Medical Treatment Group Research Articles

The Evaluation Characteristics of Type B Aortic Intramural Hematoma and Ten Years Treatment Outcomes

Background: Type B aortic intramural hematoma (IMH-B) is recognized as a subset of aortic dissection. The evolution of uncomplicated IMH-B is very difficult to predict. How and when to deal with this disease is unclear. The present study constructed two models to explore this problem. One is the morphology evolution model, which explored the risk factors and predictors for the IMH-B patients. Another is the predictive model confirmed the predictors and the time for invasive treatment of uncomplicated IMH-B patients. Objective: To explore the evolution predictors and detect the time for invasive treatment of uncomplicated IMH-B patients. Methods: Themorphology evolution model demonstrated that all 81 patients were diagnosis with CTA images. The initial and follow-up data were retrospectively studied. The evolution data were collection and measurement from initial and follow-up CTA images data. The predictive model showed that predictors of progression were detected with cox regression analysis. Results: All 81IMH-B patients were followed-up ranged from 1.2 to 36 months (median, 22 months). 26 patients accepted invasive treatment (24 underwent TEVAR and 2 underwent Surgery). 55 patients received medical treatment. Invasive treatment (IT) group overall events are 1/26 (3.8%); medical treatment (MT) group overall events are 33/55 (60.0%); IT group vs. MT group: p . Moreover, we found that most events related aorta occurred within 30 days. Multivariate Cox regression analysis MDAD (hazard ratio, 3.58; 95% CI, 1.25- 5.78; p - 7.84; p - 5.63; p Conclusions: MDAD > 45 mm, MDAHT > 10 mm, and IMH with PAU may be the important predictors for uncomplicated IMH-B patients. Most adverse aorta related events occurred within 30 days. It would be careful follow-up, closely observe for these patients within 30 days, and take necessary treatment strategies in time.

The preliminary diagnostic and therapeutic outcomes of chronic thromboembolic pulmonary hypertension registry rajaie cardiovascular medical and research center

Introduction: We herein present the preliminary results of our center's chronic thromboembolic pulmonary hypertension (CTEPH) registry of the tertiary outcomes of patients diagnosed with CTEPH and treated with pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), or medical treatment. Methods: The present retrospective cross-sectional study was conducted on patients who received treatment for CTEPH in Rajaie Cardiovascular Medical and Research Center over the past four years, from 2016 to 2020. The data were obtained from routine hospital admission and outpatient visit records. The patients were divided into PEA, BPA, and medical treatment groups, and the outcomes and complications of the procedures were reported. Results: Twenty-eight patients, at a median age of 40 (33–59) years were included in our study and were followed for approximately 20.0 (16.2–23.7) months. PEA was performed on 13 (46%) patients, BPA on 10 (35%), and medical therapy only on 5 (17%). Death occurred in 4 (30%) patients after surgery, and 10 (77%) had a surgical complication. There were no deaths or recorded complications in the other two groups, but the rates of postprocedural pulmonary hypertension (30% vs. 91%; P = 0.006) and rehospitalization (7% vs. 73%; P < 0.001) were significantly lower in the operated patients. The 1-year survival rate among the entire study population was 85.7%. Conclusions: The possibility of CTEPH incidence, especially in high-risk patients with dyspnea, should always be borne in mind given its large morbidity and mortality rate and its chances of curability with early diagnosis and proper treatment.

Are the immature granulocyte count and percentage important in continue medical treatment in acute appendicitis? A prospective, randomized, and controlled study.

Although appendectomy is still a curative therapy for acute appendicitis, medical treatment has come to the fore in uncomplicated cases. This study aimed to determine the importance of immature granulocyte (IG) count and percentage for the role of medical treatment success in uncomplicated acute appendicitis. Acute appendicitis cases were prospectively registered between July 2019 and April 2020. Using ball drawing, patients were divided into two groups as medical treatment (Group M) and undergo appendectomy (Group A). Group M was divided into two subgroups as those who responded to medical treatment medically responded (MR) and failed medical treatment (MF) within 24 h of follow-up. Changes in IG count and percentage, C-reactive protein levels, neutrophil-lymphocyte ratio, and white blood cell count between initial administration and 24th h of follow-up were examined. Sixty-four patients who met the inclusion criteria were followed as 31 patients in Group A and 33 in Group M. At Sub-group MF 11 patients and Subgroup MR 22 patients were followed up. At the 24th h of the follow-up, the IG count and percentage were higher in the Group MF (for IG count: Between Group A and MF, p=0.002; between Group A and Group MR, p=0.111; and between Group MR and MF, p<0.001) (for IG percentage: Between Group A and MF, p=0.001; between Group A and MR, p=0.809; and between Group MF and MR, p=0.001). This decrease in the IG count and percentage suggests that the response to medical treatment was effective [for IG count: F (148.862) = 61, p≤0.001, η2=0.707] [for IG percentage: F (10.157) = 0.252, p≤0.001, η2=0.504]. IG count and percentage are effective for evaluating the success of medical treatment of uncomplicated acute ap-pendicitis and they guide in the decision to continue medical treatment of uncomplicated acute appendicitis.

Medical Adjuvant Therapy in Reducing Thrombosis With Arteriovenous Grafts and Fistulae Use: A Meta-Analysis of Randomized Controlled Trials.

Hemodialysis is required for patients with end-stage renal disease (ESRD) that require arteriovenous (AV) grafts or fistulas for vascular access. These access points are prone to thrombosis. To determine the effect of medical adjuvant therapy on AV graft/fistula patency among patients with ESRD on hemodialysis. Adhering to the PRISMA 2020 statement, a systematic search was conducted until August 20, 2021, with keywords including arteriovenous graft, fistula, patency, thrombosis, hemodialysis, adjuvant treatment. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane. A random-effects model was employed using Review Manager 5.4 for data analysis. The meta-analysis pooled in 1985 participants with 1000 (50.4%) in the medical adjuvant treatment group. At a snapshot, medical adjuvant therapy reduced the risk for graft thrombosis (RR = 0.64, P = .02). Notable medications included aspirin for graft thrombosis (RR = 0.36, P = .006) and ticlopidine for fistula thrombosis (RR = 0.53, P = .01). Certain antiplatelet therapies (aspirin and ticlopidine) reduced the number of patients with AV fistula/graft thrombosis among patients with high heterogeneity among the trials. Other therapies (fish oil, sulfinpyrazone, clopidogrel, and aspirin/dipyridamole) did not demonstrate significant improvement but may be promising once concrete evidence is available. Potential benefits of anti-platelet therapies may be explored to maintain the potency of AV grafts/fistulas through well-designed placebo-controlled trials and long-term follow-up.

Laparoscopic Intracapsular Myomectomy in Women 40 Years Old and Over with Symptomatic Uterine Fibroids. A Pilot Study.

Authors evaluated the impact of laparoscopic intracapsular myomectomy (LIM) in women 40 years of age and over with desire of future fertility compared with medical management of symptomatic fibroids, by a prospective cohort study in University affiliated Hospitals. This study includes a cohort of women 40 years of age and older with symptomatic intramural fibroids with desire of future fertility. Women with symptomatic fibroid uterus were offered to undergo LIM or medical management. They were encouraged to attempt conception either spontaneously or by assisted reproductive technology (ART) according to their individual preference. All women were followed for 2 years. Fibroid characteristics, pre- and post-surgical variables, including surgical complications, days of hospitalization, pregnancy rate, and obstetrical outcomes were collected. A total of 100 patient were included in the analysis. Fifty patients were assigned to the LIM group and 50 to the medical treatment group (MT). Groups were similar regarding age (43.5 ± 2.4 and 43.5 ± 2.4, p = 0.99), body mass index (23.8 ± 3.1 and 24.2 ± 3.1, p = 0.54), parity (0.46 ± 0.09 and 0.58 ± 0.09, p = 0.37), fibroid number (1.38 ± 0.6 and 1.46 ± 0.6, p = 0.53), and fibroid size (5.92 ± 1.62 cm vs. 5.94 ± 1.49 cm, p = 0.949). Of the patients who underwent LIM, 62% conceived within the study period compared with 56% in the control group ( p = 0.54). Pregnancy was achieved by ART in 44% of the patients of the LIM group and 30% in control group. There was no significant difference in pregnancy rates among the two groups regarding spontaneous pregnancy rate ( p = 0.332), nor in pregnancies obtained by ART with own eggs ( p = 0.146) and oocyte or embryo donation ( p = 0.821). The take home baby rate was 65% (20/31) in the LIM group and 61% (17/28) in the control group ( p = 0.7851). Both groups had similar rate of miscarriage ( p = 0.748). Patients 40 years old and over with symptomatic fibroid uterus who undergo LIM have similar subsequent fertility and obstetrical outcomes than women treated with medical management. LIM has no detrimental impact on future fertility in women 40 years old and over.

Effects of Surgery on the 30-Day Survival Rate in Spontaneous Supratentorial Intracerebral Hemorrhage.

Background: Spontaneous intracerebral hemorrhage (ICH) is a severe form of stroke. The efficacy of surgery as ICH treatment is controversial. We sought to compare the 30-day postoperative mortality rate between patients with surgically and medically treated ICH; Methods: This prospective study enrolled patients consecutively diagnosed with ICH and treated between 2017 and 2019. Patients meeting the study surgical indications were assigned to either surgical or medical treatment. The relationship between Glasgow Coma Scale (GCS) score, age, ICH location, ICH volume, and 30-day mortality was analyzed. Results: A total of 174 ICH patients were enrolled in this study. Of these, 136 met the surgery criteria; 65 of these underwent surgery (Group A), and 71 received medical treatment (Group B). Age and ICH location did not modify mortality. Although surgery did not overall improve mortality some better postsurgical outcomes were observed among patients surgically treated with GCS scores of at least 10 points and ICH volumes between 30 to 50 mL; Conclusions: Despite achieving an immediate reduction in intracranial pressure, surgery seems to be advantageous only for patients with ICH volumes between 30 to 50 mL and GCS scores of 10 points or higher;

Facial and hearing outcomes in transmastoid nerve decompression for Bell's palsy, with preservation of the ossicular chain.

ObjectivesFacial nerve decompression is a salvage treatment for Bell's palsy patients for whom a poor prognosis is anticipated with standard medical treatment. The transmastoid approach is a frequently performed approach, but it remains unknown if this surgery is effective when the ossicular chain is preserved. This study aimed to determine the efficacy of facial nerve decompression using the transmastoid approach in Bell's palsy.Design, setting and participantsThis retrospective study included patients who had undergone transmastoid facial nerve decompression with ossicular chain preservation and patients who met the criteria for surgery, but received only medical treatment between January 2007 and May 2019, at a single centre.Main outcome measuresAttainment of House‐Brackmann grade I at 12 months after onset of facial palsy.ResultsThe recovery rate to House‐Brackmann grade I in the decompression group in the early phase (≤18 days after onset) was higher than that of the medical treatment group, although the difference was not significant (70% vs 47%, P = .160). However, within this early surgery group, a subgroup of cases with ≥95% facial nerve degeneration demonstrated a significant improvement in recovery rate (73% vs 30%, P = .018). Among surgeries performed in the late phase (≥19 days), only a subgroup with ≥95% facial nerve degeneration was available for analysis, and the difference in recovery rate was not significant compared with medical treatment alone (26% vs 30%, P = 1.00). Post‐surgical hearing evaluation demonstrated that average hearing deterioration was 1.3 dB which was non‐significant, suggesting this procedure does not cause hearing loss.ConclusionsTransmastoid facial nerve decompression with ossicular chain preservation in the early phase after symptom‐onset is an effective salvage treatment for severe Bell's palsy with ≥95% facial nerve degeneration.

Etiological analysis and short-term efficacy evaluation of acute liver failure in children

Objective: To explore etiology, optimize the search direction of etiology, and short-term efficacy evaluation of acute liver failure in children. Methods: Children with acute liver failure who were diagnosed in the First Affiliated Hospital of Zhengzhou University from November 2011 to November 2019 were collected. Gender difference, age, living environment, etiological factors on the seasonal onset and different etiological profile of short-term prognosis were statistically analyzed. Chi-square test or Fisher's exact probability method was used to compare the rate and the constituent ratio between groups. Results: Among the 236 cases, 114 (48.31%) had unknown etiology and 122 (51.69%) had definite etiology. In the definite etiology group, 38 (16.10%), 27 (11.44%), 22 (9.32%), 15 (6.36%), 17 (7.20%), and 3 (1.27%) cases were related to drugs/toxicants, infection, congenital/vascular/biliary diseases, genetic metabolic diseases, tumor-related, and autoimmune diseases. In addition, the overall etiological distribution did not change statistically with factors such as gender, age, and seasonal onset (P > 0.05), while the difference in different living environments was statistically significant (P < 0.05). Different initial-diagnosed departments had different etiological rates, with liver transplantation department being the highest (78.26%), and pediatrics department the lowest (26.09%). In 122 children with definite etiology, there was no significant difference in gender ratio between the different etiology groups (P>0.05), but there were significant differences in age, living environment and seasonal onset (P < 0.05). Among them, congenital development/vascular/biliary tract and infectivity were the main factors in children < 3 years old, and drug/toxin-related factors were the main factors in children > 3 years old. Most of the rural children had drug/toxin and infection-related etiology, while most of the urban children had tumor and drug/toxin-related etiology. In summer and autumn, drug/toxicant correlation was dominant, while in winter and spring, infection correlation was dominant. In the unknown etiology group, the clinical cure + improvement rate between the medical treatment group and the surgical treatment group was not statistically significant (37.50% vs. 20.00%, P > 0.05), while in the definite etiology group, the above differences were statistically significant (43.96% vs. 83.87%, P < 0.05). Among the different etiology groups, the congenital/vascular/biliary group had the best short-term efficacy (72.72%, 16/22), followed by the drug/toxicity-related group (60.53%, 23/38), and the tumor-related group had the worst (23.53%, 4/17). Conclusion: The definite etiology of acute liver failure in about half of children is still vague. The population distribution of children with definite etiology is related to age, living environment and season, but not to gender. However, the different ages, different living environments, and different seasonal onsets have definite etiology, and the short-term clinical efficacy of the treatment is significantly improved after the definite etiology is identified.

Managing Nonagenarians with Acute Myocardial Infarction: Invasive versus Conservative Treatment.

Background Limited data are available to support an invasive treatment strategy in nonagenarians with acute myocardial infarction (AMI). We aimed to investigate whether percutaneous coronary intervention (PCI) is beneficial in this frail population. Methods We retrospectively analyzed 41 nonagenarians with AMI (both ST-segment-elevation and non-ST-segment-elevation MI) between 2006 and 2015 in a single center. We assessed 30-day and one-year mortality rates according to the treatment strategy. Results Among study subjects, 24 (59%) were treated with PCI (PCI group) and 17 (41%) were treated with conservative management (medical treatment group) per the clinician's discretion. The median follow-up duration was 30 months (0–74 months). Thirty-day mortality was lower in the PCI group than in the medical treatment group (17% vs. 65%; P < 0.001). One-year mortality was also lower in the PCI group than in the medical treatment group (21% vs. 76%; P < 0.001). The PCI group presented a 73% decreased risk of death (adjusted hazard ratio: 0.269; 95% confidence interval: 0.126–0.571; P < 0.001). In the Killip class 1 through 3 subgroups (n = 36), 30-day and one-year mortality were still higher among those in the medical treatment group (13% vs. 54% at 30 days; P < 0.001 and 17% vs. 69% at one year; P < 0.001). Landmark analysis after 30 days revealed no significant difference in the cumulative mortality rate between the two groups, indicating that the mortality difference was mainly determined within the first 30 days after AMI. Conclusion Mortality after AMI was decreased in correlation with the invasive strategy relative to the conservative strategy, even in nonagenarians. Regardless of age, PCI should be considered in AMI patients. However, large-scale randomized controlled trials are needed to support our conclusion.

Chronic total occlusion management in female patients: gender gap?

Abstract Background A gender gap has been known to exist in the clinical presentation, management and outcomes of coronary artery disease. Nevertheless, it is not well described how these differences pertain to the management of chronic total occlusion (CTO) of coronary arteries. The aim of this study was to compare sex-based differences in CTO management and long-term outcomes. Methods We included all consecutive patients with CTO diagnosed in an academic center between 2010 to 2014. There were no exclusion criteria. We collected demographic, clinical, and management data. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6–4.8). Results A total of 1248 consecutive patients (mean age 67.3±10.9 years; 23,5% females) with at least one CTO receiving either revascularization or optimal medical treatment (MT) were identified. The female group included 198 patients (23.5%). Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to their male counterparts (p&amp;lt;0.05). There were no differences in the number of CTOs depending on gender, but women had a higher Global SYNTAX II score (50±12 vs 44±22; p&amp;lt;0.001) compared to men. The female group had a higher positive result for ischemia or viability (90% vs. 77%; P=0.04) compared to the male group. Nevertheless, women were more often treated with MT alone compared to male patients (57% vs 49%; P=0.04), who were more likely to undergo PCI or surgery. There were no significant differences in CTO revascularization success between both groups (30% vs. 24%; P=0.40). During a median follow-up of 4.03 years (IQR 2.6–4.8), a total of 386 (31%) patients died. Women presented a higher rate of all-cause mortality in both MT and revascularization groups (52% vs. 39% and 17% vs 16%, respectively; p&amp;lt;0.001) compared to men. Although cardiac mortality was lower in the revascularized patients, it was significantly higher in women compared to men, regardless of CTO treatment strategy (37% vs. 23% and 11% vs 8%; p&amp;lt;0.001 for both). Multivariable analysis identified that female gender was associated with higher rates of cardiac mortality [OR 1.67, 95% confidence interval (CI) (1.10–2.57), P&amp;lt;0.001, but not with all-cause mortality [OR 1.37, 95% confidence interval (CI) (0.92–2.02), P=0.1]. Age, peripheral vascular disease, chronic kidney disease, the ACEF score, the Global SYNTAX I score, and MT of the CTO were also independent predictors for all-cause and cardiac mortality. Conclusions In our cohort, female patients with a CTO were significantly older and presented more prevalence of diabetes mellitus. Women with CTO were more often treated with MT alone, compared to their male counterparts, who were more likely to undergo invasive strategies - PCI or surgery. Female gender was associated with higher cardiac mortality on our cohort regardless of CTO treatment in a long-term follow-up. Figure 1 Cardiac Survival Rates Funding Acknowledgement Type of funding source: None

Early septal reduction therapy for patients with obstructive hypertrophic cardiomyopathy

ObjectiveThis study was conducted to determine the influence of early septal reduction therapy (SRT) after referral on survival in patients with obstructive hypertrophic cardiomyopathy. MethodsWe reviewed the patients with obstructive hypertrophic cardiomyopathy (resting pressure gradient ≥30 mm Hg or provoked pressure gradient ≥50 mm Hg) who were evaluated at our clinic from 2000 to 2012. Early SRT was defined as undergoing septal myectomy or alcohol septal ablation during the 6 months after index evaluation. Survival after the 6-month landmark period was analyzed in a multivariable Cox model. ResultsA total of 1351 patients were included in the landmark analysis. Patients who were more symptomatic and had received more medical treatment at index evaluation were more likely to undergo early SRT. Over a median follow-up period of 10.2 years, the survival was comparable (P = .207) but patients undergoing early SRT had, on average, improved survival compared with the medical treatment group (hazard ratio, 0.66; 95% confidence interval, 0.48-0.90) after adjustment by age and comorbidities. Further analysis revealed significant treatment heterogeneity, with increased benefit of early SRT seen in women (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), those who are in New York Heart Association functional class III or IV (hazard ratio, 0.52; 95% confidence interval, 0.36-0.76), and patients without diabetes (hazard ratio, 0.59; 95% confidence interval, 0.42-0.82). ConclusionsIn experienced hypertrophic cardiomyopathy centers, early SRT is similar to continued medical treatment for patients with obstructive hypertrophic cardiomyopathy. It appears to improve survival of female patients and those who are in New York Heart Association functional class III or IV.

Sex Differences in Endovascular Treatment for Stroke: A Population-based Analysis.

Acute ischemic stroke may affect women and men differently. We aimed to evaluate sex differences in outcomes of endovascular treatment (EVT) for ischemic stroke due to large vessel occlusion in a population-based study in Alberta, Canada. Over a 3-year period (April 2015-March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus, our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. The primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at their premorbid living situation without an increase in the level of care within 90 days of the index stroke event. In adjusted analysis, EVT was associated with an increase of 90-day home-time by an average of 6.08 (95% CI -2.74-14.89, p-value 0.177) days in women compared to an average of 11.20 (95% CI 1.94-20.46, p-value 0.018) days in men. Further analysis revealed that the association between EVT and 90-day home-time in women was confounded by age and onset-to-treatment time. We found a nonsignificant nominal reduction of 90-day home-time gain for women compared to men in this province-wide population-based study of EVT for large vessel occlusion, which was only partially explained by confounding.

Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review.

Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review. This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed. Twenty-seven cases of CSP identified during the study period. The median maternal age was 38years (range 23-47years). The gestational age at diagnosis ranged between 5weeks and 5days to 13weeks and 6days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58). The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.

Aromatase inhibitor letrozole: a novel treatment for ectopic pregnancy

To study the use of the aromatase inhibitor letrozole for treatment of ectopic pregnancy compared with methotrexate. Nonrandomized prospective cohort study. University hospital. A series of 42 consecutive patients with undisturbed ectopic pregnancy. Counseling on treatment options, including surgical treatment (control group) versus medical treatment with methotrexate (group 1) or letrozole (group 2). Primary outcome: complete resolution of ectopic pregnancy determined by serum human chorionic gonadotropin (β-hCG) levels below laboratory immunoassay detection. changes in the biochemical parameter of ovarian reserve, antimüllerian hormone (AMH), and hematologic changes associated with the two medical treatments compared with surgical treatment. Each treatment group included 14 patients, and each patient made her own treatment choice. Complete resolution of ectopic pregnancy occurred in an equal number of patients: 12 out of 14 (86%) in each of the two medical treatment groups. Methotrexate treatment was associated with statistically significantly higher liver enzymes and lower blood platelets count. The decline in β-hCG levels was faster in the letrozole group when compared with the methotrexate group. Three months after treatment, AMH levels were lower in the methotrexate group when compared with the letrozole and the surgery groups. However, the decline in β-hCG and AMH levels was not statistically significant. To our knowledge, this is the first report in the literature on the success of letrozole for the medical treatment of ectopic pregnancy. The promisingly high resolution rate and better safety profile that letrozole has compared with a chemotherapeutic agent such as methotrexate should encourage further studies.

A Combined Topical Treatment versus Surgical Treatment in Chronic Anal Fissure

In the treatment of chronic anal fissure, both surgical and topical treatment methods are used. The purpose of this study was to research a combined topical treatment that we prepared and to compare the effectiveness of lateral internal sphincterotomy in chronic anal fissure with this topical treatment. A total of 183 patients with chronic anal fissure were divided into two groups. One hundred and four patients had topical medical treatment (group 1) and seventy-nine patients underwent lateral internal sphincterotomy (group 2). In the first group, a topical combination of ointments consisting of bacitracin-neomycin sulfate, dexpanthenol, and diltiazem was applied to the anal area. Four weeks after treatment, pain and bleeding during defecation, gas/fecal incontinence, treatment-related adverse events and recovery rates were evaluated in both groups. Also, patients were examined for recurrence between the 8th and 10th weeks. There was no significant difference in recovery rates between the groups. In group 1, recovery rate was 82.7%, while in Group 2 it was 92.4% (p = 0.054). In both groups, gas/fecal incontinence ratio was significantly different, supporting the medical treatment (p = 0.02). The severity of pain and bleeding during defecation were compared between the groups. Only the severe pain was significantly higher in the medical treatment group (p = 0.018). The recurrence rate was 5.8% in the medical treatment group, but no recurrence was detected in the surgical group. Due to possible complications of surgical treatment and similar recovery rates, medical treatment of patients with chronic anal fissure can be tried before surgical treatment.

SUN-LB92 The Importance of Early Diagnosis and Treatment of Primary Aldosteronism on the Progression of Chronic Kidney Disease, Compared With Essential Hypertension: A Retrospective Cohort Study

<META NAME=“author” CONTENT=“Windows 사용자”>Introduction: Primary aldosteronism(PA) has few clinical phenotypes and features, compared with other endocrine hypertension(HTN). Even though hypokalemia is a typical sign of PA, most of PA reveals normal potassium concentration. For that reason, PA is likely to undetected and underestimated and it may account for larger proportion of total HTN than we expected. However, it has known that PA has higher risk of renal complications than essential hypertension(EH) and has been controversy which treatment between medication and operation is better for renal protection of PA. Methods: We retrospectively reviewed the medial records of patients with PA and EH of a single medical center from January, 2009 to December, 2019. PA patients were divided into medical and surgical treatment groups. EH patients were distinguished from one that satisfied with case detection test, called non-confirmed PA. We excluded cases with other secondary HTN and baseline eGFR < 60 mL/min/1.73m2. Results: Patients with PA(N=66) and patients with EH(N=514) were selected for analysis. Each baseline mean eGFR of patients with PA and EH indicated 91.2 ± 74.5 and 87.1 ± 19.7 mL/min/1.73m2 and statistically insignificant differences(P = 0.1688) as well as baseline SBP(P = 0.5403) and DBP(P = 0.8691). However, in spite of treatment of PA and controlled BP, mean eGFR of PA patients was lower than one of EH patients and its difference was statistically significant showing 66.5 ± 14.2 and 94.6 ± 195.9 mL/min/1.73m2 (P < .0001) at 2~ 5 years, 52.4 ± 17.9 and 77.6 ± 20.6 mL/min/1.73m2 (P < 0.0004) at 6~10 years. Baseline mean eGFR of PA with normokalemia and hypokalemia respectively were 77.7 ± 11.6 and 98.9 ± 92.5 mL/min/1.73m2 (P = 0.0269). Baseline mean eGFR of non-confirmed PA and EH were 82.5 ± 13.2 and 88.4 ± 21.1 mL/min/1.73m2 (P = 0.0240). Although baseline mean eGFR of PA with surgical treatment was better than one with medical treatment, it was reversal after 2~5 years indicating mean eGFR of PA patients treated with operation, 62.9 ± 16.1 mL/min/1.73m2 and one treated with spironolactone, 70.5 ± 12.6 mL/min/1.73m2 (P = 0.0010). Conclusions: This study support PA has worse effects on renal function than EH. PA is frequently unsuspected and undiagnosed because it hardly shows symptoms and signs. Many cases do not reveal main characteristics such as uncontrolled HTN and hypokalemia, so that patients with PA maybe have longstanding exposure to risk of CKD. Therefore it is necessary to do case detection test and rule out PA in initial hypertensive patients. In addition, more longitudinal study and research should be performed to decide personalized and adequate treatments for PA patients.

Renal denervation in patients with end-stage renal disease and resistant hypertension on long-term haemodialysis.

Recent randomized controlled trials have confirmed the ability of renal denervation to lower blood pressure (BP) in patients, resistant to the BP-lowering effect of multiple antihypertensive drug administration. Evidence is limited, however, in patients with end-stage renal disease (ESRD) and haemodialysis, a condition in which a persistent BP elevation, despite administration of many antihypertensive drugs, is common. Aim of the present study was to test the BP-lowering efficacy of renal denervation in patients with resistant hypertension and ESRD on haemodialysis. BP was measured repeatedly in the office and over the 24 h during 1-year follow-up. The study was conducted from February 2017 to January 2018 at the Policlinico of Monza, Monza, Italy. We included 24 men and women aged at least 20 years (mean 55 ± 16) who had ESRD, were on long-term haemodialysis and exhibited resistant hypertension, that is, elevated office and ambulatory BP values, despite multidrug antihypertensive treatment (n = 5.4 ± 1). We excluded patients with renal artery stenosis, malignancy, and a probable life expectancy less than 1 year. Twelve patients were included in the renal denervation and 12 in the medical treatment (control) group. All patients underwent office and 24 h ambulatory BP measurements at baseline and at 1, 6 and 12 months during the follow-up. In the renal denervation group, baseline office and 24 h mean SBP were 180 ± 112 and 175 ± 11 mmHg, respectively, the corresponding values in the control group being 181 ± 19 and 181 ± 20 mmHg. Most of the other baseline characteristics were also similar or only slightly different between groups, including the mean number of administered antihypertensive drugs at baseline. SBP showed an early and persistent reduction after renal denervation (office SBP: 165 ± 13; 150 ± 7 and 149 ± 11mmHg; 24 h SBP 163 ± 20, 148 ± 10 and 149 ± 17 mmHg after 1, 6 and 12 months, respectively). The BP-lowering effect was almost always present and statistically significant during both the day and night. DBP changes followed a similar pattern whereas heart rate never showed any significant change. No significant periprocedural complication of renal denervation was seen. The mean number of administered drugs did not show any significant BP change during the study. In ESRD patients under long-term haemodialysis in whom BP was markedly elevated despite administration of many antihypertensive drugs, renal denervation lowered both ambulatory and office BP. The reduction persisted over a 1-year follow-up.

Safety And Efficacy Of Vaginal Misoprostol In Treatment Of First Trimester Miscarriage

Objective: This study was conducted to determine the outcome of medical treatment with vaginal misoprostol in missed miscarriage. &#x0D; Methods: A randomized controlled study was performed in Benha Teaching Hospital between April 2016 and June 2017. Eighty patients diagnosed with miscarriage before 13 weeks of gestation and wanted to try medical treatment were included. A detailed ultrasound scan was performed to confirm the diagnosis. Patients took 400 microgram (mcg) of misoprostol vaginal as an initial dose, and repeated the same dose 4-6 hours apart. Successful medical abortion was defined as spontaneous expulsion of gestational products (including gestational sac, embryo, fetus, and placenta). Ultrasonography at least 24 hours later from the initial dose to assess the uterine cavity if gestational products were not expelled, surgical evacuation was performed.&#x0D; Results: About two-thirds of patients (77.5%) had a successful outcome. The median interval time from pill to expulsion was 18 hours in the successful medical treatment group.&#x0D; Conclusion: Medical treatment with vaginal misoprostol should be a proper option for the first trimester miscarriage, especially for the patient who want to avoid surgical procedure. We can reduce the unnecessary sedation or surgical intervention in the patients with the first trimester miscarriage.

Survival benefit of revascularization versus optimal medical therapy alone for chronic total occlusion management in patients with diabetes.

Chronic total occlusion (CTO) is common in patients with diabetes mellitus. Data on the long-term outcomes after treatment of CTOs in this high-risk population are scarce. To compare the long-term clinical outcomes of CTO revascularization either by coronary artery bypass graft (CABG) or successful percutaneous coronary intervention (PCI) versus optimal medical treatment (MT) alone in patients with diabetes. A total of 538 consecutive patients with diabetes and at least one CTO were identified from 2010 to 2014 in our center. In the present analysis, patients were stratified according to the CTO treatment strategy that was selected. MT was selected in 61% of patients whereas revascularization in the remaining 39%. Patients undergoing revascularization were younger, had higher left ventricular ejection fraction (LVEF), lower ACEF score, and more positive myocardial ischemia detection results compared to the MT group (p < .001).Patients referred for CABG had higher rates of left main disease compared to the PCI and MT groups (32% vs. 3% and 11%, respectively; p < .001). Complete revascularization was more often achieved in the CABG group, compared to the PCI group (62% vs. 32% p < .001). Multivariable analysis showed that revascularization with CABG was associated with lower rates of all-cause and cardiac mortality rates compared to MT, [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.25-0.70, p < .001 and HR 0.40, 95% CI 0.20-81, p = .011, respectively]. Successful CTO-PCI showed a trend towards benefit in all-cause mortality (HR 0.58, 95% CI 0.33-1.04, p = .06). In our registry, CTO revascularization in diabetic patients, especially with CABG, was associated with lower long-term mortality rates as compared to MT alone.

Abstract TP39: Comparative Effectiveness of Endovascular Treatment for Acute Ischemic Stroke: A Population-Based Analysis

Background: A heterogeneous patient population receives endovascular treatment (EVT) for acute ischemic stroke due to proximal large vessel occlusion every day. We aimed to conduct a population-based study of EVT in the province of Alberta, Canada, to understand the effectiveness in a complete population and how the magnitude of effect differs from the artificial world of clinical trials. Methods and Results: Within a three year period (April 2015 - March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. Primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at pre-morbid living situation without increase in level of care within 90 days of index stroke event. Median age of patients was 70 years (interquartile range (IQR) 59 - 81) and 47.8% were female. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13 - 20). EVT was associated with an increased 90-day home-time by an average of 8.5 days compared to medical treatment alone using Cragg hurdle regression (p = 0.009). Age and higher NIHSS score were associated with decreased 90-day home-time (both p = 0.001). Multivariable logistic regression showed no association between EVT and mortality at 90 days (odds ratio 0.76, 95% confidence interval 0.47 - 1.24). Conclusions: EVT for acute ischemic stroke due to proximal large vessel occlusion was effective in our province-wide population-based study and results in increased 90-day home-time by ~8.5 days. Home-time is a novel and patient-centered outcome that reflects health circumstances that are easy to understand and meaningful to patients and their caregivers.