Successful Medical Management Research Articles

Natural History and Management Outcomes of Segmental Arterial Mediolysis

Segmental arterial mediolysis (SAM) is a poorly understood, nonatherosclerotic, noninflammatory disease resulting from degeneration of the arterial media. Patients may present with aneurysm, dissection, stenosis, or bleeding from visceral or renal arteries. Indications for intervention have been poorly characterized. A retrospective review of all patients with a diagnosis of SAM was undertaken at a single institution in multiple geographic locations. Patients were identified using established criteria for the diagnosis of SAM (Table), which excluded those diagnosed with fibromuscular dysplasia. Basic demographics, presenting symptoms, diagnostic evaluation, and outcomes were reviewed. Between 2004 and 2014, there were 116 patients diagnosed with SAM; 78 (67%) were male, with a mean age of 52.5 years (range, 23-90 years). There were 76 (65.5%) patients who presented with abdominal pain, 21 (18.1%) with flank pain, 18 (15.5%) with back pain, and 11 (9.5%) with hematuria; 16 (13.8%) patients had acute hypertension and 7 (6.0%) had hypotension. Thirteen (11.2%) patients presented with abdominal pain >30 days in duration. Twelve (10.3%) patients were asymptomatic. Imaging revealed dissection in 96 (82.8%) patients, aneurysm in 49 (42.2%), stenosis in 24 (20.7%), occlusion/thrombosis in 18 (15.5%), pseudoaneurysm in 12 (10.3%), hemorrhage in 9 (7.8%), and arteriovenous fistula in 1 (0.9%). Disease location was renal in 57 (49.1%) patients, celiac in 51 (44.0%), superior mesenteric in 48 (41.4%), hepatic in 23 (19.8%), splenic in 18 (15.5%), inferior mesenteric in 3 (2.6%), and pancreatic in 3 (2.6%). Forty-five (38.8%) patients demonstrated evidence of end-organ ischemia. Twenty-three (19.8%) patients underwent intervention, including 11 endovascular and 8 open interventions. Four patients underwent both open and endovascular interventions. Thirteen (86.7%) endovascular procedures involved embolization. Seven (58.3%) patients with open intervention underwent bypass grafting, two (16.7%) ligation, and two (16.7%) thrombectomy. One (8.3%) patient underwent thrombectomy with patch angioplasty. Indications included large aneurysm in 12 patients (41.4%), end-organ ischemia in 9 (31.0%), hemorrhage in 6 (20.7%), and chronic pain in 2 (6.7%). There was one perioperative death. Presence of dissection was associated with successful medical management (P = .0007). Statistically significant variables associated with need for intervention included pseudoaneurysm (P = .002) and hemorrhage (P = .0003). There were 109 (94%) patients who underwent serial imaging, with mean follow-up of 37.2 months (range, 0-197.2 months). Nine (8.3%) patients had progression of radiologic findings and 17 (15.6%) had new findings seen in a different artery. Presentation of patients with acute abdominal pain was the only statistically significant variable associated with new findings on subsequent imaging (P = .03). SAM remains an uncommon yet important disease process that may require intervention. Therefore, it is important that the vascular surgery community be aware of this disease. Patients with SAM presenting with dissection are more likely to avoid invasive intervention. Those presenting with pseudoaneurysm and hemorrhage are more likely to fail to respond to medical management, and intervention should be considered. Serial imaging is imperative to identify disease progression, especially in those patients who present with acute abdominal pain.TableCriteria for diagnosis of segmental arterial mediolysis (SAM)ClinicalExclusion of congenital predispositions for dissection (eg, Ehlers-Danlos, Loeys-Dietz, and Marfan syndromes)Exclusion of collagen vascular disease, arteritis, or fibromuscular dysplasiaAcute presentation: abdominal, flank, or back pain; hematuria, hypertension, hypotension, strokeChronic presentation: abdominal pain, hypertension, hematuriaMay also be asymptomaticRadiographicDissection, fusiform aneurysm, occlusion, beaded appearance, wall thickening of the visceral or renal arteries, organ infarctionNo contiguous aortic dissection or atherosclerosisSerologicAbsence of inflammatory markers (eg, antinuclear antibody, antineutrophil cytoplasmic antibody, complement) Open table in a new tab

Successful medical management of acute mesenteric ischemia due to superior mesenteric and portal vein thrombosis in a 27-year-old man with protein S deficiency: a case report

BackgroundAcute mesenteric ischemia poses a diagnostic challenge due to nonspecific clinical clues and lack of awareness owing to its rarity. Ischemia due to mesenteric venous thrombosis has a good prognosis compared to arterial cause and can be managed conservatively with early diagnosis. The portomesenteric venous system is an unusual site of thrombosis in patients with protein S deficiency, and its thrombosis is an uncommon cause of acute mesenteric ischemia.Case presentationWe present a case of a 27-year-old Mongolian man who presented with acute abdominal pain increasing in severity, and refractory to repeated attempts at treatment with a misdiagnosis of acute peptic ulcer disease. Contrast-enhanced computed tomography of his abdomen detected complete occlusion of the superior mesenteric vein, an extension of acute thrombus into the portal vein, and ischemic mid-jejunal loops. Early diagnosis and immediate anticoagulation with continuous intravenous infusion of unfractionated heparin prevented subsequent consequences. On further workup, our patient was diagnosed with isolated protein S deficiency. We started lifelong thromboprophylaxis with warfarin to prevent recurrence and our patient was asymptomatic on the latest follow-up 5 months after discharge.ConclusionDespite accurate detection of acute mesenteric ischemia by contrast-enhanced computed tomography, high index of suspicion is indispensable for its early diagnosis. Early diagnosis and immediate anticoagulation will prevent subsequent complications and need for surgical intervention. Young patients without known risk factors presenting with venous thrombosis in atypical sites should be investigated for prothrombotic diseases.

Report of Successful Medical Management of Progressive Gastric Band Penetration-to-perforation: 12 Serial EGDs During 50 months of Observation

Report of Successful Medical Management of Progressive Gastric Band Penetration-to-perforation: 12 Serial EGDs During 50 months of Observation

Successful medical management of a case of Austrian syndrome\u2014an uncommon entity in the modern antibiotic era: a case report

BackgroundAustrian syndrome—the combination of meningitis, pneumonia and infective endocarditis due to Streptococcus pneumoniae infection, is a rare entity. In literature only a few hundreds of cases are reported but surprisingly we did not find any report on Austrian syndrome in or from Bangladesh.Case presentationWe report the case history of a middle aged Bangladeshi diabetic man, who had fever, cough, shortness of breath and altered mentation. He had tachycardia, bi-basal lung crepitations, new cardiac murmurs and meningism. Diagnostic work-up revealed Austrian syndrome. Because of the rarity of the condition, this case is reported.ConclusionA case of pneumococcal pneumonia or meningitis should raise suspicion of concomitant endocarditis and Austrian syndrome, specially if there is heart failure, as early recognition and treatment may appear life-saving.

Emphysematous pyelonephritis with Dengue hemorrhagic fever: A successful medical management of a fatal scenario

Emphysematous pyelonephritis is a life threatening acute necrotizing infection with associated gas formation involving the renal parenchyma and perinephric tissues. Dengue fever, according to the WHO, is the most rapidly spreading mosquito borne viral infection in the world. Dengue Hemorrgahic Fever is a more severe form of dengue fever and is characterized by fever, bleeding manifestations, plasma leakage and thrombocytopenia. This is a case of a 56 year old female, who presented with history of fever, headache, myalgia and dysuria; and was diagnosed to have emphysematous pyelonephritis with Dengue Hemorrgahic Fever. She was successfully managed with intravenous antibiotics and platelet transfusions, without any urological interventions. Asian Journal of Medical Sciences Vol.8(5) 2017 101-103

Successful medical management of caesarean scar ectopic pregnancy: Case report


 

Controversies Regarding Management of Vesico-ureteric Reflux.

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

Abstract #725: Successful Medical Management with Mifepristone in a Patient with Occult Ectopic Cushing’s Syndrome

Abstract #725: Successful Medical Management with Mifepristone in a Patient with Occult Ectopic Cushing’s Syndrome

A Study on Clinical Trends of Ectopic Pregnancy in a Tertiary Care Hospital

Introduction: Ectopic pregnancy is the most common cause of maternal morbidity during first trimester of pregnancy. This study is done to analyse various management, clinical parameters and morbidity associated with ectopic pregnancy. Aim: To study the incidence, clinical trends, management aspect, morbidity and mortality profile of ectopic pregnancy in a tertiary care hospital. Materials and methods: Retrospective study conducted in women diagnosed as ectopic pregnancy over a period of 18 months. Total of 64 cases during this time period were included. Data were collected from case sheets in medical records department. All the parameters were tabulated and analysed. Results: The peak age of incidence is 26 to 30 years. Ectopic pregnancy is found to be more common in multigravida. The most common gestational age at presentation is 6-8 weeks. Risk factors are associated with (26 cases) 40.62% of cases. Most common symptom being amenorrhoea. The commonest site is right tubal ectopic pregnancy. The most common morbidity being anaemia. Most common surgery done is partial salpingectomy (48 cases). The success rate of medical management is 88.88%.There is no mortality. Conclusions: Early diagnosis of ectopic pregnancy decreases the morbidity. Proper evaluation of cases with high risk factors during early pregnancy itself will help in early diagnosis which in turn favours successful medical management and decreases in morbidity as well as preservation of fertility.

OC13.06: Predictive factors for the success of medical management of miscarriage

OC13.06: Predictive factors for the success of medical management of miscarriage

Medically managing obesity: Offering hope or a disincentive to change?

ObjectiveAs weight loss in primary care remains minimal, Health Professionals are advised to medically manage obesity-related risk factors including blood pressure and cholesterol. This experimental study evaluated the impact of medically managing risk factors on obese patients’ motivation to change their behaviour. MethodsA vignette study with two arms: successful medical management (ie risk factors have improved) vs failed medical management (ie no change) set in three General Practices in the South of England. Overweight and obese patients (n=170) rated their behavioural intentions and beliefs after reading a vignette describing an overweight patient who had received either successful or failed medical management of their risk factors (blood pressure and cholesterol). ResultsFollowing successful medical management overweight and obese patients reported increased intentions to lose weight and a greater understanding of their condition. ConclusionMedical management may change patient’s understanding of their weight problem and motivate them to lose weight. Practice implicationsSuccessful management relating to improvements in blood pressure and cholesterol may offer renewed hope and motivate obese patients to change their behaviour. This could be used as a teachable moment to encourage patients to see that obesity need not be an inevitable part of their lives.

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss.

Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss. We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED. Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P< .01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P < .01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED. Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Management of non-tubal ectopic pregnancies at a large tertiary hospital

There are limited data on the management of non-tubal ectopic pregnancies (NTEP). We reviewed the management of these cases at a tertiary centre with a dedicated institutional protocol. All cases of confirmed NTEP were retrospectively identified from 2006 to 2014. Records were reviewed for presenting features, mode and success of initial management, preservation of fertility and length of hospital stay. The main outcome measure was the success rate of medical management with methotrexate. The 60 cases identified included 34 cornual, 14 Caesarean section scar, nine cervical and three cervical involving previous Caesarean scar. Primary surgical management was performed in 22 patients. Thirty-eight patients received medical therapy with single or multidose methotrexate. Successful medical management was observed in 33 (87%); however, length of stay was significantly longer compared with surgical patients (mean 14 ± 12 days versus 5 ± 2 days, P < 0.01). Hysterectomy was performed in three patients (one surgical group, two medical group). There was one case of methotrexate toxicity with no long-term adverse outcome. Medical management of NTEP is a safe first-line therapy for clinically stable patients desiring preservation of fertility despite a longer period of inpatient monitoring and follow-up.

Outcomes of modified endoscopic Lothrop in aspirin-exacerbated respiratory disease with nasal polyposis.

Patients with aspirin-exacerbated respiratory disease (AERD) and chronic rhinosinusitis with nasal polyps (CRSwNP) are often reported to be recalcitrant to standard medical and surgical intervention. Failure rates of standard endoscopic sinus surgery in these patients are reported to be as high as 90%. We review the outcomes for our cohort of AERD patients undergoing endoscopic sinus surgery and endoscopic modified Lothrop procedure (EMLP). Data was collected prospectively between January 2001 and December 2013. Information including demographics, asthma status, aspirin sensitivity, 22-item Sino-Nasal Outcome Test (SNOT-22), Lund-Mackay scores, and endoscopic ostium assessment were collected for up to 5 years. Minimum follow-up was 6 months. A total of 31 AERD patients underwent complete sphenoethmoidectomy, maxillary antrostomy and EMLP during the study period with an average follow-up of 36 months. Polyp recurrence was seen in a total of 18 patients (58%). Seven patients required revision EMLP following initial surgery demonstrating a failure rate of 22.5%. AERD patients had a statistically significant increased risk of both nasal polyps recurrence and need for revision surgery. Revision EMLP was needed due to recurrence of nasal polyps in 6 cases and frontal ostium stenosis in a single case. Time to revision EMLP was similar between the groups. Complete sphenoethmoidectomy, maxillary antrostomy, and EMLP is successful in a significant majority of patients with AERD and CRSwNP. It is well tolerated with a low complication rate and facilitates successful ongoing medical management of the condition in patients with AERD.

Retroperitoneal Air after ERCP with Sphincterotomy: Frequency and Clinical Significance &amp;lt;/br&amp;gt;—Retroperitoneal Air after Sphincterotomy

Background and Aim: After successful medical management of a patient with a clinical picture suggestive of post-sphincterotomy duodenal perforation, in which a computerized axial tomography (CAT) scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, concern arose as to the frequency of pneumoretroperitoneum following endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ES) and if any procedure dependent factors were associated with this problem. Aim: To assess the frequency and clinical significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Methods: Fifty consecutive patients, who had undergone ERCP with sphincterotomy, were submitted to abdominal CT examinations within 24 hours after completion of the procedure. One patient was with a large precut, but a failed ERCP was also included. The ERCP findings were unknown to the radiologist. Results: Seven (14%) of 50 patients showed CT findings of retroperitoneal air. All of them had uneventful post-procedural recovery. No clinical or laboratory abnormality was found in this group of patients. The presence of retroperitoneal air was not associated to the variables: precut, biliopancreatic disease type, endoscopic sphincterotomy length, additional endoscopic procedure (balloon exploration, gallstone extraction, stent insertion) or procedure duration. Conclusion: After ERCP with ES, retroperitoneal air is frequently found. In the absence of physical symptoms, retroperitoneal air is not clinically relevant and does not require specific treatment.

Successful treatment of neonatal severe hyperparathyroidism with cinacalcet in two patients.

SummaryNeonatal severe hyperparathyroidism (NSHPT) is a rare disorder caused by inactivating calcium-sensing receptor (CASR) mutations that result in life-threatening hypercalcemia and metabolic bone disease. Until recently, therapy has been surgical parathyroidectomy. Three previous case reports have shown successful medical management of NSHPT with cinacalcet. Here we present the detailed description of two unrelated patients with NSHPT due to heterozygous R185Q CASR mutations. Patient 1 was diagnosed at 11 months of age and had developmental delays, dysphagia, bell-shaped chest, and periosteal bone reactions. Patient 2 was diagnosed at 1 month of age and had failure to thrive, osteopenia, and multiple rib fractures. Cinacalcet was initiated at 13 months of age in patient 1, and at 4 months of age in patient 2. We have successfully normalized their parathyroid hormone and alkaline phosphatase levels. Despite the continuance of mild hypercalcemia (11–12 mg/dl), both patients showed no hypercalcemic symptoms. Importantly, patient 1 had improved neurodevelopment and patient 2 never experienced any developmental delays after starting cinacalcet. Neither experienced fractures after starting cinacalcet. Both have been successfully managed long-term without any significant adverse events. These cases expand the current literature of cinacalcet use in NSHPT to five successful reported cases. We propose that cinacalcet may be considered as an option for treating the severe hypercalcemia and metabolic bone disease found in infants and children with inactivating CASR disorders.Learning points NSHPT due to mutations in the CASR gene occurs with hypercalcemia and metabolic bone disease, but not always with severe critical illness in infancy.NSHPT should be considered in the differential diagnosis for a newborn with a bell-shaped chest, osteopenia, and periosteal reactions.Neurodevelopmental consequences may occur in children with hypercalcemia and may improve during treatment.Calcimimetics can be used to successfully treat the pathophysiology of NSHPT directly to control serum calcium levels.

Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess.

Pediatric peritonsillar abscess (PTA) is a common infection, particularly in the adolescent population. Physical examination alone is not always sufficient to diagnose this pathology, and thus, computed tomography is often utilized as a diagnostic adjunct. With growing concern over radiation exposure in the pediatric population, we conducted a prospective study to investigate the use of ultrasonography in the detection of pediatric PTA. Prospective single arm cohort study. Pediatric patients examined in consultation for concern for PTA were prospectively enrolled in the study. Patients were managed based on clinical symptoms and presentation. Transcervical ultrasonography of the peritonsillar region was performed on all patients. Clinical outcomes were reviewed retrospectively and compared to ultrasound findings. Forty-three patients (age range, 2-20 years) were enrolled in the study. The sensitivity and specificity of transcervical ultrasound when compared to clinical outcomes were 100% and 76.5%, respectively. The positive and negative predictive values were 52.9% and 100%, respectively. Fisher exact test showed a statistically significant association (P < .01) between negative ultrasonography and successful medical management, and multivariate regression analysis showed a strong correlation between ultrasound findings and presence/absence of purulence during surgical intervention (P = .01). Transcervical ultrasonography is a useful tool in diagnosing pediatric PTA. This imaging modality not only avoids undue radiation exposure, but it also proves to be an excellent tool at identifying patients who will not need surgical intervention. To our knowledge, this is the first study to explore this technique for the diagnosis of pediatric PTA. 2b.

Acute systemic embolism due to an idiopathic floating thrombus of the thoracic aorta: success of medical management: a case report

BackgroundIdiopathic thoracic aortic mural thrombi are rare. They can be responsible for dramatic systemic embolization. Early treatment is imperative because of their high morbidity and mortality rate.Case presentationA 55-year-old previously healthy Moroccan male came in an array of acute right lower limbs pain and abdominal sensibility. Severe systemic embolism involving the lower extremities, spleen, kidney, and digestive tract, due to an idiopathic mural thrombus of the thoracic aorta was diagnosed. He received medical treatment leading to the complete disappearance of the thrombus and the effects caused by the latter.ConclusionsWhen faced unexplained peripheral embolization, research for a thrombus of the thoracic aorta should be performed. Medical treatment should be considered for its management, especially in patients with high surgical risk.

(518) - Outcomes After Successful Medical Management of Hemolysis in HeartMateII Patients: A Single Center Experience Over 6 Years

Hemolysis is a precursor to pump thrombosis and dysfunction. Not all patients with pump thrombosis are candidates for surgical ‘bailout’ surgery.We present data on HeartMate 2 patients that were successfully medically managed when having hemolysis. Data was collected on 229 HeartMate 2 implants from 2008-2014. We had 52 discrete hemolysis events in 41 unique patients. Hemolysis was defined by LDH >450 u/l and PFH >15mg/dl. Patients were routinely treated with heparin or bivalirudin and aggressive oral and intravenous antiplatelet therapy. Pump dysfunction causing heart failure, LVAD alarms, LV dilation, or nondecompression of LV with ramp study was thought to be pump thrombosis. Non surgical candidates continued with aggressive medical therapy. The hemolysis rate was 0.14 event/patient year supported. The thrombosis rate was 0.08 event/pt. year supported. Hemolysis/Thrombosis event rate ratio was 1.75. There were 41 patients with hemolytic events, with 9 patients having recurrent hemolysis. Median time to hemolysis post implant was 170 days. There were 18 episodes within 90 days and 21 episodes after 365 days post implant. Average LDH was 1599 and average PFH was 106.When computed for death or transplant: there was 1 event every 2.75 pt. support years in the patients without hemolysis v/s 1 event every 2.91 pt.support years (p=ns). Average post hemolysis survival was 0.98 years. Average survival post hemolysis in successfully medically managed patients was 2.14 years compared to patients who were surgically managed. Hemolysis is an ominous event in patients with durable LVADS. Not all hemolysis results in pump replacement, death or transplant. >40% of patients can successfully be treated medically when they develop hemolysis. Approximately 20% of patients develop recurrent hemolysis, but only 20% of those require surgical therapy. Further analysis may help in identifying and risk stratifying low and high risk LVAD patients with hemolysis.

(320) - Contributing Factors to the Successful Medical Management of Suspected Left Ventricular Assist Device Thrombosis

(320) - Contributing Factors to the Successful Medical Management of Suspected Left Ventricular Assist Device Thrombosis