Initial Conservative Treatment Research Articles

Functional outcomes of early versus delayed pyeloplasty in prenatally diagnosed pelvi-ureteric junction obstruction

Although initial conservative management is popular in the management of antenatally detected pelvi ureteric junction (PUJ) obstruction [1-3], several authors [4,5] have questioned this approach and expressed concern about failure to recover the function lost during expectant management following surgery. In this single center prospective study, we have compared the functional outcomes following early versus delayed pyeloplasty in SFU grade 3-4 PUJ obstruction. Among those children, who presented between 2004 and 2013, with prenatal diagnoses of unilateral PUJ obstruction (n = 886), those with SFU grade 1 or 2 hydronephrosis on USG (n = 533) were excluded. In the remaining 353 children with SFU grade 3 and 4 hydronephrosis, 243 had obstructive pattern on radionuclide scan. After excluding those with severely impaired or supranormal split renal function (SRF), palpable mass, single kidney status, bilateral disease and associated other urological anomalies a total of 126 children were included in the study group. Parents who were unwilling for a frequent follow-up underwent early pyeloplasty, (Group I: n = 62) while the remaining underwent initial conservative management, with 3 monthly USG and nuclear scans (Group II; n = 64). In this group pyeloplasty was performed whenever there was deterioration in SRF >10%, or urine infection or pain during the follow-up. A standard open dismembered pyeloplasty was performed by the same surgeon in all patients. Radionuclide scan was performed at 1 year, at the same center using the same protocol, to assess final SRF and drainage. The functional outcomes were compared using student's t test and chi square test. Group I comprised of 62 patients while Group II 64 patients. The mean age at pyeloplasty was 2.8 months in group I while 12.5 months in group II. There was no significant difference in the initial antero posterior diameter (APD) between the groups; 30.2 (±3.2) mm in group I and 29.6 (±3.7) mm in group II. At 1-year follow up after surgery, there was improvement in the APD, 16.8 (±4.2) mm in group I and 18.2 (±4.5) mm in group II, with no significant difference between them. In group I, the initial mean SRF was 34.1% (±6.4) and there was significant improvement (p = 0.01) in mean SRF to 37.2 (±7.1) at 1-year follow up after surgery. In group II, the mean SRF was 35.9 (5.7) initially and there was a deterioration to 32.6 (±5.5) before surgery (Figure). At 1-year follow up after surgery, there was a marginal improvement to 33.5 (5.6), however it was significantly lower compared to the initial SRF (p = 0.01). Compared to initial function, at 1-year follow up after pyeloplasty, SRF improved in significantly higher number of patients; 17/62 (27.4%) in group I while only 7/64 (10.9%) in group II (p = 0.03) (Table). There was significantly fewer patients with deterioration in final SRF at 8/62 (12.9%) in group I compared to 22/64 (34.4%) in group II (p = 0.03). Although several publications [1-3] have reported functional recovery during initial conservative treatment of PUJ obstruction, in our study a large proportion of patients (80%) in Group II had loss of function during follow-up. This is probably because the study population included only SFU grade 3-4 with obstructive renogram. Several authors have expressed concern about irreversible loss of renal function during expectant management [4,5]. Findings of our study reveal that irrespective of initial SRF, early pyeloplasty in prenatally diagnosed SFU grade 3-4 PUJ obstruction leads to significant improvement of SRF, while delayed pyeloplasty leads to a marginal but, significant loss. This fact should be highlighted to parents so that informed decisions can be made regarding early versus delayed surgery.

Clinical features and treatment outcomes of dental implant-related paranasal sinusitis: A 2-year prospective observational study.

As dental implant-related paranasal sinusitis has different pathophysiology and clinical features from primarily rhinogenic paranasal sinusitis, the standard treatment protocol for dental implant-related paranasal sinusitis has not yet been established. The aim of this study was to analyze the clinical characteristics and treatment results of dental implant-related paranasal sinusitis. We conducted a prospective single-center study of 19 patients who were treated for odontogenic sinusitis developing in relation to dental implant from September 2008 through May 2012. The age of the patients ranged from 33 to 78years, with the mean age of 54.5years. Foul odor and postnasal dripping were the two most common complaints. All patients underwent nasal endoscopic examination and paranasal sinus CT before treatment, and initial conservative treatment for 1week. Patients unresponsive to medical treatment underwent endoscopic sinus surgery (ESS). All patients were classified into the conservative and surgical groups for analysis and followed up for 2years after initial diagnosis. Four patients (21%) were successfully treated conservatively, while 15 patients (79%) underwent surgical treatment. One of these 15 patients required revision surgery. After 2years, all patients were successfully treated, so there were no more clinical signs of recurrent sinusitis in any patients. The survival rate of implants was 100%. Compared to those of the conservative group, symptom duration, the Lund-MacKay CT score, status of the ostiomeatal unit (OMU), and the condition of the maxillary sinus floor were significantly more severe in the surgical group. In our study, the majority of patients who once developed paranasal sinusitis associated with dental implants required surgical treatment. Findings of paranasal sinus CT may be important in determining treatment option.

Current aspects of eyelid, lacrimal and orbital surgery in childhood

During childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults. This review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood. The study comprises a PubMed literature review and own clinical results. The most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions. Eyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.

Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis

Background. The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established. The aim of our prospective randomized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC. Methods. Between March 2007 to December 2008, 50 patients with diagnosis of acute cholecystitis were assigned randomly to early group, n = 25 (LC within 24 hrs of admission), and delayed group, n = 25 (initial conservative treatment followed by delayed LC, 6–8 weeks later). Results. We found in our study that the conversion rate in early LC and delayed LC was 16% and 8%, respectively, Operation time for early LC was 69.4 min versus 66.4 min for delayed LC, postoperative complications for early LC were 24% versus 8% for delayed LC, and blood loss was 159.6 mL early group versus 146.8 mL for delayed group. However early LC had significantly shorter hospital stay (4.1 days versus 8.6 days). Conclusions. Early LC for acute cholecystitis with cholelithiasis is safe and feasible, offering the additional benefit of shorter hospital stay. It should be offered to the patients with acute cholecystitis, provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon.

Conservative approach to the management of large adenomatoid odontogenic tumor: A viable alternative

Adenomatoid odontogenic tumor (AOT) is a relatively rare, odontogenic tumor, commonly associated with the impacted successional tooth. It is characterized by benign, nonaggressive, and indolent growth. Thus, the proposed treatment for AOT is enucleation with removal of the associated impacted tooth. In this case report, we discuss marsupialization as a more conservative initial treatment modality for a large AOT with good cosmetic outcomes. The case of a 13-year-old boy with an unusually large maxillary AOT is presented. This large follicular variant of AOT was successfully managed by marsupialization with a 1-year follow-up. Marsupialization can be a preferred initial surgical approach to facilitate regression of the bony swelling and to promote eruption of the impacted tooth with or without orthodontic treatment. We suggest consideration of decompression or marsupialization as an initial conservative treatment modality for the follicular variants of AOT with acceptable cosmetic outcomes and tooth salvage.

A Case Report of Chronic Low Back Pain with Ochronosis

Reported here is a 47-year-old man with ochronosis and ongoing low back and leg pain symptoms who underwent low back surgery due to lumbar disc hernia. Presenting this patient, we caution clinicians to consider ochronosis in the differential diagnosis of lumbar discopathy, and we would like to emphasize again the roles of x-ray imaging as an initial diagnostic method and conservative treatment before surgical interventions for relevant pathologies.

Long-Term Follow-Up of Patients with Vestibular Schwannomas after Initial Conservative Treatment

Background: The natural course of vestibular schwannomas is still not ascertained. The treatment options are surgery, radiosurgery or “wait-and-scan.” Conversion from observational to active treatment is reported in 15 to 85% of cases. The present study evaluates a long-term follow-up of initially conservatively treated patients, to identify a cut-off time for further follow-up. Methods: In the 10-year period (1997-2006), 161 consecutive patients (mean age 54 years, 53% males) were referred to our department with newly diagnosed vestibular schwannomas. The mean tumor size at presentation was 22 mm (6-60 mm), the tumor was intracanalicular in 27 cases (17%). Primary treatment was surgery in 62 (39%) and radiosurgery in 7 patients (4%), respectively. The remaining 92 patients (57%) were initially followed conservatively with regular MRI scanning. Results: Two patients from conservatively treated group were lost to follow-up, leaving 90 patients for further analysis. The mean tumor size in this group was 16 mm (6-40 mm). Overall 49 of these patients (54%) have received treatment (surgery in 23 and radiosurgery in 26 cases, respectively) after a mean of 25 months (10-67 months) of initial follow-up; 17 of these patients (35%) within 1 year from diagnosis. The remaining 41 untreated patients have been followed for a mean of 90 months (29-180 months), in 28 cases for more than 67 months. Conclusions: The results indicate that life-long follow-up is unnecessary in case of no evidence of tumor growth over several years. We propose termination of routine follow-up after 10 years.

Role of the transumbilical laparoscopic-assisted single-channel, single-port procedure in an interval appendectomy for pediatric mass-forming appendicitis: a preliminary retrospective analysis.

A transumbilical laparoscopic-assisted single-channel, single-port procedure was introduced during laparoscopic interval appendectomy for mass-forming appendicitis in children. The aim of this study was to evaluate the results of the original laparoscopic interval appendectomy. This study analyzed 31 children who underwent laparoscopic interval appendectomy using a single-channel, single-port procedure. The appendectomy was usually planned 8-12 weeks following initial conservative treatment. The procedure was a single-channel surgery using a 12-mm single port. Both a 5-mm telescope and grasper were inserted simultaneously into the single channel. The grasper held the appendix, and an extracorporeal appendectomy was performed. Appendectomy was planned for 29 patients, as 2 patients deviated from the protocol. The procedure was successful in 21 patients (72.4%). An accessory port was necessary in eight patients, two of whom successfully underwent laparoscopic surgery; the remaining six were converted to open appendectomy. The average length of surgery was 43 min in the single-channel, single-port procedure. No postoperative complications occurred in any patient. The single-channel, single-port procedure was successfully performed in over 70% of the patients. This preliminary retrospective analysis indicates that the procedure is safe and potentially beneficial in children with mass-forming appendicitis who require laparoscopic interval appendectomy.

Treatment Results for Spontaneous Isolated Superior Mesenteric Artery Dissection according to Our Previous Guidelines and Collective Literature Review

Isolated superior mesenteric artery dissection (ISMAD) is not a rare disease. However, its optimal treatment strategy has not yet been established. This study included 13 consecutive patients with ISMAD who were treated between April 2010 and July 2013 according to published treatment guidelines. Through a literature search, 10 studies on treatments and outcomes for ISMAD that were published from 2007 to the present were analyzed. In the present study, 11 patients had acute onset abdominal pain and 2 patients were asymptomatic. Twelve patients were treated with conservative treatment, whereas 1 patient underwent coil embolization. In the literature review, initial conservative treatment, endovascular procedure, and surgical repair were done in 172, 25, and 14 patients, respectively. Bowel resection was done in 8 patients (3.7%) due to bowel necrosis. Conservative treatment failed in 15 patients (6.8%) during follow-up. If bowel necrosis or arterial rupture was not present, conservative treatment of ISMAD was a safe and effective treatment. Aneurysmal type IV patients on computed tomography scan should be carefully followed up, and if there is a recurrence of pain or aneurysmal progression, an endovascular procedure could be safely performed.

Randomised Prospective Controlled Trial of Topical 2% Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano.

Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2% diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71% had complete healing of fissure at 6weeks, with fair amount of pain relief (mean VAS-3.38), and in group B, 96% showed healing of fissure, with excellent pain relief (mean VAS-1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.

Das akute Knietrauma: Praxisrelevante Aspekte

The acute knee injury represents one of the most common reasons to visit a general practitioner or an emergency department in a hospital. The initial assessment of an acute knee injury usually is affected by severe swelling, pain and a significant lack of motion. Conventional radiographs in three planes may provide additional information to limit the differential diagnosis. A clinical re-evaluation after five to ten days usually allows proper functional testing and therefore correct diagnosis in the majority of cases can be made. With suspicious clinical findings, MRI may be helpful to evaluate ligamentous, meniscal and cartilaginous structures. Femoro-tibial knee dislocation represents the most harmful acute knee injury and needs to be further evaluated and treated in an adequate medical institution in every suspicious case. Rapid vascular diagnostic with (CT)-angiography is crucial. Behind a multi-ligament injury of the knee a spontaneously reduced dislocation may hide and proper neuro-vascular exam therefore is mandatory in every patient. When fracture, blocking and major instability can be excluded at initial assessment, there is usually no need for any acute surgical intervention and initial conservative treatment may be conducted on an out-patient basis for most of the patients. Priority of surgical treatment depends on the injury pattern and delayed intervention with a pre-habilitative phase may be beneficial for certain pathologies.

Role and timing of coronary intervention in non-ST-elevation myocardial infarction

Non-ST-elevation myocardial infarction (NSTEMI) has become the most common presentation of acute myocardial infarction. Its treatment is challenging and often less straightforward compared with ST-elevation myocardial infarction (STEMI). First, clinicians must decide whether an initial invasive or an initial conservative treatment is appropriate for their NSTEMI patient. If an invasive strategy is chosen, subsequent decisions on the optimal timing of coronary angiography and possible intervention have to be made. Both aggressive and conservative strategies have their own potential risks and benefits. Aggressive strategies may result in more procedural complications, which is especially unwanted in patients otherwise at low risk of events. By contrast, conservative strategies may be harmful in high-risk patients who benefit most from early reperfusion therapy. We aim to discuss the evidence base of this decision process where risk stratification is of paramount importance with the goal of obtaining the opt...

Treatment of Traumatic Stapediovestibular Luxation

Stapediovestibular luxations are rare lesions that are most commonly caused by direct, penetrating trauma to the external ear canal. In this type of ossicular dislocation, disruption of the annular ligament or footplate fracture may lead to a perilymphatic fistula (PLF) presenting with cochleovestibular symptoms including (progressive) sensorineural hearing loss, tinnitus, and vestibular symptoms. The objective of this article is to define the optimal treatment of stapediovestibular luxations and review the literature on this topic. We present a case of internal stapediovestibular dislocation and pneumolabyrinth after penetrating trauma with predominantly conductive hearing loss and incapacitating vertigo. Middle ear inspection with removal of the luxated incus, repositioning of the stapes with a "stapedial strut" and closure of the tympanic membrane. Hearing outcome and vestibular symptoms of this patient are presented, and all comparable cases in the literature are reviewed. Complete resolution of the vestibular symptoms and stabilization of the bone conduction thresholds. In patients with pneumolabyrinth after middle ear trauma with mild symptoms, we recommend initial conservative treatment with close monitoring of hearing. In patients with severe, persisting, or progressive vestibulocochlear symptoms, exploratory tympanotomy should be performed to check for and treat PLF. Oval window fistula repair is reported to have variable hearing outcomes but offers complete resolution of vestibular symptoms in most cases. The stapedial strut is one of the possible surgical techniques in case of an internally luxated stapes.

Outcomes from surgical treatment of middle-third clavicle fractures non-union in adults: A series of 21 cases

IntroductionThe aim of our study was to evaluate the results of surgical treatment of clavicle non-union after failure of conservative treatment. Our hypothesis was that stable fixation with bone graft derived from local bone stock (fracture site) or the iliac crest was essential to achieve bone union. Material and methodsTwenty-one patients with a symptomatic middle-third clavicle non-union after failure of initial conservative treatment were included in the study. Delay between the initial fracture and surgery for non-union was 27months (6–144). In five cases, the non-union was hypertrophic and bone graft was obtained locally from the callus. In 16 patients, the non-union was atrophic. Bone was harvested from the iliac crest as cortico-cancellous graft (7 patients) and cancellous graft (8 patients). One patient refused bone grafting. A 3.5-mm plate with non-locking screws was placed anterior in 12 and superior in 9 patients. ResultsAt 41months average follow-up (minimum of 12months), 20 patients were available for review. Bone healing was obtained initially in 15 cases. Six complications required a revision procedure: 3 for infection and 3 for mechanical failure. At last follow-up, 19 patients were satisfied with the surgery. Average Constant score was 84±26 points (7–100), and Quick DASH score 17±22 points (0–91). Radiographic bone healing was obtained in 19 of the cases. ConclusionTreatment of middle-third clavicle non-union after initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited and effective treatment. Our hypothesis was verified. Preoperative evaluation of appearance of the non-union X-rays can be used to determine the type of bone graft needed, but the final decision is often taken during surgery. Level of evidenceLevel IV.

Abstract 29: The Surgical Trial in Lobar Intracerebral Haemorrhage - Analysis of Crossover Patients

Background: STICH II was an international multicentre pragmatic randomised parallel group trial to establish whether a policy of early surgery (ES) improved outcome compared to a policy of initial conservative treatment (ICT) for patients with superficial lobar intracerebral haemorrhage (ICH). The results of the “intention to treat analysis” have been published and showed a non-significant trend in favour of early surgery. However, as observed in other surgical trials, there was a substantial crossover of patients from the ICT group with 21% having surgery within 14 days of randomisation. This paper investigates these patients and their effect on outcome. Methods: Patients from the ICT group who underwent surgery within 14 days were identified and compared with patients who continued to receive conservative treatment and with patients randomised to ES. The protocol defined “early surgery” as within 12 hours of randomisation so analyses were also conducted using this definition. Per protocol and treatment received analyses were conducted. Results: For this analysis there are 285 ICT patients with outcome assessed, 233 had no surgery and 62 patients had surgery within 2 weeks: 23 within 12 hours. Of 297 patients randomised to ES, 278 had surgery within 12 hours. Surgical ICT patients had lower GCS (13 v 14) and larger volumes (54ml v 32ml) of haematoma at randomisation (p<0.0001) than non-surgical ICT. They also showed lower GCS and larger volumes (54ml v 40ml) than per protocol ES patients. Surgical ICT patients were much more likely to have an unfavourable outcome than non-surgical (84% v 63%, p < 0.002). If the surgery was after 12 hours the unfavourable outcome was higher (89%). There were no differences in outcome between per protocol ES and non-surgical ICT but there were major differences in baseline measures between these patients. Death rates were highest in ICT patients having surgery within 12 hours (48%) compared with later surgery (31%), non-surgical ICT patients (20%) and ES patients (17%). Conclusions: Patients randomised to conservative treatment who deteriorate and have surgery differ considerably from those that do not deteriorate and from those who are randomised to early surgery. Further work is needed to develop ways of analysing these data.

A Randomized Clinical Trial and Meta-analysis of Early Surgery vs Initial Conservative Treatment in Patients With Spontaneous Lobar Intracerebral Hemorrhage

A Randomized Clinical Trial and Meta-analysis of Early Surgery vs Initial Conservative Treatment in Patients With Spontaneous Lobar Intracerebral Hemorrhage

Medial patellofemoral ligament

Traumatic and nontraumatic patellofemoral instability (PFI) in children and adolescents is a complex problem. It is determined by a large number of mechanical and pathomorphologic conditions, mainly seen in nontraumatic dislocations. Although conservative treatment with a short immobilization, followed by early passive motion and isometric quadriceps strengthening, can be considered in real traumatic dislocations without any cartilaginous injury, a surgical intervention should be considered in atraumatic cases. As 90% of PFI are nontraumatic and correlated with skeletal deformities, the redislocation rate is reported to be up to 80% after initial conservative treatment. To optimize the results, the causing disorder for PFI has to be considered imperatively. In addition to bony disorder, further risk factors have to be taken into consideration for determining the optimal time for surgery. As biomechanical and clinical studies have shown the importance of the medial patellofemoral complex, especially the medial patellofemoral ligament (MPFL), against patellar lateralization, the reconstruction or minimally invasive double-bundle reconstruction of the MPFL is the main surgical technique to treat PFI in children, as it can be used even in open epiphysial cartilage. Further surgical interventions correcting bone deformities, such as trochleoplasty or tibial tubercle osteotomies addressing lower limb deformities, should be performed after closure of the epiphysial cartilage. It is the goal of this overview to explain the pathoanatomy of PFI, the demanding clinical and radiological examinations and treatment options.

Factors associated with significant ocular injury in conservatively treated orbital fractures.

Purpose. To determine factors associated with the presence of significant ocular injury in subjects with orbital fractures. Subjects. A consecutive prospective cohort of 161 patients presenting to a general tertiary referral hospital with orbital fractures and undergoing initial conservative treatment was identified. Subjects were assessed at time of injury for the need for emergency surgery, and those initially treated conservatively were subsequently followed up by the Ophthalmology Department to assess for ocular injury requiring ophthalmic management at 1–7 days after injury. Associations between ocular injury and age, sex, visual acuity, presence of blowout fracture, extent of orbital involvement, and presence of distant facial fractures were assessed. Results. 142 male (average age of 32 [95% CI 30–35]) and 19 female (average age of 49 [95% CI 39–59]) subjects were identified. 17 subjects were diagnosed with significant ocular injury. Ocular injury was significantly associated with LogMAR VA worse than 0.2 (OR 49 [95% CI 11–217, P < 0.0001]), but no relationship was noted for age, sex, presence of blowout fracture, extent of fractures, or presence of distal facial fractures. LogMAR visual acuity worse than or equal to 0.2 had a 98% negative predictive value for ocular injury in the setting of orbital fractures. Conclusions. Demographic and nonophthalmic fracture characteristics were not useful predictors of ocular injury in orbital fractures. LogMAR visual acuity worse than or equal to 0.2 is a highly sensitive and useful guide of the need for ophthalmic referral in subjects with orbital fractures.

Abdominal tuberculosis with an acute abdomen: our clinical experience.

Tuberculosis is an important cause of morbidity in India. Abdominal Tuberculosis is a great mimicker and is difficult to diagnose. This prospective observational study is based on those patients who were diagnosed to be suffering from Abdominal Tuberculosis only after they presented with an acute abdomen. This study aims to document the nature of different types of acute presentation in Abdominal Tuberculosis according to involved sites and surgical pathology. The study also discusses the indications and extent of surgical intervention. Seventy new cases of Abdominal Tuberculosis (out of 718 cases of acute abdomen) were diagnosed and treated over a period of three years in the surgical ward of Calcutta National Medical College. Macroscopic appearance of abdominal tissues during surgery suggested the diagnosis of tuberculosis. The diagnosis was confirmed by histopathology and tissue culture. All patients were subsequently treated with a full course of antitubercular drugs (ATD). The clinical presentations of acute abdomen included acute intestinal obstruction, perforative peritonitis and acute appendicitis etc. Terminal ileum and ileocaecal region were predominantly involved. The most common pathology was intestinal stricture with or without perforation. Most of the patients (approx 78.5%) required emergency surgery as a therapeutic intervention. A two-stage procedure was preferred in peritonitis and sepsis. Most of the remaining patients (12.8%) required surgery after initial conservative treatment for the first few days. Undiagnosed Abdominal Tuberculosis represents a notable percentage (10%) of patients who present with an acute abdomen as a surgical emergency. Abdominal Tuberculosis is very difficult to diagnose and diagnosis is often delayed till an acute abdomen is presented with. Almost all patients needed surgical intervention. Irrespective of surgery, all patients of abdominal tuberculosis require a full ATD.

Spontaneous absorption of extensive subinternal limiting membrane hemorrhage in shaken baby syndrome.

The Shaken Baby Syndrome (SBS) is characterized by subdural hematomas (SH), retinal hemorrhages (RH), and multiple fractures of long bones without external evidence of head trauma. Subinternal limiting membrane (ILM) hemorrhage, also known as macular schisis, is a characteristic finding of this entity. There is no guideline on the right time to indicate surgical treatment. This report describes an abused child with massive sub-ILM hemorrhage, which showed spontaneous absorption after less than two months of follow-up. Due to the possible spontaneous resolution, we suggest an initial conservative treatment in cases of sub-ILM hemorrhage related to SBS.