chronic calcific pancreatitis. She was diagnosed to have FCPD based on her findings. She was managed with insulin, pancreatic enzyme supplementation and analgesics for pain relief. Due to her intractable pain poorly responding to medical management, she underwent Roux-en-Y pancreaticojejunostomy but later developed massive pericardial effusion hemorrhagic in nature with pleural effusion and ascitis. Analysis showed high possibility of adenocarcinoma though the primary focus could not be confirmed as the patient developed sepsis and unfortunately succumbed to her illness. Though FCPD is a rare entity, it is important to rule out chronic calcific pancreatitis as underlying etiology in all patients of diabetes presenting with recurrent pain abdomen and also to periodically screen FCPD patients for pancreatic malignancy. This helps to prevent progression to complications by an early medical intervention. Surgical intervention may be considered an option in case of failure of medical management, though data of its usefulness is very rare.

Predictors of Failure of Medical Management in Uncomplicated Type B Aortic Dissection

Optimal medical therapy (OMT) for uncomplicated type B aortic dissection (uTBAD) provides excellent short-term outcomes but is associated with a high incidence of failure. This study identified predictors of aortic intervention and mortality in uTBAD patients undergoing OMT. A retrospective review of the Emory University School of Medicine aortic database identified 314 uTBAD patients undergoing OMT from 2000 to 2016. Two hundred sixty-three (84%) patients had imaging at presentation analyzed for maximum aortic diameters (ADs), false lumen (FL) status, and visceral vessel perfusion. Cox proportional hazards models were constructed to estimate hazards ratios (HRs) and identify predictors of OMT failure. The mean age of patients was 58 ± 12 years, and 67% were men. FL status was patent in 59.4%, partially thrombosed in 39.8%, and completely thrombosed in 0.8% of patients. Over a median follow-up of 5.6 (interquartile range, 1.4 to 8.5) years, 44.9% of patients failed OMT and underwent intervention (n= 58 open, n= 83 endovascular). The estimated incidence of OMT failure was 46%. Multivariate analysis identified the presence of diabetes, renal failure, DeBakey 3B dissection, and a descending thoracic AD of 4.5 cm or greater (HR, 1.39; 95% confidence interval, 1.24 to 1.56; p < 0.001) to be independent predictors of failure of OMT. FL status or the distribution of visceral vessels arising from the FL did not predict OMT failure. There is a significant incidence of OMT failure in uTBAD patients. A descending thoracic AD of 4.5 cm or greater at the time of diagnosis is an independent predictor of failure of OMT.

Eustachian Tube Balloon Dilation: Emerging Practice Patterns for a Novel Procedure.

To review the role of eustachian tube balloon dilation (ETBD) in the setting of chronic Eustachian tube dysfunction (ETD) and ascertain how ETBD is currently being used in practice today. An online survey included 20 questions designed by 3 investigators to examine how otolaryngologists utilize ETBD in the management of ETD. The survey was distributed to the members of the American Rhinologic Society (ARS), American Otological Society (AOS), and American Neurotology Society (ANS) in their respective annual electronic mailings in April and May of 2017. A total of 1105 and 633 surveys were sent to ARS and AOS/ANS members, respectively. Of those, 157 surveys were returned (126 from ARS and 31 from AOS/ANS). Of those returning the survey, 72 (50%) had not performed ETBD and were excluded from subsequent analysis. Forty-four (66%) respondents consider ETBD after failure of medical management; conversely, 18 (27%) and 26 (39%) consider ETBD after failure of 1 or more trial of myringotomy tube placement. Routine testing for ETBD includes audiogram with tympanometry 64 (96%) and preoperative computer tomography (CT) 38 (57%). Fifty-three (80%) practitioners only perform ETBD in adults 18 years and older. Thirty-four (53%) respondents describe ETBD as "great" or "good," while 27 (42%) were unsure, and only 3 (5%) did not like ETBD. Eustachian tube balloon dilation is a novel technique for the treatment of chronic ETD, and its role continues to evolve and develop. Current practice patterns demonstrate wide variability in the assessment of ETD, heterogeneity in the timing of ETBD, and controversy in preoperative CT screening.

Predictors of Successful Outcomes of Selective Nerve Root Blocks for Acute Lumbar Disc Herniation.

Study Design:Prospective, observational cohort study.Objective:Selective nerve root block (SNRB) is an effective, standard interventional procedure for failed medical management in lumbar disc herniation (LDH). However, the factors that would predict successful outcomes in patients undergoing SNRB have not been clearly studied.Methods:Patients with failed conservative treatment for acute LDH, treated with SNRB were periodically followed till 1 year. Patients who failed to have pain relief or had recurrent pain after SNRB, underwent surgery. The pattern of radiculogram during SNRB was classified into 4 types—“arm,” “arrow,” “linear,” and “splash.” Various clinical factors, radiological factors, and radiculograms were compared between patients who had consistent pain relief (group A) and those patients who did not (group B).Results:A total of 91 patients underwent SNRB. Sixty-nine had good pain relief maintained till 1 year (75.8% success). Twenty-two patients underwent surgery after failed NRB at a mean of 6.3 weeks. Patients with sensory symptoms (P = .01), higher mean preinjection Oswestry Disability Index (ODI) score (P = .02), higher mean postinjection ODI score at 3 weeks (P = .004), nonmanual job (P = .01), lumbosacral transitional segment (P = .00 005), and splash pattern of radiculogram (P = .005) were predictive of failed NRB. Logistic regression analysis showed that lumbosacral transitional segment at the level of LDH is the most significant factor predicting poor outcome.Conclusions:SNRB is an effective technique to provide consistent symptom relief at least till 1 year in patients with acute LDH. The study identified several factors that predicted poor outcomes of SNRB and such patients can be forewarned about need for later surgery.

Long-term outcomes following restorative proctocolectomy ileal pouch-anal anastomosis in pediatric ulcerative colitis patients: Multicenter national study in Japan.

BackgroundFew studies have investigated surgical outcomes following a colectomy in pediatric patients with ulcerative colitis (UC).PurposeThis study aimed to determine long‐term outcomes in a large cohort of pediatric patients who underwent proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for UC.MethodsPediatric patients (<17 years old) who underwent surgery at 12 different hospitals in Japan between May 1979 and March 2015 were included in this study. Information was obtained by the use of a questionnaire survey.ResultsThere were 113 (53.3%) male and 99 (46.7%) female pediatric patients. The most common indication for elective surgery was failure of medical management, whereas emergency surgery was carried out for fulminant cases. A hand‐sewn IPAA was used with a mucosectomy in 112 (52.8%), stapled anastomosis in 93 (43.9%), and not specified in 7 (3.3%) patients. Small bowel obstruction and surgical site infection were the most frequent early postoperative complications (POC), whereas pouchitis, small bowel obstruction, and perianal fistula were frequent late POC. The most common late POC was pouchitis, found in 38 (17.9%) of the patients, whereas pouch failure was noted in 11 patients at the latest follow‐up examination. Cumulative pouch survival rate after 10 years was 91.7%. There were no significant differences regarding gender or anastomotic procedure in relation to cumulative pouch survival rate.ConclusionTo avoid pouch failure following an IPAA procedure, it is important to recognize that pouchitis or an anal fistula may lead to this condition in pediatric UC patients.

Blood Pressure Response during Cardiopulmonary Exercise Testing in Heart Failure.

The prognostic value of peak V˙O2 and V˙E/V˙CO2 slope measured during cardiopulmonary exercise (CPX) testing has been well established in patients with advanced heart failure, but blood pressure response to exercise is less well characterized. We retrospectively studied 151 outpatients who underwent CPX testing as part of an advanced heart failure evaluation. The outcome of interest was failure of medical management, defined by death, cardiac transplantation, or left ventricular assist device placement. Patients were stratified into tertiles by change in systolic blood pressure (SBP) (<13, 13-26, and ≥27 mm Hg) during exercise. Patients in the lowest tertile had the lowest peak V˙O2 (10.2 vs 10.6 vs 13.6 mL·kg·min, P = <0.001), the highest V˙E/V˙CO2 slope (42.8 vs 42.1 vs 36.3, P = 0.030), the shortest mean exercise time (5.1 vs 6.0 vs 7.0 min, P = <0.001), and the highest probability of failure of medical management at 1.5 yr (0.69 vs 0.41 vs 0.34, P = 0.011). After multivariate adjustment, increased SBP <20 mm Hg during exercise was associated with a lower hazard of medical management failure (hazard ratio = 0.96, 95% confidence interval [CI] = 0.934-0.987), whereas SBP increases >20 mm Hg were associated with an increased hazard (hazard ratio = 1.046, 95% CI = 1.018-1.075). In conclusion, changes in SBP during CPX testing provide additional prognostic information above standard clinical variables. The peculiar increase in risk noted in those with a rise in SBP >20 mm Hg is less clear and needs to be investigated further.

The role of ultrasonography in methotrexate therapy for ectopic pregnancy.

Medical management of ectopic pregnancy with methotrexate, an antimetabolite of folic acid, is an important alternative to surgical treatment, as it ensures a similar outcome whilst being far less invasive. Ultrasound evaluation does not only facilitate an accurate diagnosis, but also helps to select patients most likely to benefit from methotrexate treatment, as opposed to those with a high likelihood of failure of medical management, who are thus eligible for primary surgical treatment. Ultrasound also allows to monitor the outcome of methotrexate therapy. This study is a review of literature regarding the management of ectopic pregnancy with methotrexate. Such ultrasound findings as the size of the ectopic mass, presence of fetal heart rate and free fluid have been confirmed as effective eligibility criteria for therapy with methotrexate. In the future, possibly also endometrial stripe thickness and the vascularity of the ectopic mass may be considered predictive of successful methotrexate therapy. The initial increase in size of the ectopic mass following methotrexate therapy confirms its effectiveness, and should not prompt concern.

Arthroscopic Dorsal Capsuloplasty in Scapholunate Tears EWAS 3: Preliminary Results after a Minimum Follow-up of 1 Year

Purpose We retrospectively evaluated the results of all arthroscopic dorsal scapholunate (SL) capsuloplasty without pinning in patients presenting predynamic instability and dorsal capsuloscapholunate septum lesions on arthro-computed tomography scan after failed medical treatment. Materials and Methods Fifteen patients, mean age 34.3 years, underwent all arthroscopically assisted dorsal capsuloplasty. Patients were assessed preoperatively and postoperatively by a clinical (pain, Watson's test, range of motion, and strength), functional (quick disabilities of the arm, shoulder, and hand), patient-rated wrist evaluation, and Mayo wrist score scores), and radiological (SL gap and dorsal intercalated segmental instability [DISI]) examination. SL tears were evaluated during surgery by European Wrist Arthroscopy Society (EWAS) classification. Results The mean follow-up period was 20.2 months (range, 12-41). Preoperatively, positive Watson's test was noted in all cases. DISI deformity was noted in three cases without any SL gap. The SL instability was graded EWAS IIIB ( n = 8) or EWAS IIIC ( n = 7). Postoperatively, positive Watson's test was noted in only one case. Activity pain decreased from 7.8 preoperatively to 2.4 postoperatively. Range of motion in flexion-extension increased from 92.9 degrees preoperatively to 126.2 degrees postoperatively. Grip strength increased from 24.2 preoperatively to 38.2 postoperatively. At final follow-up, range of motion in flexion-extension and grip strength were estimated at 87 and 91% compared with contralateral side, respectively. All functional scores were significantly improved at the last follow-up. No radiographic SL gapping in grip views or DISI deformity was noted. Discussion Cadaveric studies demonstrated that the dorsal portion of SL ligament is critical for the stability of the SL complex. The entire arthroscopic SL capsuloplasty technique provides reliable results for pain relief, avoiding postoperative stiffness associated with open procedures. It is an alternative technique for patients with predynamic SL instability after failure of medical management and shall not prelude the resort to any further open procedure. Level of Evidence This is a level IV, case series.