Failure Of Medical Treatment Research Articles

Management of Orbital Complications of Acute Rhinosinusitis in Pediatric Patients: A 15-Year Single-Center Experience.

The major clinical dilemma managing acute rhinosinusitis (ARS) in pediatric population is distinguishing uncomplicated rhinosinusitis from a complicated bacterial ARS and orbital complications, the latter requiring antimicrobials and surgical intervention. However, factors associated with severe orbital complications and the optimum management strategy remains controversial. The objectives of this study were to characterize the clinical outcomes of children with orbital complications of ARS and to identify risk factors associated with disease severity. This retrospective cohort analysis evaluated the clinical outcomes of 61 children admitted for orbital complications between January 1, 2002 and December 31, 2017. Descriptive statistics were performed to examine the demographics and clinical findings. We compared groups using Mann-Whitney U test for continuous variables and χ for categorical variables. Although two-thirds of children had received prehospital antibiotics, half of the cohort presented with post-septal orbital complications. While 83% of isolates obtained from the same patients were susceptible to the prehospital antibiotics given, the majority of those who received prehospital antibiotics nevertheless required surgical intervention. We observed significant association between the age of presentation and disease severity. Children >5 years of age presented with more severe orbital complications despite prehospital antibiotics and were more likely to require surgical intervention (P < 0.001). In this study, stage II/III orbital complications at presentation and older age were the most important determinants of medical treatment failure. Early referral to eye, nose and throat (ENT) should be considered for children >5 years with ARS due to worse orbital complications despite prehospital antibiotics.

Pediatric Autoimmune Inner Ear Disease: A Rare, But Treatable Condition.

Autoimmune inner ear disease (AIED) is a rare, but treatable cause of sudden sensorineural hearing loss in children. Most cases present acutely and involve both ears. The precise mechanism of hearing loss in AIED is not known. Many suspected etiologies have been proposed including infections, vascular abnormalities, and trauma. However, 70% of cases are defined as idiopathic. There are no standardized diagnostic criteria for AIED, and the diagnostic process may be challenging. Positive auto antibodies and response to immunosuppressive therapy support the diagnosis. Treatment may include corticosteroids and steroid-sparing immunosuppressive medications. A high index of suspicion is recommended as the hearing loss may be stabilized or even reversed with early treatment. Long-term medical treatment failures generally have good outcomes with cochlear implantation. [Pediatr Ann. 2019;48(10):e391-e394.].

Refractory Duodenal Ulcer and Upper Gastrointestinal Bleeding Following Yttrium-90 Transarterial Radioembolization

Abstract Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma. Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.

Image-Guided Stereotactic Ventricular Catheter Placement for Refractory Idiopathic Intracranial Hypertension: Accuracy and Effectiveness

AbstractBackground: Although lumboperitoneal shunt (LPS) is a common procedure for surgical management of idiopathic intracranial hypertension (IIH). However, many studies doc-umented a high failure and complications rate. Ventricular shunts were not commonly used for surgical management IIH due to the difficulty of inserting a shunt into normal or slit ventricles. Also, stereotactic surgery not available in every hospital.Aim of the Study: This article retrospectively evaluate the accuracy, efficacy, and safety of using stereotactic image-guided insertion of ventricular catheter in patients with IIH.Patients and Methods: The authors reviewed the clinical records of all patients in whom stereotaxy was used to guide the placement of a ventricular catheter for IIH. Stereotactic guided ventricular catheter placements were performed on sixteen patients presenting with clinical manifestation of IHH to target the frontal horn of the lateral ventricle after failure of traditional medical or previous surgical treatment. Results: We had fourteen females and two males. Their age ranged from 20 to 45 years (average 29.7). The mean follow-up period was 43.9 months (ranged from 10 to 84 months). Eleven patients had previous LPS insertion with at least one trial of revision. Five patients subjected to stereotactic VPS as a first procedure. Accurate ventricular catheter place-ment was done from the first trial in all patients which was confirmed on postoperative CT scan. Four patients underwent stereotactic ventriculo-atrial shunts due to decrease CSF absorptive capacity of peritoneal cavity due to multiple lumboperitoneal shunt revision. All patients showed improve-ment or stabilization of their visual manifestation after ven-tricular shunt insertion. Headache improved in fourteen patients whereas two patients still had headache that respond to medical treatment. We had no mortality and two patients required shunt revision.Conclusions: Image-guided stereotactic ventricular cath-eter placement is an effective, safe and durable management option that can help in management of IIH when the ordinary medical and surgical methods fail. Also it may be the first choice in certain selected cases.

Processing Techniques for Scanning Electron Microscopy Imaging of Giant Cells from Giant Cell Tumors of Bone.

Giant cell tumor (GCT) of bone is a common benign lesion that causes significant morbidity due to the failure of modern medical and surgical treatment. Surface ultra-structures of giant cells (GCs) may help in distinguishing aggressive tumors from indolent GC lesions. This study aimed to standardize scanning electron microscopic (SEM) imaging of GC from GCT of bone. Fresh GCT collected in Dulbecco's Modified Eagle Medium was washed to remove blood, homogenized, or treated with collagenase to isolate the GCs. Mechanically homogenized and collagenase-digested GCs were imaged on SEM after commonly used drying methodologies such as air-drying, tetramethylsilane (TMS)-drying, freeze-drying, and critical point-drying (CPD) for the optimization of sample processing. The collagenase-treated samples yielded a greater number of isolated GC and showed better surface morphology in comparison to mechanical homogenization. Air-drying was associated with marked cell shrinkage, and freeze-dried samples showed severe cell damage. TMS methodology partially preserved the cell contour and surface structures, although the cell shape was distorted. GC images with optimum surface morphology including membrane folding and microvesicular structures on the surface were observed only in collagenase-treated and critical point-dried samples. Collagenase digestion and critical point/TMS-drying should be performed for optimal SEM imaging of individual GCs.

Combined management of a disfiguring facial hemangioma by endovascular embolization and surgical excision: Case report

Abstract Infantile hemangiomas are considered the most common benign soft tissue tumors of infancy, occurring in 4%–10% of children under 1 year of age, with female to male ratio about 4:1. Within the first weeks of life, they enter a rapid proliferative phase lasting for 3–6 months; a period of stabilization for a few months follows with spontaneous involution usually occurring over several years. However, when they ulcerate, grow massively, cause disfigurement, or affect the normal function or cosmetic development, they become a serious problem. Common locations for problematic hemangiomas include the face, ear, orbit, and airway. These hemangiomas subsequently require early and aggressive treatment for preservation of ideal functional and cosmetic outcomes. Here, we present a case of frontonasal cutaneous hemangioma with left intra-orbital extension, which was managed with combined efforts of interventional radiology in the form of endovascular embolization followed by surgical excision, after the failure of medical treatment in the form of propranolol for 6 months.

Mineral-Vitamin Treatment Associated with Remission in Attention-Deficit/Hyperactivity Disorder Symptoms and Related Problems: 1-Year Naturalistic Outcomes of a 10-Week Randomized Placebo-Controlled Trial.

Objective: This article presents 1-year follow-up of a randomized placebo-controlled trial with open-label extension evaluating the efficacy of a broad-spectrum micronutrient (vitamins and minerals) intervention. The object was to determine if dominant treatment at follow-up was associated with differential psychological outcomes. Methods: Ninety percent of the original sample of 93 children with attention-deficit/hyperactivity disorder (ADHD) were followed 52 weeks postbaseline. Assessments included measures of ADHD, mood, anxiety, and general function based on parent/clinician report. Outcome was considered based on dominant therapy at 52 weeks (trial micronutrients [n = 19], medications [n = 21], and no treatment [n = 35]). Nine children were not categorized due to inconsistent therapies. Results: Based on dominant treatment, more of those who stayed on trial micronutrients (84%) were identified as "Much" or "Very Much" improved overall relative to baseline functioning, compared to 50% of those who switched to psychiatric medications and only 21% of those who discontinued treatment [χ2(2) = 19.476, p < 0.001]. Fifteen (79%) of those still taking micronutrients, 8 (42%) of those using medications, and 7 (23%) of those who discontinued treatment were considered remitters based on parent-reported ADHD [χ2(2) = 15.3, p < 0.001]. Those who stayed on micronutrients were more likely to have failed medication treatment in the past. The micronutrient group also displayed better outcomes on measures of parent-rated hyperactivity and anxiety, and clinician-rated general function and mood, with moderate to large between-group effect sizes (micronutrients vs. medication: ES = 0.73-1.01; micronutrients vs. no treatment: ES = 0.54-1.01). Most common reasons for stopping trial micronutrients were cost and number of pills to swallow. No continued side effects were associated with micronutrients. Conclusions: Children who benefitted from micronutrients in the short term maintained changes at follow-up, without side effects. While both those who continued micronutrients and those who switched to medication showed improved ADHD symptoms, psychiatric medication use was associated with deterioration in mood and anxiety. Inherent selection bias limits generalizability.

Feasibility, Complications, and Recurrence after Discoid Resection for Colorectal Endometriosis: A Series of 93 Cases

Laparoscopic discoid colorectal resection is a surgical option for bowel endometriosis, 1 of the most severe forms of endometriosis. However, no study has clearly analyzed the feasibility or the complication and recurrence rates of the procedure in a homogeneous population with specific criteria for discoid resection. The aims of this study were to evaluate the rate of conversion to segmental resection, the need for double discoid resection, and the complication and recurrence rates. We conducted a prospective study of 93 consecutive patients who underwent discoid resection in Tenon University Hospital, Paris, France. The median follow-up was 20 months. We included patients with colorectal endometriosis (≤3 cm long and <90° of bowel circumference) experiencing failure of medical treatment or associated infertility. All the patients underwent a discoid colorectal resection using a transanal circular stapler. The primary end point was the rate of conversion to segmental resection (3.2%). The secondary end point was the rate of double discoid resection (6.5%). The overall complication rate was 24%, and the severe complication rate (i.e., Clavien-Dindo IIIB) was 3% (n = 4). Postoperative voiding dysfunction requiring bladder self-catheterization was observed in 16% (n = 15). The mean duration of bladder self-catherization was 30 days (range, 15-90) including 11 cases (74%) lasting less than 30 days and 4 cases lasting more than 30 days. No patients required bladder self-catheterization over 3 months. No difference in the complication rate or in voiding dysfunction was observed between double and single discoid resection. The low rate of conversion to radical resection confirms the satisfactory preoperative evaluation of bowel endometriosis. Few publications report the rate of conversion to radical surgery. This raises the crucial issue of the right indications for discoid resection. The present study confirms that discoid resection is probably the best option for small lesions because of its high feasibility and low complication rate. Further studies are required to evaluate the technique for larger colorectal endometriotic lesions.

Prospective evaluation of oral corticosteroid as a predictor of postoperative olfactory recovery after functional endoscopic surgery for nasal polyposis.

Anticipating the possibility of olfactory recovery after functional endoscopic surgery (FES) in nasal polyposis (NP) is difficult. The main objective of this study was to assess the predictive factors of recovering the sense of smell after radical bilateral ethmoidectomy. Secondary objectives were to identify other predictors of olfactory recovery. Open prospective study was conducted at the Nantes University Hospital including all patients with NP operated on in the Ear, Nose, and Throat Department between January 2011 and September 2017. These patients underwent functional endoscopic surgery (radical ethmoidectomy) after medical treatment failure. Olfaction was quantified prospectively and systematically during the preoperative consultation using a visual analog scale. Multivariate analysis evaluated the presence of predictive factors of postoperative olfactory recovery. One hundred nineteen patients were included in the study. Overall, olfaction was partially improved after surgery. For patients who presented greater than 50% recovery of olfaction after systemic corticosteroid therapy before surgery, we observed a predictive better rate of olfactory recovery after surgery (p < 0.001). Age over 65years, a history of sinonasal surgery, associated asthma, and bacterial colonization were not associated with less postoperative olfactory recovery. This study identified an objective factor that may influence olfactory recovery after FES using a therapeutic trial for olfactory recovery after oral corticosteroid treatment taken before surgery.

Outcome of Botulinum Toxin-A intraprostatic injection for benign prostatic hyperplasia induced lower urinary tract symptoms: A prospective multicenter study.

Our aim was to determine the factors predicting the outcome of intraprostatic injection of Botulinum Toxin-A (BTX-A) in the treatment of benign prostatic hyperplasia (BPH)-induced lower urinary tract symptoms (LUTS) and to evaluate its efficacy and safety. Between September 2016 and May 2018, 45 Egyptian patients, with BPH-induced LUTS were included; the indication was afailure of medical treatment, unfit, or refusing surgical intervention. Measurements of prostate size by TRUS, total PSA level before and 12 weeks after injection. IPSS, uroflow, and postvoiding residual urine (PVR) were measured before injection, 2, 4, 8 and 12 weeks postinjection. 100 U BTX-A vial was diluted with 10 mL of saline then injected into the transition zone at base and midzone of the prostate by TRUS. The mean patients' age was 64.4 ± 6.6 years. Mean baseline IPSS 24.06 decreased to 18.75 at 2 weeks and progressively decreased to 16.37 at 12 weeks (P < 0.001), Q max of 9.08 mL/s. increased to 10.44 at 2 weeks and 11.44 at 12 weeks (P < 0.001), mean prostate volume was 67.44cc; decreased to 66.06cc (P < 0.001) at 12 weeks and mean residual urine was 82.62 mL and decreased to 57.66 mL at 12 weeks. Intraprostatic injection of BTX-A as modality treatment of LUTS/BPH significantly improve IPSS, Q max , PVR, and decrease prostate volume. We can suspect better results with this line of treatment in patients with IPSS ≤ 22 and Q max ≤ 10 mL/min and prostate volume ≤ 56.5cc.

SUN-449 Medical versus Surgical Treatment of Macroprolactinomas (MP): Indications, Efficacy, and Safety

Introduction: Prolactinomas are primarily treated with medical therapy. Given the efficacy of dopamine agonists (DAs), surgery has remained a second-line treatment option. Objective: to evaluate the indications, efficacy, and safety of both treatments in MP. Methods: We performed a retrospective analysis of all patients with MP treated at our institution from January 2007 to October 2018. We divided the patients into two groups: medical treatment with DA (Group 1) and surgery (Group 2). Results: Prolactinomas (n: 69) constituted 36.9% of the total population of pituitary adenomas of our hospital (n: 187). 81.2% were MP (n: 56), from which 53.6% were included in Group 1 (n: 30) and 46.4% in Group 2 (n: 26). The mean follow-up was 50.9 months. There were no significant differences in age, sex, initial prolactin (PRL) value and tumor size between groups. Within the surgical indications (n:24), 29.2% were operated due to uncertain diagnosis, 29.2% due to visual impairment, 25% due to failure of medical treatment, 4.2% due to DAs intolerance, 4.2% due to apoplexy, 4.2% due to fistula and 4.2% due to the patient choice. 68.2% of the patients received DA therapy prior to surgery (15/22). There were no significant differences in the complication rate between both groups (66.7% Group 2 vs 40.7% Group 1, p: 0.09), although panhypopituitarism was significantly more frequent in Group 2 (54.2% vs 25.9%, p: 0.049, RR: 2.089). There were no significant differences between age, sex, tumor reduction and evolution between both groups. Invasive tumors (Knosp 4) were more frequent in Group 2 (59% vs 32%, p: 0.0149). Patients with biochemical persistence were younger (m: 25.5 ± 11 vs 40.7 ± 13.3 years, p: 0.01) and had a higher Knosp value (median 4 vs 3, p: 0.04) than patients in remission. Patients with postsurgical complications had a higher Knosp value in the initial image (median 4 vs 3, p: 0.04). Only 17.4% of the patients in group 2 were able to remain off DA after surgery. Conclusion: The percentage of patients with MP in our series is greater than that reported in the literature. As a neurosurgical reference center, we generally receive patients with more complex tumors. Although we had a high percentage of surgeries in patients with MP, this was due to the tumor characteristics or to an inadequate response to the DAs in our series. The patients who required surgical treatment had more invasive tumors, and coincidentally, these had the greatest number of complications. However, the only statistically significant complication between the two groups was panhypopituitarism. Despite the fact that only a small group of the operated patients could remain without medical treatment and that there were no differences in the evolution, surgery remains an alternative effective treatment option particularly for those patients with intolerance to DAs or highly invasive or resistant tumors.

Therapeutic strategies in the treatment of Menière's disease: the Italian experience.

Ménière's disease (MD) is an inner ear disorder of unknown etiology, whose pathological substrate is the endolymphatic hydrops. Different treatments have been proposed; however, evidence of their effectiveness is lacking. The aim of this study was to evaluate by a questionnaire which medical and surgical treatments are used in Italy for the treatment of MD and to compare them with those proposed in other countries. An electronic questionnaire of 40 questions was formulated and sent to Italian otolaryngologist (ENT) divided into two groups: Group 1 ("generalists" 60.8%) and Group 2 ("neurotologist- NO" 39.2%). One hundred and twenty five ENT replied. Treatment of the acute phase, apart from symptomatics, was based on diuretics that are prescribed by 83.5% of respondents, steroids, prescribed by 66.7%, and vasodilators, prescribed by 22%. In the intercritical phase, 87.2% of respondents recommended low-salt diet, 78.4% of respondents prescribed betahistine, and 52.8% diuretics. Statistical analysis did not show correlation neither with the declared specialization nor with the number of patients treated. In case of failure of medical treatment, IT gentamicin was suggested by 48.8% of the respondents and IT steroids by 40.8%. Statistical analysis showed that generalists prefer IT steroids and NO IT gentamicin (p 0.019). In case of failure of both medical treatment and IT treatment, vestibular neurectomy was indicated by 58.4% of the respondents, 6.4% indicated endolymphatic sac surgery, and 2.4% surgical labyrinthectomy. In Italy, the treatment of MD stand on a gradual approach that starts from the dietary-behavioral changes and a pharmacological therapy based on betahistine. In refractory cases, IT treatment initially with steroids and, therefore, with gentamicin allows the control in vertigo in the majority of cases. In case of failure of IT treatment, VNS is the surgery of choice.

Secondary Discitis Masquerading as Treatment Failure of Primary Discitis: Case Report and Review of the Literature.

Vertebral osteomyelitis often presents with localized back pain at the site of infection and elevated inflammatory markers. It can generally be treated conservatively with antibiotics targeted at the causative microorganism, but failure of medical treatment often necessitates surgical debridement. There are no reports in the literature that describe a secondary infection masquerading as treatment failure of the primary infection. We present a case of a 29-year-old male with a history of intravenous drug abuse who was treated with antibiotics for methicillin-sensitive Staphylococcus aureus T6-7 discitis/osteomyelitis. The patient later returned with worsened back pain and was initially thought to have experienced failure of medical therapy, but instead was found to have a secondary discitis at a different level, with biopsy-proven different microorganism (Enterobacter cloacae). This case illustrates the possibility of secondary discitis masquerading as treatment failure of the primary discitis. Repeat imaging and biopsy of the new lesion avoided a surgical procedure in this patient.

PD19-09 CLUSTER ANALYSIS REVEALS PROSTATE ENLARGEMENT AND DETRUSOR DYSFUNCTION DRIVE NEED FOR SURGICAL TREATMENT OF BPH/LUTS

INTRODUCTION AND OBJECTIVES:Men choose surgical treatment of BPH/LUTS for a variety of indications including bothersome symptoms, failure of medical treatment, urinary retention, and complications ...

Traitement des adénomes de la prostate par embolisation

Benign Prostatic Hyperplasia (BPH) concerns 50% of men older that 60 Years old and can induce symptoms also earlier. Medical treatment are mostly alpha blockers (AB), 5-alpha réductase inhibitors (5ARI) and phospho-diestérase inhibitors. In case of failure or poor tolerance of drug treatment, surgery can be indicated, after evaluation of the Bladder Outlet Obstruction (BOO), based on urodynamic studies. Endoscopic or open surgery is selected according to the size of the prostate, the expertise of the urologist and patient preference. Surgical treatment is very efficient but carries frequent complications, especially retrograde ejaculation which is very frequent and can compromise fertility and sexual pleasure. Prostatic Artery Embolisation, an outpatient intervention performed by Interventional Radiologists and available in France since 2012 is a new alternative to surgery in case of failure or poor tolerance of medical treatment. It consists in super-selective injection of calibrated micro-particles into both prostatic arteries after femoral artery puncture at the groin. It is safe and efficient and provides appropriate symptomatic improvement BOO related to BPH.

Bilateral synovial cyst of the thoracic spine causing paraparesis

Spinal synovial cysts are degenerative extradural lesions mostly found in the lumbar region, and more rarely at cervical or thoracic levels and in a bilateral presentation. We report a patient with a history of progressive paraparesis associated with bilateral cervicothoracic synovial cysts, causing spinal canal narrowing and cord compression, ultimately resulting in myelopathy. A review of the literature summarizes previous reports on this topic. Surgical excision of the extradural mass, decompression of the spinal canal and instrumented fusion were performed, improving lower limb deficit and gait. Post-surgical MRI showed evidence of complete cyst resection, and good arthrodesis consolidation with adequate sagittal balance. Surgical excision is indicated in case of medical treatment failure or increasing symptom severity. Given the strong pathophysiological link between synovial cysts and spinal instability, concomitant instrumented fusion may help improve outcome.

The effectiveness of neutrophil to lymphocyte ratio in prediction of medical treatment failure for tubo-ovarian abscess.

We aimed to compare the neutrophil-to-lymphocyte ratio (NLR) in tubo-ovarian abscess (TOA) patients who responded to medical treatment or who underwent surgical intervention due to medical treatment failure. The files of the patients, hospitalized in our Obstetrics and Gynecology Department with TOA diagnosis between August 2015 and December 2017, were evaluated retrospectively. The conservative management group was comprised of 38 of the 81 patients (46.9%) who responded to sole medical treatment with the triple antibiotic regimen (gentamicin-clindamycin-ampicillin) and the surgical intervention group was comprised of 43 patients (53.1%) who did not respond to medical treatment and needed further surgery and/or interventional radiologic abscess drainage. Demographic and clinical data, imaging findings, and laboratory results including NLR were compared between two groups. There were statistically significant differences between the groups in terms of age, TOA diameter, white blood cell and neutrophil counts, and NLR levels (P < 0.05). The mean NLR was 7.4 ± 5.8 for the conservative management group and 10.3 ± 5.8 for the surgical intervention group (P = 0.004). The area under the curve (AUC) for NLR was 0.69 (threshold value was ≥6.97, 95% confidence interval, sensitivity 79.1%, specificity 57.9%). On multiple regression analysis, a significant correlation was identified between age, NLR and resistance to the medical treatment. Neutrophil-to-lymphocyte ratio and age are significantly higher in patients with medical treatment failure and NLR could be used as a novel marker in addition to white blood cell in the prediction of medical treatment failure in TOA patients.

Is Meconium Obstruction Distinguishable from Intestinal Obstruction through Ultrasound

Background: Since the treatment of meconium ileus is very different from other types of intestinal obstruction, it is very important to distinguish these two entities. The aim of this study was to assess sonographic findings to differentiate meconium ileus from other types of obstruction. Methods: This study was performed in Dr. Sheikh and Akbar hospitals, Mashhad Medical University of Science, Iran, during 2017- 2018. The imaging signs of 25 newborns (aged 2-8 days) with delayed passage of meconium were documented. These neonates were suspicious of low type intestinal obstruction. In cases with the simple form of meconium ileus and the small left colon syndrome, ultrasonic guided Gastrografin enema was performed for the treatment. In the patients with the failure of medical treatment and in other surgical cases, the appropriate surgical procedure was performed. Results: The subjects in this study were diagnosed with small bowel atresia (n=9), a simple form of meconium ileus (n=6), a complicated form of meconium ileus (n=3), small left colon syndrome (n=3), bowel atresia and duplication (n=1), and Hirschsprung’s disease (n=3). The ultrasound findings were as follows: a totally or partially micro-colon in almost all patients, collapsed small bowel in right lower quadrant in all of the patients with bowel atresia, hypoechoic meconium in rectosigmoid in small left colon syndrome and Hirschsprung’s disease, hypoechoic tubular or beaded intraluminal inspissated meconium within terminal ileum, and the floating air bubbles (sonographic soap bubble sign) within fluids on proximal dilated loops in meconium ileus cases. Conclusion: Although plain abdominal radiography confirmed bowel obstructions in all patients with delayed passage of meconium, it had a low level of specificity in the diagnosis and cause of obstruction. Abdominal ultrasound had a high level of accuracy in the correct diagnosis of meconium obstructions and its differentiation from other intestinal obstructions. Accordingly, it eliminates the need to do a diagnostic contrast enema in order to differentiate these entities.

Postoperative compensation after neurotomy in Meniere's disease: Retrospective study of 15 cases

IntroductionVestibular neurotomy is a functional surgery for Meniere's disease in the event of medical treatment failure. The aim of the study was to assess the efficacy and complications of vestibular neurotomy, and to address the question of postoperative compensation. Material and methodAll patients included in this retrospective study underwent a vestibular neurotomy at our center between 2009 and 2016. A preoperative evaluation was performed including MRI, audiometry, and videonystagmography. The functional level of disability was evaluated by the Dizziness Handicap Inventory (DHI) score. In all patients suboccipital retrosigmoid approach was performed. All patients underwent early postoperative vestibular rehabilitation. One month and two years after surgery, we assessed the effectiveness of treatment on dizziness, disability and imbalance. At the time of this study (2 to 8 years), DHI and patients’ satisfaction by patient's global impression of change (PGIC) scale were evaluated. ResultsFifteen patients aged between 42 and 74 years of age were included in our study. Postoperative complications occurred in two patients (meningitis and a wound infection). At one month, all patients had a dramatic clinical improvement with decreased vertigo. Two years after surgery, 85% of the patients were cured and had no dizziness or balance disorder. Only one patient experienced bilateralization and only one had a persistent poor compensation. ConclusionVestibular neurotomy is a very effective treatment in the case of Meniere's disease resistant to medical treatment, with very good functional results and an extremely low failure rate.

Medical versus surgical treatment of first trimester spontaneous abortion: A cost-minimization analysis.

BackgroundTraditionally the gold-standard technique for the treatment of spontaneous abortion has been uterine evacuation by aspiration curettage. However, many studies have proposed medical treatment with misoprostol as an alternative to the conventional surgical treatment. The aim of this study was to apply cost minimization methods to compare the cost and effectiveness of the use of vaginal misoprostol as a medical treatment for first trimester spontaneous abortion with those of evacuation curettage as a surgical treatment.Methodology/Principal findingsWe present a longitudinal, prospective and quasi-experimental research study including a total of 547 patients diagnosed with first-trimester spontaneous abortion, in the period from January 2013 to December 2015. Patients were offered medical treatment with 800 mg vaginal misoprostol or evacuation curettage. Patients treated with misoprostol were followed-up at 7 days and a transvaginal ultrasound was performed to confirm the success of the treatment. If it failed, a second dose of 800 mg of vaginal misoprostol was prescribed and a new control ultrasound was performed. In case of failure of medical treatment after the second dose of misoprostol, evacuation curettage was indicated. The effectiveness of each of the treatment options was calculated using a decision tree. The cost minimization study was carried out by weighting each cost according to the effectiveness of each branch of the treatment. Of the 547 patients who participated in the study, 348 (64%) chose medical treatment and 199 (36%) chose surgical treatment. The overall effectiveness of medical treatment was 81% (283/348) and surgical treatment of 100%. The estimated final cost for medical treatment was € 461.92 compared to € 2038.72 for surgical treatment, which represents an estimated average saving per patient of € 1576.8.Conclusions/SignificanceMedical treatment with misoprostol is a cheaper alternative to surgery: in the Spanish Public Healthcare System, it is five times more inexpensive than curettage. Given its success rates higher than 80%, mild side effects, controllable with additional medication and the high degree of overall satisfaction, it should be prioritized over the evacuation curettage in patients who meet the treatment criteria.