Opt For Surgery Research Articles

Stereotactic body radiotherapy in ultracentrally located lung tumors

Stereotactic body radiotherapy (SBRT) is a highly conformal radiotherapy technique that delivers high doses of radiation per fraction, typically in 1 – 5 fractions. It is a standard treatment option for patients with early-stage non-small cell lung cancer that is peripherally located, for those who are medically inoperable, or for patients who do not opt for surgery. Similarly, SBRT is considered an effective treatment option for oligometastatic lung tumors. However, in the case of ultracentrally located lung tumors—tumors situated close to the central airway and mediastinal region—there is an increased risk of severe toxicities (grade 4 – 5) due to the dose tolerances of the surrounding organs at risk. The definition of ultracentrally located lung tumors remains unclear. Some studies define an ultracentral lung tumor as one in which the gross tumor volume directly involves the proximal bronchial tree or trachea, while others define it as the planning target volume (PTV) that includes the trachea or main bronchial system. In addition, some studies consider tumors whose PTV touches or overlaps with the central bronchial tree, esophagus, pulmonary vein, or pulmonary artery as ultracentral. In addition, the optimal SBRT regime and organ-at-risk dose limitations for ultracentral tumors have yet to be clearly established. The aim of this review is to explore and discuss the role of SBRT in the treatment of ultracentrally located lung tumors.

Effect of bariatric surgery on cardio-psycho-metabolic outcomes in severe obesity: A randomized controlled trial.

Randomized evidence comparing the cardiovascular effects of surgical and conservative weight management is lacking. In this single-center, open-label randomized trial, obese patients with indication for Roux-en-Y gastric bypass (RYGB) and able to perform treadmill cardiopulmonary exercise testing (CPET) were included. After a 6-12 month run-in phase of multimodal anti-obesity treatment, patients were randomized to RYGB or psychotherapy-enhanced lifestyle intervention (PELI) and co-primary endpoints were assessed 12 months later. Thereafter, PELI patients could opt for surgery and patients were reassessed 24 months after randomization. Co-primary endpoints were mean change (95 % confidence intervals) in peak VO2 (ml/min/kg body weight) in CPET and the physical functioning scale (PFS) of the Short Form health survey (SF-36). Of 93 patients entering the study, 60 were randomized. Among these (median age 38 years; 88 % women; mean BMI 48·2 kg/m2), 46 (RYGB: 22 and PELI: 24) were evaluated after 12 months. Total weight loss was 34·3 % after RYGB vs. 1·2 % with PELI, while peak VO2 increased by +4·3 ml/min/kg (2·7, 5·9) vs +1·1 ml/min/kg (-0·2, 2·3); p < 0·0001. Respective improvement in PFS score was +40 (30, 49) vs +10 (1, 15); p < 0·0001. 6-minute walking distance also favored the RYGB group: +44 m (17, 72) vs +6 m (-14, 26); p < 0·0001. Left ventricular mass decreased after RYGB, but not with PELI: -32 g (-46, -17) vs 0 g (-13,13); p < 0·0001. In the non-randomized follow-up, 34 patients were assessed. Favorable changes were sustained in the RYGB group and were repeated in the 15 evaluated patients that opted for surgery after PELI. Among adults with severe obesity, RYGB in comparison to PELI resulted in improved cardiopulmonary capacity and quality of life. The observed effect sizes suggest that these changes are clinically relevant.

Outcome and quality of life after intracranial meningioma surgery in cats.

The present study aimed to evaluate the postoperative quality of life (QOL) after surgery for the treatment of intracranial meningioma in cats. The study included 14 cases that underwent craniotomy from May 2009 to March 2021. Owners were contacted via telephone after a median time of 967 (range 227-4209) days after surgery and surveyed with a specially designed questionnaire that consisted of three domains, subdivided into different items. Physical behaviour, including general condition, food intake, mobility and overall impression, was evaluated from 0, reflecting the worst status, to 10, reflecting the best. The development of preoperative existing clinical signs, seizures and concurrent medication were evaluated individually for each patient. The time span necessary for the improvement of each item was recorded. Finally, satisfaction about the decision for surgery was ranked from 0 to 10. Thirteen questionnaires were completed. Three cats were evaluated twice owing to revision surgery. Owners reported a statistically significant (P <0.001) improvement from immediately after the operation to 240 days after surgery. Preoperative clinical signs resolved in 95% of cases. All questioned owners would opt for surgery again. QOL after surgery for intracranial meningioma in cats seems encouraging regarding our study. Nevertheless, limitations, such as small sample size, recall bias, lack of a control group and validation of the questionnaire, need to be kept in mind when interpreting the results.

Care trajectories of surgically treated patients with a prolactinoma: why did they opt for surgery?

PurposeTo describe care trajectories in patients with prolactinoma, aiming to clarify the rationale for surgery.MethodsRetrospective observational cohort study of consecutive patients with prolactinoma undergoing surgery from 2017 to 2019 at the referral center (RC), prior to surgery being considered a viable treatment option (i.e. PRolaCT study). Demographics and clinical data (type and duration of pretreatment and surgical indications, goals, and outcomes) were collected from patient records. Care trajectories were divided into three phases: (1) diagnosis and initial treatment, (2) endocrine treatment at the RC, and (3) surgical treatment.Results40 patients were included (31 females (77.5%), median age 26.5 (14–63) years. Indications for surgery were dopamine agonist (DA) intolerance (n = 31, 77.5%), resistance (n = 6, 15.0%), and patient/physician preference (n = 3, 7.5%). Patients were pretreated with DA (n = 39 (97.5%)), and surgery (n = 3 (7.5%)). Median disease duration at surgery was 4 (0–27) years. Primary surgical goal was total resection in 38 patients (95.0%), of which biochemical remission was achieved 6 months postoperatively in 23 patients (62.2%), and clinical remission in 6 patients (16.2%), missing data n = 1.ConclusionCare trajectories were highly individualized based on patient and tumor characteristics, as well as the multidisciplinary team’s assessment (need for alternative treatment, surgical chances and risks). Most patients were pretreated pharmacologically and had broad variation in timing of referral, undergoing surgery as last-resort treatment predominantly due to DA intolerance. High quality imaging and multidisciplinary consultations with experienced neurosurgeons and endocrinologists enabling treatment tailored to patients’ needs were prerequisites for adequate counseling in treatment of patients with prolactinoma.

Association of Patient-Reported Outcomes Measurement Information System Measures With Injection and Surgical Treatment Response in Patients With De Quervain Tenosynovitis

Treatment of de Quervain tenosynovitis is largely empiric. Patient-Reported Outcomes Management Information System (PROMIS) scores at the time of diagnosis might provide insights into the probability of success of nonsurgical management and predict the necessity for surgical treatment. We aimed to identify which, if any, of the PROMIS metrics may be used to identify patients who will opt for surgery or be managed with injection alone. Patients presenting to a tertiary academic medical center from 2014 to 2019, with a sole diagnosis of de Quervain tenosynovitis, were identified and separated by initial and most invasive treatment of either injection or surgery. These groups were then dichotomized using cut points of more than one SD from the mean on the PROMIS physical function and pain interference scales, and a logistic regression model was used to determine the odds ratio of surgical intervention. Patients who had low physical function or high pain interference had significantly increased odds of ultimately undergoing surgery. Age ranging from 40 to 60 years and female sex were also associated with increased odds of undergoing surgery. Patients who scored lower than 40 for physical function or higher than 60 for pain interference had significantly increased odds of eventually undergoing surgical release for de Quervain tenosynovitis. PROMIS scores may identify patients who are likely to fail steroid injections as a sole nonsurgical intervention and inform an individualized discussion about surgical management of this condition. Prognostic IV.

Management of Mahayoni with Sthanik Chikitsa in Procidentia: A Case Report

Introduction: Vata Dosha plays a critical role in disorders related to female reproductive system. If the woman sleeps in a Vishama posture or on an uncomfortable bed during sexual intercourse, then the Vayu gets aggravated to cause dilatation of the openings of her uterus and vagina. Since the dilated openings do not get closed, she suffers from Vedana and Ruksha, Phena mixed Srava of blood from the Yoni is produced. There will be protuberance of the Masah, and she suffers from Shoola in the joints and Vakshana Pradesha. Diagnosis intervention and outcome: On the basis of symptoms and genitourinary examination the diagnosis of Mahayoni Vyapada was made and Sthanik Chikitsa Yoni Prakshalan, Yoni Abhyanga, Yoni Parishek and Yoni Pichu was done for 10 days twice daily. Assessment was done using pelvic organ prolapse distress inventory questionnaire, urinary distress inventory, colorectal anal distress inventory And pelvic organ prolapse quantification. Patient got remarkable relief in the span of 10 days which was notable in primary complaints and assessment criteria. Conclusion: Ayurveda explains many methodologies for treating gynaecological disorders Sthanik Chikitsa holds great significance in Prasuti Tantra and Stree Roga. Sthanik Chikitsa possess very promising results in the management of various gynaecological disorders. Thus, it can be concluded that Sthanik Chikitsa can be used combined with oral drugs to provide symptomatic relief in patients who may not be fit for surgical correction or do not opt for surgery.

What are the long-term patient-reported and clinical outcomes after lateral clavicle fractures? A cross-sectional study of 619 patients

BackgroundLateral clavicle fractures account for 17% of all clavicle fractures and large studies comparing nonoperative and operative treatment are lacking. Therefore, patients cannot be properly informed about different treatment options and prognosis. We assessed long-term patient-reported and clinical outcomes in patients with lateral clavicle fractures.MethodsA multicenter cross-sectional study was performed in patients treated for lateral clavicle fractures between 2007 and 2016. Primary outcome included patient-reported outcome measures (PROMs) (DASH, EQ-5D, return to work, sports, cosmetics and satisfaction). Questionnaires were sent to 619 eligible patients, of which 353 (57%) responded after a mean follow-up of 7.4 ± 2.8 years. Secondary outcome included adverse events and secondary interventions. Outcomes after nonoperative vs. operative treatment (stratified by nondisplaced vs. displaced fractures) were compared using Student t tests and linear regression analysis.ResultsNondisplaced lateral clavicle fractures were treated nonoperatively and resulted in excellent PROMs. Six patients (3%) developed a nonunion. For displaced lateral clavicle fractures, no differences were found between nonoperative and operative treatment with regard to DASH score (7.8 ± 12.5 vs 5.4 ± 8.6), EQ-5D (0.91 ± 0.13 vs 0.91 ± 0.09), pain (0.9 ± 1.7 vs. 0.8 ± 1.6), patient satisfaction (90.1 ± 25.5 vs. 86.3 ± 20.4), return to work (96.4% vs. 100%) and sports (61.4% vs. 62.3%). The absolute risk of nonunion in patients with a displaced fracture was higher after nonoperative than operative treatment (20.2% vs. 2.9%; p = 0.002), with six patients needing treatment to avoid one nonunion.ConclusionsNondisplaced lateral clavicle fractures should be treated nonoperatively and result in good functional outcomes and high union rates. For displaced fractures, neither nonoperative nor operative treatment seems superior. Patients opting for nonoperative treatment should be informed that nonunion occurs in 20% of patients, but only half of these need additional operative treatment. Patients who opt for surgery should be told that nonunion occurs in only 3%; however, most patients (56%) will require secondary intervention for elective implant removal. Regardless of the type of treatment, no differences in functional outcome and PROMs should be expected at long-term follow-up.

Prevalence and survival of TNBC patients vs non-TNBC patients in India: A multi-centric real-world experience based study.

e13064 Background: Triple-Negative Breast cancer (TNBC) is a highly aggressive form of breast cancer, characterized by the lack of expression of Estrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal Growth Factor-2 (HER-2). Patients with TNBC do not benefit from hormonal or Trastuzumab therapy due to the lack of appropriate targets for these drugs. The current retrospective multicentric hospital-based study at HCG, India, aims to analyze the available treatment paradigms in TNBC patients in real-world evidence. Methods: Data from 3180 female breast cancer patients was collected and compiled from various medical records department (MRD) and hospital database from three HCG centers. The data comprised demographic and clinicopathological details, treatment details and survival information. In addition, the clinical and pathological parameters and survival outcomes were compared between TNBC and non-TNBC patients. Results: About 22.92% (729/3180) patients had TNBC, and 77.08% (2451/3180) patients had designated as non-TNBC. In the TNBC subgroup, 22.36% (163/729) patients belonged to the younger age group (&lt; 40 years), 65.98% (481/729) patients were in the 41-65 age group, while 11.66% (85/729) patients were &gt; 65 years old. Whereas the age-wise distribution in the non-TNBC group was as follows: &lt; 40 years- 15.46% (379/2451) patients, 41-65 years- 70.34% (1724/2451) patients, and &gt; 65 years- 14.2% (348/2451) patients. In the present cohort, TNBC and non-TNBC groups' mean age was 51.06 ± 12.15 years and 53.29 ± 11.55 years, with no statistical significance. About 11.8% (86/729) of patients in the TNBC group and 10.4% (255/2451) of patients in the non-TNBC group opted for neo-adjuvant chemotherapy. About 32.37% of patients in TNBC and 37.45% of patients in the non-TNBC group underwent surgery. The 5-year OS was 68.58% and 83.41% for TNBC and non-TNBC patients, respectively, with a median 5-year survival of 2.13 years (95% CI 2.528-3.204) for TNBC patients whereas 5-year median survival of 2.096 (95% CI 1.36-4.368). The mean survival in TNBC patients &lt; 40 years was 10.14 years, which was significantly lower when compared to patients in the 41-65 years (14.12 years) and &gt; 65 years (19.45 years). Also, patients in the TNBC group who underwent surgery had a higher mean survival of 16.72 years than those who did not opt for surgery (14.49 years). Further, chemotherapy and radiotherapy also increased the life expectancy in patients in both the TNBC and non-TNBC groups. Conclusions: In the present study cohort, TNBC distribution in the at the HCG center in the Indian subcontinent is similar to that of the western population (23% in the US and the UK). Adjuvant chemotherapy and radiotherapy were significantly higher among TNBC cases than non-TNBC cases. Lack of patient consent or proper patient follow-up further reduces survival

Cardio-psycho-metabolic outcomes of bariatric surgery: design and baseline of the WAS trial.

Obesity is a rapidly emerging health problem and an established risk factor for cardiovascular diseases. Bariatric surgery profoundly reduces body weight and mitigates sequelae of obesity. The open, randomized controlled Würzburg Adipositas Studie (WAS) trial compares the effects of Roux-en-Y gastric bypass (RYGB) vs psychotherapy-supported lifestyle modification in morbidly obese patients. The co-primary endpoint addresses 1-year changes in cardiovascular function (peak VO2 during cardiopulmonary exercise testing) and the quality of life (QoL) (Short-Form-36 physical functioning scale). Prior to randomization, all included patients underwent a multimodal anti-obesity treatment for 6–12 months. Thereafter, the patients were randomized and followed through month 12 to collect the primary endpoints. Afterwards, patients in the lifestyle group could opt for surgery, and final visit was scheduled for all patients 24 months after randomization. Sample size calculation suggested to enroll 90 patients in order to arrive at minimally 22 patients per group evaluable for the primary endpoint. Secondary objectives were to quantify changes in body weight, left ventricular hypertrophy, systolic and diastolic function (by echocardiography and cardiac MRI), functional brain MRI, psychometric scales, and endothelial and metabolic function. WAS enrolled 93 patients (72 women, median age 38 years, BMI 47.5 kg/m2) exhibiting a relevantly compromised exercise capacity (median peakVO2 18.3 mL/min/kg) and the QoL (median physical functioning scale 50). WAS is the first randomized controlled trial focusing on the effects of RYGB on cardiovascular function beyond hypertension. In addition, it will provide a wealth of high-quality data on the cerebral, psychiatric, hepatic, and metabolic function in obese patients after RYGB.

The Growing Demand in Europe for Reconstructive Clitoral Surgery after Female Genital Cutting: A Looping Effect of the Dominant Discourse?

When activism to combat «female circumcision» gained momentum in the 1980s, a discursive gap was created that persists until today. On the one hand, campaigners, activists, governments and some scholars promoted a discourse that focused on these practices as mutilations; on the other hand, not all scholars were willing to adopt the new term (FGM, «female genital mutilation») or to drop the perspective that these practices must be described within their wider contexts, with the full variations in different settings. Starting from this gap, this article discusses «reconstructive clitoral surgery», or «clitoris repair», as a cultural phenomenon growing out of the first discursive stream. Using Ian Hacking’s concepts «interactive kinds» and «looping effect», I argue that the increasing demand for reconstructive clitoral surgery in European countries needs to be understood in relation to the dominant anti-FGM discourse. While many interdisciplinary teams around Europe strive toward providing a holistic and respectful care for women requesting the surgery, I contend that the ubiquitous anti-FGM discourse has negative effects for both circumcised women who opt for surgery and those who do not.

Diagnosis and treatment of thyroid nodules in Spain. Results of a national survey

IntroductionThyroid nodule (TN) is a common reason for consultation in daily practice. The purpose of this study was to evaluate the diagnosis and treatment of TNs in our environment and to assess the current status regarding the existence and structure of high-resolution TN clinics. Material and methodsMembers of the Spanish Society of Endocrinology and Nutrition were invited in 2018 to participate in an online survey on the diagnostic and therapeutic processes of TN. ResultsA total of 211 valid surveys were received. Of all respondents, 30.8% stated that there were high-resolution TN clinics in their environment, with the endocrinologist being the main person responsible for performing ultrasonography (87.7%) and fine needle aspiration (FNA) (69.2%). For ultrasound classification of TNs, 32.7% used the ATA criteria, 32.2% the TI-RADS criteria, and 22.7% no classification. In situ verification of sample suitability was performed in 35.5% of the cases, and molecular analysis in 8.1%. With regard to clinical discharge, 65.4% would consider it after 5 years of follow-up and with a benign FNA. In the event of a Bethesda III result, 50.2% of respondents would repeat FNA and 35.5% would opt for surgery; if a Bethesda IV result was found, 95.8% would opt for surgery. ConclusionsHigh-resolution TN clinics are structures increasingly implemented in our environment where the endocrinologist is the main person responsible for performing ultrasonography and FNA. The standard clinical practice in our specialty is consistent with most recommendations concerning clinical practice guidelines for TNs.

Tumor Biology is King: Secondary Tumors of the Thyroid From 2 Medical Centers in China.

Background:We studied the clinical characteristics, diagnosis, treatment, and prognosis of secondary tumors of the thyroid (STTs) and analyzed this rare phenomenon based on our clinical experience.Methods:We reviewed 16 000 malignant thyroid tumors diagnosed at 2 medical centers in China from 1978 to 2018, including 55 patients with STTs.Results:The most frequent primary tumor sites included lung (21.8%), gastrointestinal (18.2%), breast (14.5%), and kidney (12.7%). The median age at STT diagnosis was 56 years. The time from diagnosis of primary tumor to metastases to the thyroid ranged from 0 to 108 months, with the longest interval being for renal cell carcinoma (RCC; mean: 49 months). There were 22 cases of single metastatic foci and 33 cases of multiple metastatic foci. At the time of STT diagnosis, 42 patients had multiple organ metastases and 13 patients had only thyroid metastases. Thyroid function was examined in 50 patients, including 23 with Hashimoto’s thyroiditis. Metastases were diagnosed histologically and confirmed by negative immunohistochemistry for thyroid markers. Twenty-one patients were treated with resection, including total thyroidectomy in 14 and unilateral lobectomy in 7. Thirty-four patients were treated without resection, but 2 were treated with tracheotomy. The median survival time of all patients with metastasis was 10 months (range: 1-96 months). Patients with primary RCC had the best prognosis (median survival time: 52 months), followed by patients with breast cancer (33 months). Patients who underwent thyroid surgery had a better prognosis than patients without thyroid surgery. Patients with single metastatic foci or single organ metastases had a better prognosis than patients with multiple metastatic foci or multiple organ metastases.Conclusions:Metastasis to the thyroid is a rare clinical phenomenon, and sometimes a diagnosis of STT is difficult; so, we need to pay more attention to it. While prognosis appears to be related to surgery or some characteristics of metastatic spread, these data suggest it is more complex. Tumor biology is king; in fact, prognosis was mainly related to the biological behavior of the primary tumor. We cannot only opt for surgery; thus, case selection is important, and the treatment strategy for STT patients should be determined individually according to their specific biological behaviors.

Gender differences in the 3-month utilization of nonoperative therapies prior to primary lumbar microdiscectomy

Patients with lumbar intervertebral disc herniation classically trial a brief course of conservative management prior to microdiscectomy surgery. Gender differences have previously been identified in the selection and symptomatic response to commonly-utilized nonoperative treatments. However, whether gender differences exist in the degree and cost of nonoperative therapy in this cohort remains unknown. Therefore, the purpose of this study was to assess for gender differences in the utilization and costs of nonoperative therapy in patients diagnosed with symptomatic lumbar intervertebral disc herniation 3-months prior to undergoing microdiscectomy. Medical records from adult patients diagnosed with a lumbar intervertebral disc herniation undergoing index microdiscectomy procedures from 2007 to 2017 were collected retrospectively from a large insurance database. The utilization of nonoperative therapy within 3-months after initial lumbar herniation diagnosis was determined. A total of 13,106 patients (55.4% Males) underwent index microdiscectomy. Male patients were more likely to fail conservative management and opt for surgery (Males: 2.9% vs. Females: 1.8%, p < 0.0001). A greater percentage of female patients utilized muscle relaxants (p = 0.0049), lumbar epidural steroid injections (p = 0.0007), and emergency department services (p = 0.001). The total direct cost of conservative treatment prior to microdiscectomy was $13,205,924, with males accountable for $7,457,023 (56.5%). When normalized by number of patients utilizing the respective therapy, males used fewer units of NSAIDs (males: 84.2 pills/patient; females: 97.3 pills/patient) and muscle relaxants (males: 77.5 pills/patient; females: 89.0 pills/patient). These results suggest that gender differences exist in the utilization of nonoperative therapies for the management of a lumbar intervertebral herniated disc prior to microdiscectomy surgery.

Diagnóstico y tratamiento del nódulo tiroideo en España. Resultados de una encuesta nacional

IntroductionThyroid nodule (TN) is a common reason for consultation in daily practice. The purpose of this study was to evaluate the diagnosis and treatment of TNs in our environment and to assess the current status regarding the existence and structure of high-resolution TN clinics. Material and methodsMembers of the Spanish Society of Endocrinology and Nutrition were invited in 2018 to participate in an online survey on the diagnostic and therapeutic processes of TN. ResultsA total of 211 valid surveys were received. Of all respondents, 30.8% stated that there were high-resolution TN clinics in their environment, with the endocrinologist being the main person responsible for performing ultrasonography (87.7%) and fine needle aspiration (FNA) (69.2%). For ultrasound classification of TNs, 32.7% used the ATA criteria, 32.2% the TI-RADS criteria, and 22.7% no classification. In situ verification of sample suitability was performed in 35.5% of the cases, and molecular analysis in 8.1%. With regard to clinical discharge, 65.4% would consider it after 5 years of follow-up and with a benign FNA. In the event of a Bethesda III result, 50.2% of respondents would repeat FNA and 35.5% would opt for surgery; if a Bethesda IV result was found, 95.8% would opt for surgery. ConclusionsHigh-resolution TN clinics are structures increasingly implemented in our environment where the endocrinologist is the main person responsible for performing ultrasonography and FNA. The standard clinical practice in our specialty is consistent with most recommendations concerning clinical practice guidelines for TNs.

What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials.

Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and Constant scores, though not approaching the MCID. At the subtype level, anterosuperior plating ranked highest in DASH and Constant functional scores with mean differences reaching 10-point improvement for Constant scores (95% CI 4.4 to 2.5) and 7.6 point improvement for DASH (95% CI 5.2 to 20). We found that surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. In aggregate, surgical treatment did not increase functional scores by amounts that patients were likely to consider clinically important. Use of specific subtypes of plating (anterior, anterosuperior) resulted in improvements in the Constant score that were slightly above the MCID but did not reach the MCID for the DASH score, suggesting that any outcomes-score benefits favoring surgery were likely to be imperceptible or small. In light of these findings, we believe patients can be informed that surgery for this injury can increase the likelihood of union incrementally (about 10 patients would need to undergo surgery to avoid one nonunion), but they should not expect better function than they would achieve without surgery; most patients can avoid surgery altogether with little absolute risk of nonunion. Patients who opt for surgery must be told that the decision should be weighed against complications and the possibility of undergoing a second procedure for hardware removal. Patients opting not to have surgery for acute midshaft clavicle fractures can be told that nonunion occurs in slightly more than 10% of patients, and that these can be more difficult to manage than acute fractures. Level I, therapeutic study.

Graves’ disease

Graves' disease develops when pathogenic thyroid receptor antibodies stimulate the thyroid gland resulting in excessive thyroid hormone production. Children and adolescents with Graves' disease can present in a variety of ways to many different clinical teams with a diverse range of underlying symptoms and signs. Graves' disease is usually managed initially with the anti-thyroid drug (ATD) carbimazole. However, only 20–25 % of young patients remit (remaining euthyroid when the ATD is stopped in the longer term) after a 2 year course of ATD treatment. Some families or patients who relapse then opt for surgery (total thyroidectomy) or radioiodine (RI) rather than returning to ATD. Unfortunately the young person then requires life-long thyroid hormone replacement. This is not an ideal outcome and new therapeutic approaches are needed if patients with Graves’ are to spend their adult lives free of daily medication with ATD or thyroxine replacement. This article discusses the known science and offers advice for diagnosis and treatment options.

The knowledge of beauty salon clients about hallux valgus therapy. Preliminary study

&lt;b&gt;Introduction:&lt;/b&gt; Hallux valgus is a frequent painful deformity of the feet, and occurs most often in women of different ages. People with hallux valgus have, among others, a genetic predisposition, a weaker ligament-and joint structure of the foot, pes planus (flatfoot), rheumatoid arthritis, muscular balance disorders, are obese, and wear improper footwear. &lt;br/&gt;&lt;b&gt;Purpose:&lt;/b&gt; To assess the knowledge of beauty salon clients on the subject of professional care of hallux valgus. &lt;br/&gt;&lt;b&gt;Materials and methods:&lt;/b&gt; Research was conducted in a beauty salon in Lomza, Poland using an original questionnaire. The study was approved (No. 4/2013) by the senate of the Ethics Committee of the Lomza State University of Applied Sciences. &lt;br/&gt;&lt;b&gt;Results:&lt;/b&gt; The conducted research showed that 48% of the surveyed women dealt with hallux valgus using orthopedic insoles, and 26% underwent procedures recommended by a specialist. Respondents knew kinesiotherapy and taping as treatment methods for this ailment. The vast majority of the surveyed women would undergo non-surgical hallux valgus treatment, and only a few would opt for surgery. &lt;br/&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The knowledge of the studied women about hallux valgus was quite extensive.

Efficiency of surgical management of miscarriage within a central London teaching hospital

Introduction: The National Institute for Health and Clinical Excellence advises women diagnosed with miscarriage should be offered, where appropriate, all three management options: expectant, medical and surgical (which includes surgical management of miscarriage under general anaesthetic [SMM]). Women who opt for surgery often expedite the miscarriage process for physical, social, and psychological reasons. Currently there is no standard for the maximum time a woman should need to wait for her preferred SMM option. In our unit, we aim to achieve SMM within five days of decision.

Emakumezkoaren gernu-inkontinentzia

Emakumezkoetan gernu-inkontinentzia (GI) sarritan agertzen den osasun-arazo bat da, haien bizikalitatea sendo asaldatzen duena; halere, lotsa edota informazio faltagatik ia erdiek ez dute kontsultatzen. Gernu-inkontinentzia mota ezberdinak daude eta horien artean bi dira nagusiak: premiazko gernu-inkontinentzia (PGI) eta estresagatiko gernu-inkontinentzia (EGI). Bai ginekologoak bai urologoak azter dezake arazo hau eta beharrezko ikerketa burutu ondoren tratamendu egokiena ezarri; hasteko teknika kontserbatzaileak erabiltzen dira, zeinak zoru pelbikoko muskuluen indartzean, gernu-maskuriaren heziketan edota eguneroko bizi-ohiturak aldatzean oinarritzen diren. Horiek porrot egiten badute, inkontinentzia motaren arabera tratamendu ezberdinak daude. PGIan tratamendu farmakologikoa erabil dezakegu, antimuskarinikoak edota beta 3 agonista adrenergikoak hain zuzen. EGIaren kasuan, ostera, kirurgiara joko dugu; badaude horretarako hainbat teknika, urteetan zehar hobetuz joan direnak, gaur egun erabiliena uretra azpiko xingolak direlarik, polipropilenozkoak. Xingolen eraginkortasun-tasa altua da, mota ezberdinak daude bakoitza bere berezitasunekin eta horiek ezagutzea ezinbestekoa da pazienteari aholku egokiena emateko. Beraz funtsezkoa da emakumeek jakin dezaten gernu-inkontinentzia ez dela zahartzearen ondorio normal bat eta badaudela horretarako konponbideak.

FA03.06: THE COST BENEFIT OF A WATCH AND WAIT POLICY FOR COMPLETE CLINICAL RESPONDERS FOLLOWING NEO-ADJUVANT THERAPY IN ESOPHAGEAL CANCER

Abstract Background Survival for esophageal cancer remains poor despite neo-adjuvant chemo-radiotherapy (nCRT) and surgical resection. The median survival for nCRT plus surgery in the CROSS trial was 48 months with a pathological complete response (pCR) rate of 29%. All pCR patients will have been clinical complete responders (cCR) and while surveillance and salvage surgery (S + SS) for cCR in rectal cancer is well investigated, it is unclear whether the outcomes are similar in esophageal cancer. As morbidity and mortality following esophagectomy is high, avoidance of surgery for predicted pCR would represent a clear advantage. Our unit offers a supported choice for cCR patients to opt for surgery or for surveillance. There is currently no literature on the cost benefit of a watch and wait policy for esophageal cancer patients with a complete clinical response. Methods We identified all cCR patients from a prospectively collected database of esophageal cancer patients offered curative treatment with nCRT from 1999 to 2017. We costed the S + SS group for whom accurate costing data was available and we matched these, according to time of follow up, to a control group of cCR who underwent surgery. Cost (from the National DRG cost manual) was calculated based on cost of surgery, ICU stay, admission length, and follow up radiological and endoscopic procedures. The data was analysed using a two-tailed, equal variance t-test. Results Of 237 patients who received nCRT, 86 had a cCR. Of these, 15 patients in the S + SS fulfilled the selection criteria with a mean follow up of 10.2 compared with 10.4 months in the control group (P = 0.925). The mean number of days in hospital was 19.2 vs. 43.2 days consecutively during the follow up period. The mean estimated cost to the HSE was €91,480 for S + SS compared with €301,280 for the controlled surgery group (P = 0.01). Conclusion This study identified a significant cost benefit for surveillance over surgery. Further studies are required to accurately identify those who cannot benefit from surgery and to assess quality of life years gained and cost per year of life are needed. Disclosure All authors have declared no conflicts of interest.