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Introduction: Urinary incontinence (UI), especially stress UI, is common after prostatectomy. Penile compression devices (PCDs) may be a safe, tolerable option for conservative management in men who are not candidates for or not interested in surgical intervention for their UI. Areas covered: This article examines the epidemiology of post-prostatectomy urinary incontinence (PPI), and options for management. All available studies on PCDs are explored, including those on biomechanics, safety, tolerability, and user experience. History, availability of PCDs, and areas for future development are discussed. Expert opinion: PCDs are an option for conservative management of PPI. They are recommended for those men without impairment in cognition, dexterity, or sensation. They should be worn for short periods of time and are best used during situations when incontinence might be precipitated. Overall, data suggest they are well tolerated and effective when tested, but large randomized comparative trials and studies of long-term use with relevant patient reported outcome measures are lacking. More studies are needed on commercially available PCDs. Biomechanical studies suggest that there are superior designs and materials both for efficacy and tolerability. With an aging population, and more older men going for prostate surgery, a larger market for these devices is likely. [ABSTRACT FROM AUTHOR]

Background: An estimated 40% of all traumatic brain injury (TBI) occurs in ≥70-year-olds with a high prevalence of traumatic subdural haematoma (tSDH). It is anticipated that an expanding elderly population will lead to a proportional increase in the incidence of patients with tSDH presenting to UK trauma centres, but the long-term clinical outcomes and factors influencing functional outcomes in this patient group remain poorly understood. Aim: To examine the management and clinical outcomes for elderly (≥70 years) patients diagnosed with tSDH. Methods: Patient data for this single-centre, retrospective cohort study were analysed from a Major Trauma Centre (MTC) electronic patient records between January 2013 and December 2019. Results: Two hundred and eighty patients were included, 43% aged 70-79, 42% aged 80-89 and 15% >90. In total, 37% underwent a surgical intervention. The 6-month survival in the severe, moderate, and mild TBI groups was 14%, 43%, and 67%, respectively. The 6-month survival in the surgical group was 58%, vs. 60% in the conservatively managed group. Surgical intervention did not significantly impact Extended Glasgow Coma Score (GOS-E) at 6 months, regardless of injury severity. Advanced age (p = 0.04), mixed intracranial injuries (p < 0.0001), craniotomies (p = 0.03), and poor premorbid performance status (p = 0.02) were associated with worse survival and functional outcomes. Conclusions: Our study demonstrated that increasing age, increasing severity of TBI and poorer premor-bid performance status were associated with significantly poorer 6-month survival and functional outcomes in elderly patients with tSDH. Burr hole evacuation was associated with better functional outcomes compared to craniotomy, but overall, there was no significant difference in the outcomes of the surgical and non-surgical groups. We identified strong risk factors for death and poor functional outcomes at 6-months which are important to consider when counselling patients and families about the long-term prognosis of elderly patients with tSDH and can help guide clinical decision-making. [ABSTRACT FROM AUTHOR]

Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR. Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice. Experts agree effectiveness of interventions differs through the evolution of LR. To date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition. Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication. Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered. Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity. [ABSTRACT FROM AUTHOR]

We report a case of traumatic C3-C4 disc prolapse in a 58 years old male, who underwent ACDF at our centre. On the third post-operative day, a hypopharyngeal rent with implant exposure was discovered. The patient suffered aspiration pneumonitis. He was tracheostomised and percutaneous endoscopic gas-trostomy (PEG) feeding was started. He was managed conservatively with appropriate antibiotics and physiotherapy. He recovered and after 6 months the PEG was removed and oral feeding resumed. He was doing well 42 months after the initial surgery. [ABSTRACT FROM AUTHOR]

Simultaneous bilateral shoulder dislocations are extremely rare occurrences and are rarely associated with exercise. We present an unusual case of bilateral simultaneous shoulder dislocation which occurred during an unsupervised Pilates Reformer exercise session. A 41-year-old female felt sudden severe pain and forward displacement in both shoulders during abduction and external rotation. Bilateral anterior shoulder dislocation was confirmed with initial X-rays in the emergency department. Spontaneous reduction of the right shoulder was observed in the emergency room and then the left side was reduced under general anesthesia. Physical therapy modalities, exercises for shoulder girdle and core strength were implemented as conservative management. The patient returned to desk work and had pain-free range of motion with satisfactory strength on both sides in the fourth week and performed daily life activities without any symptoms in the tenth week. This case highlights the importance of training under supervision of an exercise instructor, even if it is considered a "so-called safe" exercise method. [ABSTRACT FROM AUTHOR]

Gallstone diseases impose a significant economic burden on the health care system; thus, determining cost-effective management for gallstones is essential. We aim to estimate the cost-effectiveness of cholecystectomy compared with conservative management in individuals with uncomplicated symptomatic gallstones or cholecystitis in India. A decision-analytic Markov model was used to compare the costs and QALY of early laparoscopic cholecystectomy (ELC), delayed laparoscopic cholecystectomy (DLC), and conservative management (CM) in patients with symptomatic uncomplicated gallstone/cholecystitis from an Indian health system perspective. Incremental cost-effectiveness ratio (ICER) was calculated. One-way and probabilistic sensitivity analyses were performed to test parameter uncertainties. ELC and DLC, compared to CM, incurred an incremental cost of -₹10,948 ($146) and ₹1,054 ($14) for the 0.032 QALYs gained. The ICER was -₹3,42,758 ($4577) for ELC vs. CM, and ₹33,183 ($443) for DLC vs. CM, suggesting ELC and DLC are cost-effective. ELC saved ₹12,001 ($160) for 0.0002 QALYs gained compared to DLC, resulting in an ICER of -₹6,43,89,441 ($8,59,733). The results were robust to changes in the input parameters in sensitivity analyses. ELC is dominant compared to both DLC and CM, and DLC is more cost-effective than CM. Thus, ELC may be preferable to other gallstone disease managements. [ABSTRACT FROM AUTHOR]

Aim of the study: This article reports on a series of patients with placenta accreta spectrum (PAS) disorder who were treated conservatively with Methotrexate (MTX) administration with or without embolization. We investigate whether there is a place for MTX in conservative treatment of PAS. Methods: We present a single-center retrospective case series of five patients. In all patients, diagnosis was unexpected and not made prenatally. Conclusion: The benefits should be weighed against the possible drug toxicity. Today high-quality evidence is lacking. PAS covers a broad spectrum of pathology, standardization in prenatal and postnatal diagnosis can help to compare evidence on treatment. [ABSTRACT FROM AUTHOR]

To compare maternal and perinatal outcomes between randomized trials and observational studies in which conservative management was performed for more than 48 h in patients with early-onset severe preeclampsia. We searched PubMed, LILACS, Cochrane and Google Scholar. The studies were divided in two groups: randomized and observational studies, from 1990 to 2018 that included patients with severe preeclampsia before 34 weeks of gestation with pregnancy prolongation ≥48 h but that did not include fetal growth restriction or HELLP syndrome at the beginning. The main variables recorded were maternal and perinatal complications. Forty-four studies met the inclusion criteria, and 5 of these were randomized. The average pregnancy prolongation was 9 days, with no difference between groups. Maternal complications were significantly more common in observational studies, RR = 0.71, 95% CI (0.54–0.93), p =.009. Perinatal complications were also significantly more common in observational studies (RR = 0.89, 95% CI (0.80–0.98), p =.01) at the expense of stillbirth and neonatal deaths. The percentages of cesarean sections were significantly higher in randomized studies, RR = 1.54, 95% CI (1.46–1.64). There were 2 maternal deaths, both in observational studies. Observational studies in which conservative management of early-onset preeclampsia is performed and do not include patients with fetal growth restriction or patients with HELLP syndrome and where at least 2 days of pregnancy prolongation is achieved are associated with significantly more maternal and perinatal complications. [ABSTRACT FROM AUTHOR]

To present the success rate of nonsurgical management of full-thickness inflammatory macular hole (IMH) Retrospective case series of five patients with IMH. Five eyes from five patients with IMH enrolled in the current case series. All five eyes had successful closure with corticosteroid in the form of topical, periocular, or intravitreal injections. Systemic immunomodulatory treatment was employed for two patients, in addition to local therapy. For local therapy, one patient received topical eye drops, subtenon injection of corticosteroid, and intravitreal injection of combination of corticosteroid and anti-VEGF was performed in two patients. The closed macular hole reopened in one patient after two years, which required pars plana vitrectomy and anatomical and visual success achieved. Inflammatory macular holes can be closed with non-surgical interventions, although reopening may occur which requires surgery. [ABSTRACT FROM AUTHOR]

To evaluate the impact of different ultrasound signs in the management and the role of ultrasound guidance in the surgical evacuation of partial placental tissue retention. This is an observational cohort study and retrospective case assessment of 82 patients with clinical symptoms of partial placental retention following a third trimester singleton livebirth between January 2013 and May 2019. The ultrasound signs were recorded using a standardized protocol and the outcome of the management strategy and the use of ultrasound guidance during any surgical procedure was evaluated. Out of the 64 patients who had a vaginal birth, 25 (39.1%) had a manual removal of the placenta at delivery. Fifteen patients were confirmed as not having retained placental tissue and did not require further treatment. Four patients were referred after failed surgical management and four after failed conservative management. All surgical procedures were vacuum aspiration and forceps removal under continuous ultrasound guidance. A significantly lower gestational age at delivery (p <.05), shorter interval between delivery and ultrasound diagnosis (p <.05) and lower number of patients presenting with heavy bleeding was found in the conservative compared to the surgical management subgroups (p <.05). The incidence of feeding vessels was significantly (p <.05) higher in the surgical than in the conservative management subgroups and associated with increased myometrial vascularity. Six patients developed intra-uterine adhesions. In four of these cases, ultrasound examination showed a hyperechoic mass surrounded by normal myometrial vascularity and no feeding vessel. Ultrasound imaging accurately differentiated between patient with and without partial placental retention after third trimester livebirth. Ultrasound-guided vacuum aspiration is safe and efficient in these cases. [ABSTRACT FROM AUTHOR]

To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta. In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal–neonatal outcomes. In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar. Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved. [ABSTRACT FROM AUTHOR]

Endometrial cancer is the most common gynecologic malignancy in developed countries, with increasing incidence among younger, nulliparous patients. These epidemiological shifts are attributed to increasing rates of obesity, in combination with delayed childbearing. This highlights a need for fertility-sparing options for individuals who wish to delay standard surgical management with hysterectomy, bilateral salpingoophorectomy, and assessment of pelvic/para-aortic lymph nodes. Careful consideration should be taken to select which patients are suitable candidates for fertility-sparing methods. Typically, these are patients found to have FIGO grade 1 tumors of the endometrioid subtype without myometrial invasion. Currently, conservative treatment options include the use of oral progestins and levonorgestrel-releasing intrauterine devices, with an emerging role for hysteroscopy for direct visualization of the uterine cavity, targeted tissue sampling, and tumor resection. This paper aims to highlight the role of office hysteroscopy for diagnosis, hysteroscopic tumor resection, and follow-up in suitable endometrial cancer patients who wish to preserve their uterus until childbearing is complete. [ABSTRACT FROM AUTHOR]

Intrauterine balloon tamponade (IUBT) is an established fertility-sparing and life-saving treatment for postpartum haemorrhage. However, high-level evidence is lacking for specific aspects of its use. Our aim was to evaluate a large case series of IUBT to inform evidence-based clinical practice. 296 cases of IUBT over a three-year period at a tertiary obstetric referral centre were identified and reviewed. Demographic, clinical, and procedural outcome measures were collected; including rates of success and failure of IUBT, duration of tamponade, and complications. IUBT was successful in 265 (90%) of women and failed in 18 (6%). All failures occurred within six hours of balloon insertion. Once deemed stable and successful at six hours, no women required return to theatre or further intervention. The mean duration of intrauterine balloon tamponade was 18.5 hours. A large variance in clinical practice exists including duration of intrauterine balloon tamponade, and method and timing of removal. A number of changes informed by the results will be introduced and prospectively audited to improve IUBT use. What is already known on this subject? Intrauterine balloon tamponade (IUBT) is an important second-line treatment option in severe postpartum haemorrhage (PPH). IUBT is easy to use, is effective especially in the setting of uterine atony, and is associated with minimal complications. What the results of this study add? This study confirms the high rate of success for IUBT in controlling PPH. We found that after six hours, if deemed successful, it is rare that further intervention is required. In addition, tamponade beyond 12 hours, gradual or incremental deflation of the balloon, and antibiotic cover beyond the duration of tamponade are unlikely to yield any further safety benefit. What the implications are of these findings for clinical practice and/or further research? Our findings suggest that women should not be required to fast for balloon removal; removal of the balloon should occur by 12 hours if deemed stable and adequately resuscitated; deflation and removal of the balloon can occur at once; and antibiotics should be ceased after balloon removal. These will allow women to mobilise and recover sooner, and improve flow and throughput in our high-acuity care areas. [ABSTRACT FROM AUTHOR]

Aim: This randomized prospective pre-post test, single-subject, case series (NCT04094389) feasibility study evaluated the feasibility of conducting a clinical trial to compare the effect of three different trigger finger orthotic daily wear schedules on digital triggering and pain level in adults with trigger finger. Methods: Nine participants enrolled through convenience sampling were randomly assigned to a wear group: continuous, sleeping, or waking. Descriptive statistics were utilized to describe participant demographics and examine the data for changes across the six to ten weeks of study. Results: The study successfully obtained feasibility data regarding participant recruitment rate, demographics, methods as well as orthotic wear comfort, functionality, adverse effects and wearing compliance. The rate of recruitment was 1.9 participants per month. Conclusions: The results suggest it is feasible to perform a RCT, though recruitment was challenging. Recruitment for a RCT may be facilitated by broadening the inclusion/exclusion criteria to obtain participants. [ABSTRACT FROM AUTHOR]

Greater trochanteric pain syndrome (GTPS) is an umbrella term used to describe several pathologies contributing to lateral hip pain. The most prevalent pathology is gluteal tendinopathy. Conservative management of GTPS is predominantly now focused on the use of corticosteroid injections (CSIs) and gluteal exercises. To compare CSIs and gluteal exercises on pain in adults with GTPS. A systematic search of AMED, CINAHL, MEDLINE, EMBASE, TRIP and the Cochrane Library was conducted from inception to January 2021. Critical appraisal was completed using the Critical Appraisal Skills Programme tool. Data were extracted to obtain population characteristics and procedural details. Seven articles met the eligibility criteria out of a total of 336; five articles were randomised control trials (RCT) and two were cohort studies, equivalent to 758 and 70 participants, respectively. Studies generally reported significant benefits of CSIs <12 weeks and gluteal exercises >8 weeks for the reduction in lateral hip pain (p <.05). Critical appraisal demonstrated varied study quality and significant heterogeneity. CSIs appear to be a successful treatment intervention in the short-term to decrease lateral hip pain but not in the long-term. Gluteal exercises plus education on avoiding tendon compression appears to be as successful as CSIs in the short and superior in the long-term. [ABSTRACT FROM AUTHOR]

Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders. [ABSTRACT FROM AUTHOR]

Pneumolabyrinth, defined by the presence of air in the labyrinth, is a rare clinical finding that can occur as a result of middle ear trauma, such as a traumatic injury with Q-tips. We report the case of a patient that presented to the emergency department with vertigo and hearing loss complaints after aural cleansing with a Q-tip. On examination, the left tympanic membrane was perforated and there were signs of left vestibulopathy. A high-resolution CT scan was performed, and it showed the presence of air in the inner ear. Conservative management, instead of a surgical approach, was performed, with overall good vestibular and hearing outcomes. There is no clinical consensus on the best treatment of pneumolabyrinth, since, even with surgery, outcomes, mainly hearing outcomes, are usually poor. Nevertheless, surgery is usually reserved for patients with incapacitating vertigo or worsening hearing loss. [ABSTRACT FROM AUTHOR]

In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean–hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta in situ, thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature. [ABSTRACT FROM AUTHOR]

Background: External auditory canal (EAC) cholesteatoma (EACC) is rare and its treatment for different lesions has not yet been standardized. Objective: This study aimed to explore the clinical features of EACC with bone erosion, and to assess the curative effect of initial complete cholesteatoma debridement (ICCD). Material and methods: Clinical characteristics and prognosis of 41 ears were analyzed retrospectively. Results: The bone erosion of the EAC was most commonly affected on the posterior wall (37 ears), next by the inferior wall (34 ears), the anterior wall (30 ears) and the superior wall (23 ears). Hearing loss (36 ears) was the most common symptom, followed by otalgia (33 ears), otorrhea (18 ears), tinnitus (11 ears) and pruritus (3 ears). The hearing impairment of mean air conduction and air-bone gaps were improved from 39.2 dB to 22.7 dB, and 23.5 dB to 7.1 dB after the ICCD procedure, respectively. Four ears presented recurrence during the follow-up time and accepted a revision-debridement. Conclusion and significance: The ICCD might be applicable in the treatment of patients in the early stages and with non-extensive bone defect; however, close and long-term surveillance is essential and serial debridement is probable. [ABSTRACT FROM AUTHOR]

Study Design: Systematic review. Background: Existing systematic reviews and meta-analyses do not support a specific physical therapy treatment for lateral elbow tendinopathy (LET). The results of these studies, however, may not accurately represent the current state of evidence. This may be due, in part, to methodological limitations in these studies, specifically the lack of utilization of standardized and disease-specific outcome measures. Objectives: To determine the effectiveness of physical therapy interventions in treating chronic lateral elbow tendinopathy as assessed in randomized controlled trials (RCTs) using pain-free grip strength and/or patient-rated tennis elbow evaluation questionnaire as outcome measures. Methods: A search of PubMed, Physiotherapy Evidence Database (PEDro), Scopus database, Google Scholar and bibliography was conducted from inception to November 2018. The methodological quality of the identified RCTs were assessed using the PEDro scale and the modified Sackett scale was used to appraise findings based on the level of evidence. Results: A total of two thousand nine hundred and six citations were identified, however, only twenty-two RCTs matched the eligibility criteria and were included in the review. The identified studies varied in design, investigated diverse physical therapy modalities that were applied for dissimilar periods, assessed outcome measures at unalike periods, and showed inconsistent results. Conclusion: A rigorous review of literature showed insufficient evidence to support or refute the effectiveness of many of the current physical therapy interventions for chronic LET. Nevertheless, the results might suggest immediate efficacy of mobilization with movement of the elbow joint and short-term efficacy of myofascial release technique. Level of evidence: Therapy, level 1a- [ABSTRACT FROM AUTHOR]

We present a case of spontaneous 79% regression in the size of a vestibular schwannoma (VS). A 41-year-old lady with a large (36 mm) vestibular schwannoma underwent serial follow-up MRI scans which demonstrated the shrinkage over 9 years; the highest relative spontaneous regression recorded in the literature for vestibular schwannoma of this size. [ABSTRACT FROM AUTHOR]

Female pelvic floor muscles form a diaphragm that spans the entire pelvic cavity. They consist of the fibers of the coccygeus and the levator ani muscles, the latter of which is composed of five parts. Together with their fascia, the pelvic floor muscles provide support for the urethra, the vagina, and the rectum and constrict the urethral, vaginal, and anal orifices. Alterations in the composition of the pelvic floor muscles at menopause appear to affect their properties and, thereby, their ability to function adequately. This can lead to an increased prevalence in urinary incontinence and other lower urinary tract dysfunction, pelvic organ prolapse, and genitourinary syndrome of menopause. This article aims to define the pelvic floor muscles and functions and to summarize the direct and indirect changes to women's pelvic floor muscles during and after menopause and through aging. A particular focus is also given to the evidence-based literature on how to keep pelvic floor muscles healthy during menopause and in postmenopause using conservative management therapy. [ABSTRACT FROM AUTHOR]

Introduction: Congenital muscular torticollis (CMT) is a neck deformity that involves unilateral shortening of the sternocleidomastoid (SCM). Conservative physiotherapy management of CMT is primarily focused on stretching the affected SCM. However, there is limited research evidence on the use of stretching to improve the extensibility of SCM in infants with CMT. Aim: To investigate the effectiveness of stretching for infants with CMT. Method: A systematic search of AMED, CINAHL, MEDLINE, EMBASE, Physiotherapy Evidence Database (PEDro) and Cochrane Library was conducted during the period 2011–2018. Results: Seven articles that met eligibility criteria were reviewed out of a total number of 415 articles that were screened; two articles were randomised control trials and five were cohort studies. The studies typically reported statistically significant benefits of stretching for the restoration of cervical range of movement and SCM thickness (p < 0.05). Appraisal of the studies revealed varied quality. Conclusion: The results suggest that stretching is an effective treatment intervention for the management of infants with CMT and early physiotherapy referral can lead to decreased treatment duration. However, due to a variation in study quality; additional high-quality research is needed to help formulate more robust conclusions. [ABSTRACT FROM AUTHOR]

Intracranial lipomas are rare, benign lesions, of congenital origin commonly found incidentally on imaging studies. We describe a case of interpeduncular lipoma in an 18 year-old female presenting with a painful left complete oculomotor (IIIrd) nerve palsy and associated headache, which to the best of our knowledge has not been reported in an adult patient. Following eye patching and steroid treatment, at 6-week follow-up the patient's pain had significantly improved however the complete IIIrd nerve palsy remained. Evidence suggests improvement will occur regardless with conservative management independent of radiological changes to the lipoma. [ABSTRACT FROM AUTHOR]

There is no doubt that organised cervical screening programmes have significantly reduced the rates of cervical cancer by detection and treatment of high-grade cervical intraepithelial neoplasia (CIN2, CIN3). National UK guidelines do not differentiate between CIN2 and CIN3 as separate entities and recommend treatment for both, although a degree of uncertainty exists regarding the natural history of CIN2. This national survey of British Society for Colposcopy and Cervical Pathology members aimed to assess attitudes towards conservative management (CM) of CIN2 in the UK and identify potential selection criteria. In total, 511 members responded (response rate 32%); 55.6% offered CM for selective cases; 12.4% for all cases; 16.4% had formal guidelines. Most agreed age group was >40yrs (83%), HPV 16/18 positive (51.4%), smoking (60%), immuno-compromise (74.2%), and large lesion size (80.8%) were relative contraindications for CM. 75.9% favoured six-monthly monitoring, with 80.2% preferring excisional treatment for persistent high-grade disease. Many UK colposcopists manage CIN2 conservatively without formal guidelines. Potential selection criteria should be investigated by a multicentre study. Impact statement Although anecdotally some colposcopists manage many women with CIN2 conservatively, this National Audit of British Society for Colposcopy and Cytopathology members, we believe, is the first time this has been formally recorded. The survey assesses current attitudes towards conservative management (CM) of CIN2 and seeks to identify potential selection criteria that could be used to identify suitable women. It received over 500 responses and significantly, identified many colposcopists recommending CM of CIN2 for patients despite the lack of any formal guidance regarding this approach. The greater majority of respondents were keen to consider participating in a multicentre trial on CM of CIN2 targeting the UK screening population (25-64 years). The paper has international relevance as ACOG and ASCCP have recently changed their guidance for the management of CIN2 in younger women and now recommend CM with monitoring rather than first line ablative or excisional treatment due to concerns regarding overtreatment, especially in women who have not yet completed their family. [ABSTRACT FROM AUTHOR]

The objective of this article is to provide an informative and narrative review for the general Gynaecologist regarding the pathophysiology and conservative treatments available for faecal incontinence (FI). A PubMed search was performed by library staff and an author using the keywords: anal incontinence, faecal incontinence, accidental bowel leakage, outpatient clinic management of faecal incontinence and defecatory dysfunction. As the social limitations of FI can be devastating and long-term patient satisfaction rates after anal sphincteroplasty remain reportedly-low, the role of clinic-based management of FI has continued to grow. The purpose of this article is to provide the Obstetrician and Gynaecologist with a basic template for screening, evaluation and management of faecal incontinence in the clinical setting. [ABSTRACT FROM AUTHOR]

Endometriosis can affect up to 10% of women of reproductive age, in a wide range of clinical presentations that vary from mild to severe or deep endometriosis. Deep endometriosis can affect the urinary tract in 1–5% to 15–25% cases. Even though deep endometriosis’ surgeries are usually complex with higher rate of complications, conservative management is not always considered as an option because of its high failure rates. This paper describes two cases of deep endometriosis with ureteric involvement (hydronephrosis) treated conservatively with a double-pigtail stent plus a Levonorgestrel intrauterine device, after conservative surgery, who remained symptom free with no evidence of recurrence at 3 years follow-up, avoiding radical high-risk surgery.Impact statementSeveral treatments have been described for endometriosis. From a symptomatic perspective, conservative medical management has been proposed with a variable response. Concerning deep endometriosis (affecting the urinary or digestive tract), the definitive treatment has always been thought to be radical surgery. However, this can lead to several complications.To illustrate a possible more conservative approach this paper describes two cases of deep infiltrating endometriosis affecting the ureter, treated conservatively with a temporary pigtail ureter stent plus a Levonorgestrel intrauterine device. The management demonstrates that, in a selected population, conservative treatment solves the urinary disease avoiding the surgical complications and, what is more, improving patients’ symptoms in a permanent way.Further prospective studies are needed to confirm whether the introduction of this management in clinical practice would reduce the need for surgery thereby, avoiding high-risk surgery and improving the success rate of conservative management. [ABSTRACT FROM PUBLISHER]

This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were managed conservatively, except in one case in which the patient requested surgery because she also wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective and all the surgical procedures were initiated laparoscopically. There were seven complications in the surgically managed group: conversion to laparotomy (n = 3), bowel injury (n = 2), bladder injury (n = 1), and wound infection (n = 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5 years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive complications, it may also be the cause of both adhesions and complications, resulting in a vicious cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may be better managed without treatment.Impact statementIn this study we try to find an answer for the question of “Should removal of a translocated intrauterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?” From only the theoretical point of view there were some reports supporting conservative management in asymptomatic patients. The other studies addressing this issue were case reports including few patients with a short-term follow-up. The novelties of the present study include multi-centre design, detailed clinical and surgical information about the patients and the long period of follow-up.Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook this study with the aim of providing a perspective about patients with TIUD for those faced with this situation.This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients were managed conservatively, and symptomatic patients were operated. There are important implications resulting from this study that in asymptomatic patients leaving the IUD in place may be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate of complications with surgical management. [ABSTRACT FROM PUBLISHER]

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder without the presence of gallstones. In children with malignancies or chemotherapy-induced neutropenia, AAC is very rare. Clinical diagnosis of AAC remains difficult in this patient population but an early recognition followed by an appropriate intervention may confer a benefit. Only three pediatric patients with underlying hematological malignancies whose clinical treatment course was complicated by the development of AAC have been described. We describe a neutropenic pediatric patient who developed AAC following chemotherapy for acute T-cell acute lymphoblastic leukemia (T-ALL), which was successfully managed with conservative treatment. Abbreviations:AAC: Acute acalculous cholecystitis; T-ALL: T-cell acute lymphoblastic leukemia; TPN: Total parenteral nutrition [ABSTRACT FROM PUBLISHER]

Objective:The aim of this study was to evaluate the risk factors and treatment options for ureteroenteric strictures (UES) following radical cystectomy (RC) and ileal conduit (IC) formation, and specifically to comment on the conservative management of UES in asymptomatic patients. Materials and methods:The datasheets were reviewed of 304 consecutive patients who were treated with an RC and IC between January 2001 and May 2011 in a Belgian tertiary center and who followed a strict follow-up protocol. Long-term treatment outcomes were retrospectively analyzed. Results:Twenty-two patients (7.2%) were diagnosed with UES (affecting 27 ureters in total), when a new-onset hydroureteronephrosis or increase of the pre-existing hydroureteronephrosis was detected by ultrasound or computed tomography. A retrograde loopogram was then performed to confirm the UES. The mean follow-up time was 33 months. A decline in renal function, the presence of flank pain and urinary tract infections were indications for interventional treatment. Six patients underwent double-J stent placement, two patients received percutaneous nephrostomies as a definitive treatment and two patients underwent ureterointestinal reimplantation. Asymptomatic patients with a UES and a favorable renal function were conservatively managed. They remained asymptomatic during follow-up and required no active treatment. Conclusions:No clinical variable was independently associated with an increased risk of UES. These long-term data suggest that a selected patient population of asymptomatic patients with good renal function at the time of UES diagnosis can be safely managed conservatively. [ABSTRACT FROM AUTHOR]

Background: Conservative management is often the first-choice treatment for baseball players with disabled throwing shoulder (DTS). Considering the high popularity of baseball in Japan, we suspected that there might be some evidence regarding this topic in the Japanese-language literature. Objective: This study aimed to systematically review Japanese-language primary studies investigating the effectiveness of conservative management for DTS in baseball. Methods: Eight databases were systematically searched from inception to 7 April 2016. Data on authors, publication years, sample characteristics, types of interventions, outcome measures and results were extracted. Data were synthesised qualitatively. Results: Seven studies with low evidence level and low-to-moderate study quality were included. Interventions examined in the included studies were downward throwing, combined physiotherapy interventions and joint distension. Forming correction, stretching for posterior shoulder muscles and strengthening exercises to improve scapular/trunk stability were commonly used in combined physiotherapy interventions. Downward throwing and combined physiotherapy interventions corresponded with expert opinions described in the English-language literature. Due to the lack of studies with high level of evidence, however, it was difficult to determine the genuine effects of these interventions. Conclusion: Our systematic review found limited evidence about the effectiveness of any conservative management for baseball players with DTS. Although downward throwing and combined physiotherapy interventions might be appropriate management in some cases, further studies of higher level of evidence and greater methodological rigour are required. [ABSTRACT FROM AUTHOR]

This is a systematic review for evaluating failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) following radiological or conservative surgical interventions for abnormally invasive placenta (AIP). Twelve cohort studies and 8 case series or case reports were included. The cumulative outcomes showed success rates of 159/177 (89.8) for arterial embolisation, a secondary hysterectomy in 20/177 (11.3%), a subsequent menstruation in 74/85 (87.1%) and a subsequent pregnancy in 3/10 (30%). Artery occlusion balloon presented a success rate of 33/42 (78.6%), and a secondary hysterectomy presented that of 8/42 (19%). Uterus-preserving surgery showed a success rate of 48/76 (63.2), a secondary hysterectomy in 23/76 (30%), maternal mortality in 2/54 (3.7%), a subsequent menstruation in 20/37 (81.1%) and a subsequent pregnancy in 21/27 (77.8%). This review indicates that different uterine-sparing radiological and surgical techniques may be effective in managing AIP in select patients. [ABSTRACT FROM AUTHOR]

Background: Currently over 55% of end-stage renal disease (ESRD) patients are aged ≥60 years and patients >75 years represent the fastest growing segment of the dialysis population. We aimed to assess whether the Groningen frailty indicator (GFI) can be used to distinguish fit older ESRD patients, likely able to tolerate and benefit from dialysis, from frail older patients who need further evaluation with a geriatrician’s comprehensive assessment.Methods: All patients aged ≥65 years visiting the pre-dialysis unit at the Gelre hospital between 2007 and 2013 were included and underwent the GFI (n = 65). Patients with GFI ≥ 4 (frail) were referred for geriatric consultation (n = 13). Results of the GFI and nephrologists’ evaluation were compared with geriatrician’s assessment. Survival rates and outcomes after one year of follow up were recorded.Results: Twenty patients (32%) were identified as frail. Of the problems identified by the geriatrician in 13 patients, 55% were not reported in the nephrologists’ notes. The first year after inclusion, 30% of patients with a GFI ≥ 4 died, compared to 9% of fit patients (p = 0.04). Moreover, 90% of frail patients had been hospitalized one or more times, compared to 53% in the fit group (p = 0.005).Conclusion: Although the GFI can be a useful instrument to identify ESRD patients at risk, both the GFI and the nephrologists’ assessment failed to identify specific geriatric impairments. Further research is needed to develop a specific frailty indicator for ESRD patients and to determine the value and effect of a comprehensive geriatric assessment in ESRD patients. [ABSTRACT FROM PUBLISHER]

We aimed to investigate whether conservative management of preterm premature rupture of membranes (PPROM) at 32–34 weeks’ gestation improves outcome. In this retrospective analysis of singleton pregnancies, the study group included patients with PPROM at 28–34 weeks’ gestation and the control group included patients presented with spontaneous preterm delivery at 28–34 weeks’ gestation. Both groups were subdivided according to gestational age – early (28–31 weeks’ gestation) versus late (32–34 weeks’ gestation). Adverse neonatal outcome included neonatal death, intraventricular haemorrhage grade 3/4, respiratory distress syndrome, periventricular leucomalacia and neonatal sepsis. The study and control groups included 94 and 86 women, respectively. The study group had a lower incidence of adverse neonatal outcome at the earlier weeks (28–31), compared with the control group at the same gestational age. In contrast, at 32–34 weeks’ gestation no difference in the risk for adverse neonatal outcome was noticed. Additionally, within the study group, chorioamnionitis rate was significantly higher among those who delivered at 32–34 weeks’ gestation (p< 0.01). No advantage for conservative management of PPROM was demonstrated beyond 31 weeks’ gestation. Moreover, conservative management of PPROM at 32–34 weeks’ gestation may expose both mother and neonate to infectious morbidity. [ABSTRACT FROM PUBLISHER]

Foetal membranes bulging into the abdominal cavity is a unique initial manifestation of silent or complete uterine rupture during pregnancy. Since silent uterine rupture has potential risk for complete uterine rupture, which leads to acute life-threatening complications for both the mother and baby, it is difficult to determine whether to manage expectantly or surgically, including repair of the uterine wall or termination of the pregnancy, especially in the early second trimester. We present here a case of a herniated amniotic sac with overstretched uterine wall of the fundus presenting as silent uterine rupture, which was incidentally detected on routine ultrasonography at 18 weeks' gestation in a 38-year-old primigravida with a history of myomectomy for diffuse uterine leiomyomatosis. Magnetic resonance imaging examination revealed that the myometrium thickness was fully maintained at the site of the foetal membranes ballooning. The pregnancy was therefore managed expectantly and continued to successful delivery at 30 weeks' gestation. The precise assessment of the uterine wall may be essential to manage a herniated amniotic sac presenting as silent uterine rupture and to optimise the outcome of the pregnancy. We review all cases of a herniated amniotic sac out of focally overstretched uterine wall before 34 weeks' gestation. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) injuries are often seen in young participants in sports such as soccer, football, and basketball. Treatment options include conservative management as well as surgical intervention, with the goal of enabling the patient to return to cutting and pivoting sports and activities. Individualized anatomic ACL reconstruction is a surgical technique that tailors the procedure to the individual patient using preoperative measurements on plain radiographs and magnetic resonance imaging and intraoperative measurement to map the patients’ native ACL anatomy in order to replicate it as closely as possible. Anatomic ACL reconstruction, therefore, is defined as reconstruction of the ACL to its native dimensions, collagen orientation, and insertion site. The surgical reconstruction is followed by a specific rehabilitation protocol that is designed to enable the patient to regain muscle strength and proprioception while facilitating healing of the reconstructed ACL prior to the patient’s returning to sports activities. [ABSTRACT FROM AUTHOR]

Epiploic appendagitis (EA) is an uncommon cause of abdominal pain. It is a benign condition but may mimic other serious causes of acute abdomen such as appendicitis, diverticulitis, and gynecological emergency in severe cases. Knowledge of this condition in the differential diagnosis of abdominal pain can save unnecessary hospital admission, antibiotics, and surgery. In this article, we present the case of a 43-year-old female who presented to our hospital with a 2-day history of right lower quadrant abdominal pain and diarrhea. She was diagnosed with EA with computed tomography of abdomen with contrast and was managed conservatively with good outcome. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection. Methods: Retrospective case series at University tertiary care Hospital. Eight patients diagnosed with cervical pregnancy with embryonic heart activity managed conservatively. The intervention was ultrasound-guided local injection of methotrexate (1 mg/kg) and potassium chloride (2 meq/mL). Measurements were occurrence of morbidity, necessity for further intervention, the initial titers of beta-hCG, interval of time in which the levels of beta-hCG became negative, period for regression of cervical pregnancy at ultrasound and future pregnancy. Results: All patients were treated successfully. The initial levels of beta-hCG ranged from 3013 to 71199 mUI/mL. One case evaluated with infection. There was no need for additional intervention in our series study. The interval of time for the levels of beta-hCG becomes negative range from 2 to 12 weeks. The period for the regression of the cervical pregnancy at ultrasound range from 3 to 14 weeks. In two cases intrauterine pregnancies occurred after the treatment. Conclusion: Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided injection is an effective treatment avoiding the need of further intervention. [ABSTRACT FROM AUTHOR]

Hepatocellular adenoma (HCA) is a rare benign liver-cell neoplasm, occurring predominantly in young obese women using oral contraceptives. HCA is a heterogeneous disease, which includes four subtypes (including unclassified) associated with various risks of haemorrhagic complications and malignant transformation. Magnetic resonance imaging is the modality of choice for both diagnosis and subtype characterization of HCA whereas percutaneous biopsy has only limited impact on the therapeutic strategy. In men HCA should be always resected while in women surgery should only be considered for lesions ≥5 cm and after cessation of hormonal therapy. Women with single or multiple HCAs <5 cm may be followed with regular MRI imaging since the vast majority of HCA remains stable or decreases in size. Pregnancy should not be discouraged provided close sonographic surveillance is undertaken. [ABSTRACT FROM AUTHOR]

Because of the lack of agreement on when rectus diastasis (RD) is pathologic, the aim was to investigate indications for surgical repair. This study presents classifications of RD, current knowledge on the relation to pregnancy, and conservative and surgical management. A systematic search in Pubmed, Embase, Cochrane, and Cinahl revealed 437 studies. Inclusion criteria were applied according to the above mentioned subjects of interest. In total 28 studies were included, representing 3725 patients, 11 of these by assessing reference lists of included studies. Only one RCT was found; most studies were case-series lacking statistical analysis. RD was common in post-partum women. Antepartum activity level may have a protective effect on RD and exercise may improve post-partum symptoms of RD. Repair was done during abdominoplasty or laparoscopically. The patient-satisfaction was high and long-term recurrence was reported by one study, while five reported no recurrence. Overall major complications were few, while minor complications were primarily seroma and wound complications. RD is by itself not a true hernia and, therefore, not associated with the risk of strangulation. Repair is mostly done due to cosmetic reasons. The condition does not necessarily require repair, and conservative management may be an alternative. If done, the protrusion of the abdomen, rather than the diastasis itself should influence the decision of repair. It is recommended that future studies use the established classifications (e.g. Beer, Rath, or Nahas) when reporting RD and long-term outcome of treatment. Comparison of surgical techniques and studies that address and compare conservative management with surgery are needed. [ABSTRACT FROM AUTHOR]

Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described In part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables. [ABSTRACT FROM AUTHOR]

Antibiotic lock therapy (ALT) - instillation of high concentrations of anti-microbial agent with or without anti-coagulant into the lumen of central venous catheters - is considered a valid conservative treatment for catheter-related bloodstream infection (CRBSI) in patients highly dependent on maintaining the catheter. Results from randomized controlled studies have indicated that the effectiveness of ALT is moderate, but recent findings from experimental studies and observational case series point to considerable efficacy and safety of this therapy, which is usually associated with concomitant systemic treatment. In this article, the current knowledge about ALT for patients with CRBSI is reviewed and discussed, with emphasis on existing controversies and the results obtained according to the various uses of the catheters and the etiologies of infection. [ABSTRACT FROM AUTHOR]

Objective: Abnormal implantation of placenta previa is life-threatening condition. The purpose of this study was to evaluate the impact of the conservative management of pregnancies with such complication on maternal morbidity rate and the chance for uterine preservation (fertility). Methods: Eleven patients with abnormal implantation of placenta previa were analyzed prospectively. This complication was diagnosed antenatally by two-dimensional ultrasound and color flow Doppler. The following outcomes were analyzed: need for blood transfusion, admission and duration of stay in intensive care unit, infections, coagulopathies, time between cesarean section and delivery of placenta, hysterectomy and preservation of uterus. Results: Among the 20 085 women who had a singleton gestation, 11 (0.054%) were identified with placenta previa with abnormal placentation. In five patients (group A), hysterectomy was performed because of hemorrhage or placenta ablation. In six patients (group B), conservative management succeeded and placenta were preserved. In group A, placenta were delivered earlier (2 d-8 weeks) in comparison with group B (6-15 weeks). Estimated blood loss during the delayed delivery of placenta was higher in the group with hysterectomy (respectively, 450-1600 and 300-500 ml). Conclusions: Conservative management of placenta previa with abnormal implantation decreases the risk of severe hemorrhage at the time of delivery and can preserve fertility. [ABSTRACT FROM AUTHOR]

Abstract: Background: Lipomatous tumours of the adrenals are almost always benign. The importance of recognising their characteristic radiological features, leading to their correct treatment, is fundamental, as there has been an increase in the identification of these lesions. Our goal was to review all lipomatous tumours of the adrenal glands, particularly myelolipomas, their imaging methods and surgical management, updated in 2011. Methods: This was a retrospective review of articles published in the USA and Europe, from 1979 to date. The sites from which information was retrieved covered PubMed, Medscape, Clinical Imaging, Histopathology, Urologia Internationalis, Archives of Surgery, JACS, the American Urological Association, BMJ, Medline, and Springer Link. We report areas of controversies in addition to well established guidelines. Results: We reviewed 45 articles, that confirmed, with a high level of evidence-based medicine, that the diagnosis of a lipomatous adrenal tumour is made by various imaging procedures, particularly computed tomography (CT). We emphasise the importance to their management of the initial size of the adrenal mass, its increase in size over time, in addition to the presence of symptoms. Conclusion: Lipomatous tumours of the adrenals are most frequently benign. The diagnosis is usually made by various techniques, in particular CT. The fundamental characteristics indicating the necessity of surgical intervention are the symptoms presented, volume of the tumoral mass (>5cm), and the increase in size of the tumour as shown in two consecutive imaging studies. [Copyright &y& Elsevier]

Background and Purpose: Intermittent distance exotropia is difficult to conservatively manage, with techniques varying widely between institutions. This review aims to examine current literature on conservative management for intermittent distance exotropia, investigate its impact upon current clinical practice, and identify areas for further research. Method: A literature search was performed using PubMed, Web of Knowledge, LILACS, and the University of Liverpool Orthoptic Journals and Conference Transactions Database. All English-language papers published between 1950 and the present day were considered. Results: Intermittent distance exotropia is a difficult condition to manage because of its variability/uncertain natural history, although control scores can facilitate management decisions. Research is required to establish recommended dosages for antisuppression occlusion and determine whether other treatments such as minus lenses are more effective. Use of orthoptic exercises has declined, but recently certain exercises have been shown to improve surgical outcomes if applied preoperatively. Prisms are mainly used postoperatively. Minus lens therapy is recommended as a first line treatment, but may not always be successful. Conclusion: Conservative management techniques for intermittent distance exotropia have their place as both an alternative and an adjunct to surgery. However, further research needs to be conducted to determine which techniques are appropriate for which patients. [ABSTRACT FROM AUTHOR]

Subdural haematomas co-existing in the cranium and spine are considered extremely rare. We report 2 cases demonstrating the condition described here with a review of literature. One of these 2 patients was the first case in which the spinal lesion was found before the cranial lesion. A 66-year-old man without trauma presented with paraparesis accompanied by severe leg pain. The patient was diagnosed as having spinal subdural haematoma extending from L1 to S1 vertebral levels with magnetic resonance images (MRI). Two days after admission, the patient developed disorientation and abnormal behavior; therefore, computed tomography (CT) of brain was performed, and chronic cranial subdural haematoma was observed. A 60-year-old man who developed headache showing gradually progressive was diagnosed as having cranial subdural haematoma on CT. Three days after admission, he became insomnolent due to severe low back pain radiating to ankle. On MRI, subdural haematoma was found extending from L3/4 to S2 vertebral levels. Only brain surgery was performed for all cases by the neurosurgeons. Paraparesis and severe leg pain, which were derived from spinal lesions, showed recovery approximately 2 weeks after onset and spinal subdural haematoma was completely resolved on MRI obtained 2 or 5 months after onset, respectively. There is a possibility that the incidence of spinal subdural haematoma concurrent with cranial subdural haematoma could be underestimated because the doctor had not obtained CT or MRI of the brain. Doctors should aware of such a condition and check patients with spinal subdural haematoma for neurological signs derived from brain lesions. Spontaneous resolution of spinal subdural haematoma was observed; therefore, surgery for this condition should be indicated only for patients with moderate or severe paraparesis or paraparesis deteriorated. [ABSTRACT FROM AUTHOR]

Background: Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual's TOS symptoms. Objective: Part 2 of this review focuses on management of TOS. Conclusion: The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient's symptoms. [ABSTRACT FROM AUTHOR]

Objective: To document the natural history of vestibular schwannomas treated conservatively, and to find if there are any predictive factors for growth and need for active intervention. Design: A retrospective review of patient notes and radiology, mostly MRIs. Subjects: Eighty-eight patients managed conservatively for unilateral vestibular schwannoma and that have had at least two radiological investigations. Outcome measures: Change in tumour size over time was evaluated. Linear and logistic regression, respectively, were used to determine which factors (of age, size at diagnosis, audiology at presentation, length of follow-up or growth within first year of follow-up) would predict overall growth and active intervention. Characteristics of those that required active intervention is also demonstrated. Results: Of the 88 patients, the average size of schwannoma at diagnosis was 10.88 mm. The mean length of radiological follow-up was 3.65 years. 51.1% of schwannomas grew, 12.5% shrank and 36.4% remained the same size. The mean rate of growth was 1.24 mm per year. 25.0% failed conservative treatment, with 19 patients having stereotactic radiosurgery and three undergoing microsurgery. Only growth in the first year of follow-up was found to significantly predict total growth. Size at diagnosis and growth in first year of follow-up were significantly found to predict active intervention. Conclusions: There remains a place for conservative treatment in those with small tumours, the elderly and those with significant co-morbidities. Growth in the first year of follow-up should be considered in determining whether to treat actively or not. [ABSTRACT FROM AUTHOR]

Several key questions help to clarify the evolving debate concerning management of end-stage renal disease and withdrawal of dialysis. First, what is the evidence about survival, quality of life, and course of illness, following conservative management or dialysis withdrawal? Second, what criteria are used for deciding on conservative management or withdrawing dialysis, and how are these criteria justified? Third, who should make the decision and how should it be reached, particularly when there is cognitive impairment and the patient cannot make the decision for themselves? Decision criteria, the evidence, and who decides are each considered in this review. [ABSTRACT FROM AUTHOR]