Efficacy of Nonoperative Treatments for Lateral Epicondylitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Lateral epicondylitis is a common overuse injury affecting approximately 1 to 3 percent of the population. Although symptoms may disappear spontaneously within 1 year, the clinical guidelines for conservative treatment are not clear. The authors' objective was to examine the outcomes of nonsurgical treatments for lateral epicondylitis through a meta-analysis and provide a treatment recommendation using the available evidence. METHODS: The authors searched the PubMed, EMBASE, Scopus, and Web of Science databases to identify primary research articles studying conservative treatments (electrophysiotherapy, physical therapy, and injections) for lateral epicondylitis. The authors included randomized controlled trials published in peer-reviewed journals. Data related to outcomes (pain, grip strength, Patient-Rated Tennis Elbow Evaluation score, and Disabilities of the Arm, Shoulder and Hand score) and complications were extracted. RESULTS: Fifty-eight randomized controlled trials were included in the meta-analysis. Electrophysiotherapy was effective in improving pain [mean difference, -10.0 (95 percent CI, -13.8 to -6.1)], Patient-Rated Tennis Elbow Evaluation score [mean difference, -10.7 (95 percent CI, -16.3 to -5.0)], and Disabilities of the Arm, Shoulder and Hand score [mean difference, -11.9 (95 percent CI, -15.8 to -7.9)]; and physical therapy improved pain [mean difference, -6.0 (95 percent CI, -9.7 to -2.3)] and Patient-Rated Tennis Elbow Evaluation scores [mean difference, -7.5 (95 percent CI, -11.8 to -3.2)] compared to placebo. Injections did not improve any outcome measures. Patients who received electrophysiotherapy and injections reported higher adverse effects than physical therapy patients. CONCLUSIONS: Patients who received electrophysiotherapy and physical therapy reported statistically and clinically improved scores in pain and function compared to placebo. Injections may put patients at higher risk for adverse effects compared to other conservative treatments. When managing lateral epicondylitis conservatively, electrophysiotherapy and physical therapy should be prioritized before other interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Quality of Life and Traditional Outcome Results at 1 Year in Elderly Patients Having Critical Limb Ischemia and the Role of Conservative Treatment.

INTRODUCTION: Revascularization is the cornerstone of the treatment of critical limb ischemia (CLI), but the number of elderly frail patients increase. Revascularization is not always possible in these patients and conservative therapy seems to be an option. The goals of this study are to analyze the 1-year quality of life (QoL) results and mortality rates of elderly patients with CLI and to investigate if conservative treatment could be an acceptable treatment option. METHODS: Patients with CLI ≥70 years old were included in a prospective observational cohort study in 2 hospitals in the Netherlands between 2012 and 2016 and were divided over 3 treatment modalities: endovascular therapy, surgical revascularization, and conservative treatment. The World Health Organization Quality of Life (WHOQoL-Bref) instrument, a generic QoL assessment tool that includes components of physical, psychological, social relationships and environment, was used to evaluate QoL at baseline, 6 months, and 1 year. RESULTS: In total, 195 patients (56% male, 33% Rutherford 4, mean age of 80) were included. Physical QoL significantly increased after surgical (10.4 vs 14.9, P < .001), endovascular (10.9 vs 13.7, P < .001), and conservative therapy (11.6 vs 13.2, P = .01) at 1 year. One-year mortality was relatively low after surgery (10%) compared to endovascular (40%) and conservative therapy (37%). CONCLUSION: The results of this study could not be used to designate the superior treatment used in elderly patients with CLI. Conservative treatment could be an acceptable treatment option in selected patients with CLI unfit for revascularization. Treatment of choice in elderly patients with CLI is based on multiple factors and should be individualized in a shared decision-making process.

Cost-effectiveness of the treatments for critical limb ischemia in the elderly population.

OBJECTIVE: The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery. METHODS: In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs). RESULTS: At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY). CONCLUSIONS: Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision.

Early Autologous Blood-Patch Pleurodesis versus Conservative Management for Treatment of Secondary Spontaneous Pneumothorax.

BACKGROUND: Autologous blood-patch pleurodesis has been effectively utilized as a treatment option for the condition of secondary spontaneous pneumothorax (SSP). Moreover, it can be used with persistent air leak, with or without residual air space. However, there have been no robust reports for the optimal timing for autologous blood-patch pleurodesis. The aim of this study is to compare early autologous blood-patch pleurodesis with conservative management of SSP. METHODS: We conducted a randomized controlled study at the Menoufia University Hospital. A total of 47 patients with SSP were randomly allocated into two groups: group A (23 patients) received intrapleural instillation of 50 mL autologous blood 3 days after insertion of chest drain and group B (24 patients) managed conservatively. The duration required for air leak to seal, chest drainage duration, length of hospital stay, and the incidence of complications were compared and statistically analyzed. RESULTS: The duration of air leak, duration to drain removal, and length of hospital stay were all significantly shorter in group A than in group B. CONCLUSION: Early intrapleural instillation of autologous blood is successful in sealing air leak in patients with SSP with persistent air leak, who are not fit or not willing to undergo surgery. It is superior to conservative treatment or late instillation of autologous blood, even if their lungs are not fully expanded.

[Sigmoid volvulus at the University Hospital of Iceland 2000-2013].

Backround Sigmoid volvulus is an uncommon cause of bowel obstruction in most western societies. Treatment options include colonoscopy in uncomplicated disease with elective surgery later on. The aim of this study was to assess what treatment sigmoid volvulus patients receive along with long-term outcomes at Landspitali University Hospital. Methods The study was retrospective. Patients diagnosed with sigmoid volvulus at Landspitali University Hospital from 2000-2013 were included. Information regarding age, sex, and duration of hospital stay, treatment, short and long-term outcomes were gathered. Results Forty-nine patients were included in the study, of which 29 men and 20 women. Mean age was 74 (25-93). One patient underwent acute surgery on first arrival due to signs of peritonitis. Others (n=48) were treated conservatively in the first attempt with colonoscopy (n=45), barium enema (n=2) and rectal tube (n=1). Three other patients underwent acute surgery due to failed colonoscopy, 8 patients had planned surgery during the index admission. Thirty-six patients were discharged after conservative treatment with colonoscopy (n=35), barium enema (n=1) or rectal tube (n=1). Two patients came in for elec-tive surgery later on. Twenty-two patients (61%) had recurrence. Median time to recurrence was 101 days (1-803). Disease-free probability in 3, 6 and 24 months was 66%, 55% and 22% respec-tively. Total disease related mortality was 10.2%. Mortality (30 days) after acute surgery was 25% (1/4) and 16,6% (3/18) after planned surgery. Conclusions Sigmoid volvulus has high recurrence rate if not treated operatively. Total mortality due to sigmoid volvulus at Landspitali is low but surgery related mortality high.

The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes.

BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN: This is a prospective, observational study. SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Management of Idiopathic Overactive Bladder Syndrome: What Is the Optimal Strategy After Failure of Conservative Treatment?

CONTEXT: A considerable number of patients affected by the overactive bladder syndrome (OAB) do not respond to pharmacotherapy and bladder training due to unsatisfactory response or intolerability. OBJECTIVE: To review the available literature assessing therapeutic effect of the available third-line treatment modalities for OAB. EVIDENCE ACQUISITION: PubMed, Medline, and Cochrane databases were searched for all studies comparing outcomes of the available third-line treatment modalities for OAB. EVIDENCE SYNTHESIS: Several minimally invasive surgical procedures are available for patients with refractory OAB. These therapies include intravesical botulinum toxin type A, posterior tibial nerve stimulation, and sacral neuromodulation. CONCLUSIONS: None of the mentioned therapeutic modalities shows strong superiority over another. If the results of one therapy are not satisfactory, switching to another third-line treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns. All these factors should be taken into consideration before initiation of treatment. PATIENT SUMMARY: In the management of drug-resistant overactive bladder syndrome, the different minimally invasive treatments that are available are equal. If the results of one therapy are not satisfactory, switching to another treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns.

Transurethral resection of the prostate provides more favorable clinical outcomes compared with conservative medical treatment in patients with urinary retention caused by benign prostatic obstruction.

BACKGROUND: To evaluate the long-term surgical outcomes of patients with urinary retention (UR) caused by a benign prostatic obstruction (BPO) who underwent transurethral resection of the prostate (TURP), and compare their outcomes with those of patients who received medication without surgical intervention. METHODS: This retrospective cohort study analyzed claims data collected during the period of 1997-2012 from Taiwan's National Health Insurance Research Database. We examined geriatric adverse events among patients who had received a diagnosis of symptomatic benign prostatic hyperplasia and whom experienced UR, and compared those who received TURP and medication only. Primary outcomes included urinary tract infection (UTI), UR, inguinal hernia, hemorrhoids, stroke, acute myocardial infarction, and bony fracture. We excluded patients who had concomitant prostate cancer, bladder cancer, or a long-term urinary catheter indwelling, as well as those who did not receive α-blocker medication regularly. Those aged <50 or >90 years were also excluded. The enrolled patients were categorized into TURP (n = 1218) and medication only (n = 795) groups. After 1:1 propensity score matching, we recorded and compared patients' characteristics, postoperative clinical outcomes, and geriatric adverse events. RESULTS: The TURP cohort had a lower incidence of UTI and UR during the postoperative follow-up period from 2 months to 3 years than did the medication only group (20.7% vs. 28.9% and 12.5% vs. 27.6%, respectively, p < 0.001). The life-long bone fracture incidence was also lower in the TURP cohort (7.9% vs. 9.2%, p = 0.048). The incidence of other outcomes during the postoperative follow-up period did not differ between the two groups. CONCLUSIONS: Compared with conservative treatment, TURP provides more favorable clinical outcomes in patients with UR caused by BPO. Patients who underwent TURP had a lower risk of UTI, repeat UR episodes, and emergent bony fracture. Thus, early surgical intervention should be considered for such patients.

Optimising conservative management of chronic low back pain: study protocol for a randomised controlled trial.

BACKGROUND: Lower back pain is a global health issue affecting approximately 80% of people at some stage in their life. The current literature suggests that any exercise is beneficial for reducing back pain. However, as pain is a subjective evaluation and physical deficits are evident in low back pain, using it as the sole outcome measure to evaluate superiority of an exercise protocol for low back pain treatment is insufficient. The overarching goal of the current clinical trial is to implement two common, conservative intervention approaches and examine their impact on deficits in chronic low back pain. METHODS/DESIGN: Forty participants, 25-45 years old with chronic (>3 months), non-specific low back pain will be recruited. Participants will be randomised to receive either motor control and manual therapy (n = 20) or general strength and conditioning (n = 20) exercise treatments for 6 months. The motor control/manual therapy group will receive twelve 30-min sessions, ten in the first 3 months (one or two per week) and two in the last 3 months. The general exercise group will attend two 1-hour sessions weekly for 3 months, and one or two a week for the following 3 months. Primary outcome measures are average lumbar spine intervertebral disc T2 relaxation time and changes in thickness of the transversus abdominis muscle on a leg lift using magnetic resonance imaging (MRI). Secondary outcomes include muscle size and fat content, vertebral body fat content, intervertebral disc morphology and water diffusion measured by MRI, body composition using dual energy X-ray absorptiometry, physical function through functional tests, changes in corticospinal excitability and cortical motor representation of the spinal muscles using transcranial magnetic stimulation and self-reported measure of pain symptoms, health and disability. Outcome measures will be conducted at baseline, at the 3-month follow-up and at 6 months at the end of intervention. Pain, depressive symptomology and emotions will be captured fortnightly by questionnaires. DISCUSSION: Chronic low back pain is ranked the highest disabling disorder in Australia. The findings of this study will inform clinical practice guidelines to assist with decision-making approaches where outcomes beyond pain are sought for adults with chronic low back pain. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12615001270505 . Registered on 20 November 2015.

Non-pharmacological conservative therapy for phantom limb pain: A systematic review of randomized controlled trials.

The aim of this manuscript was to investigate the effectiveness of conservative therapy for phantom limb pain (PLP). In this systematic review, CINAHL, AMED, the Cochrane database of systematic reviews, PEDro, psychology and behavioral sciences collection, and MEDLINE were systematically searched for appropriate randomized controlled trials (RCTs). Selected papers were assessed for risk of bias, and evidence was graded using the GRADE approach. Twelve RCTs met initial inclusion/exclusion criteria, of which five were of sufficient quality for final inclusion. There is conflicting evidence from two RCTs for the effectiveness of electromagnetic shielding limb liners on pain in the short term. There is limited evidence supporting the effectiveness of both hypnosis in the short term and graded motor imagery (GMI) in the short-to-medium term. Additionally, there is limited evidence that a single session of mirror therapy has no immediate effect on PLP. Limb liner discomfort was the only adverse effect identified. This review identifies a range of conservative therapies, many of which demonstrate preliminary evidence of potential with respect to clinically worthwhile effects above control interventions and few, if any, adverse effects. However, there is a paucity of high-quality evidence upon which to make any firm clinical conclusions.