Acute limb ischemia (ALI) in a pediatric patient is a rare condition but may result in lifelong disability. A paucity of evidence exists to derive treatment guidelines; some surgeons advocate ...conservative management over invasive measures. The purpose of this study was to evaluate the role of surgical revascularization in the pediatric population and outcomes of conservative vs surgical management.
The Healthcare Cost and Utilization Project State Inpatient Database (California, Iowa, and New York) between 2007 and 2013 was queried using International Classification of Diseases, Ninth Revision codes. Patients were stratified into two cohorts: conservative management and surgical management. Each group was further subdivided into three age groups: infant (<24 months), child (<12 years), and adolescent (<18 years). Outcome variables included mortality, amputation status, length of hospital stay, and hospital charge.
A total of 1576 pediatric patients with ALI were identified among 6,122,535 pediatric admissions (26 per 100,000 admissions). Average age was 9.9 ± 7.1 years. There were 263 patients who underwent surgical revascularization. The conservative management group was younger (5.8 ± 6.2 vs 9.2 ± 6.1 years; P < .01). Otherwise, baseline characteristics were similar between the two groups. Overall, the amputation rate was low (<2%; n = 28), especially in the upper extremities. Outcomes of conservative management and surgical revascularization were similar for mortality (P = .34), amputation (P = .46), length of hospital stay (15.4 vs 12.9 days; P = .07), and hospital charge ($281,794 vs $288,507; P = .28). In subgroup analysis, infants had less concomitant orthopedic injury than other age groups. Children demonstrated a higher likelihood of associated upper extremity injury and operative revascularization (P < .01) than infants or adolescents. In infants, mortality was higher and surgical intervention was associated with longer hospital stay (29.5 ± 34.4 days vs 45.6 ± 31.6 days; P = .02) and larger health care expenditure ($467,885 ± $638,653 vs $1,099,343 ± $695,872; P < .01).
Pediatric ALI is a rare entity and is associated with low amputation and mortality rates. Among the pediatric age cohorts, infants with ALI are at higher risk of in-hospital mortality than older age groups are. Surgical intervention is not associated with improved limb salvage or mortality. Nonoperative management may be considered an initial treatment modality, but further research is needed to elucidate which important subset of pediatric patients benefit from open or endovascular operative intervention.
Low back pain is a musculoskeletal condition that affects many people worldwide and although there are several types of conservative treatments, either physiotherapy and/or pharmacological, the ...patient does not always obtain satisfactory results after treatment. To improve this situation, many prognostic models have been studied, developed, and validated. However, it is uncertain the available evidence about the prognostic models for predicting the success or failure of patients with low back pain after a conservative treatment.
Identify and evaluate prognostic models’ ability to predict success or failure in patients with low back pain after receiving conservative treatments.
Literature searches were conducted in three different electronic databases (MEDLINE, EMBASE and CINHAL). Prognostic models predicting the success or failure of conservative treatment in adults with low back pain were considered eligible. Studies investigating low back pain related to a severe pathology were excluded. Two independent reviewers performed the study selection and data extraction. The individual performances of the prognostic models were performed descriptively.
Searches initially retrieved 13,013 studies. After analysis considering inclusion criteria, 81 studies were included in this systematic review. Of these, 78 (96.3%) developed and internally validated the prognostic models, and only 4 (3.7%) developed and externally validated the models. Regarding the discrimination of the models studied, the c-statistics or area under the curve (AUC) ranged from 0.44 to 0.96. Regarding the calibration, the calibration slope and intercept ranged from 0.74 to 1.06 and from -0.01 to 0.34, respectively. Regarding the sensitivity and specificity of the prognostic models, there was a variation between 31.0% and 94.5% and from 14.9% to 93.7%, respectively.
Although prognostic models have been developed, discrimination and calibration, as well as specificity and sensitivity, varied significantly among them. In addition, there were few studies investigating the external validation of these models.
Although some prognostic models have been developed, validated, and are able to predict success or failure in patients with low back pain undergoing conservative treatment, necessary to implement such models in clinical practice due to the lack of evidence regarding external validation.
BACKGROUND:Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. ...Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain.
METHODS:The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score.
RESULTS:At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by −0.14 (97.5 percent CI, −9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants.
CONCLUSIONS:Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, II.
Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, ...retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively.Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16-31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury.For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up.Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation.Median follow-up of the 5 surviving children was 51 months (range: 36-160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine.Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients.All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications.In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children.
In this study, patients who were undergoing mechanical ventilation received conservative oxygen therapy (i.e., a fraction of inspired oxygen set at 0.21) or usual oxygen therapy with no specific ...limit, with a lower limit of 90% for oxygen saturation. The number of ventilator-free days did not differ significantly between the two groups.
Much of the literature describing treatment for thoracoabdominal aortic aneurysm (TAAA) consists of operative series reported by centers of excellence. These studies are limited by referral and ...selection bias and exclude patients who are not candidates for the reported modality of repair. Little is known about the patients who are not referred or selected for repair. For those undergoing intervention, outcomes such as functional status after surgery are rarely reported. In this study, we address these gaps by reporting two primary end points: 1-year survival and a “good” outcome (defined as successful aneurysm exclusion, freedom from permanent loss of organ system function, and return to preoperative functional status after surgery) in a cohort of TAAA patients, including all nonoperative and operative patients, irrespective of treatment modality.
A single-institution database was screened by diagnosis codes for TAAA from 2009 to 2017 using the International Classification of Diseases versions 9 and 10. Diagnosis was confirmed by retrospective chart review and computed tomography findings of aneurysmal degeneration ≥3.2 cm of the paravisceral aorta in continuity with aneurysmal aorta meeting standard criteria for repair. Patients <18 years of age and those with mycotic aneurysm were excluded. Patients were either managed nonoperatively or by one of four operative strategies: (i) open; (ii) endovascular with branched endografts; (iii) hybrid, defined as iliovisceral debranching followed by endograft placement; or (iv) partial repair in which the paravisceral segment was intentionally left unaddressed.
Among the entire cohort of 432 patients with TAAA, significant comorbidities were seen in 143 (33%). Forty-seven percent of the patients were managed nonoperatively. Of these, 65% survived to 1 year. A survival benefit was seen in the open, endovascular, and partial, but not hybrid, operative groups compared with the nonoperative group during a 3-year period. Overall 1-year survival was 81%, but only 65% had a good outcome (P = .0016).
Nearly half of the patients in this inclusive cohort study did not undergo repair despite access to a variety of operative techniques. Many of these patients die in the short term due to high burden of comorbid disease rather than aneurysm rupture. Among those undergoing operation, a notable difference between survival and good outcome was observed. Operation appears to confer a survival advantage among appropriately selected patients with TAAA, but a large proportion are high risk and may not benefit from operative repair due to limited baseline survival and lower probability of good outcome.
This study aimed to evaluate the efficacy of comprehensive hysteroscopic evaluation and lesion resection combined with progestin therapy in young patients with endometrial atypical hyperplasia (EAH) ...and early stage endometrial cancer (EEC) who wished to preserve their fertility.
Patients with EAH (n = 120) or well-differentiated EEC (n = 40, FIGO stage IA, without myometrial invasion) were retrospectively included. All patients received constant oral progestin combined with hysteroscopic evaluation every 3 months until achieving complete response (CR). The location, number and size of each suspected lesion or cluster were detailly recorded during the hysteroscopy.
The median age was 32.0 year-old (range, 22–47 year-old). Totally 148 patients (97.4%) achieved CR while 3 EAH and 1 EEC patients presented with disease progression, and 8 patients were still in treatment. The mean treatment duration for achieving CR was 6.7 ± 0.3 months (range, 1–18 months). After adjusting for patient age, body mass index (BMI), history of pregnancy and type of conservative therapies, lesion size ≤2 cm (OR, 0.701; 95% CI, 0.496–0.991; P = 0.045) was significantly correlated with shorter treatment time to achieve CR. Among 60 patients attempted to conceive after achieving CR, 45.0% (15/60) had been pregnant, 25.0% (15/60) delivered live birth, 13.3% (8/60) are still in pregnancy, while 6.7% experienced spontaneous abortion.
Comprehensive hysteroscopic evaluation and lesion resection plus progestin therapy seem to be an effective and safe fertility sparing therapy for patients with EAH or EEC. Endometrial lesion size ≤2 cm correlated with a shorter treatment period to achieve CR.
•Mean treatment duration to achieve CR was 6.7 ± 0.3 months, using progestin therapy combined with hysteroscopic evaluation.•Endometrial lesion size ≤2 cm correlated with a shorter treatment period to achieve CR.•Comprehensive hysteroscopic evaluation seems to be effective for EAH and EEC patients who wish to preserve fertility.
Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center ...are evaluated and a review of the literature is presented.
A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed.
Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio OR, 1.45; 95% confidence interval CI, 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed.
A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.
PDF
