Conservative Treatment Group Research Articles

Evaluation of the medium-term outcomes in the treatment of severe multiple rib fractures in blunt chest trauma

Subjects and method: A total of 164 patients were diagnosed with blunt thoracic trauma (BTT) associated with rib fractures between October 2020 and October 2023 at Viet Duc Friendship Hospital, Cho Ray Hospital, and Viet Tiep Friendship Hospital. The study population was divided into two groups: Group 1: Patients with BTT who underwent rib fixation surgery using plates and screws. Group 2: Patients with BTT who did not undergo rib fixation surgery (conservative treatment). This is a multicenter descriptive study with longitudinal follow-up, including a non-randomized control group. Results: More than 3/4 of patients were male (75.6%). The main cause of injury in the study was traffic accidents, accounting for 65.9%. The average VAS score 1 month after surgery was 0.83 in the group with surgical stabilization of rib fractures by plates and screws, while in the conservative treatment group it was 1.47 points (p < 0.05). After 3 months, complications of hemothorax occurred in the conservative treatment group with 3.1%, only 1 patient in the group with surgical stabilization of rib fractures by plates and screws had hemothorax accounting for 1.6%. However, the above difference was not statistically significant. The total quality of life score in the group with surgical stabilization of rib fractures by plates and screws after 1 month was on average 0.7 points, after 3 months was 0.95 points. However, in the conservative treatment group, the increase was not high, after 1 month was 0.62 points, after 3 months was 0.77 points (p < 0.01). Conclusion: The surgical stabilization of rib fractures by plates and screws is effective for mid-term results with low complication rates, improving quality of life and effectively reducing pain in patients with blunt chest trauma.

Efficacy and Safety of Secondary Surgical Treatment for Refractory Recurrent Corneal Erosion.

To investigate the efficacy and safety of secondary surgical intervention of combined phototherapeutic keratectomy (PTK) with alcohol delamination and peripheral anterior stromal puncture (ASP) for refractory recurrent corneal erosion (RCE). This retrospective comparative study defined refractory RCE as cases persisting for more than 6 months after primary surgical intervention. A total of 115 eyes from 115 patients with refractory RCE, treated either with (n = 92) or without (n = 23) the secondary surgical treatment combining PTK and ASP between January 2021 and January 2023, were included. The Kaplan-Meier survival analysis method was used to determine the intervention's efficacy. The mean age was 34.4 ± 10.8 years, with a predominance of male patients (60%). Over a follow-up period exceeding 1 year, the recurrence rate was markedly lower at 27.2% in the group undergoing secondary surgical treatment compared with 69.6% in those receiving conservative treatment. Kaplan-Meier survival analysis revealed significantly reduced recurrence rates in the surgical group versus the conservative treatment group (log-rank test, P = 0.007). Notably, 96% of recurrences in the surgical cohort occurred within the first 6 months postintervention, with no recurrences observed after 9 months. At the final follow-up, 12% necessitated further surgical procedures 6 months after the secondary intervention. The study reported no significant surgical complications. The secondary surgical approach combining PTK with alcohol delamination and ASP presents a viable and safe treatment alternative for patients with refractory RCE, demonstrating a significant reduction in recurrence rates.

FEATURES OF LATE CORONARY ARTERY REVASCULARIZATION IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Objective. To compare the results of surgical and conservative treatment of patients with acute myocardial infarction admitted to a medical institution 48 hours after the occurrence of a coronary event.Materials and methods. The analysis of surgical treatment and postoperative observation of 43 patients with acute coronary syndrome admitted to hospital treatment within 72 to 120 hours from the onset of acute myocardial infarction was performed. All patients were divided into 2 groups: Group 1 (n = 17) included patients who underwent PCI for vital indications due to the presence of one or more emergency conditions in patients. Group 2 (n = 26) included patients who were hospitalized in a stable condition: they had no pain syndrome, life-threatening cardiac arrhythmias; hemodynamic parameters were within normal limits. The patients underwent complex conservative therapy, PCI was recommended on a delayed basis.Results. Two months after the treatment, higher myocardial functioning indices, and, as a result, better quality of life, were recorded in patients in the surgical treatment group. A greater number of fatal complications were recorded in patients after myocardial revascularization (which is explained, in all likelihood, by the extensive area and depth of damage to the heart muscle), and the number of non-fatal complications prevails in the conservative treatment group.

The Role of Duplex Ultrasound and Flow/Pressure Ratio in Predicting Invasive Treatment for High Venous Pressure in Patients Undergoing Hemodialysis.

Background and Objectives: Vascular access complications, particularly high venous pressure, pose significant challenges for hemodialysis patients undergoing hemodialysis. Limited research has focused on identifying predictive factors for invasive treatment. This study aimed to identify patients who might benefit from frequent monitoring and conservative management based on duplex ultrasound (DUS) evaluation. Materials and Methods: This retrospective study included 72 hemodialysis patients with high venous pressure who underwent DUS. Patients were divided into conservative (n = 26) and invasive treatment groups (n = 46). Key factors such as flow/pressure ratio, blood flow, and venous pressure were analyzed. Logistic regression was used to identify risk factors for invasive treatment, while receiver operating characteristic (ROC) analysis was performed to establish the optimal cutoff for the flow/pressure ratio. Results: Three months after the DUS, 3.85% of the conservative group experienced access failure, compared to 71.7% in the invasive group. The flow/pressure ratio was significantly lower in the invasive group (1.28 ± 0.26 vs. 1.47 ± 0.23, p < 0.05). A higher flow/pressure ratio (OR: 0.063, 95% CI: 0.004-0.932, p = 0.044) and the presence of tortuous veins (OR: 0.080, 95% CI: 0.007-0.897, p = 0.0405) were associated with a lower risk of invasive treatment. ROC analysis showed a flow/pressure ratio cutoff of 1.38 (AUC: 0.706, p = 0.004). Conclusions: Duplex ultrasound plays a crucial role in evaluating arterio-venous access in patients with high venous pressure. It provides a non-invasive assessment of vascular complications, helping avoid unnecessary invasive procedures. The flow/pressure ratio is significantly associated with the risk of invasive treatment, providing a valuable threshold for assessing risk and guiding clinical decision-making to optimize treatment strategies.

Sex-related differences in outcomes and prognosis of severe calcific mitral stenosis due to mitral annular calcification: A propensity-score matched cohort study.

The prevalence of severe calcific mitral stenosis (MS) is higher in female patients. The aim of the study was to assess the sex-related differences in clinical characteristics and prognosis in patients with severe calcific MS. Among 7154 adult patients with MS due to mitral annular calcification who underwent echocardiography between October 2010 and August 2020, 287 patients with severe MS were retrospectively analyzed. The endpoint was all-cause mortality. We calculated a propensity score matched analysis with 22 potential confounding covariates including clinical characteristics and medication usage. In the entire cohort, there was a predominance of female patients (66%), and the mean age was 72±11years. While 97 patients (34%) underwent MV intervention, 190 patients (66%) were conservatively managed. During a median follow-up of 12months (25th -75th percentile: 3-29months), 102 patients (36%) died. The cumulative survival rate of female patients was lower compared with male patients in conservative treatment group (p=0.012), while the cumulative survival rate was comparable between the sexes in MV intervention group (p=0.63). Even after propensity score matching in 170 patients (85 females and 85 males), similar results were obtained (p=0.012 for conservative treatment group, p=0.61 for MV intervention group). Female sex predominated in patients with severe calcific MS. Female patients with severe calcific MS had worse prognosis than male patients when treated conservatively, while in patients undergoing MV intervention, prognosis was similar between the sexes.

Case characteristics and surgical efficacy in elderly patients over 65 years of age with cervical spinal cord injury without fracture and dislocation: a retrospective study

ObjectiveThe outcomes of surgical and conservative treatment in elderly patients with cervical spinal cord injury without fracture and dislocation (CSCIWFD) were evaluated over medium- and long-term follow-up periods and the case characteristics were analysed.MethodsData from 39 elderly patients over 65 years of age with CSCIWFD who were admitted to our hospital between January 2010 and June 2022 were retrospectively analysed. Neurological recovery was assessed using the American Spinal Injury Association (ASIA) grading criteria and the Japanese Orthopaedic Association (JOA) score at admission, after surgery, and at the final follow-up. Post-injury imaging data were used to evaluate potential underlying lesions and injury types. In the surgical treatment group, the sagittal and transverse diameters of the cervical spinal canal were measured using magnetic resonance imaging at admission and the final follow-up to effectively assess spinal cord decompression.ResultsAt the final follow-up, the JOA score of the 21 patients who underwent surgical treatment was significantly higher than that of the patients who received conservative treatment (P < 0.001). Additionally, the ASIA grading showed a significant improvement compared to the conservative treatment group (P < 0.003). The sagittal and transverse diameters of the cervical canal in the surgical treatment group were significantly larger at the final follow-up than at admission, indicating surgical decompression (P < 0.001).ConclusionElderly men are the most commonly affected group with CSCIWFD, typically presenting with a history of low-energy trauma. For these patients, active surgical management is recommended following the stress period, assuming their physical condition is suitable. Our results suggest that even in patients with prolonged injury, improvement in neurologic and motor function may be superior to conservative treatment after thorough decompression surgery.

Brainstem Cavernomas: Functional Results and Prognosis Long-Term Follow-Up Cohort of Patients Treated Non-Operatively and Operatively

Introduction: Cerebral cavernous malformation (CCM) is an abnormally large collection of low flow vascular channels without brain parenchyma intervening between the sinusoid vessels. Brainstem Cavernoma Malformations (BSCMs) account for 0.5 to 0.9 % in the literature. Functional results, bleeding and subsequent bleeding have been reported in several studies in the literature relative to the management both for surgery and non-operative treatment. Our study aimed to evaluate long term functional outcomes of patients treated both operatively and non-operatively. Materials and Methods: A cohort of 44 patients has been followed for 29 years either retrospectively and prospectively. The retrospective period extended from October 1992 to September 2020 while the prospective one was the one year follow-up (FU) till September 2021. Data have been collected from patients’ archived files, schedule visits to the physician and phone calls. Patients in whom the diagnosis of BSCMs have been confirmed clinically and by image findings were included in our study. Functional status were assessed using both modified Rankin Scale (mRs) score over an interval from 0 to 5 and Karnosky Index (KI) from 0 to 100. Muscle strength was assessed by muscular testing over an interval from 0 to 5. Zero meant absence of muscular contraction while 5 was normal muscle motion. Magnetic Resonance Imaging (MRI) was systematically carried out in patients who had not got imaging control for 2 years. During FU period each patient who presented a new and sudden clinical symptom related to the involvement of brainstem was reassessed clinically and image work-up to rule out a rebleeding episode. Univariate analysis was conducted for establishing statistical significance between early haemorrhages, rebleeding, clinical and demographic features. Results: Forty patients presented 57 bleeding episodes. Thirteen patients (29.54 %) underwent surgery. Thirteen ones had eighteen recurrent bleeding episodes, i.e. a rate of 31.69±0.65 SD. Initial average mRs score was 0.67±0.79 SD for the conservative treatment group while the operated on patients had 2.15±1.14 SD. Postoperatively, mRs score was 2.07±1.44 SD. Final FU mRs was 0.93±00 SD and 1.81±00 SD for non-operative and operative treatment respectively. Surgery reduced the rate of rebleeding (p=0.04). The long-term functional outcome improvement was similar between non-operative and operative treatment (p=0.27). The predictive factors of bleeding and rebleeding reported were woman gender (p=0.0074) and pons location (p=0.0001) while age and Zabramski radiologic type were not significant. Conclusion: Our finding sustains similar functional outcomes to both non-operative and operative treatment. Nevertheless, surgery reduced the rate of rebleeding and remains largely related to the precise patient selection regarding clinical, radiologic and microsurgery features.

Abstract 4143258: Sex Differences in Health Status Outcomes: Analysis of the ISCHEMIA Randomized Clinical Trial

Background: Despite a lesser extent and severity of coronary artery disease (CAD), women had a higher burden of angina than men in the ISCHEMIA trial, suggesting that other factors may explain symptom severity in women. We aim to describe demographic and clinical characteristics, as well as differences in care patterns, associated with health status differences in women, as compared with men, in the conservative and invasive treatment groups of the ISCHEMIA trial. Methods: The ISCHEMIA trial randomized participants with moderate or severe ischemia to a routine invasive strategy of cardiac catheterization with complete revascularization plus guideline-directed medical therapy (GDMT), or an initial conservative strategy of GDMT alone with catheterization reserved for GDMT failure. Health status was a key secondary outcome. Using linear regression models we compared raw and adjusted Seattle Angina Questionnaire (SAQ) scores in women and men at baseline and at 1 year, stratified by randomized treatment strategy. Within the invasive strategy, sex differences were adjusted for completeness of revascularization among those with ≥1 coronary stenosis ≥70%. Results: Of 4,617 ISCHEMIA participants with valid SAQ data, women had lower (worse) baseline SAQ summary scores (SS) throughout follow up (Figure) after adjustment for demographics and clinical characteristics, including severity of CAD (difference 5.4 points, 95% CI 4.0-6.7). Women had lower SAQ SS after adjustment for post-randomization treatment (i.e., medical therapy, achievement of risk factor goals and, in the invasive strategy, complete revascularization), 2.4 points lower (95% CI 0.7-4.1) in the conservative group (Figure), and 1.9 points lower than in men (95% CI 0.1-3.7) in the invasive group. Findings were similar for all SAQ subscales. Conclusions: Women with chronic coronary disease in ISCHEMIA had worse health status than men at baseline and 1 year later, which was not explained by demographic or clinical characteristics, intensity of medical therapy, or completeness of revascularization.

Comparison of Clinical Outcomes of Conservative Treatment, Percutaneous Intralaminar Stabilization of Pars Defect, and Posterolateral Fusion with Interbody Fusion in Spondylolysis

Aim: This study aimed to compare the clinical efficacy of posterior lumbar interbody fusion (PLIF), percutaneous intralaminar screw pars stabilization (PS), and conservative treatment (CT) for symptomatic spondylolysis (SL). Material and Method: A retrospective randomized study was conducted on 45 patients, with 15 in each group (PLIF, PS, and CT), who underwent bilateral L5 SL and were treated between 2017 and 2022. Surgical indications included low back pain lasting &gt;6 months that was unresponsive to CT and without sciatica. The CT group comprised patients with similar pain profiles. Clinical outcomes were measured using the visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form 36 (SF-36) scores at 0, 1, 3, 6, and 12 months. Results: The study included 65% female patients with a mean age of 52 (PLIF), 44 (PS), and 46 (CT) years. Both the PS and PLIF groups showed significant clinical improvement compared with the CT group (p

An evaluation of 30 years’ experience in the use of botulinum toxin injections in the management of sixth nerve palsies

ABSTRACT Intrroduction Sixth nerve palsy is the most common type of extraocular muscle palsy. The therapy options in sixth nerve palsies include monitoring with or without conservative treatment, botulinum toxin injections or strabismus surgery. The aim of this retrospective study was to compare botulinum toxin (BT) injections into the medial rectus to conservative treatment in sixth nerve palsies. The rate of patients improved after intervention and treatment outcomes for the two treatment options were be evaluated at a German tertiary referral center. Methods A service evaluation was conducted on adult patients with sixth nerve palsy. Patient files were reviewed and data including abduction deficit and size of deviation were collected retrospectively. Patients which presented between January 1987 and April 2022 were considered. Patients were allocated into two treatment groups: BT injected into medial rectus or conservative treatment, which included observation, providing occlusion and Fresnel prisms. Inclusion criteria were attendance of two visits with orthoptic assessment. Exclusion criteria included presence of further oculomotor palsies, strabismus, strabismus surgery and suppression. Non-parametric statistical analysis was conducted using IBM® SPSS Statistics. Results A total of 606 adult patients with unilateral or bilateral sixth nerve palsy attended during the named period. A total of 137 adult patients met the inclusion criteria. Of which, 36 had a bilateral palsy, 101 had a unilateral palsy. 45.26% (n = 62) were treated with BT injections and 54.75% (n = 75) were treated conservatively. The median initial abduction deficit was greater in the BT group, (−4 to −5 after Scott and Kraft) than in the conservative treatment group (−1). The initial angle of deviation at distance was significantly larger in the BT group than in the conservative treatment group (p = <0.001). The rate of improvement in the BT group was 24.19% (n = 15) and 20% (n = 15) in the conservative treatment group. When excluding longstanding palsies rates of improvement in both groups increased to 28.85%. The improvement of the angle of deviation at distance in all patients was greater in the BT group (p = <.001). The improvement of abduction in bilateral palsies were greater in the BT group (p = .016), but in unilateral palsies, there was no significant difference in abduction improvement in the two treatment groups (OD p = .3, OS p = .406). Conclusion This service evaluation found that BT injection into medial rectus in unilateral and bilateral sixth nerve palsies did not increase the rate of improvement compared to conservative treatment. But BT injections reduced the angle of deviation to a greater extent than conservative treatment. Additionally, BT was able to improve abduction in bilateral palsies to a greater extent than conservative treatment. It is recommended a BT injection is considered in symptomatic bilateral sixth nerve palsies to enable fixation and improved ocular motility. More research is needed to verify reliable clinical guidelines for the use of BT in sixth nerve palsies.

The safety and efficacy of additional chest tube placement in patients with prolonged air leaks after pulmonary resection: a propensity score-matched analysis.

This study evaluates the symptomatic management of prolonged pleural air leaks following pulmonary resection, assesses the efficacy and safety of chest tube placement, and introduces experiences with high-positioned chest tube insertion. We retrospectively reviewed 84 patients with prolonged pleural air leaks after lung surgery at Ningbo No.2 Hospital from January 2022 to December 2023. These patients were divided into a conservative treatment group (Group A, n = 64) and a chest tube placement group (Group B, n = 20). The propensity score matching method was applied to balance confounders between the two groups, resulting in 12 matched pairs. The study compared the time to chest tube removal, average hospital stays time, postoperative drainage volume, and facial visual analog pain score between the two groups. The average hospital stays and chest tube removal time of patients in group B were significantly lower than those of patients in group A (8.00 ± 1.12 vs. 9.75 ± 1.60 days, P = 0.003, 6.92 ± 1.08 vs. 8.58 ± 1.67 days, P = 0.005, respectively). However, the mean facial visual analog pain score in group B was higher than that in group A (1.58 ± 0.58 vs. 1.00 ± 0.01, P = 0.020). There were no significant differences between the two groups in terms of postoperative drainage volume. For patients with prolonged air leaks, additional chest tube placement postoperatively significantly reduces both hospitals stay duration and chest tube indwelling time compared to conservative treatment. This method may be a potential treatment measure for prolonged air leak in selected patients.

Ultrasound-guided needle knife release for stenosing tenosynovitis of the flexor pollicis longus: a prospective randomized controlled trial

PurposeThis study aimed to evaluate the efficacy and safety of ultrasound-guided needle knife release in the treatment of stenosing tenosynovitis of the flexor pollicis longus. MethodsIn this prospective trial, 60 patients with clinically and ultrasonographically confirmed stenosing tenosynovitis of the flexor pollicis longus were randomly allocated to 1 of 3 groups: ultrasound-guided needle knife release (n = 20), traditional conservative treatment (n = 20), and open surgery (n = 20). The primary outcome measure was the Quinnell grade of triggering severity. Secondary outcomes comprised pain intensity (on visual analog scale), satisfaction (5-point Likert scale), and complications. Outcomes were evaluated at baseline, 1 week, 1 month and 3 months post-intervention by blinded assessors. ResultsAt all follow-up time points, the needle knife release group demonstrated significantly lower Quinnell grades (p < 0.05) and pain scores (p < 0.001) than the conservative treatment group; satisfaction was greater in the needle knife release group compared to the conservative treatment group at 1 month (p = 0.002) and 3 months (p < 0.001). There were no significant differences in outcomes between the needle knife release group and the open surgery group. The overall complications rate was 5% in the needle knife release group, 10% in the conservative treatment group, and 15% in the open surgery group (p = 0.574). ConclusionUltrasound-guided needle knife release is an effective and safe treatment for stenosing tenosynovitis of the flexor pollicis longus, with outcomes that are better than with traditional conservative treatment and similar to those of open surgery.

Management of Symptomatic Gallstones in Pregnancy

Gallstones, also known as cholelithiasis, are crystalline forms that occur in the gallbladder or biliary tract. Pregnancy causes various physiological changes that raise the chance of gallstone formation, which can lead to difficulties for both the mother and the fetus. Objective: To examine the safety and outcomes of conventional and interventional treatment in pregnant women with symptomatic gallstones. Methods: The study was longitudinal study. This study was conducted in Khairpur Medical College Civil Hospital Khairpur Mirs. The duration of this study was one Year, from Jan 2023 to Dec 2023. A total number of participant was (N=250) in this study. The age of participants was 18-35 years. There were included two treatment conventional and interventional. Results: The mean age of patients was 35.5 years. This study included 250 patients, had experienced gallstone symptoms. The intervention treatment group had the most participants (76%), followed by the conservative treatment group (24%). The cholecystitis participants had conservative treatment (76.3%), followed by laparoscopic treatment (53.3%). The majority participants was (66.6%) got laparoscopic therapy in the second trimester and indicate significant outcomes as compared to third trimester. The pregnant women was experienced no mortality, miscarriage during intervention therapy. Conclusions: This study supported prior findings that laparoscopic cholecystectomy can be performed safely during pregnancy, particularly in the second trimester. However, the third trimester brings additional obstacles, as seen by the higher prevalence of open cholecystectomy.

Pituitary Apoplexy: Comorbidities, Management and Outcomes. A Spanish Observational Multicenter Study

Abstract Background Pituitary apoplexy (PA) is the paradigm of endocrine and neurosurgical emergency. Objective To evaluate the comorbidities, risk factors, clinical presentation, pituitary apoplexy score (PAS) and the outcomes of surgical vs. conservative management of PA in Spain. Methods Spanish multicenter, observational study of 301 patients with acute PA. Statistical analyses compared risk factors, clinical presentation and outcomes between the surgical and conservative treatment groups, adjusting for potential confounders. The prevalence of cardiovascular risk factors in patients with pituitary apoplexy was compared with the Spanish population and with patients with non-functioning pituitary adenomas. Results Median age was 59.3 years, 201 (66.8%) were men and non-functioning adenomas (77.9%) were the most common tumor type. The prevalence of diabetes (20.3% vs 13.9%, p&amp;lt;0.01), hypertension (48.8% vs 33.4%, p&amp;lt;0.01) and dyslipidemia (44.2% vs 23.3%, p&amp;lt;0.01), exceeded the Spanish age-adjusted population prevalence. Overall, 209 (69.4%) underwent surgery and 92 (30.6%) received conservative treatment. Surgical patients had larger tumors (26.2 vs 21.0 mm, p&amp;lt;0.01), chiasmal compression more frequently (77.2% vs 53.4%, p&amp;lt;0.01) and higher values of PAS. In the follow-up, while there were no statistically significant differences in anterior pituitary hormonal deficits between treatments, permanent vasopressin deficiency was more frequent after surgery (14.8% vs 3.3%, p&amp;lt;0.01). Conclusion There is a high burden of cardiovascular risk factors among patients with PA suggesting that metabolic factors may play a potential role in the development of PA. This underscores the need for comprehensive management of these conditions in addition to treating the apoplexy itself in this population. Surgical management has a relevant place in PA approach mainly in patients with higher PAS. However, it leads permanent vasopressin deficit more frequently than conservative approach.

Incidence and Prognostic Significance of Silent Coronary Disease in Asymptomatic Patients with Severe Aortic Stenosis.

Background and Objectives: The aim of this study was to estimate the prevalence of silent coronary artery disease (CAD) in asymptomatic patients with severe aortic stenosis (AS) and assess long-term prognosis in terms of major adverse cardiovascular event (MACE)-free survival. Materials and Methods: This was a prospective study conducted at the Clinic for Cardiac Surgery, University Clinical Center of Serbia, in asymptomatic patients with severe AS, normal LVEF and stress test without signs of myocardial ischemia. Adverse cardiovascular events (cardiac death, myocardial infarction and any hospitalization due to heart disease) was monitored during one year of follow up. Results: A total of 116 asymptomatic patients with severe AS were included in the study. The average age was 67.3 ± 9.6 years, and 56.9% of patients were men. The most common cause of AS was degenerative valvular disease (83.5%). The incidence of significant CAD was 30 out of 116 patients (25.9%). The median Society for Thoracic Surgeons (STS) predicted risk of mortality score was 1.62% (25th to 75th percentile: 1.15-2.76%). The overall mean gradient across aortic valve (Pmean) was 52.30 mmHg ± 12.16, and the mean indexed AVA (AVAi) was 0.37 ± 0.09 cm2/m2. The mean LVEF was 68.40% ± 8.01%. Early surgery for aortic valve replacement was performed in 55 patients (55.2%), while 52 (44.8%) patients received conservative treatment. Twenty-two patients (42.3%) in the conservative treatment group underwent surgery during follow up. There were a total of 44 (37.9%) patients with MACE during one year of follow up. Univariate Cox regression analyses identified the following significant risk factors for MACE-free survival: presence of CAD and early conservative treatment (p = 0.004), age (p = 0.003), diabetes mellitus (p = 0.016) and STS score (p = 0.039). According to multivariate analysis, the presence of CAD with early conservative treatment was the most important predictor of MACE-free survival in asymptomatic patients with severe aortic stenosis (p ≤ 0.001). Conclusions: Early surgery for aortic valve replacement in asymptomatic patients with severe AS and concomitant CAD is beneficial for long-term survival.

The Effect of Conservative vs. Radical Treatment of Ameloblastoma on Recurrence Rate and Quality of Life: An Umbrella Review.

Ameloblastoma is a rare, benign, but locally aggressive odontogenic tumor that originates from the epithelial cells involved in tooth development. The surgical approach to treating an ameloblastoma depends on the type, size, location, and extent of the tumor, as well as the patient's age and overall health. This umbrella review's aim is to summarize the findings from systematic reviews (SRs) and meta-analyses on the effect of radical or conservative treatment of ameloblastoma on the recurrence rate and quality of life, to evaluate the methodological quality of the included SRs and discuss the clinical management. Three electronic databases (PubMed, Scopus, The Cochrane Library) were checked. The primary outcome was the recurrence rate after surgical treatment, while the secondary outcomes were the post-operative complications, quality of life, esthetic, and functional impairment. The methodological quality of the included SRs was assessed using the updated version of "A Measurement Tool to Assess Systematic Review" (AMSTAR-2). Eighteen SRs were included. The quality of the included reviews ranged from critically low (three studies) to high (eight studies). Four studies were included in meta-analysis, and they revealed that the recurrence rate is about three-times more likely in the conservative treatment group compared to the radical treatment group, and this result is statistically significant. Despite the high recurrence rate, the latter was more appropriate in the case of smaller lesions and younger patients, due to better post-operative quality of life and reduced functional and esthetic impairments. Based on the results of this overview, conservative treatment may be recommended as the first-line approach for intraosseous ameloblastoma not involving soft tissue. However, given the expectation of a higher recurrence rate, it is advisable to reduce the interval between follow-up visits. However, further prospective studies are needed to establish the best treatment choice and follow-up period.

Aortic valve replacement vs. conservative treatment in asymptomatic severe aortic stenosis: long-term follow-up of the AVATAR trial.

The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, ClinicalTrials.gov). The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥ 50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure (HF), as compared with conservative treatment strategy. A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either the early AVR group (n = 78) or the conservative treatment group (n = 79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group [hazard ratio (HR) early surgery vs. conservative treatment 0.42; 95% confidence interval (CI) 0.24-0.73, P = .002]. The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23-0.85, P = .012, for all-cause death and HR 0.21; 95% CI 0.06-0.73, P = .007, for HF hospitalizations). The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting.

Choice of Acromioclavicular Dislocation Treatment Should Not Be Influenced by Risk of Development of Acromioclavicular Osteoarthritis: A Systematic Review With Meta-Analysis.

It is currently unknown to what degree surgical or nonoperative treatment of acromioclavicular (AC) dislocation influences the development of osteoarthritis (OA). The aim of this study was to evaluate AC OA after surgical and nonoperative treatment for AC dislocations, compare OA prevalence between treatment options, and compare OA prevalence between the injured and contralateral shoulder. Articles reporting on the prevalence of OA after surgical or nonoperative treatment of an AC dislocation with a minimal 2-year follow-up were included. AC OA presence was extracted for the injured and contralateral shoulder. Treatment categories were defined based on anatomical variation in the reattachment of ligaments: AC fixation, coracoclavicular (CC) fixation, AC and CC fixation, Bosworth screw synthetic graft, tendon graft, and conservative. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Ninety-four articles were included for qualitative analysis, and 7 articles were included for meta-analysis (n = 3,812; follow-up = 2.0-24.2 years; mean age 37.6 ± 10.4 years). A total of 3,483 patients underwent surgical treatment, and 329 patients underwent conservative treatment. OA prevalence ranged from 6.7%-29.3% between 7 pooled treatment categories. Most included studies had a follow-up <10 years (94%) and OA prevalence increased with time, regardless of treatment option. There was no difference in OA prevalence between the injured and contralateral shoulder (p = 0.120). MINORS scores were varied, ranging from poor to very good. The pooled AC OA prevalence of the 7 treatment categories ranged from 6.7% for the CC fixation surgical group to 29.3% for the conservative treatment group. However, the included studies were predominantly of low quality and had varying follow-up periods, with most having relatively short follow-up durations. No difference in AC OA prevalence was found between the injured and contralateral shoulder. Based on the available evidence, treatment choice for AC dislocation should not be influenced by the potential development of AC AO. Level IV. See Instructions for Authors for a complete description of levels of evidence.

PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation

BackgroundThe benefit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease and severe aortic stenosis who are undergoing transcatheter aortic-valve implantation (TAVI) remains unclear.MethodsIn an international trial, we randomly assigned, in a 1:1 ratio, patients with severe symptomatic aortic stenosis and at least one coronary-artery stenosis with a fractional flow reserve of 0.80 or less or a diameter stenosis of at least 90% either to undergo PCI or to receive conservative treatment, with all patients also undergoing TAVI. The primary end point was a major adverse cardiac event, defined as a composite of death from any cause, myocardial infarction, or urgent revascularization. Safety, including bleeding events and procedural complications, was assessed.ResultsA total of 455 patients underwent randomization: 227 to the PCI group and 228 to the conservative-treatment group. The median age of the patients was 82 years (interquartile range, 78 to 85), and the median Society of Thoracic Surgeons–Predicted Risk of Mortality score (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after the procedure) was 3% (interquartile range, 2 to 4). At a median follow-up of 2 years (interquartile range, 1 to 4), a major adverse cardiac event (primary end point) had occurred in 60 patients (26%) in the PCI group and in 81 (36%) in the conservative-treatment group (hazard ratio, 0.71; 95% confidence interval [CI], 0.51 to 0.99; P=0.04). A bleeding event occurred in 64 patients (28%) in the PCI group and in 45 (20%) in the conservative-treatment group (hazard ratio, 1.51; 95% CI, 1.03 to 2.22). In the PCI group, 7 patients (3%) had PCI procedure–related complications.ConclusionsAmong patients with coronary artery disease who were undergoing TAVI, PCI was associated with a lower risk of a composite of death from any cause, myocardial infarction, or urgent revascularization at a median follow-up of 2 years than conservative treatment. (Funded by Boston Scientific and the Danish Heart Foundation; NOTION-3 ClinicalTrials.gov number, NCT03058627.)

Efficacy and risk factors of stent placement in the treatment of malignant tracheoesophageal fistula.

Due to the low incidence of malignant tracheoesophageal fistula and the paucity of relevant clinical studies, the benefits of stent implantation have not been well documented. It remains unclear which factors may affect fistula closure. Between January 2015 and January 2021, 344 patients who were diagnosed with malignant tracheoesophageal fistula at Zhongda Hospital, Southeast University, were retrospectively enrolled. Demographic and clinical data were collected. Risk factors for fistula closure identified by univariate analysis were further analyzed using multivariable logistic regression. A total of 288 patients were analyzed in this study, of which 94 were treated conservatively, 170 were treated with an esophageal stent, and 24 were treated with a tracheal stent. Among them, the delta Karnofsky's performance status score values (after 2 weeks/before treatment [p = 0.0028], after 1 month/before treatment [p = 0.0103]) were significantly different between conservative and stent treatment. There was a significant reduction of pneumonia incidence in the stenting group (33.53%) compared to the conservative treatment group (77.05%) after one month (p <0.0001). In addition, the closure of fistulas was influenced by four independent risk factors: 1) treatment methods (p < 0.0001), 2) fistula size (p = 0.0003), 3) preoperative white blood cell count (p = 0.0042), and 4) preoperative Karnofsky's performance status score (p = 0.0001). Stent implantation has become an effective method for treating malignant tracheoesophageal fistula compared to conservative treatment. Additionally, stent implantation, smaller fistula size, lower preoperative white blood cell count, and higher preoperative Karnofsky's performance status score suggest a better outcome.