First-line Management Research Articles

Management of Stress Urinary Incontinence by Obstetricians and Gynecologists in Jordan: A Nationwide Survey Study.

Stress urinary incontinence (SUI) is a common condition that can significantly impact a patient's quality of life. Although multiple diagnostic and treatment options exist, significant variability in SUI management exists between countries. Since women's SUI prevalence in Jordan is high, and Jordan is a lower-middle-income country, this study aimed to investigate how obstetricians and gynecologists (OBGYNs) across Jordan manage and treat women with SUI. A Google Forms survey was prepared and sent out to Jordanian OBGYNs via WhatsApp. The results were collected and arranged in Microsoft Excel and then transferred to SPSS for statistical analysis. Out of the 804 Jordanian registered OBGYNs, 497 could be reached, 240 conduct gynecological surgeries, and 94 completed the survey, providing a response rate of 39.2%. Most of the respondents were females between 41 and 55 years old. More than 70% of the OBGYNs worked in the private sector, and 88.3% operated in the capital of Jordan. Most of the respondents favored lifestyle and behavior therapy (43.6%) or pelvic floor physiotherapy (40.4%) as the first-line management for SUI. The transobturator mid-urethral sling (MUS) was the most common initial surgical treatment option. The physicians preferred two-staged procedures for the repair of pelvic organ prolapse alongside concomitant SUI. In the case of recurrent SUI following surgery, 77% of the respondents chose to refer to a urologist or urogynecologist. The Jordanian OBGYNs preferred using lifestyle/behavioral therapy and pelvic floor muscle physiotherapy as the first-line treatment to manage SUI. Secondly, the MUS would be the most frequently preferred surgical choice. To effectively manage SUI, adequate training in urogynecology and referral resources are essential in lower-middle-income countries.

The Role of Ranolazine in the Treatment of Ventricular Tachycardia and Atrial Fibrillation: A Narrative Review of the Clinical Evidence.

Cardiac arrhythmias are among the leading causes of morbidity and mortality worldwide. While antiarrhythmic drugs traditionally represent the first-line management strategy, their use is often limited by profound proarrhythmic effects. Several studies, including randomized control trials (RCTs), have demonstrated the antiarrhythmic efficacy of ranolazine, which is registered as an antianginal agent, while also establishing its safety profile. This review compiles clinical evidence investigating the antiarrhythmic properties of ranolazine, focusing primarily on ventricular tachycardia (VT) and atrial fibrillation (AF), as they are common rhythm abnormalities with serious complications. Data from RCTs indicate that ranolazine reduces VT incidence, although this effect is not universal. Therefore, we attempt to better describe the patient population that gains the most benefit from ranolazine due to VT suppression. Additionally, ranolazine is known to enhance the conversion rate of AF to sinus rhythm when combined with other antiarrhythmic drugs such as amiodarone, highlighting its synergistic effect in the atrium without provoking ventricular dysrhythmias. Despite the heterogeneity in the currently available data, ranolazine appears to be an effective and safe option for the management of various arrhythmias.

Developing a urinary incontinence primary care pathway: a mixed methods study.

While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment. To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention. Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway: Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months. While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms. Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI.

Comparison Between the Efficacy & the Safety of Single Use Flexible Ureteroscopy Lithotripsy and Miniaturized Percutaneous Nephrolithotomy (Mini PCNL) for the Management of Renal and Proximal Ureteral Calculi of ≤ 2CM

Abstract Background Urolithiasis has become a common medical problem with about 2- 3% prevalence rate and still increasing in the general population. Renal calculi represent about 80- 90% of all urinary calculi with high recurrence rate. Single Use Flexible Ureteroscopy Lithotripsy and Percutaneous Nephrolithotomy Lithotripsy are recommended in the 2013 European Association of Urology guidelines as the first line in management of lower pole calculi when renal anatomy is unfavorable for Extracorporeal Shock Wave Lithotripsy. Furthermore, Single Use Flexible Ureteroscopy Lithotripsy is extremely effective for management of calculi of ≤ 2 cm in diameter and complex renal calculi. Aim of the Work The aim of our study is to compare the outcome of using Single Use Flexible URS versus Mini-PCNL with ≤22 Fr tract accessin management of pelvic, lower calyceal and proximal ureteral calculi ≤ 2cm. It was conducted on 40 patients that were randomly divided into 2 groups. Group A were treated with Mini-PCNL (20cases), whereas group B were treated with Single Use Flexible URS (20 cases). Patients and Methods A clinical trial, it was carried out at Ain Shams University, Urology department from October 2020 to October 2021 and done over 40 patients complaining of single pelvic, lower calyceal or upper ureteric stone ≤ 2 cm. The patients underwent either Mini-PCNL or Single Use Flexible URS randomly according to simple randomization using Gpowa computer program with ratio 1:1. Results Our study showed that Single Use Flexible URS achieves a comparable stone free rates to Mini- PCNL as there is no statistically significant difference between group A and group B in the stone free rate.Flexible URS reduces the risks associated with Mini-PCNL.Blood loss is highly significant in Mini-PCNL group more than in Single Use Flexible URS group.The incidence of post-operative fever and infection is non- significant between 2 groups. It is (15%)3 cases from 20 cases in group A although, (5%)1case from 20 cases in group B. There is highly significant difference between group A and group B in both operation time and hospital stay. This means that the patients take more intra operative time in Flexible URS group than in Mini-PCNL group,but more hospitalization in Mini- PCNL group than Single Use Flexible URS group.There is no statistically significant difference between 2 groups in the need for double J stent or auxiliary procedure such as ESWL. Conclusion Single Use Flexible URS is widely used nowadays and the treatment of choice for management of renal calculi due to its high efficacy and low morbidity in management of renal stones up to 20 mm. This study indicated that Single Use Flexible URS is an effective technique for management of renal and proximal ureteric calculi ≤ 2cm. In comparison to Mini-PCNL, it not only has a similar stone free rate, but also is associated with lower complication rates, more favorable recovery time. But it has longer operative time.

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital – a retrospective review

BackgroundNon-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital.MethodsThis is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis.ResultsWithin the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy.ConclusionsIntralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

“Just got diagnosed; what worked for you?”: A Mixed-Methods Analysis of Treatment Experiences in the Prolactinoma Subreddit

ABSTRACT INTRODUCTION With improvement in complication and remission rates, recent studies have suggested the viability of transsphenoidal surgery as first-line management for prolactinomas. Reddit, an online forum, allows posters to interact with one another, discuss symptoms, treatments, and disease courses through specialized forums known as “subreddits”. Given the lack of research comparing patient experience on pharmacotherapy versus surgery, we sought to assess the sentiment of treatment within the “r/Prolactinoma subreddit” community. METHODS A search was done by filtering the r/Prolactinoma subreddit. Posts were sorted by “top” of “all time,” meaning entries with the most engagement throughout the site's history. Welch’s t-test was used to analyze treatment type, while sentiment regarding treatment was analyzed using grounded theory qualitative methods. RESULTS From 189 total entries, 82 were included; 33% (n=27/82) were posts. Of posters disclosing their treatment, 11% underwent surgery (n=9/79), while 76% received medication (n=60/79). The proportion of positive: negative sentiment and level of engagement on posts regarding pharmacotherapy vs surgical treatments were not significantly different (p&gt;0.05). Qualitative analysis showed themes of changes after medical treatment, immediate changes post-surgery, and online community. CONCLUSION Our mixed-methods study found statistically non-significant differences in sentiment when comparing Reddit posts from patients who underwent medical and surgical management. Qualitative analysis revealed several themes regarding patients’ perceptions of medical and surgical management and the benefits of an online community. The qualitative themes brought to light by this study may serve to inform future studies examining the patient experience with prolactinoma care.

Long-Term Outcomes of Respiratory Retraining Therapy for Exercise-Induced Laryngeal Obstruction

ObjectiveTo assess the long-term outcomes and efficacy of respiratory retraining therapy in patients with exercise-induced laryngeal obstruction (EILO). MethodsA retrospective chart review and prospective questionnaire-based survey was conducted on 88 patients who received respiratory retraining therapy for EILO at our institution over the past 5 years Results34 patients were included in the final analysis, with a mean age at symptom onset and age at initial evaluation of 13.67 ± 2.96 and 15.12 ± 3.48, respectively. We found a statistically significant difference in the pre-treatment and post-treatment Dyspnea Indices following respiratory retraining therapy, with a mean difference of 12.03 ± 7.18 (p < 0.001). When asked about the effectiveness of respiratory retraining therapy, the majority of patients (n = 28) reported improvement (13.3% “a little”, 13.3% “somewhat better”, 53.3% (“a lot better”, and 13.3% complete resolution of symptoms. Only 2 patients (6.7%) responded that their breathing “did not get better.” The most effective therapy techniques cited by patients were abdominal breathing (n = 10), ratio breathing (n = 5), and pursed lip or “straw” breathing (n = 5). ConclusionRespiratory retraining therapy represents an effective technique in both the short-term and long-term management of EILO. This therapy remains the first line in management of EILO due to its ease of administration, non-invasive nature, and durable effect on breathing function.

Penile prosthesis implantation is safe and effective in Peyronie's disease patients with and without erectile dysfunction.

Penile prosthesis (PP) is the mainstay of treatment in Peyronie's disease (PD) with co-existent refractory erectile dysfunction (ED). This study aimed to assess the clinical outcomes of patients who underwent PP as the first-line surgical treatment in PD without ED. A total of 636 patients underwent PP for PD from 2012 to 2022, but only 168 patients who underwent PP as first-line surgical management for PD with or without ED were included in the study. The mean (SD) age of 168 patients was 56.3 years (12.4). The mean curvature of the "PD with ED" group and the "PD without ED" group were 38.2 (5.6) degrees and 42.2 (5.9) degrees. The median (IQR) follow-up was 56.0 months (34.5- 61.4). Most (86.9%) patients underwent 3-piece inflatable PP. An important finding is that 33 patients (19.6%) without ED had undergone PP. Mechanical failure requiring revision surgery was less common in the 'without ED' group than in the ED group (6.8% vs. 10.2%, p 0.04). Most PD patients without ED (87.9%, 29/33) and with ED (88.9%, 120/135) were "satisfied" after PP implantation at six months, as defined by a score of ≥4 on a 5-point Likert scale. If surgery is offered in PD, PP may be considered a safe and effective first-line surgical treatment regardless of the ED, given the acceptable complications and high satisfaction rates. However, this new concept warrants further research.

Healing of periapical lesion by non-surgical endodontic therapy: A case series

Trauma to the anterior teeth can lead to pulp necrosis and subsequent periapical lesions. Most of the cases remain undetected unless found in an IOPAR, the tooth gets discoloured or gets secondarily infected. In such cases, non-surgical endodontic therapy can be done as the first line of management with regular follow up. Surgical approach is indicated only if the non- surgical approach becomes a failure. A series of two cases with large periapical lesion following trauma to the maxillary anteriors were treated with multivisit non –surgical endodontic therapy. Inter-appointment dressings were given. Patients were recalled for evaluation of healing. Six months follow up radiographs showed healing of the lesion with significant increase in the radiopacity suggestive of bony healing. For the treatment of periapical lesions, non-surgical endodontic therapy should be considered as first line treatment option as it proves to be a more conservative approach.

Scoring System to Evaluate Risk of Nonoperative Management Failure in Children With Intussusception

IntroductionTypical first-line management of children with intussusception is enema reduction; however, failure necessitates surgical intervention. The number of attempts varies by clinician, and predictors of failed nonoperative management are not routinely considered in practice. The purpose of this study is to create a scoring system that predicts risk of nonoperative failure and need for surgical intervention. MethodsChildren diagnosed with intussusception upon presentation to the emergency department of a tertiary children's hospital between 2019 and 2022 were retrospectively identified. Univariable logistic regression identified predictors of nonoperative failure used as starting covariates for multivariable logistic regression with final model determined by backwards elimination. Regression coefficients for final predictors were used to create the scoring system and optimal cut-points were delineated. ResultsWe identified 143 instances of ultrasound-documented intussusception of which 28 (19.6%) required operative intervention. Predictors of failed nonoperative management included age ≥4 y (odds ratio [OR] 32.83, 95% confidence interval [CI]: 1.91-564.23), ≥1 failed enema reduction attempts (OR 189.53, 95% CI: 19.07-1884.11), presenting heart rate ≥128 (OR 3.38, 95% CI: 0.74-15.36), presenting systolic blood pressure ≥115 mmHg (OR 6.59, 95% CI: 0.93-46.66), and trapped fluid between intussuscepted loops on ultrasound (OR 17.54, 95% CI: 0.77-397.51). Employing these factors, a novel risk scoring system was developed (area under the curve 0.96, 95% CI: 0.93-0.99). Scores range from 0 to 8; ≤2 have low (1.1%), 3-4 moderate (50.0%), and ≥5 high (100%) failure risk. ConclusionsUsing known risk factors for enema failure, we produced a risk scoring system with outstanding discriminate ability for children with intussusception necessitating surgical intervention. Prospective validation is warranted prior to clinical integration.

Waiting for self-healing as a primary management strategy for lower lip mucoceles.

Oral mucoceles are most frequently encountered on the lower lip. A variety of treatment options are currently employed, including surgical excision, pharmacological injections, and laser therapy. However, each of these approaches may introduce risks and potential complications. Clinical practice has demonstrated a potential for self-healing in lower lip mucoceles, making a conservative observational approach more appealing. This research is a prospective study aimed at evaluating the self-healing capacity of lower lip mucoceles. In this prospective study, patients with mucoceles were encouraged to intentionally delay medical intervention and to wait for self-healing. Disappearance of the mucocele for at least 3 months was defined as self-healing. Thirty patients with lower lip mucoceles were included. With no intervention, 24 patients (80%) reported self-healing of lower lip mucoceles. The mean natural duration of the mucoceles was 3.63 (± 4.7; 1-24) months. After self-healing of the mucocele, the patients were followed up for 17.21 (± 9.45; 2-30) months and there were no reported recurrences. Lower lip mucoceles have a high potential for self-healing and patients may be routinely encouraged to wait for self-healing. The high self-healing rate observed in this study suggests that a conservative, non-interventional approach might be considered as the first-line management for lower lip mucoceles.

Laparoscopic Sigmoid Colectomy with Natural Orifice Specimen Extraction in Sigmoid Volvulus.

Sigmoid volvulus (SV), the twisting of the sigmoid colon around its own base, is a relatively rare colonic obstruction form. Endoscopic detorsion is the first-line management option in uncomplicated patients. However, recurrence risk is as high as 90%, with a risk of mortality up to 35%. Although procedures such as sigmoidopexy, sigmoidomesopexy, sigmoidomesoplasty, extraperitonealization, or percutaneous endoscopic sigmoidopexy may prevent or reduce SV recurrence, laparoscopic sigmoid colectomy with natural orifice specimen extraction appears to be the optimal choice in selected cases. Cite this article as: Atamanalp SS. Laparoscopic sigmoid colectomy with natural orifice specimen extraction in sigmoid volvulus. Eurasian J Med. Published online May 2, 2024. doi:10.5152/ eurasianjmed.2024.24420.

First-Line Treatments and Management of Metastatic Renal Cell Carcinoma Patients: An Italian Interdisciplinary Uro-Oncologic Group Algorithm.

The treatment landscape for metastatic renal cell carcinoma (mRCC) has undergone significant transformations in recent years. The introduction of novel combination therapies involving tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors has resulted in improved oncological outcomes compared to traditional TKI monotherapy. In this evolving paradigm, the pivotal role of the multidisciplinary tumor board is underscored, particularly in shaping the therapeutic trajectory for patients eligible for locoregional interventions like cytoreductive nephrectomy and metastasectomy. In cases where systemic treatment is deemed appropriate, the absence of direct comparisons among the various combination therapies complicates the selection of a first-line approach. The clinician is faced with the challenge of making decisions based on patient-specific factors such as performance status, risk classification according to the International Metastatic Renal Cell Carcinoma Database Consortium, comorbidities, and disease characteristics, including the number and location of metastases and tumor histology. Considering these concerns, we propose, as a member of a Tuscany Interdisciplinary Uro-Oncologic Group, an algorithm to streamline the decision-making process for mRCC patients, offering guidance to clinicians in their day-to-day clinical practice.

Prescription drug monitoring program mandates and opioid prescriptions received by patients dying of cancer.

11003 Background: Strong consensus supports opioid analgesics as first-line pain management for patients with poor prognosis cancer approaching the end of life (EoL). State legislations that mandate prescriber access of Prescription Drug Monitoring Programs (PDMPs) when prescribing opioids intend to mitigate unsafe opioid prescriptions but may have unintended consequences in restricting access to opioids for patients dying from cancer. This study seeks to assess associations between state implementation of comprehensive PDMP mandates –applicable to all prescribers and all clinical settings and not allowing prescriber discretion – with opioid prescriptions received by patients dying of cancer. Methods: We used SEER cancer registry linked with Medicare fee-for-service claims to identify 184,123 Medicare beneficiaries 66 years or older who died of cancer in 2011-2019 in one of 10 SEER states with an operating PDMP by the beginning of 2011. We measured opioid prescriptions dispensed to patients near the EoL, defined as 30 days prior to death or hospice admission. We exploited staggered implementation of comprehensive PDMP mandates and assessed the association of such implementation with opioid prescriptions dispensed to patients near the EoL. We estimated logistic regressions for dichotomous outcomes and Generalized Linear Models for continuous outcomes. Results: Implementation of comprehensive PDMP mandates was associated with a reduction in the rate of 1 or more opioid days near the EoL from 47.2% to 45.2% (difference, 0.02 [95% CI, -0.027, -0.012]), a reduction in the rate of 1 or more long-acting opioid days from 15.8% to 14.7% (difference, 0.011 [95% CI, -0.016, -0.006]), and a reduction of 130.8 (95% CI, -161.5, -100.2) in total morphine milligram equivalents (MMEs) and of 135.6 (95% CI, -215.1, -56.1) in MMEs from long-acting opioids among patients who received 1 or more days of opioids/long-acting opioids. Conclusions: Comprehensive PDMP mandates were associated with 4-9% reduction in opioid prescriptions dispensed to patients at the EOL. Specific strategies are needed to effectively exempt patients with active cancer from such mandates. [Table: see text]

Non-Small Cell Lung Cancer Metastatic Without Oncogenic Alterations.

This overview provides a thorough review of current treatment approaches for first-line management of nononcogenic addicted non-small cell lung cancer. We also address pertinent clinical decision-making queries encountered in everyday practice, such as the optimal treatment strategy for PD-L1-high patients, predictive factors for response to immune checkpoint inhibitors (ICI) both in terms of patient and cancer characteristics, the potential benefits of dual checkpoint blockade, and the unresolved issue of safe discontinuation strategies for long-term responders. Around one in five patients falls into this latter category while the majority develop either primary or acquired resistance to ICI-based first-line therapy, necessitating effective subsequent lines of treatment. Docetaxel, with or without combination of antiangiogenic agents, serves as the backbone of treatment, although evidence in the post-ICI setting is limited. Given that an inflamed tumor microenvironment (TME) is crucial for ICI responses, targeting the TME in cases of acquired resistance alongside continued ICI administration appears rational, although clinical trials so far have failed to confirm this hypothesis. Antibody-drug conjugates have emerged as a promising treatment modality, offering the potential for reduced toxicity and improved efficacy by targeting specific cancer antigens. Moreover, several chemotherapy-free approaches are currently under investigation for treatment-naïve patients, including alternative ICI and drugs targeting epitopes on both cancer and immune cells.

A Narrative Review of Pharmacotherapy of Glaucoma

Progressive loss of retinal ganglionic cells (RGC) causes degeneration of optic nerve axons, which leads to blindness in glaucoma. Elevated intraocular pressure (IOP) is the most important, treatable risk factor. Currently, the management of glaucoma is centred on reducing the IOP, and drugs in the form of topical drops are the first line of management. Drugs reduce IOP either by suppressing aqueous humour secretion or improving the aqueous humour outflow. Newer drugs added during the past three decades to the armamentarium of glaucoma treatment have targeted the aqueous outflow. With an evolving understanding of the pathogenesis of glaucoma, the role of 24-h IOP control and other IOP-independent risk factors affecting ocular blood flow and RGC toxicity is also being actively studied in clinical and pre-clinical models of glaucoma. The role of available drugs in controlling IOP over 24 h is being evaluated. Improvement of ocular blood flow and neuroprotection are seen as potential drug targets for preventing the loss of RGC. In this article, we review the pharmacotherapy of glaucoma based on current therapeutic principles.

Assessment of Gamma Knife Stereotactic Radiosurgery as an Adjuvant Therapy in First-Line Management of Newly Diagnosed Glioblastoma: Insights from Ten Years at a Neuroscience Center

Gamma knife radiosurgery (GKRS), a form of stereotactic radiosurgery (SRS), has gained importance in treating glioblastoma alongside conventional chemotherapy. This study aims to assess the efficacy of combining GKRS with surgery and chemotherapy to enhance treatment outcomes for glioblastoma patients. This prospective clinical study, adhering to STROBE guidelines, assessed 121 glioblastoma patients from June 2008 to December 2022. All patients who had not undergone prior radiotherapy underwent open surgical tumor resection, GKRS, and adjuvant chemotherapy. In the analyzed cohort, the median survival post-diagnosis was 21.2 months (95% CI: 11.4–26.7) and the median progression-free survival was 13.6 months (95% CI: 12.5–28.3). The median time to first recurrence post-treatment was 14.5 months (range: 4–33 months). The median prescribed dose for GKRS was 12 Gy (range: 10–17 Gy), with a median target volume of 6.0 cm3 (range: 1.6–68 cm3). Post GKRS, 92 patients experienced local recurrence, 21 experienced distant recurrence, and 87 received additional treatment, indicating diverse responses and treatment engagement. This study evaluates the use of GKRS for glioblastomas, emphasizing its efficacy and complications in a single-center trial. It suggests integrating GKRS into initial treatment and for recurrences, highlighting the comparable survival rates but underscoring the need for further research.

Management of Dushtavrana (Non-Healing Ulcer) through Ayurveda - A Case Report

Shalyatantra is one among the Astang Ayurveda, the branch of Shalyatantra refers to surgical and parasurgical procedures in Ayurveda. Dusthavrana (non healing ulcer) are a frequently encountered problem in present era produced commonly as a complication of trauma or pathologic insult and it causes long term agony to the patient. The issue of non-healing ulcers management with Ayurvedic remedy is one of the major areas of the research and has come under increased study. This is a case report of 40-year-old female, who had an episode of Dushtavrana (non healing ulcer) and presented to the outpatient department with complaints of severe pain, itching and ulcer over right ankle region. The first line of management for Dushtavrana is Shodhana. Kalka is the specific treatment for Dusthavrana which is mentioned under Shodhana and Ropana Kriya of Saptopakrama. Yavadi Kalka is one of the formulations mentioned in Dwivraniya Chikitsa Adhyaya. Yavadi Kalka is simple, very cost-effective procedure. In the present case, Yavadi Kalka after Jaloukavacharana has shown assuring results in the management of Dushtavrana.

Abstract PO3-05-01: Locoregional Management Based on Mode of Progression for HR+/HER2- metastatic breast cancer Treated with Combined CDK4/6 inhibitor with Aromatase inhibitor

Abstract Background - Standard management for HR+/HER2- metastatic breast cancer (MBC) comprises concurrent aromatase inhibitor (AI) and cyclin-dependent kinase 4/6 inhibitor (CDK4/6i), providing improved progression-free (PFS) and overall survival over anti-estrogen alone. Eventual resistance mechanisms potentially include phenotypic changes, clonal selection, and new mutations. We theorized that limited progressive disease (LPD) would be more common on combination therapy due to eventual new mutations or clonal selection, in comparison to generalized progressive disease (GPD) occurring more frequently on AI alone due to phenotypic cellular changes across all disease sites. Potentially loco-regional treatment (LRT) options could significantly extend disease control in selected patients on combined therapy. Methods - Patterns of progressive disease (PD) for 55 historical AI-only treated controls (group A) were compared to those for 60 patients on combined treatment with an AI and a CDK4/6 inhibitor (group B) for first-line management of HR+/HER2- MBC. Mode of progression was classified as general (GPD - PD in the majority of lesions) or limited (LPD - PD in up to three lesions in a single organ). All LPDs were assessed for suitability for LRT at time of progression. PFS was assessed for those with LPD who continued present treatment after locoregional therapy. Results - LPD occurred in 13 of 55 patients (23.6%) in group A compared to 26 of 60 (43%) in group B (p = 0.026). For LPD patients, all 13 cases in group A were considered appropriate for LRT but only 3 (23.1%) received it and all patients also switched systemic therapy. In group B, 23 of 26 LPD patients were considered suitable for LRT and 16 (57.7%) received it, of whom 11 then continued first line systemic treatment. For these 11 group B patients median PFS was 12+ months (range 3 to 36+ months). LRT consisted of RT in 14 cases (bone in 13 cases, lymph node in one case) and resection in one (isolated brain metastasis). Conclusion - Patients treated with combined CDK4/6i and AI for first line HR+/HER- MBC were significantly more likely to develop LPD than those on single agent anti-estrogen, where local therapy could often be delivered with no change to systemic therapy. This strategy, applied to 11 of 60 combination treated patients (18%), delivered a median PFS in excess of a year. In contrast more general PD was more commonly observed in patients treated with AI alone, warranting change in systemic therapy. Citation Format: Andrew Redfern, Ngie Law, Indunil Weerasena, Lisa Spalding, Hilary Martin. Locoregional Management Based on Mode of Progression for HR+/HER2- metastatic breast cancer Treated with Combined CDK4/6 inhibitor with Aromatase inhibitor [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-05-01.

Denervation procedure of the lateral epicondyle for refractory lateral epicondylitis

BackgroundLateral epicondylitis is the most common cause of lateral elbow pain in adults, and non-operative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving ECRB débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. MethodsThis investigation was an IRB-approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale (VAS) pain and Single Assessment Numerical Evaluation (SANE) scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. ResultsCompared to the preoperative average, the cohort’s mean VAS pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean SANE score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. ConclusionsThe PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.