Rate Of Spontaneous Resolution Research Articles

Dural carotid-cavernous fistula successfully treated by embolization via inferior ophthalmic vein Case report

Spontaneous dural carotid-cavernous fistulas (dural CCFs) usually have an indolent course, low morbidity, and a high rate of spontaneous resolution. Surgical treatment should therefore be avoided, if possible. However, we encountered a patient with prominent venous drainage, diplopia, intolerable orbital pain, and headache. The SOV in this patient was tortuous and partly stenotic, while the inferior ophthalmic vein (IOV) was dilated but neither tortuous nor stenotic. The patient was successfully treated by embolization via this vein without complication. To our knowledge, embolization of the cavernous sinus with dural CCFs through the IOV for dural shunt syndrome has not been previously reported.

Resolution of vesicoureteral reflux during medical management in children.

A retrospective study was performed to evaluate the results of medical management of primary vesicoureteral reflux (VUR) in infants and children. The charts of 105 patients (74 boys, 31 girls) with 167 refluxing ureters were reviewed. The age at diagnosis ranged from 3 days to 9.2 years (mean 1.3 +/- 1.9 years). The mean duration of follow-up was 2.4 +/- 1.5 years. We found that the patient's sex did not influence the fate of VUR and its complications. Patients whose reflux improved while being managed medically were younger than those who did not improve, and the younger the patient the sooner the reflux resolved. Improvement and resolution of reflux were also related to grade, and the lower the initial grading the sooner the reflux resolved. Spontaneous resolution rates of reflux were 92.3%, 76.2%, 61.7%, and 32.0% for grades I, II, III, and IV, respectively. No ureters with grade V reflux resolved without complications. The most common complications in our series were renal scarring and secondary obstructive uropathy.

A Critical Review of Recent Randomized Controlled Clinical Trials in the Treatment of Asymptomatic Bacteriuria of Pregnancy

The randomized clinical trial represents the gold standard of intervention studies in clinical medicine. This is partly due to the validity of results obtained when confounders, both known and unknown, are assigned equally to treatment groups without the practitioners’ bias of treatment selection. Few clinical trials exist to assess the effectiveness of various treatment regimes for asymptomatic bacteriuria of pregnancy. This study reviews critically the randomized controlled clinical trials for the treatment of asymptomatic bacteriuria of pregnancy. Articles for the review were obtained through a literature search employing MEDLINE over a ten-year period. Nine randomized trials resulted from the search that were in the English language or had English translation available. These included five randomized trials without control groups done in a single centre, and one trial with a control group assessing prophylaxis against recurrent asymptomatic bacteriuria.Review of these studies finds that single dose therapy when compared to longer dosing regimes shows a trend to a higher cure rate but that all of the studies were under-powered. This lack of power results in a significant beta error. No difference between short and long term therapy could, therefore, be shown statistically. When a control group is introduced into the randomized trial, a high rate of spontaneous resolution is seen. Short term therapy resulted in a lower cure rate when compared to no treatment in this setting and only three day or greater treatments showed cure rates above spontaneous remission rates. The only study addressing prophylaxis was severely under-powered and suffered technical complications leading to the inability to draw any conclusions. Adequately powered studies to show effectiveness of single dose therapy and prophylaxis of asymptomatic bacteriuria of pregnancy are needed.

Otitis media reassessed.

Preview Management of otitis media in children is a controversial matter: The basic questions of why, in whom, and how it should be treated are undergoing continual reassessment. In this article, Drs Shapiro and Bluestone provide answers to these and other questions, such as Why is treatment of acute otitis media justified? When is the "wait and see" approach to otitis media with effusion inadvisable? Which common treatment approaches are ineffective? When should referral to an otolaryngologist be considered?

Antibiotic therapy and leukocytospermia: a prospective, randomized, controlled study

To determine the efficacy of common antibiotic therapies for treatment of leukocytospermia of unknown etiology. Prospective, randomized, controlled clinical study. Fertility and Endocrinology Unit at Brigham and Women's Hospital, Boston, Massachusetts. One thousand seven hundred ten male partners in infertile couples attending the Fertility and Endocrinology Unit. Concentrations of seminal peroxidase-positive granulocytes were determined during all routine semen analyses performed over a 30-month period. Of 119 men found to have leukocytospermia (> 10(6) granulocytes/mL semen) on first visit, 54 agreed to be randomized into one of three groups, and 41 patients completed the study. Group I (n = 13) and their wives received a 14-day course of oral doxycycline, 100 mg twice per day. Group II (n = 11) and their wives received a 14-day course of oral trimethoprim 160 mg-sulfamethoxazole 800 mg twice per day. Group III (n = 17) and their wives received no therapy. Four weeks after randomization, repeat semen analyses and granulocyte quantitations were done. Neither of the antibiotic regimens resulted in a significantly higher rate of resolution of leukocytospermia over that seen in the control group. There is a high rate of spontaneous resolution of leukocytospermia after one positive test. Antibiotics are no more beneficial than no therapy for treatment of this condition.

Long-term results after probing for congenital nasolacrimal duct obstruction.

The long term results of probing for congenital nasolacrimal duct obstruction were reviewed using a parental questionnaire issued to both treated and age-matched control groups. On follow up 4-13 years after probing in childhood 30% of patients still had symptoms of epiphora or discharge. Surprisingly, a similar high symptom rate was found in the controls, such that there was no statistically significant difference in the rate of symptoms between the two groups. Probing had therefore apparently reduced the symptom rate to a level close to normal for the age group concerned. All studies on the incidence of congenital nasolacrimal duct obstruction must be interpreted with reference to the known high rate of spontaneous resolution as a clear trend has been demonstrated towards a lower incidence of symptoms the longer the follow up after probing. This finding would support a policy of delay before further intervention in patients with mild residual symptoms after a technically successful probing.

Outcome of Reflux in Children with Myelodysplasia Managed by Bladder Pressure Monitoring

From June 1984 to December 1992 voiding cystourethrography performed on 209 patients with myelodysplasia revealed vesicoureteral reflux in 57 (27%). High grade reflux (3 to 5/5) occurred in 33 patients (58%). Bladder pressure at typical capacity, defined as the pressure at average catheterization volume or bladder leak point pressure, was determined urodynamically. After a mean of 56 months vesicoureteral reflux resolved or improved in 55% of patients and remained unchanged in 28%. There was no correlation between the grade of reflux and the rate of spontaneous resolution. Pressure at typical capacity of 40cm. water or more was significantly more common in patients with reflux (44%) than in those with no reflux (20%) (p <0.001). There was a strong association between pressure at typical capacity of 40cm. water or more and upper tract deterioration (p <0.0001). However, there was no correlation between pressure at typical capacity and grade of reflux (p = 0.18). Treatment of pressure at typical capacity of 40cm. water or more led to resolution or improvement of vesicoureteral reflux in 8 of 10 reevaluated patients. Hydronephrosis resolved (7) or improved (1) in 8 of 9 cases. Measurement of intravesical pressure is of paramount importance in the management of spina bifida patients with vesicoureteral reflux. Maintaining the pressure at typical capacity at less than 40cm. water is associated with increased spontaneous resolution of vesicoureteral reflux and a lower incidence of upper tract deterioration.

Value of bacterial culturing in the course of congenital nasolacrimal duct (NLD) obstruction.

The role of infection in the etiology and persistence of congenital nasolacrimal duct (NLD) obstruction is examined in a group of 334 infants who had conjunctival swabs cultured. One hundred and fifty eight (47%) of these had evidence of NLD obstruction and 176 (53%) did not. The types of organism grown from those with and without NLD obstruction were similar and occurred in almost equal proportions in each group. In addition, the rate of spontaneous resolution in those with NLD obstruction was the same, whether pathogenic bacteria were grown or not. There were no cases of orbital cellulitis, dacryocystitis, or ocular infection in those with NLD obstruction and no suggestion that secondary infection was more common in this group.

Does early expansion surgery have a role in the management of congenital subglottic stenosis?

To better define the clinical course of congenital subglottic stenosis, the authors reviewed a cohort of 27 children managed with long-term tracheotomy and interval bronchoscopy. Rates of spontaneous resolution were 19% at 6 months, 39% at 12 months, and 69% at 18 months (Kaplan-Meier survival analysis). Children older than 4 months of age at tracheotomy tended to have more rapid resolution of their stenoses (P = .08). Overall, the median time to decannulation was 15.8 months (95% confidence interval, 13.9 to 17.6 months). One death was possibly tracheotomy-related, and 12 (44%) of the children experienced complications or sequelae resulting in new or extended hospitalization. Considering the prolonged cannulation necessary for spontaneous resolution of congenital subglottic stenosis, the role of long-term tracheotomy as the sole form of management may be limited. Once the need for intervention is apparent, the authors recommend early consideration of cricoid split or laryngotracheoplasty as alternatives to long-term tracheotomy.

Expectant Management of Ectopic Pregnancy

To evaluate expectant management in selected cases of ectopic pregnancy.Transvaginal sonography and estimation of serum hCG concentrations were used in the evaluation and follow-up of ectopic pregnancy. Entry criteria for expectant management were: decreasing level of serum hCG, diameter of the ectopic pregnancy less than 4 cm, and no signs of rupture or acute bleeding by vaginal sonography.Expectant management was studied in 83 patients, representing 26% of all ectopic pregnancies during a 2-year period. In 57 patients (69%), spontaneous resolution occurred, corresponding to 18% of all ectopic pregnancies. Laparoscopy was performed in 26 because of clinical symptoms or a rise in hCG level after expectant management for 1-18 days. One patient had a tubal rupture requiring tubal resection by laparoscopy. No serious complications occurred. With increasing experience, the rate of expectant management and spontaneous resolution increased during study period.Expectant management with repeated vaginal sonography and estimations of serum hCG concentrations is a useful form of treatment for ectopic pregnancy in selected cases.

Primary Vesicoureteral Reflux in the Black Child

Primary vesicoureteral reflux is a polygenic abnormality due to a deficiency of the ureterovesical junction which allows urine in the bladder to ascend into the ureter and kidney. Fifty-one black children with primary vesicoureteral reflux were evaluated and treated at Children's Hospital from 1976 to 1986. The results of the evaluation and treatment were compared with those of 493 white patients with primary vesicoureteral reflux seen during the same time interval. The general approach to management was nonsurgical. There were no radical differences in the mode of presentation, age at presentation, and age at resolution. The distribution of reflux by maximum grade was not affected by race. Overall, 19 (37%) black children experienced spontaneous resolution of reflux. The mean duration of reflux in black children who had spontaneous resolution was 14.6 months. This duration was statistically significantly shorter than that in white patients with spontaneous resolution of vesicoureteral reflux (P less than .005). Surgical correction was believed to be required in 8 (16%) patients and 8 (16%) were lost to follow-up. Renal scarring demonstrated by intravenous pyelogram or renal scan was initially present in 12 (23%) black patients compared with 65 (13%) white patients. This was due to a higher percentage of renal scarring in black girls which was not explained by distribution of grades of reflux. There was no progression of scarring in our black patients, whereas 3 (0.6%) white patients had progression of scarring. Although vesicoureteral reflex is rarely seen in black patients (9% of series), it has similar demographic features.(ABSTRACT TRUNCATED AT 250 WORDS)

Permanent Pacemaker Placement in Chronic Atrial Fibrillation Associated with Intermittent AV Block and Cerebral Symptoms

We examined the hypothesis that a greater than or equal to 2 second pause detected on 24-hour Holter monitoring in patients with persistent atrial fibrillation and complaints of syncope or dizziness lacked sufficient specificity to warrant implantation of a permanent pacemaker. We retrospectively reviewed cases from our 24-hour electrocardiographic (Holter) monitoring data base. A total of 411 consecutive Holter monitoring records demonstrating persistent atrial fibrillation obtained during a 5-year period (1982 to 1987) were examined. One hundred and five (26%) patients had cerebral symptoms (dizziness or syncope) as a primary indication for monitoring 80 (76%) patients were identified with documented ventricular pauses of greater than or equal to 2 seconds. Three hundred and six patients (74%) underwent 24-hour monitoring without cerebral symptoms as an indication and 209 (68%) patients had greater than or equal to 2-second pauses. Clinical information was available in 164 (50 symptomatic and 114 asymptomatic) patients. There were no significant differences in the clinical or Holter findings between the two groups. Of the 50 symptomatic patients, 15 (30%) underwent permanent pacemaker placement and the remaining 35 (70%) were managed conservatively during a mean follow-up of 23 +/- 5 months. Eleven of 15 paced (73%) and 31 of 35 (89%) nonpaced patients experienced resolution of their cerebral symptoms (NS). The sensitivity of Holter monitoring in detecting pauses of greater than or equal to 2 seconds in patients with cerebral symptoms was high (76%), but the specificity (32%) and positive predictive values (28%) were low.(ABSTRACT TRUNCATED AT 250 WORDS)

小児原発性VURの検討

One hundred and four children (48 boys and 56 girls, ranging in age from 3 months to 15 years, and follow-up period of more than 2 years in all) with "primary" vesicoureteral reflux (VUR) were retrospectively analyzed with particular emphasis on resolution of VUR and occurrence of renal scar. All underwent cystoscopic examinations which failed to demonstrate any organic vesicourethral obstruction, and all were neurologically normal. The patient population was divided into 2 groups based on cystometric findings. Group 1 consisted of 74 patients with unstable bladder and Group 2 consisted of 30 patients without unstable bladder. Although both groups were initially kept under antibacterials, in Group 1 frequent voiding and anticholinergics were maintained until the bladder stabilized by itself. There was no difference in the grade of reflux between the two groups. The rate of spontaneous resolution of reflux was 18% in group 1 in which more than 60% of the patients were with high grade reflux, while in Group 2 it was 17%, similarly to Group 1, but all were with low grade reflux. The presence or absence of renal scar and its subsequent evolution were determined in 73 patients in whom serial urograms were available enough to evaluate nephrographic renal outline. The incidence of renal scar at the first visit was 26% in Group 1 and 36% in Group 2. New formation of renal scar was not found in either group. The progression of preexisting renal scar was seen only in Group 1 (5/55 patients, 9%), and not in Group 2 (0/18 patients, 0%).(ABSTRACT TRUNCATED AT 250 WORDS)

EFFECT OF ANTICHOLINERGIC THERAPY IN CHILDREN WITH PRIMARY VESICO URETERAL REFLUX AND DETRUSOR INSTABILITY

To determine the effect of anticholinergic therapy in patients with detrusor instability and vesica ureteral reflux (VUR), a prospective clinical trial was designed including urodynamic evaluation in addition to routine X-Ray and laboratory studies; 69 neurologically normal children with 99 refluxing ureters aged 4 to 12 years were included. All patients received continuous prophylactic antibacterial chemotherapy. Initial urodynaidc findings distinguished 2 groups of patients; Group I: 27 children with 40 refluxing ureters and stable bladders, and Group II: 42 children with significant detrusor instability and 59 refluxing ureters. The latter received anticholinergics (propantheline bromide and imipramine hydrochloride).Follow up evaluation (urodynamic and radiological)at 6 months revealed in Group I, reflux disappeared in 12/40 (30%) and improved in 2/40 (5%); in Group II, 30/42 pts.(41 refluxing ureters showed good clinical and urodynamic response to therapy; reflux disappeared in 27/41 refluxing ureters (66%) and improved in 10/41 (24%) whereas in 12/42 pts.(18 r.u.) not showing urodynamic response, reflux disappeared in 6/18 refluxing ureters (33%) and improved in 2/18 (11%). Preliminary data shows: a)Spontaneous reflux resolution rate in stable bladders of 30%; b)Higher reflux resolution rate, in children with detrusor instability who responded to anticholinergics, than in those who didn't; c)Detrusor instability may play a role in perpetuating primary VUR.

Evolving Techniques in the Treatment of Macular Detachment Caused by Optic Nerve Pits

Fourteen patients with macular detachments caused by optic nerve pits were treated for progressive visual loss, cystoid macular changes, or atrophy of the macular retinal pigment epithelium. Photocoagulation of the temporal disc border alone was unsuccessful in two cases but promptly reattached the macula of two patients immobilized after laser surgery. Vitrectomy and gas tamponade improved vision and flattened the macula of three patients over various periods. The detachment recurred in one patient. Prompt and sustained macular reattachment with improved vision was noted after photocoagulation, vitrectomy, and gas tamponade in eight patients, although four required second operations. The prompt reattachment and visual recovery noted in these eight patients surpasses the reported 25% rate of spontaneous resolution.

Childhood Enuresis: A Comprehensive Treatment Program

Enuresis is a common, often misunderstood, condition that affects millions of children in the United States. For most children with primary enuresis, preventing secondary psychological sequelae associated with guilt and shame is an important consideration in the decision whether or not to treat. Because the spontaneous resolution rate is 15 per cent per year, the older the child, the more important treatment becomes. It is important to distinguish primary from secondary enuresis, as most psychogenically induced enuresis is of secondary nature. A careful history can usually elicit the etiology, as well as the exacerbatory factors in both types of conditions, providing direction for treatment. Treatments include pharmacologic, behavioral, and psychotherapeutic. In some cases, surgical intervention of either a urologic or otolaryngologic nature is indicated. A multidimensional approach is often best, and we have described our program with its success rate. Treating the enuretic child can be frustrating, but is usually quite gratifying for the child, parents, and the clinician.

Medical Treatment of Chronic Otitis Media with Effusion (Secretory Otitis Media)

To determine whether antimicrobial therapy is of value in the treatment of chronic otitis media with effusion (secretory otitis media), we treated 1,429 4- to 8-year-old children--2224 affected ears--with a fixed regimen of an antibiotic mixture (Pediazole) for 10 days and a decongestant (Novafed) for 30 days. We observed the children monthly to determine the rate of clearance. Validity of diagnosis was greater than 90% with an algorithm of pneumatic otoscopy and tympanometry. Medication compliance was not measured. At 1 month, 45% of the children (48% of the ears) had cleared and at 2 months, 60% of the children (63% of the ears) had cleared. Factors such as sex and prior treatment in the preceding 3 months were no different in the cured vs. the uncured groups. Age significantly influenced the cure rate (P less than 0.0001); the older the child, the higher the clearance rate. Tympanograms type 5, 8, and 12-14 were significantly more prevalent in the uncleared group (P = 0.0001). The clear rate for unilateral cases was 76% and for bilateral cases, 47% (P less than 0.0001). Children with chronic otitis media with effusion are most likely to be cured by medical therapy/time if they are older, have unilateral disease, or a peaked tympanogram. Surgery should be withheld in these children for 2 or more months to permit the highest rate of spontaneous resolution.

Multiple pancreatic pseudocyst disease.

In an effort to determine the incidence of multiple pseudocyst disease and establish the optimal approach to this problem, the records of 91 consecutive patients diagnosed during a 36-month period as having pancreatic pseudocyst disease by sonography or computerized tomographic scanning were reviewed. Thirteen patients (14.3%) had multiple cysts; all received sonograms and six had CT scans. The combined false negative and false positive rate with sonography was 9%. Spontaneous resolution occurred involving five cysts (18%) up to 6.5 cm in size. The diagnosis of cyst multiplicity was confirmed at operation in seven cases; two of the seven operations were excisional and the remaining patients received drainage procedures. There were no operative deaths; complications included one patient who required chronic enzyme replacement therapy after excision and another patient who developed a subphrenic abscess after attempted percutaneous drainage. The incidence of multiple pseudocyst disease in our series is just over 14%. The possibility of multiplicity should be carefully investigated in each patient with pseudocyst disease. In light of the rate of spontaneous resolution, not all patients with multiple pseudocysts may require operative therapy. Because of the 7.7% false negative diagnoses with sonography, CT scanning is especially helpful when the diagnosis of multiple pseudocysts is suspected or in preoperative preparation of pseudocyst drainage. If an operation becomes necessary, a drainage procedure rather than excision should be used whenever possible to maximize gland salvage.

Cystitis Follicularis in Children with Primary Vesicoureteral Reflux

In an attempt to determine whether cystitis follicularis affects the spontaneous resolution of primary vesicoureteral reflux we reviewed the records of 65 children with reflux and cystitis follicularis. A group of children with primary vesicoureteral reflux but without cystitis follicularis was included as controls. The data did not reveal a statistically significant difference in either the rate of spontaneous resolution of reflux or the need for surgical correction between these 2 groups of children.

OSTEOCHONDRITIS DISSECANS

Osteochondritis dissecans (OCD) is a disease of unknown etiology, characterized by separation of necrotic bone from its bony bed. While the juvenile form seen in patients with open physes has a 60-90% rate of spontaneous resolution, the adult form has virtually no chance of spontaneous healing. Plain X-rays are sufficient for the diagnosis, and magnetic resonance imaging (MRI) is essential for evaluation of disease progression and/or healing. The clinical correlation of MRI criteria defined in recent years to determine stability of the lesion is high. Juvenile OCD can be treated conservatively if there are no signs of instability on magnetic resonance images. Adult patients or unstable lesions in children should be treated surgically. For stable lesions, arthroscopic antegrade perforation is indicated to increase vascularity and stimulate healing. Unstable or displaced lesions should be treated with debridement, internal fixation, and cancellous bone grafting. Although cannulated metal screws are the most widely used implants for internal fixation, biodegradable implants have also been utilized in recent years. Loose fragments that are too deformed to be internally fixed should be removed and cartilage reconstruction techniques should be employed for the remaining crater. Long-term results of loose body removal alone are unsatisfactory. Modern cartilage restoration techniques are technically demanding due to the large, deep, and unconfined nature of the defect in the femoral condyle.