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1.
Unfallchirurg ; 123(2): 143-154, 2020 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-32016493

RESUMO

Posttraumatic kyphotic deformities of the thoracolumbar spine may result in significant clinical complaints. If conservative treatment is not successful, surgical correction of the kyphosis becomes an option. In contrast to degenerative deformities, posttraumatic kyphotic deformities are usual limited to few segments and can be treated with shorter constructs. The surgical strategy depends on the rigidity and the localization of the posttraumatic kyphotic deformity. In this respect purely posterior approaches and combined posteroanterior surgical approaches are available each with different advantages and disadvantages.


Assuntos
Cifose , Fusão Vertebral , Traumatismos da Coluna Vertebral , Tratamento Conservador , Humanos , Cifose/etiologia , Cifose/cirurgia , Vértebras Lombares , Osteotomia , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas , Resultado do Tratamento
2.
Quintessence Int ; 51(3): 230-237, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32020133

RESUMO

OBJECTIVES: Severe atrophied edentulous posterior mandible with inadequate bone height superior to the inferior alveolar canal may require transposition of the inferior alveolar nerve in order to insert dental implants. Mandibular fractures are considered a rare complication of this procedure. Implant-related spontaneous fractures of the mandible represent 0.2% of patients with inserted implants in an edentulous mandible. This report presents two cases of mandibular fractures that occurred 3 to 4 weeks after inferior alveolar nerve transposition, and were managed successfully by conservative nonsurgical treatments. METHOD AND MATERIALS: Overall, 132 procedures of inferior alveolar nerve transposition in 98 patients were performed over a period of 10 years with 379 dental implants inserted in one stage with the procedure. Patients were examined every 2 weeks. The inferior alveolar nerve function was evaluated with various sensory tests. Panoramic radiographs were obtained immediately, at 3 months, and at 1 year after the surgery. The patients received implant-supported fixed prostheses after 3 to 5 months. RESULTS: The healing process was uneventful in 96 patients; however, in two patients (1.5%) spontaneous fracture of the treated site was observed 3 and 4 weeks postoperatively. The fractures lines occurred at a failed implant site. Both cases were treated conservatively. CONCLUSIONS: Spontaneous fractures following inferior alveolar nerve transposition are an important but rare complication. Conservative treatment modalities might be useful and indicated in some of those cases.


Assuntos
Perda do Osso Alveolar , Implantes Dentários , Fraturas Espontâneas , Fraturas Mandibulares , Tratamento Conservador , Implantação Dentária Endo-Óssea , Prótese Dentária Fixada por Implante , Humanos , Mandíbula , Nervo Mandibular
3.
Medicine (Baltimore) ; 99(7): e19262, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32049867

RESUMO

RATIONALE: A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare. The recommended treatment is surgery. However, some cases can be successfully treated with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage. In this case report, a spontaneous rupture of the bladder diverticulum was successfully treated non-surgically because it was deemed too risky for surgical intervention, such as non-ST segment elevation myocardial infarction (NSTEMI). PATIENT CONCERNS: A 76-year-old man presented with abdominal pain, distention, diarrhea, and oliguria for 3 days and hypotension for 1 day with no history of trauma. The patient showed direct and rebound tenderness in the lower abdomen. Computed tomography revealed an intraperitoneal bladder rupture associated with the bladder diverticula. Electrocardiography, echocardiography, and elevated cardiac enzyme suggested NSTEMI. DIAGNOSES: A spontaneous rupture of the bladder diverticulum, NSTEMI, and suspected sepsis due to gastroenteritis or urinary infection. INTERVENTIONS: The patient was treated conservatively with urinary catheterization and antibiotics for a bladder rupture and an infection. Percutaneous transluminal coronary angioplasty was performed for NSTEMI. OUTCOMES: The patient fully recovered without complications on hospitalization day 13. LESSONS: Conservative management might be an alternative for a spontaneous intraperitoneal bladder rupture in some cases. However, close observation is required, and surgical intervention is the first option for a spontaneous intraperitoneal rupture of the bladder diverticulum.


Assuntos
Divertículo/complicações , Bexiga Urinária/anormalidades , Idoso , Tratamento Conservador , Humanos , Masculino , Ruptura Espontânea/terapia
4.
N Engl J Med ; 382(5): 405-415, 2020 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-31995686

RESUMO

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).


Assuntos
Tratamento Conservador , Drenagem , Pneumotórax/terapia , Adolescente , Adulto , Tubos Torácicos , Drenagem/métodos , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pneumotórax/diagnóstico por imagem , Complicações Pós-Operatórias , Radiografia Torácica , Recidiva , Resultado do Tratamento , Conduta Expectante , Adulto Jovem
5.
Medicine (Baltimore) ; 99(4): e18883, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31977895

RESUMO

To elucidate whether nonsurgical treatment for Preiser disease is effective.Eight patients with Preiser disease (median age 59 [47-69] years) underwent nonsurgical treatment (median symptom-onset-to-treatment interval 8 [9-180] months). At presentation, 7 patients complained of constant pain and 1 of motion-related pain. Pain restricted wrist range of motion (median modified Mayo wrist score [MMWS] 17.5 [range 10-30]). Radiography revealed stages 1 to 3 disease (Herbert-Lanzetta classification). Median scapholunate angle was 62° (54°-75°), with 3 wrists suffering dorsal intercalated segment instability (DISI). Magnetic resonance imaging showed (Kalainov criteria) 4 stage 1 wrists (complete necrosis) and 4 stage 2 (incomplete necrosis). Two had concomitant Kienböck disease. All patients underwent nonsurgical treatment (ie, oral pain killer, immobilization, rest) and were monitored via radiographic and clinical evaluations. Scapholunate angles and the scaphoid area reduction ratio were calculated using radiography. Response criteria were the patients' subjective and objective status. Endpoint was the time from start of non-surgical to surgical treatment.Immobilization lasting 0 to 24 months (median 1.8 months) did not relieve their symptoms. Follow-up radiography showed that the disease stage had progressed in 5 of 8 wrists, with 5 wrists having DISI. The median area reduction ratio of the scaphoid was 11% (4%-52%) on anteroposterior views and 4% (-23% to 17%) on lateral views. Compared with the contralateral wrist, the median wrist flexion-extension arc was 61% (50%-79%) and the median grip strength 39%. Median MMWS score was 17.5 (10-25) - poor in 6 of 8 patients. Surgery was thus necessary in all patients.Nonsurgical treatment for Preiser disease did not improve subjective or objective outcomes and did not prevent deterioration of radiographic findings.Type of study/level of evidence: Therapeutic, Level V.


Assuntos
Tratamento Conservador/métodos , Osteonecrose/terapia , Osso Escafoide , Idoso , Anti-Inflamatórios não Esteroides/uso terapêutico , Feminino , Humanos , Imobilização/métodos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Osteonecrose/diagnóstico por imagem , Medição da Dor , Estudos Retrospectivos , Osso Escafoide/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Falha de Tratamento
7.
Khirurgiia (Mosk) ; (1): 67-73, 2020.
Artigo em Russo | MEDLINE | ID: mdl-31994502

RESUMO

OBJECTIVE: To compare long-term outcomes in patients after carotid endarterectomy and those who refused surgical correction and received only conservative treatment. MATERIAL AND METHODS: There were 1035 carotid endarterectomies performed at the Kemerovo Regional Clinical Hospital and Kemerovo Regional Clinical Cardiology Dispensary for the period 2014-2017. Surgery was refused by 136 patients for the same time. Thus, two groups of patients were formed: 1 - carotid endarterectomy group; 2 - conservative treatment group. INCLUSION CRITERIA: significant carotid stenosis, absence of severe neurological deficit (over 25 scores by the National Institutes of Health Stroke Scale), absence of concomitant diseases limiting long-term follow-up. RESULTS: Lethal outcome (p=0.0038) and fatal acute cerebrovascular accident (p=0.0005) were significantly more common in the 2nd group in long-term follow-up period. Thus, combined endpoint took the greatest values in patients who refused surgery compared with patients who received surgical treatment (p=0.0001). It should be noted that ischemic stroke de novo occurred in 9 (6.6%) patients of the 2nd group after 10.8 ± 2.5 months. This complication required subsequent hospitalization for carotid endarterectomy. CONCLUSION: Preventive role of carotid endarterectomy was convincingly proved in comparison with drug therapy regarding mortality and fatal ischemic stroke in patients with significant carotid stenoses within 2.5 years of follow-up period.


Assuntos
Estenose das Carótidas/tratamento farmacológico , Estenose das Carótidas/cirurgia , Tratamento Conservador/mortalidade , Endarterectomia das Carótidas/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Tratamento Conservador/efeitos adversos , Seguimentos , Humanos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
8.
Ann R Coll Surg Engl ; 102(1): e1-e3, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31155921

RESUMO

Diffuse cavernous haemangioma is a rare disease of the rectum. It usually presents with a history of rectal bleeding in children and young adults. When conservative methods fail to control bleeding, traditionally resection is recommended. A 50-year-old man presented with per rectal bleeding and was diagnosed with diffuse cavernous haemangioma of the sigmoid and rectum extending up to 40 cm in the left colon through endoscopy, magnetic resonance imaging and computed tomography. The diagnosis was confirmed by biopsy. This patient was successful managed conservatively with tranexamic acid as needed, avoiding the need for resection.


Assuntos
Antifibrinolíticos/administração & dosagem , Tratamento Conservador/métodos , Hemangioma Cavernoso/tratamento farmacológico , Neoplasias Retais/tratamento farmacológico , Neoplasias do Colo Sigmoide/tratamento farmacológico , Ácido Tranexâmico/administração & dosagem , Administração Oral , Colonoscopia , Hemorragia Gastrointestinal/etiologia , Hemangioma Cavernoso/diagnóstico , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Neoplasias Retais/diagnóstico , Neoplasias do Colo Sigmoide/diagnóstico , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Conduta Expectante
9.
World Neurosurg ; 133: e600-e608, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568912

RESUMO

BACKGROUND: Evidence is lacking regarding the role of radiologic surveillance for asymptomatic intracranial aneurysms (AIAs) in the elderly (≥65 years). We sought to establish if long-term clinical and radiologic observation is warranted for older patients with AIAs. METHODS: A retrospective cohort of 193 consecutive patients with 255 AIAs were clinically and radiologically observed between January 2011 and January 2019. The primary end points were documented aneurysm growth, subarachnoid hemorrhage, or definitive treatment with microsurgical clipping or endovascular coiling. Baseline patient and aneurysm characteristics were obtained. Univariate and multivariate comparisons were performed. RESULTS: Aneurysm growth was observed in 8 patients (4.2%) at a median follow-up of 58.2 months (interquartile range, 38.4-78.5 months). The median aneurysm size at initial diagnosis was 3.5 mm (interquartile range, 2.2-5 mm). Aneurysms larger than 7 mm selected for surveillance were noted in 37 patients (19.2%). The growth rate was estimated at 0.2 mm per person-year. At the end of the study period, 175 patients (90.7%) were alive, 6 (3.1%) were lost to follow-up, and 12 (6.2%) died of unrelated causes. During the 1025.2 person-years follow-up, no patient had experienced subarachnoid hemorrhage, and none required definitive treatment. The presence of aneurysmal bleb (odds ratio, 6.02; 95% confidence interval, 1.15-31.43; P = 0.033) and multiple intracranial aneurysms (odds ratio, 10.98; 95% confidence interval, 1.27-94.91; P = 0.029) were associated with growth. CONCLUSIONS: AIAs in older patients deemed suitable for conservative management do not require robust follow-up. The current study suggests a potential role for closer surveillance for patients with multiple intracranial aneurysms or aneurysms with bleb morphology.


Assuntos
Aneurisma Intracraniano/patologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Tratamento Conservador , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Masculino , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/etiologia , Tempo
11.
Orthopade ; 49(1): 59-65, 2020 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-30899990

RESUMO

BACKGROUND: It is understood that an effective brace therapy requires a primary curve angle reduction of 50% after administering the first orthotic brace. OBJECTIVES: The aim of the study was to determine the efficacy of conservative brace therapy for scoliosis with a curve angle above 20° and to determine possible influencing factors. MATERIALS AND METHODS: The current study included a cohort of 110 scoliosis patients with conservative brace therapy. The development of the scoliotic curve during brace therapy was documented for an average of 40 months. Influencing factors such as the initial Risser sign, age at the start of treatment, gender, curve patterns and body mass index were analyzed. RESULTS: The collective consisted of 88 patients with idiopathic and 22 with neuromuscular spinal deformities. At the beginning of the brace therapy, the average age was 12.2 ± 2.8 years with a mean scoliosis curve angle of 30.4°â€¯± 12.5°. The primary brace reduced the scoliotic curve by 31% to 20.9°. In children and adolescents with lower maturity status, the success of the brace therapy was greater than in patients with a higher Risser sign. In addition, children with obesity had less success during brace therapy than normal- or underweight children. CONCLUSIONS: The initial curvature correction of 50% required for effective brace therapy could only be achieved in one third of the patients. On average, the correction was 31%.


Assuntos
Escoliose/terapia , Adolescente , Braquetes , Criança , Estudos de Coortes , Tratamento Conservador , Humanos , Resultado do Tratamento
12.
Unfallchirurg ; 123(1): 29-35, 2020 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-30953083

RESUMO

BACKGROUND: The exact incidence of postoperative periprosthetic humeral fractures (PPHF) months or years after fracture-related implantation of a hemiprosthesis is unknown. The currently available literature is predominantly concerned with operative treatment approaches. As a rule, these involved older patients and severe fracture conditions so that severe complications and unsatisfactory healing results were described. This article presents an alternative conservative treatment approach which is discussed based on the results of treatment. PATIENTS AND METHODS: Between 2011 and 2016 a conservative treatment of 5 female patients with PPHF could be carried out. Of the patients 4 were clinically and radiologically controlled at a mean follow-up time of 23 months. The fifth patient died 2 months after the trauma and only partial information of the treatment was available. RESULT: There were no intrahospital complications and just one posthospital complication. In the case of the patient who later died, repeated and unauthorized removal of the upper arm brace occurred in the nursing institution resulting in a lesion of the radial nerve. Of the four patients who completed treatment, three were very satisfied with the outcome of treatment. The mean DASH (Disabilities of Arm, Shoulder and Hand) and Oxford shoulder scores were on average 74 and 25 points, respectively. At the time of the follow-up examination all patients were free of pain, without the use of analgesics; however, there were still some limitations in the activities of daily life, which in three of the four patients was similar to the results following implantation of the fracture prosthesis. CONCLUSION: The conservative treatment of PPHF can be a safe treatment option in multimorbid and chronically ill patients. A close outpatient control and good patient compliance are important. In incompliant and dementia patients, the risk of failure of conservative treatment is increased.


Assuntos
Tratamento Conservador , Fraturas do Úmero , Prótese Articular , Fraturas Periprotéticas , Feminino , Seguimentos , Humanos , Fraturas do Úmero/terapia , Úmero , Fraturas Periprotéticas/terapia , Resultado do Tratamento
13.
Vasc Endovascular Surg ; 54(2): 126-134, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31709914

RESUMO

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.


Assuntos
Tratamento Conservador , Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Qualidade de Vida , Procedimentos Cirúrgicos Vasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Países Baixos , Seleção de Pacientes , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
14.
N Engl J Med ; 382(2): 111-119, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31733181

RESUMO

BACKGROUND: The timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial. METHODS: In a multicenter trial, we randomly assigned 145 asymptomatic patients with very severe aortic stenosis (defined as an aortic-valve area of ≤0.75 cm2 with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥50 mm Hg) to early surgery or to conservative care according to the recommendations of current guidelines. The primary end point was a composite of death during or within 30 days after surgery (often called operative mortality) or death from cardiovascular causes during the entire follow-up period. The major secondary end point was death from any cause during follow-up. RESULTS: In the early-surgery group, 69 of 73 patients (95%) underwent surgery within 2 months after randomization, and there was no operative mortality. In an intention-to-treat analysis, a primary end-point event occurred in 1 patient in the early-surgery group (1%) and in 11 of 72 patients in the conservative-care group (15%) (hazard ratio, 0.09; 95% confidence interval [CI], 0.01 to 0.67; P = 0.003). Death from any cause occurred in 5 patients in the early-surgery group (7%) and in 15 patients in the conservative-care group (21%) (hazard ratio, 0.33; 95% CI, 0.12 to 0.90). In the conservative-care group, the cumulative incidence of sudden death was 4% at 4 years and 14% at 8 years. CONCLUSIONS: Among asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic-valve replacement surgery than among those who received conservative care. (Funded by the Korean Institute of Medicine; RECOVERY ClinicalTrials.gov number, NCT01161732.).


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Tratamento Conservador , Idoso , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/terapia , Doenças Assintomáticas/terapia , Doenças Cardiovasculares/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Gravidade do Paciente , Complicações Pós-Operatórias/mortalidade
15.
Int J Gynaecol Obstet ; 148(1): 65-71, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31593302

RESUMO

OBJECTIVE: To determine maternal outcomes for women with abnormally invasive placenta (AIP) managed using the Triple P Procedure and establish its safety as a conservative surgical management option. METHODS: A retrospective study of the outcomes of the first 50 patients who underwent the Triple P Procedure for AIP from September 2010 to May 2017 at St George's Maternity Unit. Maternity case notes and the database were reviewed to determine the volume of bleeding, procedure-related complications, hysterectomy rate, and postoperative hospitalization. RESULTS: Mean operative blood loss was 2318 mL (range, 400-7300 mL and the incidence of bladder and ureteric injuries was 2% (n=1) and 0%, respectively. Median length of hospital stay was 4 days (range, 2-8 days). Three women (6.0%) developed arterial thrombosis without any long-term complications and none of the patients required peripartum hysterectomy. CONCLUSION: The Triple P Procedure should be considered as a conservative, less risky alternative to a peripartum hysterectomy during counselling prior to surgery for women with AIP.


Assuntos
Cesárea/métodos , Tratamento Conservador/métodos , Placenta Acreta/cirurgia , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Gravidez , Estudos Retrospectivos
16.
BMJ ; 367: l6227, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31791953

RESUMO

The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.


Assuntos
Gerenciamento Clínico , Pancreatite/diagnóstico , Pancreatite/terapia , Assistência Progressiva ao Paciente/métodos , Doença Aguda , Tratamento Conservador/métodos , Drenagem/métodos , Endoscopia/métodos , Humanos
17.
Isr Med Assoc J ; 12(21): 779-784, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31814339

RESUMO

BACKGROUND: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients. OBJECTIVES: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79). METHODS: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center. RESULTS: The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines. CONCLUSIONS: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.


Assuntos
Lesões Encefálicas Traumáticas , Tratamento Conservador , Craniectomia Descompressiva , Hemorragias Intracranianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/mortalidade , Tratamento Conservador/métodos , Tratamento Conservador/mortalidade , Craniectomia Descompressiva/métodos , Craniectomia Descompressiva/estatística & dados numéricos , Feminino , Avaliação Geriátrica/métodos , Escala de Coma de Glasgow , Humanos , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/mortalidade , Israel/epidemiologia , Masculino , Prognóstico , Recuperação de Função Fisiológica , Taxa de Sobrevida
18.
J Craniomaxillofac Surg ; 47(12): 1922-1928, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810841

RESUMO

Non-surgical therapy has proved to be effective in chronic diffuse sclerosing osteomyelitis (DSO) of the mandible in children. Therefore we aimed to investigate the effect of non-surgical therapy in adult DSO patients. We included consecutive patients with DSO who received non-surgical therapy in our center. They all received occlusal splint therapy, counselling about the disease, and/or physiotherapy by a specialised team. The use of analgesics, preferably nonsteroidal anti-inflammatory drugs, was advised for symptomatic control during periods of exacerbation. Sixteen patients (11/5 female/male) aged 39.9 ± 15.0 years with DSO of the mandible were included. The mean duration of symptoms was 39.7 ± 26.3 months before referral to our center. Patients were treated with a broad range of treatments before referral. All patients underwent non-surgical treatment. In 12 patients this led to remission. Four patients still had complaints after 12 months of non-surgical therapy and started with intravenous bisphosphonate therapy. In our center, DSO of the mandible was successfully treated with non-surgical therapy, despite a long duration before referral and extensive pre-treatment. Considering this high success rate, we recommend this non-surgical approach as the first treatment option for DSO of the mandible. In case of persistence, alternative treatments such as bisphosphonates should be explored.


Assuntos
Conservadores da Densidade Óssea/uso terapêutico , Tratamento Conservador/métodos , Difosfonatos/uso terapêutico , Doenças Mandibulares/terapia , Placas Oclusais , Osteomielite/terapia , Dor/tratamento farmacológico , Periostite/terapia , Adulto , Criança , Doença Crônica , Feminino , Humanos , Masculino , Mandíbula/patologia , Doenças Mandibulares/complicações , Pessoa de Meia-Idade , Osteomielite/complicações , Dor/etiologia , Periostite/complicações , Resultado do Tratamento , Adulto Jovem
19.
Bone Joint J ; 101-B(12): 1472-1475, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31787004

RESUMO

The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction. Cite this article: Bone Joint J 2019;101-B:1472-1475.


Assuntos
Fraturas do Tornozelo/cirurgia , Traumatismos do Tornozelo/cirurgia , Moldes Cirúrgicos , Redução Fechada/métodos , Tratamento Conservador/métodos , Fixação Interna de Fraturas/métodos , Idoso , Idoso de 80 Anos ou mais , Redução Fechada/instrumentação , Tratamento Conservador/instrumentação , Estudos de Equivalência como Asunto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Ensaios Clínicos Pragmáticos como Assunto , Resultado do Tratamento
20.
Medicine (Baltimore) ; 98(49): e18255, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804358

RESUMO

RATIONALE: Unlike invasive coronary angiography and echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging allow a coronary artery fistula (CAF) comprehensive evaluation focusing on both coronary and myocardial findings. PATIENT CONCERNS: We present the case of an asymptomatic patient suspected for CAF and referred to our structure for cardiovascular evaluation. DIAGNOSIS: The patient was diagnosed a CAF without coronary artery disease on the basis of CMR and CCT. INTERVENTIONS: The patient underwent an invasive coronary angiography after which the medical staff decided not to surgically treat the CAF. Therefore, a conservative treatment was chosen with strict temporal monitoring. OUTCOMES: After less than 1 year follow-up, the patient presented stable conditions without complaints. LESSONS: Multimodal non-invasive imaging has a key role in patient assessment for disease diagnosis providing better understanding for prognosis and treatment.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Imagem Multimodal , Fístula Vascular/diagnóstico por imagem , Tratamento Conservador , Angiografia Coronária , Doença da Artéria Coronariana/terapia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Fístula Vascular/terapia
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