Failure Of Medical Treatment Research Articles

Desmoid tumors: who, when and how to treat?

The objective of this article is to summarize new treatment strategies of desmoid tumors. Desmoid tumor has an unpredictable evolution that may spontaneously regress or stabilize. A shift toward an initial frontline active surveillance has been acknowledged by experts. Surveillance monitoring should be performed frequently after the diagnosis to avoid missing a significant progression and then spaced in case of stabilization. Treatment is based on significant tumor growth or symptoms. Recent guidelines recommend commencing medical treatment. Kinase inhibitors and cytotoxic agents are the two classes of drugs where studies included progressive desmoid tumors and should be selected to guide medical practice. In a randomized trial, 2 years progression-free survival (PFS) was significantly better in the sorafenib group (81 versus 36% in the placebo group). In another randomized phase 2, 6 months PFS was 83.7% with pazopanib versus 45% with methotrexate and vinblastine. In a retrospective study, including progressive desmoid tumors, methotrexate + vinca alkaloids achieved 75 months median PFS. Cryotherapy is an alternative option in desmoid tumors with compatible locations and tumor sizes. Following medical treatment or cryotherapy failure, superficial sites represent the best indications for surgery in cases of continuous progression. In the event of a contra-indication or failure of medical treatment, in locations where surgery would be mutilating and incomplete, radiotherapy is an effective option. Active surveillance with planned imaging has become the first-line management in desmoid tumor.

P-351 Medical treatment for missed abortion- difference in gestational age based on menstrual dating and on ultrasound criteria, and the correlation to failure

Abstract Study question Does the difference in gestational age based on menstrual dating and on ultrasound criteria correlate with failure rate of medical treatment in missed abortions? Summary answer In missed abortions, the difference in gestational age based on menstrual dating and on ultrasound is inversely correlated with failure rate of medical treatment. What is known already A number of factors have been reported as predictors for Misoprostol treatment failure, including assisted reproductive treatment, primigravity, and vaginal bleeding prior to treatment. Increased rates of failure with medical management were also reported with delaying treatment after diagnosis. Study design, size, duration This was a retrospective cohort study. Overall, 778 patients who underwent medical treatment with Misoprostol for missed abortion at our institute, between 07/2015 and 12/2020 were included. Participants/materials, setting, methods Inclusion criteria were either anembryonic gestation or embryonic death, as long as pregnancy age, as measured by transvaginal sonography , correlated with 12 weeks gestation or less. Exclusion criteria included incomplete or septic abortions, multiple pregnancies, and cases that had either irregular period, missing data, or were lost to follow up. The primary outcome was treatment failure, defined as any need for surgical intervention (elective or emergency Dilation & curettage, or operative hysteroscopy). Main results and the role of chance Five hundred and eighty two patients (74.9%) had successful medical treatment, while 196 (25.1%) required surgical intervention. The gestational age based on menstrual dating and on ultrasound difference (in weeks) was 2.6±1.4 in the success group and 3.1±1.6 in the failure group (p < 0.001). On multivariant regression analysis, gestational age based on menstrual dating and on ultrasound difference was found to be independently correlated with treatment failure (aOR=1.24, CI 95% (1.01-1.51), p = 0.03). Limitations, reasons for caution We did not analyze long term consequences, such as the amount of bleeding, and time to future fertility. Moreover, patients who were treated at our institute may have been diagnosed and treated for treatment failure in neighboring hospitals and hence lost to follow-up. Wider implications of the findings The current study has shown that the difference between gestational age based on menstrual dating and on ultrasound is directly corelated with medical treatment failure. This data should be taken into account when counseling patients regarding the optimal treatment for first trimester missed abortion. Trial registration number not applicable

Tuboovaryan apseli hastalarda sistemik inflamatuvar belirteçlerin medikal tedavi başarısızlığını öngörmedeki yeri

Aim: Aimed to evaluate the role of systemic inflammatory markers and Aspartate aminotransferase to Platelet Ratio Index (APRI) sore in predicting medical treatment failure in patients with Tubo-ovarian abscess (TOA).
 Materials and Methods: Patients (n=240) hospitalized with a diagnosis of TOA between August 2016 - October 2020 were included in the study. Patients' demographic and clinical characteristics and mean C-Reactive protein (CRP) level, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and APRI score measured on admission were also recorded. The role of these parameters was investigated in predicting medical treatment failure in patients who only received medical treatment or who needed surgical treatment.
 Results: The mean age (40.95 ± 6.96 vs. 38.09 ± 7.69), abscess size (67.57 ± 19.86 mm vs. 52.78 ± 16.63 mm), CRP level, (140.61 ± 110.88 vs. 75.24 ± 36.64 mg/L), white blood cell count (13818.86 ± 5445.80 and 11845.31 ± 4424.39 μL), neutrophil count (11146.81 ± 5284.83 and 9242.03 ± 4278.60 μL) and NLR (9.52 ± 6.88 and 6.64 ± 6.30) of patients who received surgical treatment were significantly higher than those who received only medical treatment. In receiver operating characteristics (ROC) analysis area under the curve (AUC) 0.607 was statistically significant for CRP with a cut-off value of 11.57 to predict medical treatment failure (95% 0.531-0.682, sensitivity 63.3%, specificity 55.4%).
 Conclusion: NLR, PLR and APRI score are ineffective in predicting the need for surgical treatment. CRP could be used as a marker in predicting the need for surgical treatment in patients with TOA.

Tuboovaryan apseli hastalarda sistemik inflamatuvar belirteçlerin medikal tedavi başarısızlığını öngörmedeki yeri

Amaç: Tuboovaryan apse (TAO) olgularında sistemik inflamatuar belirteçler ve Aspartate aminotransferaz/Platelet Index (APRİ) skorun medikal tedavi başarısızlığını öngörmede yeri olup olmadığı araştırıldı. Gereç ve Yöntem: Ağustos 2016 – Ekim 2020 tarihleri arasında TOA tanısı ile yatırılarak tedavi edilen 240 hasta çalışmaya dâhil edildi. Hastaların demografik ve klinik özellikleri, tanı anında bakılan C- Reaktif protein (CRP), Nötrofil lenfosit oranı (NLR), Platelet lenfosit oranı (PLR) ve APRI skoru dosya kayıtlarından elde edildi. Sadece medikal (n=74) tedavi alan veya cerrahi tedavi gereken hastalarda (n=166) bu parametrelerin medikal tedavi başarısızlığını öngörmedeki yerleri araştırıldı. Bulgular: Cerrahi tedavi alan hastaların sadece medikal tedavi alanlara göre ortalama yaşı (40,95 ± 6,96 ve (38,09 ± 7,69), apse boyutu (67,57 ± 19,86 mm ve 52,78 ± 16,63 mm), CRP değeri (140,61 ± 110,88 ve 75,24 ± 36,64 mg/L), beyaz küre (13818,86 ± 5445,80 ve 11845,31 ± 4424,39 μL), nötrofil (11146,81 ± 5284,83 ve 9242,03 ± 4278,60 μL) ve NLR değeri (9.52 ± 6.88 ve 6.64 ± 6.30) anlamlı olarak daha yüksek bulundu. Receiver Operating Characteristics (ROC) eğrisi analizi (95% 0,531-0,682) ile CRP’nin >11,57 olmasının %63,3 sensitivite, %55,4 spesifite ile medikal tedavi başarısızlığını öngördüğü saptandı. Sonuç: NLR, PLR ve APRI skoru cerrahi tedavi gereksinimini öngörmede etkisizdir. CRP başvuru anında cerrahi tedavi gereksinimini belirlemek adına kullanılabilecek bir belirteçtir.

Arthroscopic Trillat technique for chronic post-traumatic anterior shoulder instability: outcomes at 2 years of follow-up.

The purpose of this study was to assess the outcomes of a new arthroscopic Trillat technique at a 2-year follow-up. Our current hypothesis was that this technique could be used for the effective treatment of chronic post-traumatic unidirectional anterior shoulder instability, and that the recurrence and complication rates, external rotation, and functional outcomes would be as good as those of the reference technique. Between April 2012 and August 2016, all patients older than 16 years who underwent the arthroscopic Trillat technique for unidirectional chronic post-traumatic anterior shoulder instability at the Dijon University Hospital (France), after the failure of well-conducted medical and rehabilitation treatment with at least 24 months of follow-up, were included. Criteria for noninclusion were association with posterior and/or inferior instabilities, voluntary instabilities, and glenoid bone loss greater than 20%. Patients attended follow-up with their surgeon before the intervention, in the immediate postoperative period, at 6 weeks, 3 and 6 months, and then by an independent observer for the last evaluation. Patients were then examined clinically with scores such as Constant, Rowe and Walch-Duplay scores, and subjective shoulder value, for shoulder range of motion, and radiographically (anteroposterior and Lamy's lateral x-rays of the operated shoulder). Forty-nine patients and 52 shoulders were included, with a mean follow-up of 40 months (range, 24-71 months). The recurrence rate of instability was 3.8% (2 of 52). No conversion to arthrotomy was necessary. No intraoperative complications, postoperative neurological lesions, or sepsis were observed. The mean Constant score was 92.1 (77.5-100) points, Walch-Duplay 82.9 (40-100), Rowe 81.73 (5-100), and subjective shoulder value 86.1 (50-100) at the last follow-up. The arm at side external rotation limitation averaged 8.4° (-25° to 40°) and the external rotation with 90° arm abduction limitation 0.34° (-5° to 15°). Forty-one patients (79%) resumed their sports activity at the same level. Fifty patients (96%) were satisfied to very satisfied. One patient developed nonunion of the coracoid process and subsequently underwent a Latarjet procedure with a good outcome. The arthroscopic Trillat procedure offers good outcomes as a first-line treatment for chronic anterior post-traumatic glenohumeral instability. It should be excluded in cases of glenoid loss greater than 20%.

Torsion of Fatty Appendage of Falciform Ligament: A Case Report

Torsion of the fatty appendage of the falciform ligament is an extremely rare condition that leads to severe abdominal pain and raised inflammatory markers. It can be recognised on ultrasound or CT scan. The pathophysiology is the same as that involved in the more common torsion and/or infarction of the greater omentum or epiploic appendages. The condition is best managed conservatively with anti-inflammatory analgesia, and the early recognition of this type of torsion may prevent unnecessary operative intervention to look for a source of abdominal pain. We report a rare case of torsion of the fatty appendage of the falciform ligament associated with pancreatitis C in 71 years old women. The management consisted of surgical treatment after failure of medical treatment with a favorable outcome.

Surgical management of secondary hyperparathyroidism in dialysis patients in Senegal.

Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease. Surgical management occurs in severe forms and/or unresponsive medical treatment. The aim of this study was to outline the indications of parathyroidectomy and its evolution after surgical approach. It was a five-year multicenter backward study in Otorhinolaryngology Department of Fann Hospital and four dialysis centers in Dakar. We include all patients with SHPT who underwent surgery. Preoperative clinical and paraclinical parameters, clinical-biological evolution, and histology findings of the resected parathyroid specimen were collected. Out of 58 patients with hyperparathyroidism, 18 patients required parathyroidectomy, corresponding to a prevalence of 31%. Mean age of patients was 46.6 ± 15.29 years and sex ratio 0.61. Mean duration on dialysis was 44.4 ± 30 months. Ten patients (55.56%) had bone pain and nine patients (50%) had joint pain. Mean serum calcium was 97.27 ± 8.66 mg/L. Mean blood phosphorus levels were 40.47 ± 9.99 mg/L. Mean iPTH rate was 1493.22 ± 1014.93 ng/mL, with a maximum of 5000 ng/mL (77N). Mean value of 25-OH Vitamin D was 32.89 ± 16.02 ng/mL. Parathyroidectomy was indicated after failure of medical treatment with persistence of a serum intact parathyroid hormone concentration above 800 μg/mL in all patients. Subtotal parathyroidectomy (7/8) was performed in 11 patients (61.1%). Two patients (11.11%) benefited from a selective parathyroidectomy (3/4). Evolution was favorable for 13 patients, corresponding to a success rate of 72.2%. It was unfavorable in five patients including one patient with hypoparathyroidism and four patients with recurrent hyperparathyroidism. Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism in developing countries.

Eight injections of Collagenase Clostridium Histolyticum May Be Effective in Calcified Plaques

ABSTRACT Introduction Peyronie's disease (PD) is the result of abnormal tissue healing in the tunica albuginea resulting in an inelastic plaque. In some instances, plaques will calcify. Several studies question the efficacy of Collagenase Clostridium Histolyticum (CCH) in calcified plaques leading to a belief that calcification is associated with failure of medical treatment and an increased risk of surgical intervention. Our objective is to measure changes in curvature before and after treatment of calcified plaques with CCH. Objective To determine change in curvature of calcified plaques treated with 8 injections of CCH Methods We prospectively evaluated PD plaques using ultrasound in all men presenting with PD starting November, 2018. Plaques were evaluated in the flaccid state and curvature was measured after the injection of intracavernosal Trimix using goniometer. We utilized a standardized system of plaque typing: type 1: thickening of the tunica albuginea without acoustic shadowing, type 2: a moderately calcified plaque with a typical ultrasound shadow, type 3: a severely calcified plaque complete acoustic shadowing. We measured pre and post CCH curvature 6 months after all eight injections using he standard manufacturer protocol. All patients were instructed on home modeling. Paired T-t was used to compare pre and post measurements. Results presented as means± standard deviations. Results We identified 19 men with calcified PD who completed all 8 injections of CCH. Mean age and curvature were 61±7 years and 55±22 degrees. Of the 19 men, 7 had type 3 plaques and 12 had type 2 plaques. There were no differences in patient age however there was a difference in baseline curvature between type 2 and 3 plaques (55±17 vs 75±17 degrees p<0.05). Curvature improved by an average of 25±20 degrees p<0.05. Interestingly, as a group, type 3 plaques improved by 37±23 degrees compared to 18±15 degrees for Type 2, however this difference was not significant Conclusions In our small cohort, 8 injections of CCH appear to be an effective therapy for men with calcified PD plaques. Interestingly, CCH remained effective even in severely calcified PD. A larger study including a comparison of non-calcified PD is needed. Disclosure Yes, this is sponsored by industry/sponsor: ISR from Endo Pharmaceuticals Clarification Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals

TUBERCULOSE PROSTATIQUE ISOLEE SIMULANT UNE HYPERTROPHIE BENIGNE DE LA PROSTATE : A PROPOS DUN CAS

Genitourinary tuberculosis accounts for approximately 5.3% of extrapulmonary tuberculosis [1]. It may involve the kidneys, ureters, bladder, prostate, vas deferens, epididymis, and testes. However, prostatic tuberculosis can exceptionally be found as an isolated lesion. We report a case of a 60-year-old patient who was admitted to the emergency room with Acute urinary retention, and was treated as benign prostatic hyperplasia, with failure of medical treatment, and indication for transurethral resection of the prostate, whose histology came back in favor of prostatic tuberculosis.

Facteurs associés à l’échec du traitement médical de la grossesse extra-utérine: cas de l’Hôpital Gyneco-Obstétrique et Pédiatrique de Yaoundé

Introductionl´objectif de notre travail était d´identifier les facteurs associés à l´échec du traitement médical de la grossesse extra-utérine (GEU) chez les femmes à l´Hôpital Gynéco- Obstétrique et Pédiatrique de Yaoundé.Méthodesil s´agissait d´une étude cas-témoins avec collecte rétrospective des données, sur une période de 10 ans, du 1er janvier 2008 au 31 décembre 2017. Les cas étaient toutes les patientes prises en charge pour GEU avec échec du traitement médical et les témoins celles chez qui le traitement médical de la GEU avait réussi. Les variables étudiées étaient: les caractéristiques sociodémographiques, cliniques, paracliniques et thérapeutiques. L´échantillonnage était consécutif et exhaustif. Nous avons réalisé une analyse multivariée.Résultatsnous avons recruté 92 patientes dont 23 cas et 69 témoins. Les variables associées à l´échec du traitement médical de la GEU après analyse univariée étaient: un taux de β-HCG initial > 10000UI/L (OR=3,05;P=0,031), un taux de β-HCG à J4 > 10000UI/L (OR=7,15;P=0,000), un taux de β-HCG à J7 > à 10000UI/L (OR=20;P=0,000), un score de Fernandez ≥ 13 (OR=3,09;P=0,020), la présence d´activité cardiaque de l´embryon (OR=2,8;P=0,036), l´antécédent d´interruption volontaire de grossesse (OR=2,67;P=0,043) et le niveau de scolarisation primaire (P=0,013). Après analyse multivariée, les facteurs prédictifs étaient: un taux de β-HCG initial >10000 UI/L (OR=8,97; P=0,004), un taux de β-HCG à J4 >10000 UI/L (OR=8,44;P= 0,007), un score de Fernandez ≥ 13 (OR=1,12;P=0,005) et la présence de l´activité cardiaque de l´embryon (OR=6,09;P=0,026).Conclusionles facteurs prédictifs de l´échec du traitement médical de la GEU à HGOPY sont liés au taux de β-HCG initial et la viabilité embryonnaire.

Nonsurgical management of Fusobacterium necrophorum sternoclavicular septic arthritis: a case report

BackgroundTo date, the gold-standard treatment for sternoclavicular septic arthritis has been surgery due to the high failure and complication rates of medical treatment. In particular, presentation of Fusobacterium sternoclavicular septic arthritis has been rarely reported and very sparsely investigated, and only one other case report of septic arthritis caused by this pathogen exists in literature.Case presentationWe report a case of an otherwise healthy 38-year-old Caucasian woman who presented with sternoclavicular septic arthritis as a complication of Fusobacterium necrophorum mediastinitis. Our patient underwent successful management through nonstandard, conservative treatment of 7 weeks of intravenous piperacillin + tazobactam followed by 6 weeks of oral amoxicillin + clavulanic acid.ConclusionWe highlight a case of the rare presentation of Fusobacterium necrophorum sternoclavicular septic arthritis that did not require surgical intervention for successful management. Though infection of the sternoclavicular joint is unusual, it continues to be seen in thoracic surgery, and there are increasing numbers of antibiotic-resistant organisms. This case broadens insight into the clinical course and treatment of such conditions. The success of conservative management in this case aligns with the similar nonsurgical course of the one previous report of Fusobacterium sternoclavicular septic arthritis occurrence. Thus, further discussion and thought for reevaluating the current standard practice of surgery for sternoclavicular joint infection is suggested. Our case supports assessing a patient’s overall health, causative organism, and extent of infection in interventional course and taking the feasibility of conservative management into more weighted consideration.

Colorectal surgery for functional bowel disorders.

Surgery is a last-resort treatment for the management of severe constipation, an alternative after failure of medical treatment. We can distinguish two types of management: "conservative" colon-sparing surgery, i.e. the Malone procedure (MP), or sacral neuromodulation (SNM), and "radical" surgery such as colorectal resection. While the place of SNM remains to be defined, the MP is well codified and has shown very satisfactory results. For radical treatment, total colectomy with ileo-rectal anastomosis is the reference procedure because it is the best documented. The place of more limited segmental colectomies is poorly defined and needs a more precise identification of the colonic segment involved. Finally, it is imperative that any severe constipation be managed within a multidisciplinary radiology-medico-surgical consultative program. Indeed, a multidisciplinary strategy allows rigorous selection of patients, the only guarantee of better long-term functional results, even though they unfortunately remain uncertain.

Review on Nano-Chemical Drug Carriers and Their Applications

This review deals with applications of nano-biochemical materials., Due to the failure of some conventional medical treatments to reach the most accurate tissue in the body, especially for cancer patients, many researchers have resorted to finding quick and therapeutic alternatives that directly treat tissue without leaving side effects, with a prior study of the toxicity of some types of nanoparticles in tissue therapy through nanocapsules. Ultra-fine and the capsule material is excreted after performing its tasks and is excreted with urine and excreta. Also, some biochemical treatments affect the stomach and others, so the researchers resorted to using a small nano-capsule that contains a mixture of treatment with a substance that helps to remove the excess from it with the exit, and thus they are substances that do not affect the rest of the body’s other tissues or healthy tissues, if the body gets rid of the excess of them.

A Retrospective Analysis of Conservative Management Versus Early Surgical Intervention in Appendicular Lump.

IntroductionAcute appendicitis happens to be increasingly common in school-going children and early part of adult life, peak incidence reaching in the teens and early twenties. Luminal obstruction of the vermiform appendix is thought to be essential for the development of appendicular ischemia, gangrene, and perforation. The treatment of choice in acute appendicitis is emergency appendectomy. Appendicitis particularly puts the surgeon in a dilemma whenever the patient presents late by around four to seven days. In case of delay in presentation, complications like appendicular lump formation occur. The factors that make the clinical presentation inconsistent which in turn makes the diagnosis challenging in the case of acute appendicitis are the variable position of the appendix, the degree/grade of inflammation, and the age of the patient.At present, the standard treatment is the Ochsner-Sherren regimen universalized by Oschner and has been mostly practised over many decades as the standard care for the appendicular lump. Conservative regimen does not work in a few cases where urgent surgical exploration is necessary. This study was conducted to compare early appendectomy versus conservative management followed by interval appendectomy in case of appendicular mass and to make a better strategy for effective management of patients with complicated appendicitis.MethodsA total of 112 patients were diagnosed as having an appendicular lump as per the available records between June 2018 and June 2021. The total study population was divided into two comparative groups depending upon the treatment they received. The patients in group-1 received medical treatment and those in group-2 had undergone surgical management. The patients in group-1 were treated according to the Ochsner-Sherren regimen. The patients in group-2 were the patients in whom emergency appendectomy was done. If the general condition of the patient did not improve, pain and tenderness didn’t subside, the size of phlegmon or abscess was increasing and other features of the acute abdomen were persistent, then it was regarded as a failure of medical treatment and the patient was prepared for surgery on an emergency basis.ResultsOut of 1192 cases of acute appendicitis admitted between June 2018 and June 2021, a total of 112 patients were diagnosed with an appendicular lump. As per the record, 64 patients were managed conventionally as per the Ochsner-Sherren regimen followed by elective interval appendectomy (group-1) and 48 cases were managed with an emergency surgical procedure (group-2).In group-1, out of 64 patients, non-operative treatment was successful in 58 patients (90.62%). Among the remaining patients, there was a failure of non-operative treatment in six patients and they were subjected to emergency surgical exploration (9.37%). So a total of 58 patients underwent interval appendectomy after six weeks. Out of 54 patients who had undergone emergency appendectomy in both groups, the per-operative finding was an appendicular lump in 55.5% of patients while a total of 44 patients in group-2, were discharged from the hospital within six days (91.66%). But in group-1, only 16 patients were discharged from the hospital within six days (25%), rest were discharged from the hospital after more than seven days of stay.ConclusionEarly appendectomy in appendicular mass is safe due to the improvements in surgical techniques and better postoperative care.

OP18 Efficacy and safety of filgotinib for the treatment of perianal fistulizing Crohn’s Disease: Results from the phase 2 DIVERGENCE 2 study

BackgroundTreatment of perianal fistulizing Crohn’s disease (PFCD) is a major unmet need. Filgotinib (FIL) is a once-daily, oral, preferential Janus kinase 1 inhibitor in development for the treatment of inflammatory bowel diseases. The efficacy and safety of FIL for the treatment of PFCD was evaluated in the phase 2, double-blind, randomized, placebo (PBO)-controlled DIVERGENCE 2 study (NCT03077412).MethodsPatients (18–75 years old) with PFCD (documented diagnosis of CD for at least 3 months and 1–3 external openings [EOs] with drainage [spontaneous or on compression] for ≥ 4 weeks before screening) previously treated with antibiotics, immunomodulators and/or tumour necrosis factor inhibitors (TNFi) were randomized (2:2:1) to receive FIL 200 mg, FIL 100 mg or PBO once daily for up to 24 weeks. Active luminal CD was permitted providing that the Crohn’s Disease Activity Index score was ≤ 300 at screening. The primary endpoint was combined fistula response (reduction of ≥ 1 from baseline in the number of draining EOs determined by investigator assessment and no fluid collections > 1 cm on centrally read pelvic magnetic resonance imaging [MRI]) at Week 24. Combined fistula remission (closure of all draining EOs present at baseline and no fluid collections > 1 cm) at Week 24 was a key secondary endpoint. The study was not powered for statistical comparisons and was prematurely terminated owing to low recruitment rates during the COVID-19 pandemic.ResultsBaseline characteristics were broadly similar across the treatment groups (Table 1). Overall, 91.2% of patients had complex perianal fistulae and TNFi treatment had previously failed in 64.9% of patients. A lower proportion of patients randomized to receive FIL 200 mg discontinued the study compared with those who received PBO (Table 2). The proportion of patients who achieved a combined fistula response at Week 24 was numerically higher in the FIL 200 mg group (47.1%; 90% confidence interval [CI]: 26.0–68.9) than in the PBO group (25.0%; 90% CI: 7.2–52.7) (Figure 1), with similar results observed for combined fistula remission (FIL 200 mg [47.1%; CI: 26.0–68.9] versus PBO [16.7%; CI: 3.0–43.8]) (Figure 2). Treatment-emergent severe adverse events were highest in the FIL 200 mg group (Table 2). Adverse event rates were otherwise similar across treatment groups. ConclusionIn this phase 2 study, numerically higher fistula response and remission rates were observed after 24 weeks of treatment with FIL 200 mg versus PBO in patients with active PFCD and a history of multiple medical treatment failures. FIL was well tolerated overall. Further studies of FIL for the treatment of PFCD are warranted.

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-ovarian Abscess: External Validation of a Recently Published Risk Score

To assess the external validity of a recently published clinical risk score estimating the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) based on 4 clinical variables on admission. The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. Results were assessed using rigorous methods for clinical prediction models. Safety-net teaching hospital system in Houston, Texas. One hundred and sixty nine consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with intravenous antibiotic agents; others required a drainage procedure. Electronic health records were reviewed and the 4 clinical predictors of failed conservative treatment were captured (age, white blood cell count on admission, abscess size, and presence of bilateral abscess). A clinical risk score was calculated for each patient. The prediction model was created using the risk score in a multivariate logistic regression. Then the calibration, discrimination, and accuracy of the model were evaluated to perform the external validation analysis. Among 169 eligible patients, 50.2% were successfully treated with intravenous antibiotic agents and 49.8% needed abscess drainage. Patients undergoing drainage were more likely to be older, be diabetic, to present with elevated white blood cell count and fever, and to have a larger abscess size on univariate analysis. Among the 4 known predictors of drainage, abscess size was found to be the strongest. Significant difference in clinical characteristics was noted between our cohort and the reference cohort, and the model needed recalibration to adjust for these differences. The area under the receiver operating characteristic curve was 0.77 (0.71-0.84) indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. Our results provide external validation of a simple clinical risk score predicting failed medical treatment in patients with TOA.

Controlling Post-Partum Hemorrhage Using A Novel Technique of Multiple Sponge-Holding-Forceps Applied Along Cervical Canal

Introduction: Postpartum hemorrhage (PPH) is not only one of the leading causes of maternal mortality but also the most feared complication amongst obstetricians. Despite various predictive factors, PPH can occur in low risk pregnancies without predictive factors. Application of sponge holding forceps vaginally can invariably stop bleeding, leading to prevention of serious consequences.
 Aims & Objectives: To determine the proportion of success of PPH control using sponge holders applied vaginally to the cervix after failure of medical treatment and before going for hysterectomy, in immediate post partum period.
 Place and duration of study: This study was a cross-sectional study conducted at the labour room, Indus Hospital Raiwind for duration of one year from June 2020 to June 2021.
 Material & Methods: Clinical and demographic features were recorded on a pre-designed proforma. Parity and gravidity was determined. Amount of bleeding was estimated and recorded. Additionally, the final result of patients was reported, as well as if they required surgical intervention. Data was analyzed using SPSS 24.p value ?0.05 was considered significant.
 Results: The mean (SD) age in our study was 26.28 (4.11) years. In this study majority of the patients were primipara 65% (n=26) and 35% (n=14) were multipara. On the basis of gravidity, more patients 37.5% (n=15) were primigravida while multigravida and grand multigravida patients were 27.5% (n=11) and 35% (n=14) respectively. The mean (SD) blood loss before the procedure was 720 (200) ml while after the procedure it was 90 (130) ml (p=0.02). This procedure was successful in all the patients and there was no need of further surgical intervention.
 Conclusion: Our study concludes that use of sponge holding forceps as cervical clamp around cervix is one of the effective, economic and safe procedure for PPH patients.

Effectiveness of selective laser trabeculoplasty in advanced open‐angle glaucoma

AbstractPurposeTo study the effectiveness and safety of selective laser trabeculoplasty (SLT) for the treatment of advanced open‐angle glaucoma.MethodsWe carried out a prospective longitudinal study, including patients with advanced open‐angle glaucoma. Selective laser trabeculoplasty has been indicated either after failure of medical treatment or in cases of poor adherence to medical treatment. Measurements were obtained at 1 week, 1 month, 3 months and 6 months. Success was defined as a reduction in intraocular pressure (IOP) of more than 20% from baseline or a reduction of at least one antiglaucoma eye drops with stable intraocular pressure. A p value less than 0.05 was considered as statistically significant.ResultsFifty‐nine eyes were included in the study. Three types of glaucoma were present in our study: primary open‐angle glaucoma was the most common type followed by exfoliative glaucoma and pigmentary glaucoma. The success rate was 76.5% for failure of medical treatment and 80% for poor adherence. The most frequent side effects were the inflammatory reaction (18.6%) and the early IOP spikes (25.4%). The predictors of its effectiveness were the initial intraocular pressure (p = 0.03) and the percentage reduction in intraocular pressure at 1 month (p = 0.002).ConclusionsSelective laser trabeculoplasty is an effective and easy‐to‐perform physical treatment of advanced open‐angle glaucoma with a satisfactory safety profile (1,2). It overcomes poor adhesion problems. Our results need to be extended to assess long‐term success.Bibliography1. Garg A, Gazzard G. Selective laser trabeculoplasty: past, present, and future. Eye (Lond). 2018 May;32(5):863–876.2. Sina Elahi, Harsha L Rao, Alina Dumitru, Kaweh Mansouri. Predictors of Success in Selective Laser Trabeculoplasty: Data From the Lausanne Laser Trabeculoplasty Registry. J Glaucoma. 2020 Jul;29(7):550–555.

Analysis of causes of failure of medical treatment in patients undergoing surgery for benign prostate enlargement.

To analyse causes of failure of medical management in benign prostate enlargement (BPE) in patients who undergo surgery following medical treatment and to elucidate parameters which warrant for early surgical treatment. Records of 747 patients who underwent surgery for BPE were reviewed for prostate volume, median lobe enlargement, post void residual urine, duration and type of medical treatment given for BPE. We used univariate and multivariate analysis to find out significant parameters for medical treatment failure. A total of 601 patients (80.45%) received medical treatment for their lower urinary tract symptoms (LUTS), for a duration ranging between 3 months and 2 years. Statistically significant difference was found between age, prostate volume, intravesical projection, PSA and acute urinary retention with failure of medical treatment. BPE patients with failure to respond with medical management within 3-6 months and/or associated with large size prostate, intravesical projection and raised serum PSA should better be offered surgical treatment.

Audiological characteristics and exploratory treatment of a rare condition of acute-otitis-media-associated sudden sensorineural hearing loss.

BACKGROUNDAcute otitis media (AOM) is a common disease that is more prevalent in children. Most studies concerning AOM-associated sudden sensorineural hearing loss are case reports and retrospective in nature, hence the etiology of AOM-associated sudden hearing loss has not been fully established.AIMTo analyze audiological characteristics of AOM-associated sudden hearing loss and evaluate efficacy of combined tympanostomy tube placement (TTP) and intratympanic methylprednisolone.METHODSEight adult patients who were diagnosed with AOM-associated sudden hearing loss and ineffectively treated by conventional medical therapy were enrolled in this study. Basic data were collected, and pure tone audiometry was performed to assess the audiological characteristics. Combination therapy with TTP and intratympanic methylprednisolone injection was given to the patients.RESULTSMixed or sensorineural hearing loss was observed at high frequencies (2–4 kHz). All the cases in this study were cured after TTP and intratympanic methylprednisolone. After treatment, the average hearing threshold at affected frequencies was significantly lower than those in the pretreatment group (P < 0.05) and was similar to that in the healthy ears (P > 0.05).CONCLUSIONAOM rarely induces sudden sensorineural hearing loss. Combination therapy with TTP and intratympanic methylprednisolone injection may be effective after failure of conventional medical treatment.