Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study

Objective To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. Design Retrospective, single-center observational study. Setting Intensive Care Medicine. Patients AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). Interventions Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. Main variables of interest Reasons for switching, NIRS failure and mortality rates. Results A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2–8] vs. 12 [8–30] days, p = 0.001). Conclusions NIRS combination is used in real life and both switches’ strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. ... (AU)

Objetivo Explorar los patrones combinados de soporte-respiratorio-no-invasivo (SRNI), las razones para cambiar de SRNI y su potencial impacto en los resultados clínicos en pacientes con insuficiencia-respiratoria-aguda-hipoxémica (IRAH). Diseño Estudio observacional retrospectivo unicéntrico. Ámbito Cuidados Intensivos. Pacientes Pacientes con IRAH (excluyendo causa cardíaca y acidosis respiratoria) que recibieron tanto ventilación-no-invasiva (VNI) como cánula-nasal-de-alto-flujo (CNAF). Intervenciones Se categorizó a los pacientes según el primer cambio de SRNI realizado (CNAF-to-VNI o VNI-to-CNAF) y se evaluaron estrategias específicas de SRNI (VNI trial-like vs. Non-VNI trial-like y cambio único vs. múltiples cambios de NIRS) de manera independiente. Variables de interés principales Razones para el cambio, así como las tasas de fracaso de SRNI y la mortalidad. Resultados Un total de 63 pacientes recibieron SRNI combinado, 58,7% clasificados en el grupo CNAF-to-VNI y 41,3% en el grupo VNI-to-CNAF. Los cambios de CNAF a VNI ocurrieron por empeoramiento de la IRHA (100%) y de VNI a CNAF por mejora respiratoria (76.9%). Las tasas de fracaso de SRNI fueron mayores de CNAF a VNI que de VNI a CNAF (81% vs. 35%, p < 0.001). Dentro de los pacientes de CNAF a VNI, no hubo diferencia en las tasas de fracaso entre los grupos VNI trial-like y no-VNI trial-like (86% vs. 78%, p = 0.575), pero la mortalidad fue menor en el grupo VNI trial-like (14% vs. 52%, p = 0.02). Dentro de los pacientes de VNI a CNAF, el fracaso de VNI fue menor en grupo de cambio único vs. múltiple (15% vs. 53%, p = 0.039). Conclusiones Los cambios de estrategia de SRNI son comunes en el manejo clínico diario de la IRHA. El cambio de CNAF a VNI impresiona de ser una escalada terapéutica y en este contexto la realización de un VNI-trial puede ser beneficioso. Al contrario, cambiar de VNI a CNAF impresiona de ser una desescalada terapéutica y parece segura si no hay fracaso ... (AU)

Optimized braces for the treatment of adolescent idiopathic scoliosis: A study protocol of a prospective randomised controlled trial.

INTRODUCTION: Adolescent Idiopathic Scoliosis (AIS) is a 3D deformity of the spine that affects 3% of the adolescent population. Conservative treatments like bracing aim to halt the progression of the curve to the surgical threshold. Computer-aided design and manufacturing (CAD/CAM) methods for brace design and manufacturing are becoming increasingly used. Linked to CAD/CAM and 3D radiographic reconstruction techniques, we developed a finite element model (FEM) enabling to simulate the brace effectiveness before its fabrication, as well as a semi-automatic design processes. The objective of this randomized controlled trial is to compare and validate such FEM semi-automatic algorithm used to design nighttime Providence-type braces. METHODS AND ANALYSIS: Fifty-eight patients with AIS aged between 10 to 16-years and skeletally immature will be recruited. At the delivery stage, all patients will receive both a Providence-type brace optimized by the semi-automatic algorithm leveraging a patient-specific FEM (Test) and a conventional Providence-type brace (Control), both designed using CAD/CAM methods. Biplanar radiographs will be taken for each patient with both braces in a randomized crossover approach to evaluate immediate correction. Patients will then be randomized to keep either the Test or Control brace as prescribed with a renewal if necessary, and will be followed over two years. The primary outcome will be the change in Cobb angle of the main curve after two years. Secondary outcomes will be brace failure rate, quality of life (QoL) and immediate in-brace correction. This is a single-centre study, double-blinded (participant and outcome assessor) randomized controlled trial (RCT). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT05001568.

Management of acute diverticulitis in Stage 0-IIb: indications and risk factors for failure of conservative treatment in a series of 187 patients.

Left-sided acute diverticulitis in WSES Stage 0-IIb preferentially undergoes conservative management. However, there is limited understanding of the risk factors for failure of this approach. The aim of this study was to investigate the factors associated with the decision to perform conservative treatment as well as the predictors of its failure. We included patients with a diagnosis of WSES diverticulitis CT-driven classification Stage 0-IIb treated in the Emergency Surgery Unit of the Agostino Gemelli University Hospital Foundation between 2014 and 2020. The endpoints were the comparison between the characteristics and clinical outcomes of acute diverticulitis patients undergoing conservative versus operative treatment. We also identified predictors of conservative treatment failure. A set of multivariable backward logistic analyses were conducted for this purpose. The study included 187 patients. The choice for operative versus conservative treatment was associated with clinical presentation, older age, higher WSES grade, and previous conservative treatment. There were 21% who failed conservative treatment. Of those, major morbidity and mortality rates were 17.9% and 7.1%, respectively. A previously failed conservative treatment as well as a greater WSES grade and a lower hemoglobin value were significantly associated with failure of conservative treatment. WSES classification and hemoglobin value at admission were the best predictors of failure of conservative treatment. Patients failing conservative treatment had non-negligible morbidity and mortality. These results promote the consideration of a combined approach including baseline patients' characteristics, radiologic features, and laboratory biomarkers to predict conservative treatment failure and therefore optimize treatment of acute diverticulitis.

Botanical Briefs: Australian Stinging Tree (Dendrocnide moroides).

Dendrocnide moroides (also known as gympie-gympie, mulberrylike stinging tree, or stinger) is arguably the most brutal of stinging plants, even leading to death in dogs, horses, and humans in rare cases. They can be recognized as shrubs with heart-shaped, serrated, dark green leaves that are covered in what appears to be soft downy fur with red to dark purple raspberries growing on long stems. After contact, there is immediate piloerection and local swelling, which may disappear after 1 hour or last as long as 24 hours, but the subjective pain, pruritus, and burning can persist for months. One can only treat conservatively with symptom management, and the most successful method of removing plant hair is hair removal wax strips, which are considered an essential component of a first aid kit where D moroides is found.

Methodology and application of three-dimensional technology for brace design and production for treatment in patients with adolescent idiopathic scoliosis: a scoping review protocol.

INTRODUCTION: Conservative treatment for adolescent idiopathic scoliosis (AIS) using bracing has proven to be effective at reducing curve progression. However, variation in brace design and lack of brace specificity hamper clinical treatment outcomes as well as the predictability and comparison hereof. To overcome this, recent technological developments aim to generate transparent and objective criteria for brace manufacturing by applying computer-aided design software and additive manufacturing to produce braces for scoliosis treatment. Yet, the extent of its applicability and clinical implementation are to be determined. This study will identify and map the available evidence for the methodology and application of three-dimensional technology for the design and production of clinical braces used for treatment in patients with AIS. METHODS AND ANALYSIS: This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. This scoping review will consider studies on methodology of three-dimensional technological methodology and applications that have been or are currently being applied in brace treatment of AIS. The following databases will be searched: MEDLINE, Web of Science, Cochrane Database of Systematic Reviews and Embase (OVID). Search limits will be applied; for example, only articles written in the English language published after 2000 will be included. The retrieved articles will be screened independently by two researchers. A third researcher will be consulted in case of disagreement. Data from relevant articles will be independently extracted by two researchers and presented in a tabular manner accompanied by a descriptive narration. ETHICS AND DISSEMINATION: Considering the nature of the study, no ethical approval needed to be requested. The study result will be submitted to a peer-reviewed journal.

Manejo das disfunções temporomandibulares. Parte I: tratamento conservador / Management of temporomandibular joint disorders. Part I: conservative treatment

Objetivo: Apresentar as modalidades de tratamentos conservadoras e minimamente invasivas mais usadas disponíveis no arsenal terapêutico das desordens temporomandibulares (DTM). Revisão da literatura: Os objetivos do tratamento invariavelmente incluem redução da dor, diminuição das atividades parafuncionais e restauração da função. Dentre as alternativas conservadoras e minimamente invasivas, podemos citar os dispositivos interoclusais, exercícios terapêuticos, eletrofototermoterapia, agulhamento seco e infiltração de anestésicos locais em pontos gatilho, injeção de sangue autógeno para controle da luxação mandibular, terapia cognitivo comportamental, toxina botulínica, viscossuplementação, controle farmacológico da dor aguda e crônica. As DTMs afetam uma proporção significativa da população. Somente após o fracasso das opções não invasivas é que devem ser iniciados tratamentos mais invasivos e irreversíveis. No entanto, algumas condições, como a anquilose e neoplasias, por exemplo, são essencialmente tratadas cirurgicamente e tentativas de tratamentos conservadores podem trazer piora na qualidade de vida ou risco de morte. Considerações finais: Uma abordagem de equipe multidisciplinar para o manejo é essencial no cuidado fundamental de todos os pacientes com DTM, para que o tratamento possa ser especificamente adaptado às necessidades individuais do paciente.

Aim: To present the most widely used conservative and minimally invasive treatment modalities available in the therapeutic arsenal for temporomandibular disorders (TMD). Literature review: Treatment goals invariably include pain reduction, reduction of parafunctional activities and restoration of function. Among the conservative and minimally invasive alternatives, we can mention interocclusal devices, therapeutic exercises, electrophototherapy, dry needling and infiltration of local anesthetics in trigger points, autogenous blood injection to control mandibular dislocation, cognitive behavioral therapy, botulinum toxin, viscosupplementation, pharmacological control of acute and chronic pain. TMD affects a considerable proportion of the population. Only after non-invasive options have failed should more invasive and irreversible treatments be initiated. However, some conditions, such as ankylosis and neoplasms, for example, are treated surgically and attempts at conservative treatments can lead to worsening quality of life or risk of death. Conclusions: A multidisciplinary team approach to management is essential in the fundamental care of all TMD patients, so that treatment can be specifically tailored to the patient's individual needs.

Eficacia del tratamiento de rehabilitación para el síndrome del túnel carpiano: un ensayo clínico controlado aleatorizado / Efficacy of rehabilitation treatment for carpal tunnel syndrome: A randomized controlled clinical trial

Introducción y objetivo El síndrome del túnel carpiano es la neuropatía del nervio mediano más frecuente. Existen múltiples tratamientos invasivos y no invasivos, incluyen férulas, ultrasonido terapéutico (UST) e infiltraciones con esteroides (IE) que han demostrado una mejora en los estudios de conducción nerviosa (ECN), sin embargo, se desconoce el efecto de los tratamientos conservadores combinados. El objetivo fue determinar la eficacia del tratamiento conservador para mejorar los ECN y las manifestaciones clínicas en pacientes con síndrome del túnel carpiano. Métodos Pacientes con diagnóstico de síndrome del túnel carpiano mediante ECN, sin enfermedades que afecten al nervio periférico. Todos firmaron consentimiento informado y fueron aleatorizados en 3 grupos de tratamiento (G1: férula+UST; G2: férula+IE; G3; férula+UST+IE). Participaron 3 médicos especialistas en rehabilitación (médico 1: realizó los ECN; médico 2: realizó evaluaciones clínicas; médico 3: realizó la IE). Tratamientos: UST (10 sesiones continuas de lunes a viernes durante dos semanas, 3MHz, 0,8W/cm2, 8min) aplicado por el mismo fisioterapeuta. Infiltración: dosis única, 1ml de metilprednisolona (40mg/ml) mezclado con 1ml de (0,5%) bupivacaína. Férula: férulas neutras volares hechas a la medida, de fibra de vidrio para uso nocturno. Resultados Se incluyeron 30 pacientes y 30 manos, con una edad de 50,5±7,5 años, todas ellas mujeres. Los grupos no tenían diferencias en las variables electrofisiológicas y clínicas al inicio del estudio. Tras la intervención (4 semanas) los grupos 2 y 3 mostraron mejoría en el ECN (p<0,05) siendo mayor en el grupo 3. En la evaluación final (8 semanas) todos los grupos mostraron una mejoría en las variables electrofisiológicas y clínicas. Conclusiones El tratamiento combinado de férula+UST+IE presenta resultados significativos en el ECN a las 4 semanas de seguimiento, en comparación a los otros dos grupos (AU)

Introduction and objective Carpal tunnel syndrome is the most common median nerve mononeuropathy. There are multiple conservative treatments, invasive (corticoid injections [CI]) and non-invasive (splinting, therapeutic ultrasound [TUS], laser, exercise). However, the treatment choice is controversial. The aim was to determine the efficacy of conservative treatment to improve the clinical and electrophysiological evaluations. Methods Outpatients referred whit carpal tunnel syndrome clinical diagnosis to perform nerve conduction study (NCS) were included, without chronic or metabolic diseases that affect the peripheral nerves, without carpal tunnel syndrome treatment and with mild or moderate axonotmesis or neuropraxia in NCS baseline. Patients who signed informed consent forms were randomized in three treatment groups (Group 1: TUS+splint; Group 2: CI+splint and Group 3: TUS+CI+splint) were referred for clinical evaluations. The NCS was performed in each patient at baseline, fourth and eighth weeks by the same physiatrist and the clinical evaluations were performed at baseline and the final follow-up. Results Thirty patients were included; mean age was 50.7±7.5 years and all of them females, without differences in NCS or clinical variables in the baseline evaluations. All groups exhibited improvement in some clinical and electrophysiological variables in the final evaluation, though only group 3 showed improvement on median/ulnar nerves sensory peak latency difference (1.2±0.4 vs. 0.4±0.4; p=0.001) starting in week four. Conclusions The conservative treatment in patients with CTS improves NCS and clinical variables, including the most sensitive electrophysiological test (medial/ulnar difference), though if we combined three treatments (splint+TUS+CI), the improvement was found to be faster and remarkable (AU)

Tobacco Smoking Is a Strong Predictor of Failure of Conservative Treatment in Hinchey IIa and IIb Acute Diverticulitis-A Retrospective Single-Center Cohort Study.

Background and Objectives: Therapeutic management of patients with complicated acute diverticulitis remains debatable. The primary objective of this study is to identify predictive factors for the failure of conservative treatment of Hinchey IIa and IIb diverticular abscesses. Materials and Methods: This is a retrospective cohort study that included patients hospitalized from 1 January 2014 to 31 December 2022 at the Emergency Surgery Department of the Cagliari University Hospital (Italy), diagnosed with acute diverticulitis complicated by Hinchey grade IIa and IIb abscesses. The collected variables included the patient's baseline characteristics, clinical variables on hospital admission, abscess characteristics at the contrast-enhanced CT scan, clinical outcomes of the conservative therapy, and follow-up results. Univariable and multivariable logistic regression models were used to identify prognostic factors of conservative treatment failure and success. Results: Two hundred and fifty-two patients diagnosed with acute diverticulitis were identified from the database search, and once the selection criteria were applied, 71 patients were considered eligible. Conservative treatment failed in 25 cases (35.2%). Univariable analysis showed that tobacco smoking was the most significant predictor of failure of conservative treatment (p = 0.007, OR 7.33, 95%CI 1.55; 34.70). Age (p = 0.056, MD 6.96, 95%CI -0.18; 0.99), alcohol drinking (p = 0.071, OR 4.770, 95%CI 0.79; 28.70), platelets level (p = 0.087, MD -32.11, 95%CI -0.93; 0.06), Hinchey stage IIa/IIb (p = 0.081, OR 0.376, 95%CI 0.12; 1.11), the presence of retroperitoneal air bubbles (p = 0.025, OR 13.300, 95%CI 1.61; 291.0), and the presence of extraluminal free air at a distance (p = 0.043, OR 4.480, 95%CI 1.96; 20.91) were the other variables possibly associated with the risk of failure. In the multivariable logistic regression analysis, only tobacco smoking was confirmed to be an independent predictor of conservative treatment failure (p = 0.006; adjusted OR 32.693; 95%CI 2.69; 397.27). Conclusion: The role of tobacco smoking as a predictor of failure of conservative therapy of diverticular abscess scenarios highlights the importance of prevention and the necessity to reduce exposure to modifiable risk factors.

Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis.

Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.

Ameloblastoma uniquístico con patrón plexiforme: revisión de la literatura a propósito de un caso clínico / Unicystic ameloblastoma with a plexiform pattern: literature review regarding a clinical case

En 1827 el médico James William Cusack describió una lesión tumoral expansiva con características clínicas similares al ameloblastoma. Para el 2017 la Organización Mundial de la Salud lo clasificó como un tumor odontogénico benigno de origen epitelial. En la actualidad hemos aceptado la teoría de su etiología asociada con una mutación en el biomarcador BRAF-V600E, donde se presentan claras heterogeneidades extra/intratumorales en el metabolismo de la tumorogénesis; la mutación en BRAF genera cambios en la regulación de la odontogénesis, en conjunto con el gen CDC73 presente en el cromosoma 1 q25-q32, lo que produce un cambio en la proteína parafibromina que inhibe la proliferación celular durante el crecimiento y la división celular, esto afecta en conjunto al gen p53 y su homólogo p63 presentes en el cromosoma 17, por lo que se tiene como resultado la expresión de quistes y tumores dentales como el ameloblastoma. La presente obra muestra el caso clínico de un paciente femenino de 11 años de edad con aumento de volumen en la región submandibular izquierda de 7 × 4 cm, con seis años de evolución; de tal manera que fue diagnosticado con ameloblastoma uniquístico y tratado de forma conservadora mediante enucleación, posteriormente fue valorada anualmente hasta que la paciente cumplió los 18 años de edad (AU)

In 1827, physician James William Cusack described an expansive tumor lesion with clinical characteristics similar to ameloblastoma. For 2017, the World Health Organization classified it as a benign odontogenic tumor of epithelial origin. Currently, we have accepted the theory of its etiology associated with a mutation in the BRAF-V600E biomarker, where there are clear extra/intratumoral heterogeneities in the metabolism of tumorigenesis; the BRAF mutation generates changes in the regulation of odontogenesis, together with the CDC73 gene present on chromosome 1 q25-q32, producing a change in the parafibromin protein that inhibits cell proliferation during cell growth and division, which together it affects the p53 gene and its p63 homolog is present on chromosome 17, resulting in the expression of dental cysts and tumors such as ameloblastoma. This work provides the clinical case of an 11-year-old patient with an increase in volume in the left submandibular region of 7 × 4 cm of 6 years of evolution. Being diagnosed as a unicistic ameloblastoma and treated conservatively by enucleation, it is subsequently evaluated annually until the patient reaches 18 years of age (AU)

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children.

INTRODUCTION: in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. METHODS: retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. RESULTS: only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. CONCLUSION: the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

Preservação da fertilidade em pacientes com câncer ginecológico / Fertility preservation in gynecologic cancer patients

CONTEXTO CLÍNICO O câncer ginecológico afeta diretamente a fertilidade, pois o tratamento consiste na remoção cirúrgica do sistema reprodutor e/ou na sua exposição a agentes gonadotóxicos. Entretanto, pacientes em estádios iniciais e que estejam dentro de critérios estabelecidos podem ser tratadas com cirurgias conservadoras da fertilidade, com resultados oncológicos equivalentes aos dos tratamentos tradicionais. As técnicas de preservação da fertilidade, como criopreservação de oócitos, embriões e tecido ovariano, também podem ser oferecidas em algumas situações. A American Society of Clinical Oncology (ASCO) publicou recomendações sobre a preservação de fertilidade, com o objetivo de aumentar a conscientização sobre o tema, e, juntamente com a American Society for Reproductive Medicine (ASRM), recomenda que pacientes em idade fértil com câncer passem por aconselhamento reprodutivo. Essas pacientes apresentam menores taxas de arrependimento, mesmo quando optam por desistir do tratamento conservador. O interesse na preservação da fertilidade aumentou nas últimas décadas, tanto pelo fato de as mulheres postergarem a gestação como pelo aumento da incidência de câncer em jovens. A taxa de incidência de todos os cânceres aumentou 29% entre 1973 e 2015 em adolescentes e adultos jovens de ambos os sexos. O câncer de colo uterino, em mulheres de 20-29 anos, aumentou anualmente em uma média de 10,3% entre 2000 e 2009. A omissão em orientar pacientes com câncer sobre as possibilidades de preservação da fertilidade pode gerar questionamentos futuros; em alguns países. isso já se configura má prática médica.

Nonoperative management of lisfranc injuries - A systematic review of outcomes.

BACKGROUND: Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively. METHODS: A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery. RESULTS: High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes. CONCLUSION: Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

Conservative management of complicated colonic diverticulitis: long-term results.

BACKGROUND: The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. AIM: To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. METHODS: This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. RESULTS: We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). CONCLUSIONS: Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

One-year follow-up of conservative management of appendicitis: results from a single centre during extended lockdown in the COVID-19 pandemic.

INTRODUCTION: Conservative management with antibiotics was recommended by the UK Surgical Royal Colleges early in the COVID-19 pandemic as the first-line treatment for acute uncomplicated appendicitis. METHODS: This is a prospective single-centre cohort study of patients aged 16 years or over, diagnosed clinically and confirmed radiologically with acute appendicitis in a secondary care setting who were initially treated conservatively with antibiotics. The primary outcome was the response to conservative management with antibiotics. Secondary outcomes were: antibiotic duration; operative rates; surgical approach (open, laparoscopic or conversion to open); complication rates; COVID-19 positive rate; rates of readmission within 12 months; and length of hospital stay. RESULTS: A total of 109 patients were included in the study, 67 of whom were male. Median age was 37 (range 17-93) years. A further 28 patients were excluded because of a decision to manage operatively on the index admission or because of other diagnoses. Thirty-three patients (30.3%) had surgery on the index admission after failed conservative management and 15 (13.8%) had surgery on readmission. On histology, 32/48 patients (66.7%) had a diagnosis of complicated appendicitis and 18/48 (37.5%) had a confirmed appendicolith. CONCLUSIONS: There was a high readmission rate (47/109; 43.1%) for surgery, a radiological drain or conservative management within the first year following initial conservative management. There is a significant risk of recurrence of symptoms, particularly in the presence of an appendicolith. Laparoscopic appendicectomy should be the first-line treatment, with conservative management reserved for patients with acute uncomplicated appendicitis who are COVID-19 positive or have comorbidities.

Tratamento funcional das fraturas de tornozelo Weber B com carga e mobilização imediatas / Functional treatment of Weber B ankle fractures with weight-bearing and immediate mobilization

Introdução: As fraturas do tornozelo são lesões comuns, apesar de ocorrer em todas as idades, são mais comuns entre homens jovens e mulheres idosas, constituem cerca de 9% de todas as fraturas, com uma incidência de 107 a 187 por 100.000 pessoas por ano. A abordagem de tratamento selecionada ocorrerá de acordo com as condições do paciente e a opção do médico de acordo com cada situação em específico. Objetivo: Avaliar o desfecho do tratamento não cirúrgico e funcional de pacientes com fraturas estáveis e sem desvio do maléolo lateral tipo Weber B, com carga e mobilização articular imediatas. Método: estudo retrospectivo de uma série de pacientes com fratura estável e sem desvio do maléolo lateral tipo Weber B, que foram tratados de forma não cirúrgica com carga e mobilização articular imediatas, de janeiro 2016 a julho 2022. Os pacientes dessa pesquisa foram provenientes do Hospital do Servidor Público Municipal de São Paulo e da Clínica de Ortopedia e Traumatologia Ortocity. Resultados: Os pacientes tinham idade média de 54,7 anos, diagnosticados após eventos traumáticos (quedas, acidentes, etc.) por meio de exames radiográficos, 50% da amostra com comorbidades, especialmente HAS, 73,3% com desvio de 1mm, mais de 50% com consolidação em até 8 semanas, mais de 60% retornaram às atividades normais em até 16 semanas, as complicações ocorreram em aproximadamente 70% da amostra, porém todas leves e sem necessidade de nova abordagem de tratamento posterior. Conclusão: Nesse sentido, pode-se afirmar que a abordagem conservadora associado à mobilização e carga imediatas formam uma alternativa viável de tratamento, com bons resultados de recuperação funcional, semelhantes aos pacientes tratados por abordagens cirúrgicas, conforme a literatura levantada para este estudo. Palavras-chave: Fratura de tornozelo. Abordagem conservadora. Weber B. Resultados funcionais.

A Method of Conservative Management of Giant Omphalocele Useful in Preventing Rupture of Sac.

BACKGROUND: Omphalocele consists of congenital malformation of anterior abdominal wall defects occurring at the midline with herniation of the viscera through this defect. Giant omphaloceles constitute a challenging situation as such conservative management has been advocated as an effective method of treatment. This study aimed to compare the conventional method of dressing the omphalocele sac using gauze, an escharotic agent, and a crepe bandage to our improvised method of the usage of a sterilization wrap over the escharotic agent with a crepe bandage. METHODS: This was a retrospective comparative review of 7 babies with giant omphalocele that was treated with topical honey and the non-adherent sterilization wrap covering (group B) and compared with 6 babies that had honey, sofratulle ,and dry gauze covering (group A) that was initially done in our center. RESULTS: All of the babies who were in group B had an uneventful epithelization of the sac with no rupture; also, no death occurred in this group. However, three in group A had sacs that ruptured before epithelization. Two of these died from complications of sepsis following rupture of the sac, one had a small point on the sac which was ruptured and it healed with a dressing left in place for a week. CONCLUSION: The use of Kimberley-Clark sterilization wrap prevents rupture of the sac while using the escharotic agent, thereby reducing mortality. We advocate that gauze should not make any contact with the omphalocele sac.

CONTEXTE: Omphalocele consiste en une malformation congénitale deanomalies de la paroi abdominale antérieure survenant à la ligne médiane avechernie des viscères à travers ce défaut. Omphalocèles géantsconstituent une situation difficile en tant que telle gestion conservatricea été préconisé comme une méthode de traitement efficace. Cette étudevisant à comparer la méthode conventionnelle d'habillage dusac omphalocèle utilisant de la gaze, un agent escharotique et un pansement en crêpeà notre méthode improvisée d'utilisation d'une enveloppe de stérilisation sur leagent escharotique avec un pansement en crêpe. MÉTHODES: Il s'agissait d'une revue comparative rétrospective de 7 bébés atteints deomphalocèle géant qui a été traité avec du miel topique et le revêtement d'enveloppement de stérilisation non adhérent (groupe B) et comparé à 6bébés qui avaient du miel, de la sofratulle et de la gaze sèche couvrant (groupe A)cela a d'abord été fait dans notre centre. RÉSULTATS: Tous les bébés qui étaient dans le groupe B ont eu une situation sans incident.épithélisation du sac sans rupture; de plus, aucun décès n'est survenu dans cegroupe. Cependant, trois dans le groupe A avaient des sacs qui se sont rompus avantépithélisation. Deux d'entre eux sont morts de complications de la septicémiesuite à la rupture du sac, on avait une petite pointe sur le sac quia été rompu et il a guéri avec un pansement laissé en place pendant une semaine. CONCLUSION: L'utilisation de l'emballage de stérilisation Kimberley-Clark prévientrupture du sac lors de l'utilisation de l'agent escharotique, réduisant ainsimortalité. Nous préconisons que la gaze ne devrait pas entrer en contact avecle sac omphalocèle. MOTS-CLÉS: Omphalocèle géant, Enveloppe de stérilisation Kimberly.

Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease.

Background: Most patients are unaware of approaches to treating advanced chronic kidney disease (CKD) other than dialysis. Methods: We developed a dedicated decision aid on conservative kidney management using human-centered design principles in three phases: (1) discovery: engagement of informants to understand their needs and preferences; (2) design: multiple rapid cycles of ideation, prototyping, and testing of a decision aid with a small group of informants; and (3) implementation: testing the decision aid in real-world settings with attention to how the decision aid can be further refined. Informants included a national patient advisory committee on kidney diseases, 50 patients with stage 4 or 5 CKD and 35 of their family members, and 16 clinicians recruited from the greater Seattle area between June 2019 and September 2021. Results: Findings from the discovery phase informed an initial prototype of the decision aid, which included five sections: a description of kidney disease and its signs and symptoms, an overview of conservative kidney management and the kinds of supports provided, self-reflection exercises to elicit patients' values and goals, the pros and cons of conservative kidney management, and the option of changing one's mind about conservative kidney management. The prototype underwent several rounds of iteration during its design phase, which resulted in the addition of an introductory section describing the intended audience and more detailed information in other sections. Findings from its implementation phase led to the addition of examples of common questions that patients and family members had about conservative kidney management and a final section on other related educational resources. Conclusions: Human-centered design principles supported a systematic and collaborative approach between researchers, patients, family members, and clinicians for developing a decision aid on conservative kidney management.