Non-surgical management in children with non-refluxing primary megaureter: a systematic review and meta-analysis.

BACKGROUND: Children with non-refluxing primary megaureter are mostly managed by a watchful approach with close follow-up and serial imaging. OBJECTIVES: This systematic review and meta-analysis aimed to determine whether there is sufficient evidence to support the current non-surgical management strategy in these patients. DATA SOURCES: A comprehensive search including electronic literature databases, clinical trial registries, and conference proceedings was performed. DATA SYNTHESIS METHODS: Outcomes were estimated as pooled prevalence. If meta-analytical calculations were not appropriate, outcomes were provided in a descriptive manner. RESULTS: Data from 8 studies (290 patients/354 renal units) were included. For the primary outcome, differential renal function estimated by functional imaging, meta-analysis was impossible due to reported data not being precise. Pooled prevalence for secondary surgery was 13% (95% confidence interval: 8-19%) and for resolution 61% (95% confidence interval: 42-78%). The risk of bias was moderate or high in most studies. LIMITATIONS: This analysis was limited by the low number of eligible studies with few participants and high clinical heterogeneity, and the poor quality of the available data. CONCLUSIONS: The low pooled prevalence of secondary surgical intervention and high pooled prevalence of resolution may support the current non-surgical management in children with non-refluxing primary megaureter. However, these results should be interpreted cautiously due to the limited available body of evidence. Future studies should overcome existing limitations of imaging methods by using standardized, comparable criteria and report outcome parameters in a quantitative manner. This would allow more sufficient data synthesis to provide evidence-based recommendations for clinical decision-making and counseling. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered on PROSPERO under CRD42019134502.

Novel endoscopic management of gastroenterological anastomosis leakage by injecting gel-forming solutions: an experimental animal study.

BACKGROUND: Anastomotic leakage (AL) after gastrointestinal surgery remains a challenging complication that requires surgical or non-surgical treatment. Although various therapeutic endoscopic techniques are available, no definitive interventions exist. We developed a therapeutic endoscopic submucosal injection method using novel gel-forming mixed solutions to close AL and evaluated the elasticity of the developed hydrogel. The safety and efficacy of the injection method were explored in porcine AL models. METHODS: We developed a novel gel-forming solution, and the formed gel lasted approximately one week within the gastrointestinal wall. An indentation test evaluated the elasticity of the novel hydrogel. After the confirmation of AL on porcine anterior gastric walls, sodium alginate was endoscopically injected into the submucosal layer around the leakage site circularly, followed by a calcium lactate/chitosan-based solution. After that, the outcomes data were collected, and histopathological effectiveness was evaluated. RESULTS: The increased sodium alginate elasticity with the addition of calcium lactate/chitosan-based solution facilitated long-lasting gel formation. Four pigs with AL underwent this intervention consecutively. Each endoscopic injection was completed in less than 5 min. No significant complications were observed for 3 weeks after the intervention. All AL sites were macroscopically healed. Histopathologic findings at 3 weeks showed that the wall defect was filled with collagen fibers that had grown around the site of the muscle layer tear. No tissue necrosis was observed. CONCLUSION: This preclinical study demonstrated that the therapeutic injection method for gastroenterological AL using gel-forming solutions could be an alternative endoscopic treatment, especially in patients with severe conditions or comorbidities. The optimal target of this treatment is small size and early AL without poor blood flow or intense hypertrophic scar lesions.

The feasibility, facilitators, and barriers in the initial implementation phase of 'good life with osteoarthritis in Denmark' (GLA:D®) in Switzerland: a cross-sectional survey.

BACKGROUND: The guideline-based, conservative, non-pharmacological management of hip and knee osteoarthritis in clinical practice has been insufficient in Switzerland until now. The implementation of "Good Life with Osteoarthritis in Denmark" (GLA:D®), a programme designed to address this evidence-performance gap, was started in 2019 in Switzerland. This study investigated the acceptance and practicality of the GLA:D® Switzerland programme and identified the facilitators and barriers to its implementation, to support the development of tailored implementation strategies. METHODS: This is a non-experimental observational study. A cross-sectional survey was performed among the physiotherapists (PTs) of the first five GLA:D® Switzerland certification courses, using the Measurement Instrument for Determinants of Innovations (MIDI) to identify the facilitators and barriers. Descriptive statistics were calculated, and qualitative content analysis was used for open-ended questions. RESULTS: In the online survey, 86 GLA:D® certified PTs participated (response rate: 61%). The majority of 51 PTs (63.7%) worked in private practices. Of the responding PTs 58 (78.4%) were satisfied with the general concept of the GLA:D® Switzerland programme. Practicality was evaluated positively, particularly the second and third individual session (n = 40 PTs, 83.3%), the 40 m Fast-paced Walk Test (43, 89.6%), the 30 s Chair Stand Test (45, 93.8%), and the exercise programme (40, 83.3%). The marketing (12, 15%), the 'data entry' (5, 10.4%), 'register the patient' (7, 14.6%), and the digital patient questionnaire (9, 14.2%) were rated less positively. In total, 12 facilitators and 12 barriers were identified. The barriers were mainly related to adopting user, e.g., perceived personal disadvantages. Barriers were also found in the organisational context, e.g., time available. Facilitators were associated with the GLA:D® Switzerland programme itself, e.g., completeness, relevance for patients, and the adopting user, e.g., self-efficacy, and in the organisational context, e.g., material resources and facilities. Topics related to the socio-political context were raised in the answers to the open-ended questions, e.g., general awareness level of the GLA:D® Switzerland programme and patient recruitment. CONCLUSION: The acceptance, practicality and facilitators identified from the initial implementation are encouraging. However, the identified barriers and activities rated with low practicality require tailored strategies to support a successful implementation of the GLA:D® Switzerland programme.

Italian Orthopaedic and Traumatology Society (SIOT) position statement on the non-surgical management of knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical management of this disease. While recognising the gap between scientific evidence and clinical practice, this position statement aims to present recommendations for the non-surgical management of knee OA, considering the available evidence and the clinical knowledge of experienced surgeons. The overall goal is to offer an evidenced-based expert opinion, aiding clinicians in the management of knee OA while considering the condition, values, needs and preferences of individual patients. METHODS: The study design for this position statement involved a preliminary search of PubMed, Google Scholar, Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023, followed by screening of relevant articles (systematic reviews and meta-analyses). A Società Italiana Ortopedia e Traumatologia (SIOT) multidisciplinary task force (composed of four orthopaedic surgeons and a rheumatologist) subsequently formulated the recommendations. RESULTS: Evidence-based recommendations for the non-surgical management of knee OA were developed, covering assessment, general approach, patient information and education, lifestyle changes and physical therapy, walking aids, balneotherapy, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, pharmacological interventions and injections. CONCLUSIONS: For non-surgical management of knee OA, the recommended first step is to bring about lifestyle changes, particularly management of body weight combined with physical exercise and/or hydrotherapy. For acute symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), topic or oral, can be used. Opioids can only be used as third-line pharmacological treatment. Glucosamine and chondroitin are also suggested as chronic pharmacological treatment. Regarding intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA [platelet-rich plasma (PRP) as second line), in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.

Novel, disposable, self-inserted, vaginal device for the non-surgical management of pelvic organ prolapse: efficacy, safety, and quality of life.

BACKGROUND: We evaluated a novel disposable, collapsible, ring-shaped vaginal device that is self-inserted within an applicator and removed with a string. The device was developed to overcome the drawbacks of existing ring pessaries for non-surgical pelvic organ prolapse management (POP). METHODS: The primary objective efficacy endpoint of this prospective, interventional, multicenter, self-controlled, and home-use study was the proportion of subjects with improved staging on the Pelvic Organ Prolapse Quantification (POP-Q) scale. Subjective efficacy was assessed using the POP symptoms alleviation score. Safety was evaluated by recording the rate and incidence of adverse events (AEs) in a daily diary, and quality of life (QoL) was evaluated using the modified Pelvic Floor Impact (PFIQ-7) and Pelvic Floor Disability Index (PFDI-20) questionnaires. RESULTS: A total of 94 usage cycles were observed in a group of 52 participants (mean age 60.2 ± 10.5 years, 81.1% postmenopausal) who used the device for 3558 days. Of these, 24 participants completed one usage cycle, 14 completed two usage cycles, and 14 completed three usage cycles with 28-45 days of ProVate use in each usage cycle. All patients experienced greater than two POP-Q stage reductions. The descent was completely reduced to POP-Q stage 0 in 97.8% of participants. The POP symptom alleviation questionnaire showed significant subjective efficacy (P < 0.0001). The modified PFDI-20 and PFIQ-7 scores also improved substantially (P < 0.0001 for both). There were 91 nonserious device-related AEs: 98.9% were mild and 87.9% anticipated, with no vaginal infection, and one case of urinary tract infection. CONCLUSION: The novel device substantially reduces prolapse and provides significant subjective POP symptom relief and QoL improvement, with minimal AEs. The device may enable women to self-manage their prolapse with a small, disposable device that minimizes self-touching and frequent dependency on the clinic. TRIAL REGISTRATION: Clinical. TRIALS: gov , NCT02239133 , posted September 12, 2014 (retrospectively registered).

[Diagnosis and treatment of kidney damage following stab and blunt abdominal injuries]. / Diagnostika i lechenie povrezhdenii pochek pri zakrytykh travmakh i koloto-rezanykh raneniyakh zhivota.

OBJECTIVE: To improve treatment outcomes in victims with kidney damage following blunt and stab abdominal trauma by using of minimally invasive methods of diagnosis and treatment. MATERIAL AND METHODS: About 1.2-3.5% of all victims arrived to the Dzhanelidze St. Petersburg Research Institute for Emergency Care have kidney injuries. We analyzed the results of treatment of 117 patients with isolated and combined blunt and stab abdominal injuries. The retrospective (2014-2017) group included 62 victims, and the prospective (2018-2021) group enrolled 55 patients who were treated according to the new algorithm. This algorithm included non-surgical and minimally invasive management for patients with systolic blood pressure >90 mm Hg after contrast-enhanced CT. Angiography with selective embolization was required for ongoing bleeding. We analyzed incidence of open interventions, organ-sparing procedures, complications, duration of treatment and mortality. Between-group differences were assessed using the χ2 test and Student's test. RESULTS: In both groups, kidney damage in most victims with abdominal trauma was due to road accident and catatrauma. Most patients had combined abdominal injuries, mainly in combination with head and chest lesions. Severity of injuries and clinical condition were similar in both groups. In the retrospective group, there were 9 laparotomies with nephrectomy. Nephrorraphy was performed in 8 cases, kidney vessel suture - in 4 patietns. In the prospective group, nephrectomy was performed in 3 patients with unstable hemodynamics and injuries AAST grade V. Nephrorraphy was performed in 4 victims. In one case, vascular suture was applied for tangential vein damage. All laparoscopies in both groups were diagnostic without nephrectomy. We used non-surgical treatment in 34 patients of the prospective group. One patient underwent angiography and selective embolization of renal artery branches. There were no significant between-group differences in the incidence of infectious and non-infectious complications. Mortality rate was 30.6% (n=19) and 27.3% (n=15) in the retrospective and prospective groups, respectively. CONCLUSION: The proposed algorithm for kidney injury made it possible to reduce the incidence of laparoscopies and laparotomies by 2 times, preserve the damaged kidney in 94.5% of cases and avoid invasive treatment in 62% of victims.

The influence of alternate part-time patching on control of intermittent exotropia: a randomized clinical trial.

PURPOSE: To evaluate the effect of alternate part-time patching on deviation control in patients with intermittent exotropia in comparison to observation. METHODS: In a randomized clinical trial, untreated 3-8-year-old children with intermittent exotropia were randomly divided into patching group who treated with alternate part-time patching and observation group. Deviation control was assessed with 3-point and 6-point scales. Stereoacuity and suppression were evaluated with Titmus and Worth-4-dot tests respectively. All exams were repeated 3 and 6 months after beginning of treatment. RESULTS: Seventy-six patients (35 in patching and 41 in observation group) with a mean age of 4.99 ± 1.33 years completed the 6-month course of study. Based on 3-point scale, deviation control was significantly better in patching group after 3 and 6 months at near and after 3 months at far (p = 0.011, 0.011, and 0.03, respectively) but non-significant after 6 months at far (p = 0.16). According to 6-point scale, deviation control was also significantly better in patching group after 3 months (p = 0.03 at far, 0.003 at near) and 6 months (p = 0.03 at far, 0.003 at near). Three and 6 months stereoacuity was not significantly different between groups (p = 0.86 for both). However, there was greater stereoacuity changes among patching group in comparison with observation group from baseline to 3 and 6 months (p = 0.006 for both). CONCLUSION: Patching seems effective in improving deviation control of 3-8-year-old children with intermittent exotropia in comparison with observation based on two common office control scales. TRIAL REGISTRATION NUMBER AND DATE: NCT03700632 (10/9/2018).

[Spontaneous course of traumatic tympanic membrane perforations]. / Spontaner Heilungsverlauf traumatischer Trommelfellperforationen.

BACKGROUND: Traumatic eardrum perforation is a common presentation in otorhinolaryngologic practices and emergency clinics. A consistent management strategy (active intervention vs. watchful waiting) is, however, still lacking. OBJECTIVE: In the following study, the outcome of watchful waiting is analyzed and presented. MATERIALS AND METHODS: A collective of 272 patients presenting at two different specialist ENT practices within days of traumatic tympanic membrane perforation from June 2002 to March 2019 were analyzed. Treatment was non-surgical, with prospective monitoring. Whereas antibiotics were not given at all in one practice, they were given only upon signs of infection in the other practice. The outcome was evaluated retrospectively on the basis of patient files. RESULTS: The collective consisted of 185 males and 87 females. Mean age was 30 years (range: 7 months to 82 years). The perforations were most commonly located in the upper anterior and lower posterior quadrants. According to Griffin grading, the size was grade I in 97%. The three most common causes were impact to the ear, barotrauma, and foreign bodies. Under a watchful waiting regimen, 95% of the patients presenting for follow-up checks showed complete closure. CONCLUSION: Watchful waiting can be assessed as appropriate in traumatic eardrum perforation, provided otorhinolaryngologic follow-up is ensured. An exception is blast injury, which is now much less common in Central Europe, as this is associated with a risk of secondary cholesteatomas. In these rare cases, active treatment with surgical exploration of the middle ear including relining the perforation is indicated.

Spontaneous spinal epidural haematoma: management and main risk factors in era of anticoagulant / antiplatelet treatment.

AIM OF THE STUDY: Spontaneous spinal epidural haematomas (SSEH) are rare nosological units wherein acute collections of blood develop in the spinal canal. SSEH are usually manifested by sudden severe back pain accompanied by the development of neurological symptoms. In this study, we retrospectively describe management and the main risk factors of SSEH in a series of 14 cases. MATERIAL AND METHODS: Between 2010 and 2019, we examined 14 patients (age range 17-89 years, 10 women) diagnosed with SSEH. Eight cases were patients using anticoagulant therapies (six warfarin, one dabigatran, one apixaban) and two others were using ASA of 100 mg/day. The exact localisation and extent of changes was determined from acute magnetic resonance imaging. Three people using warfarin had INR values higher than 3.0 at the time of their diagnosis. RESULTS: Ten patients (71%) were taking oral anticoagulants or antiplatelet agents. In seven patients, SSEH were localised in the lower cervical/thoracic spine. Ten patients (71%) had arterial hypertension. Six patients underwent acute surgery due to rapidly developing spinal cord compression. Eight patients (57%) with slight or mild neurological symptoms were successfully managed without surgery. CONCLUSIONS: SSEH should be suspected in any patient receiving anticoagulant/antiplatelet agents who complains of sudden, severe back pain accompanied by neurological symptoms. SSEH is mostly localised in the lower cervical/thoracic spine. Arterial hypertension appears to be a risk factor of SSEH. Early decompression is an important therapeutic approach; in cases with minor neurological deficits, conservative treatment may be chosen.

Phase II multicenter randomized controlled clinical trial on the efficacy of intra-articular injection of autologous bone marrow mesenchymal stem cells with platelet rich plasma for the treatment of knee osteoarthritis.

BACKGROUND: Mesenchymal stromal cells are a safe and promising option to treat knee osteoarthritis as previously demonstrated in different clinical trials. However, their efficacy, optimal dose and addition of adjuvants must be determined. Here, we evaluated the clinical effects of a dose of 100 × 106 bone marrow mesenchymal stromal cells (BM-MSCs) in combination with Platelet Rich Plasma (PRGF®) as adjuvant in a randomized clinical trial. METHODS: A phase II, multicenter, randomized clinical trial with active control was conducted. Sixty patients diagnosed with knee OA were randomly assigned to 3 weekly doses of PRGF® or intraarticular administration of 100 × 106 cultured autologous BM-MSCs plus PRGF®. Patients were followed up for 12 months, and pain and function were assessed using VAS and WOMAC and by measuring the knee range of motion range. X-ray and magnetic resonance imaging analyses were performed to analyze joint damage. RESULTS: No adverse effects were reported after BM-MSC administration or during follow-up. According to VAS, the mean value (SD) for PRGF® and BM-MSC with PRGF® went from 5 (1.8) to 4.5 (2.2) (p = 0.389) and from 5.3 (1.9) to 3.5 (2.5) (p = 0.01), respectively at 12 months. In WOMAC, the mean (SD) baseline and 12-month overall WOMAC scores in patients treated with PRGF® was 31.9 (16.2) and 22.3 (15.8) respectively (p = 0.002) while that for patients treated with BM-MSC plus PRGF® was 33.4 (18.7) and 23.0 (16.6) (p = 0.053). Although statistical significances between groups have been not detected, only patients being treated with BM-MSC plus PRGF® could be considered as a OA treatment responders following OARSI criteria. X-ray and MRI (WORMS protocol) revealed no changes in knee joint space width or joint damage. CONCLUSIONS: Treatment with BM-MSC associated with PRGF® was shown to be a viable therapeutic option for osteoarthritis of the knee, with clinical improvement at the end of follow-up. Further phase III clinical trials would be necessary to confirm the efficacy. Trial registration Clinical Trials.gov identifier NCT02365142. Nº EudraCT: 2011-006036-23.

Radiation and hormonal therapy for primary treatment of stage I endometrial cancer and long-term survival.

OBJECTIVES: Estimate the association between non-surgical management (NSM) (e.g. hormonal or radiation therapy) and overall survival among women with stage I endometrioid endometrial cancer (EEC) and identify patient and facility characteristics associated with receipt of NSM. METHODS: Women >45 years of age with clinical stage I EEC were identified in the National Cancer Database from 2004 to 2016. Women treated with NSM were compared with women treated initially with hysterectomy. Patient and facility characteristics associated with NSM were evaluated using logistic regression models. Association with overall survival was examined using log-rank tests, Kaplan-Meier curves, and Cox proportional hazards regression models with and without propensity score matching (PSM). RESULTS: A total of 112,469 women underwent treatment for stage I EEC between 2004 and 2016. 2776 (3%) received NSM, of whom 1987 (71%) received radiation therapy, 688 (25%) received hormonal therapy, and 101 (4%) received both. Older age, black race, higher Charlson-Deyo scores, Medicaid insurance, and low annual facility hysterectomy volume were associated with receiving NSM. The 5-year survival rate was 40% (95%CI: 37%-42%) for women with NSM compared to 89% (95%CI: 88%-89%) for hysterectomy. Women treated with NSM died at a faster rate than those who underwent primary hysterectomy (HR 7.6, 95%CI: 7.2-8.0; p < 0.001). This statistically significant difference in survival persisted in adjusted Cox proportional hazards models and after PSM. CONCLUSIONS: Women treated with NSM had a significantly higher risk of death compared to those undergoing hysterectomy for stage I EEC. Caution should be used when selecting patients for NSM given its worse outcomes.

Alternative strategies for the management of ovarian hyperstimulation syndrome, the role of intra-abdominal hypertension control.

The aim of this study is to analyze the methods for reducing intra-abdominal pressure (IAP) in the management of the moderate and severe forms of ovarian hyperstimulation syndrome (OHSS). We carried out a systematic review of the literature. An evaluation of clinical trials, meta-analysis, case-reports, and reviews assessing the management of conditions associated with OHSS and intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2019) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2019). The principles of treatment of IAH syndrome can be considered in the treatment of moderate and severe forms of OHSS. Medical treatment of patients with increased IAP in OHSS should be started early to prevent further organ dysfunction and avoid a transition to a more severe stage of IAH and ACS. Some of the new, non-surgical methods, such as continuous negative extra-abdominal pressure, are a promising option in specific groups of patients with OHSS. This review provides suggestions for the management of OHSS based on the principles of therapy for IAH syndrome. Further well-designed studies are needed to confirm these initial data.

A multisite longitudinal evaluation of patient characteristics associated with a poor response to non-surgical multidisciplinary management of low back pain in an advanced practice physiotherapist-led tertiary service.

BACKGROUND: Non-surgical multidisciplinary management is often the first pathway of care for patients with chronic low back pain (LBP). This study explores if patient characteristics recorded at the initial service examination have an association with a poor response to this pathway of care in an advanced practice physiotherapist-led tertiary service. METHODS: Two hundred and forty nine patients undergoing non-surgical multidisciplinary management for their LBP across 8 tertiary public hospitals in Queensland, Australia participated in this prospective longitudinal study. Generalised linear models (logistic family) examined the relationship between patient characteristics and a poor response at 6 months follow-up using a Global Rating of Change measure. RESULTS: Overall 79 of the 178 (44%) patients completing the Global Rating of Change measure (28.5% loss to follow-up) reported a poor outcome. Patient characteristics retained in the final model associated with a poor response included lower Formal Education Level (ie did not complete school) (Odds Ratio (OR (95% confidence interval)) (2.67 (1.17-6.09), p = 0.02) and higher self-reported back disability (measured with the Oswestry Disability Index) (OR 1.33 (1.01-1.77) per 10/100 point score increase, p = 0.046). CONCLUSIONS: A low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management of LBP in tertiary care. Patients with these characteristics may need greater assistance with regard to their comprehension of health information, and judicious monitoring of their response to facilitate timely alternative care if no benefits are attained.

Comparative clinical and cost analysis between surgical and non-surgical intervention for knee osteoarthritis.

OBJECTIVE: To evaluate the management and costs of osteoarthritis of the knee (OAK), a progressive joint disease due to bone and cartilage degeneration, with significant personal and societal impact. METHODS: We prospectively analyzed the clinical outcomes and quantifiable cumulative direct costs of patients with OAK referred to our multidisciplinary OA program over a two year time period. One hundred thirty-one subjects were assessed. All demonstrated radiographic criteria for moderate to severe OAK. Western Ontario McMaster Osteoarthritis Index (WOMAC), Minimal Clinically Important Improvement (MCII), and change in BMI were recorded and analyzed. Total medical and surgical direct costs for all subjects during the two year time period were determined. RESULTS: Five patients underwent total joint replacement during the two years of study. Among the group as a whole, a significant overall improvement in WOMAC scores was noted at the two year time point follow-up. After dividing the group into tertiles by baseline WOMAC scores, 46% achieved MCII. Significant weight loss was noted for individuals with baseline BMI of > 30. As all patients were considered "de facto" surgical candidates at referral, an average net savings of $9551.10 of direct costs per patient, or a potential total of $1,203,438.60 for the entire group, could be inferred as a result of medical as opposed to surgical management. CONCLUSION: These findings support the benefits of multidisciplinary medical management for patients with significant OAK. This approach is clinically beneficial and may provide significant cost savings. Such models of care can substantially improve the long-term outcome of this highly prevalent condition and reduce societal and financial burdens.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.

OBJECTIVE: To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. METHODS: We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. RESULTS: Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. CONCLUSION: These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

"I was considering surgery because I believed that was how it was treated": a qualitative study on willingness for joint surgery after completion of a digital management program for osteoarthritis.

OBJECTIVE: To explore, using a qualitative approach, reasons for patients' continued willingness or their shift in willingness for total joint replacement (TJR) surgery, following participation in Joint Academy, a Swedish, digital, non-surgical treatment program for osteoarthritis (OA). DESIGN: Nineteen patients with hip or knee OA were interviewed after finishing their first 6 weeks in the treatment program, using a semi-structured interview guide. The interviews were transcribed verbatim and analyzed using a systematic text condensation method. RESULTS: Analysis of the interview data revealed three main categories of reasons provided for the participants' decisions regarding surgery: 1) Various reasons for participating in Joint Academy with three sub-categories: (a) longstanding pain affects daily life, (b) last chance for improvement and (c) mandatory treatment to be eligible for total joint replacements (TJR); 2) Willingness for TJR following treatment, which included four sub-categories: (a) surgery - the last resort, (b) reduced pain and improved functioning, (c) no perceived improvements after treatment, and (d) trust in healthcare providers; and 3) Expectations of TJR. The shift in willingness towards or away from TJR was mainly due to the perceived success of Joint Academy in improving their functioning. CONCLUSION: Several patients reconsidered their options and had changed their attitude to TJR after participation in a digital program aimed at reducing OA symptoms and improving functioning. These results highlight the importance of providing patients with adequate information about non-surgical management options to facilitate shared decision-making, and possibly reduce the need for surgery.

A non-surgical alternative to the management of myopathic ptosis.

Oculopharyngeal Muscular Dystrophy (OPMD) is a systemic progressive autosomal dominant myopathy which results in ptosis due to levator weakness. Surgical correction can be complicated by corneal exposure and a non-surgical alternative, such as ptosis props, can be uncomfortable in patients with preserved orbicularis function. We describe a case of a 57-year-old gentleman with OPMD, who declined surgical intervention, and self-manages his ptosis with cosmetic glue.

Cross-cultural adaptation and implementation of Good Life with osteoarthritis in Denmark (GLA:D™): group education and exercise for hip and knee osteoarthritis is feasible in Canada.

OBJECTIVE: Adapt and evaluate the feasibility of implementing Good Life with osteoArthritis in Denmark (GLA:DTM) in Canada for people with mild to severe hip/knee osteoarthritis. METHODS: Patients triaged to non-surgical management participated in two education sessions and 12 supervised, neuromuscular exercise classes. We used the RE-AIM implementation framework evaluating outcomes of Reach, Effectiveness/Efficacy, Adoption, Implementation and Maintenance. Patients completed surveys pre-program and at 3 months follow-up. Program fidelity was evaluated at four observations against a priori criteria. We conducted semi-structured interviews with therapists post-program. RESULTS: 72 patients consented to participate, 59 started the program and one withdrew on physician advice. The remaining 58 provided follow-up data. Mean age was 67 years; 78% were female and 52% had body mass index (BMI) >25. The effect of the program was demonstrated: 40% improvement in pain with 59% achieving a clinically important improvement of ≥2 points on the Numeric Pain Rating scale. Statistically significant improvement also occurred in the Hip disability/Knee injury and Osteoarthritis Outcome Score subscales. 24% reported increased physical activity. Program fidelity was demonstrated with all criteria met. Therapists emphasized that rolling recruitment allowed appropriate supervision and resulted in participants encouraging each other. 99% of participants indicated they benefitted from and were satisfied with the program and 90% reported using the knowledge daily. 52% were willing to pay >$250 Cdn for the program. CONCLUSION: GLA:DTM implementation was feasible in the Canadian context with results similar to those of >7,000 participants in Denmark. Implementation and evaluation of GLA:DTM Canada is now occurring nationally.

Patterns of medical management of overactive bladder (OAB) and benign prostatic hyperplasia (BPH) in the United States.

AIMS: Overactive bladder (OAB) and benign prostatic hyperplasia (BPH) are highly prevalent conditions that place a large burden on the United States (US) health care system. We sought to analyze patterns of prescription medication usage for incident OAB in men and women, and for incident BPH in men using US health insurance claims data. MATERIALS AND METHODS: This study used Truven Health MarketScan® Commercial and Medicare Supplemental Research databases. The data were pooled from diverse points of care. BPH subjects included men age 18+ with the first and last two diagnoses of BPH ≥30 days apart and no BPH diagnosis for 1 year prior. OAB subjects included men and women age 18+, who were diagnosed similarly with incident OAB. The type of medication, medication continuation (persistence), and switching to a different medication were analyzed through September 30, 2013. RESULTS: Medication persistence was much higher overall for BPH than OAB (56% vs 34%, respectively, P < 0.0001), and was highest among men with BPH age 65+ (62%). Patients age 18-64 were less likely to continue medication than older adults (age 65+) for both BPH and OAB. A 9.4% of patients in the OAB cohort and 6.9% of men with BPH switched from one medication to another. CONCLUSIONS: Persistence was higher with BPH than OAB medications overall, whereas switching rates were higher in the OAB group. The lower persistence of OAB medication may be due to less efficacy or tolerability. The possibility of under treatment of OAB also warrants future investigations.

General health factors may be a barrier to effective non-surgical multidisciplinary rehabilitation of common orthopaedic conditions in tertiary care settings.

BACKGROUND: To explore patient characteristics predictive of a poor response to multidisciplinary non-surgical rehabilitation of three common orthopaedic conditions within a tertiary care service. METHODS: A retrospective audit of medical records of patients who had undergone multidisciplinary non-surgical management of their knee osteoarthritis (KOA, n = 190), shoulder impingement syndrome (SIS, n = 199), or low back pain (LBP, n = 242) within a multisite tertiary care service was undertaken. Standardised clinical measures recorded by the service at the initial consultation were examined using a base binary logistic regression model to determine their relationship with a poor response to management (ie. not achieving a minimal clinically important improvement in the condition disability measure pre-post management). RESULTS: Factors predictive of a poor response following non-surgical management included;; higher levels of anxiety (OR 1.11, P < 0.02) and lower functional score (OR 0.76, P < 0.04) for KOA, higher number of comorbidities (OR 1.16, P < 0.03) for SIS, and coexisting cervical or thorax pain (OR 2.1, P = 0.04) and lower pain self-efficacy (OR 0.98, P = 0.02) for LBP. CONCLUSIONS: General health issues may present a barrier to achieving favourable outcomes in response to multidisciplinary non-surgical rehabilitation for the management of common orthopaedic conditions in a tertiary care setting. Clinicians may need to consider these broader patient issues when designing management strategies for patients with these conditions.