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Porphyria cutanea tarda is the most common type of porphyria. It is associated with a deficiency of uroporphyrinogen decarboxylase enzyme responsible for heme synthesis. Clinical manifestations are predominantly dermatological and very rarely present with ocular involvement. Although scleral thinning in the interpalpebral area is a well-documented entity, sight-threatening corneal involvement is rarely described. We, herein report a case of a 58-year-old man who presented with ocular surface dryness, photophobia and mild redness. Slit-lamp biomicroscopy revealed corneo-scleral thinning in both eyes. The diagnosis was confirmed with a urine porphyrin test, serum iron and serum ferritin levels. We started him on conservative management after which he was lost to follow-up. He presented again after 6 years with total corneal opacification and progressive loss of vision in the right eye.

Traumatic dental injuries result in damage to many dental and periradicular structures. They can be conservatively managed depending on the extent of the injury. Maxillary central incisors are most commonly involved in traumatic dental injuries mainly because of their anterior and protrusive positioning. The treatment of immature permanent teeth with severe internal resorption poses a lot of challenges to the clinician. The objective of the present article is to report successful management of traumatised maxillary central incisor with incomplete root formation and severe internal resorption in a 10-year-old boy using triple antibiotic paste, mineral trioxide aggregate and fibre-reinforced composite.

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.

Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.

A newborn baby was referred to ENT team with recurrent episodes of desaturations which were worse on feeding and relieved by crying. She was born at 36 weeks with low birth weight (1.9 kgs) to a mother with history of high alcohol intake; Apgar score 6 (1 min) and 9 (5 min). Respiratory distress at

Hemolytic anemia and pure red cell aplasia are rare hematological complications of hepatitis B virus infection. We herein report a 24-year-old man who was diagnosed with hemolytic anemia and possible transient pure red cell anemia eight weeks after a severe episode of acute hepatitis B virus infection. Rapid recovery was observed with conservative management. Hemoglobin returned to baseline within three months. As the clinical features of hemolytic anemia associated with hepatitis B virus have not yet been elucidated, we conducted a systematic review and present an analysis of the 20 reported cases, including our present case.

OBJECTIVE Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. However, some patients may have good clinical outcomes without surgery. The authors sought to compare the radiological and clinical outcomes of patients with PA who were managed conservatively versus those who underwent early surgery. METHODS Patients with symptomatic PA were identified. Radiological, endocrinological, and ophthalmological data were reviewed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients without visual symptoms or whose symptoms improved on high-dose steroids were treated conservatively. Log-rank and univariate analysis compared clinical and radiological outcomes between those receiving early surgery and those who underwent intended conservative management. RESULTS Sixty-four patients with PA were identified: 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA; 64.7% vs 27.7%, p = 0.009); visual field (VF) deficits (64.7% vs 19.2%, p = 0.002); and cranial neuropathies (58.8% vs 29.8%, p < 0.05) at presentation. Tumor volumes were greater in the early surgical cohort (15.1 ± 14.8 cm3 vs 4.5 ± 10.3 cm3, p < 0.001). The median clinical and radiological follow-up visits were longer in the early surgical cohort (70.0 and 64.4 months vs 26.0 and 24.7 months, respectively; p < 0.001). Among those with VA/VF deficits, visual outcomes were similar between both groups (p > 0.9). The median time to VA improvement (2.0 vs 3.0 months, p = 0.9; HR 0.9, 95% CI 0.3–3.5) and the median time to VF improvement (2.0 vs 1.5 months; HR 0.8, 95% CI 0.3–2.6, p = 0.8) were similar across both cohorts. Cranial neuropathy improvement was more common in conservatively managed patients (HR 4.8, 95% CI 1.5–15.4, p < 0.01). Conservative management failed in 7 patients (14.9%) and required surgery. PA volumes spontaneously regressed in 95.0% of patients (38/40) with successful conservative management, with a 6-month regression rate of 66.2%. Twenty-seven patients (19 in the conservative and 8 in the early surgical cohorts) responded to a prospectively administered Visual Function Questionnaire-25 (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative 95.5 ± 3.8, surgery 93.2 ± 5.1, p = 0.3). Younger age, female sex, and patients with VF deficits or chiasmal compression were more likely to experience unsuccessful conservative management. Surgical outcomes were similar for patients receiving early versus delayed surgery. CONCLUSIONS These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available.

AIM: To present our experience in managing testicular involvement in penetrating scrotal injuries, trying to highlight a possible role for conservative management of selected cases. METHODS: We reviewed retrospectively all-penetrating scrotal injuries presented to Alyarmook teaching hospital for the period between January 2009 and November 2015, including only those injured victims who reached the hospital alive. Patients’ charts reviewed regarding their demographic data including age, status being civilian or military, and married or single. We documented as well the cause of injury (bullets vs. explosive devices), laterality, associated injured organs, and type of management performed whether operative or non-operative conservative approach. Postoperative complications were recorded while in-patient and after a follow-up period of at least 1 month. RESULTS: Thirty-one penetrating scrotal injuries were identified, resulted in 34 injured testicles. The patients’ mean age was 34.35 years (±12.89standard deviation [SD]) (18–70 years). Most of the victims 24 (77.4%) were civilians. Explosive devices were the cause of injury in 23 patients (74.2%), while bullets were the cause in the remaining 8 patients (25.8%). Orchidectomy needed to be done in 17 (50%) testicles, while 11 (32.4%) injured testes were repaired by suturing. Six cases (17.6%) were treated conservatively without any surgical intervention. The overall testicular salvage rate was (50%). Twenty-one patients (68%) had associated injuries, mostly fractures. Complications occurred in 10 (32.2%) patients, including two mortalities. CONCLUSIONS: Management of genitourinary injuries continues to be a challenging task. In our penetrating testicular injured series, we succeeded to salvage 50% of the injured testes. Non -surgical treatment is feasible in selected patients, an approach that needs further study and longer follow-up.

The first US Food and Drug Administration (FDA) approval for cervical total disc replacement (CTDR) was issued in 2007. Since then, 8 more artificial discs have been granted FDA approval for single-level CTDR. Two of these have also been approved for 2-level CTDR. All devices are indicated for levels C3 to C7 for symptomatic patients with radiculopathy or myelopathy caused by disc herniation or spondylosis unresponsive to conservative management. Trials have shown noninferiority of CTDR compared with anterior cervical decompression and fusion in their overall success. Hybrid surgery and CTDR of 3 or more levels are not FDA approved.

LAY SUMMARY Many non-acute muscle and skeletal injuries can be rehabilitated with conservative management, such as physiotherapy or physiatry, rather than orthopedic surgery. In the primary care centre, the authors noted that almost half of patients with non-acute muscle and skeletal injuries referred to orthopedic surgery did not need orthopedic intervention. Referrals to orthopedic surgery, for which conservative management is more appropriate, contribute to wait times and delay the recovery process. To improve access to conservative management and reduce the demand for orthopedic services, this study looked at the benefits of using physiotherapists to screen electronic medical records (EMRs) to determine if patients needed orthopedic intervention or conservative management. The results show physiotherapy screening increased the percentage of patients referred to orthopedic surgery that truly required orthopedic intervention from 47.9% to 63.7%. This emerging practice may lead to shorter wait times for patients to see an orthopedic surgeon, fewer in-person assessments, and improved access to conservative treatment.

Deep-seated intracranial arteriovenous malformations (AVMs) represent a subset of AVMs characterized by variably reported outcomes regarding the risk of hemorrhage, microsurgical complications, and response to stereotactic radiosurgery (SRS). We aimed to compare outcomes of microsurgery, SRS, endovascular therapy, and conservative follow-up in deep-seated AVMs. A prospectively maintained database of AVM patients (1990-2017) was queried to identify patients with ruptured and unruptured deep-seated AVMs (extension into thalamus, basal ganglia, or brainstem). Comparisons of hemorrhage-free survival and poor functional outcome (modified Rankin scale [mRS] 2) were performed between conservative management, microsurgery (±pre-procedural embolization), SRS (±pre-procedural embolization), and embolization utilizing multivariable Cox and logistic regression analyses controlling for univariable factors with p 0.05. Of 789 AVM patients, 102 had deep-seated AVMs (conservative: 34; microsurgery: 6; SRS: 54; embolization: 8). Mean follow-up time was 6.1 years and did not differ significantly between management groups (p = 0.393). Complete obliteration was achieved in 49% of SRS patients. Upon multivariable analysis controlling for baseline rupture with conservative management as a reference group, embolization was associated with an increased hazard of hemorrhage (HR = 6.2, 95%CI [1.1-40.0], p = 0.037), while microsurgery (p = 0.118) and SRS (p = 0.167) provided no significant protection from hemorrhage. Controlling for baseline mRS, microsurgery was associated with an increased risk of poor outcome (OR = 9.2[1.2-68.3], p = 0.030), while SRS (p = 0.557) and embolization (p = 0.541) did not differ significantly from conservative management. Deep AVMs harbor a high risk of hemorrhage, but the benefit from intervention Remains uncertain. SRS may be a relatively more effective approach if interventional therapy is indicated.

Összefoglaló. Az agyalapimirigy-apoplexia ritka klinikai kórkép, mely hirtelen kialakult bevérzés vagy infarktus következményeként jelenik meg. A hypophysisadenomás betegek 2–12%-ában fordul elő, a leggyakrabban funkcionálisan inaktív daganatokban, de jelentkezhet gyógyszeresen kezelt adenomákban is. Klinikai képe hirtelen kialakuló heves fejfájás, mely látászavarral vagy kettős látással társulhat, de meningealis izgalmi jel, a tudati szint romlása is előfordulhat. A bevérzés miatt kialakult kortikotropinhiány kezelés nélkül mellékvese-elégtelenséghez vezet. A mágneses rezonancia a komputertomográfhoz képest jobban kimutatja az adenoma bevérzését vagy akár infarktusát. Retrospektív tanulmányok a korábbi, azonnali idegsebészeti beavatkozás helyett a konzervatív kezelés létjogosultságát emelik ki. Orv Hetil. 2021; 162(38): 1520–1525. Summary. Pituitary apoplexy is a rare clinical syndrome secondary to haemorrhage or infarction of pituitary adenoma. The prevalence is 2–12% of pituitary adenoma patients especially in nonfunctioning tumours but may be found in medically treated adenomas as well. Its clinical picture is sudden onset of headache with visual disturbances and/or ocular palsy. Meningeal signs and altered consciousness can occur. Corticotropin deficiency if untreated can lead to adrenal insufficiency. Compared to computed tomography, magnetic resonance imaging better demonstrates the haemorrhage or even infarction of pituitary adenoma. Retrospective studies emphasize the wait-and-see management instead of the formerly considered urgent neurosurgical intervention. Orv Hetil. 2021; 162(38): 1520–1525.

Background: Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. Objectives: The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Design: Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). Setting/Subjects: U.S. community-based nephrologists and nephrology fellows. Results: Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the “reaction of their attending/supervising physician or other providers” as a barrier to NIWD and “lacking their attending physician's support” as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was “discordant opinions among patient and family”; fellows ranked “time to hold conversation” highest. Nephrologists' highest barrier to DD was the “finality of the decision (death)”; fellows ranked the “inertia of the clinical encounter” highest. Conclusions: Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.

Mohammad Noah Hasan Khan,1 Abdul Basit Jamal,2 Ahmad Faraz,3 Hassan Shafique,4 Muhammad Umar Rasool,5 Muhammad Waqas Ilyas,6 Muhammd Hamza Jamshed,7 Waleed Riaz,8 Mehwish Usman9 1Trauma and Orthopedic Surgery, Royal Victoria Hospital, Belfast, Northern Ireland; 2Trauma and Orthopedic Surgery, Ittefaq Hospital Trust, Lahore, Pakistan; 3Department of General Surgery, Royal Victoria Hospital, Belfast, Northern Ireland; 4Trauma and Orthopedic Surgery, Royal London Hospital, London, UK; 5Trauma and Orthopedic Surgery, North Manchester General Hospital, Manchester, UK; 6Trauma and Orthopaedics University Hospital Southampton, Southampton Hampshire, UK; 7Trauma and Orthopedics, The Hillingdon Hospitals NHS Trust, Uxbridge, UK; 8General Surgery Royal Victoria Hospital, Belfast, Northern Ireland; 9Trauma and Orthopedics, Manchester Royal Infirmary, Manchester, UKCorrespondence: Mohammad Noah Hasan KhanTrauma and Orthopedic Surgery, Royal Victoria Hospital, Belfast, Northern IrelandEmail noah_khan@hotmail.comIntroduction: The COVID-19 pandemic has led to a change in the delivery of acute and emergency surgical services. With emphasis on reducing unnecessary operative intervention and performing more CT scans, there has been a shift in managing acute appendicitis conservatively. We evaluate the impact of this shift on the management of acute appendicitis.Methods: A single UK centre retrospective study evaluating patients with suspected acute appendicitis pre-COVID-19 rota (18 March 2020) and post-COVID rota implementation. Data including demographics, inflammatory markers, imaging, mode of management and operative findings were collected. Logistic regression with SPSS was used to determine which factors were associated with conservative management and treated with antibiotics.Results: A total of 161 patients were analysed, 82 pre-COVID19 and 79 post-COVID19. Of the pre-COVID-19 patients, 67.07% underwent appendicectomy while the rest were conservatively managed; 24.3% of these patients underwent a CT scan only. Post-COVID-19, 22.78% of patients underwent appendicectomy with a higher percentage of diagnostic CT scans performed, 43/79 (54.4%, p < 0.001). The proportion of histologically normal appendicectomies was significantly reduced in the post-COVID-19 era (12.78% vs 0.00%; p-value 0.001). Logistic regression analysis showed a normal WCC to be associated with greater likelihood of conservative management. No conservatively managed patients returned to theatre in the 30-day follow-up period.Conclusion: Due to the restrictions imposed by the post-COVID-19 rota, a greater proportion of patients were managed conservatively with comparable patient outcomes. The approach also led to fewer negative appendicectomies owing to greater reliance on imaging.Keywords: appendicitis, COVID-19, imaging, non-operative management

Introduction Controversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey. Methods Our regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected. Results From 2011–2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7–66) days if no associated anomalies; time to epithelialisation 73 (27–199) days. Dressings were well tolerated. Definitive closure occurred at 17(11–38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection. Conclusion This is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a ‘normalisation’ of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.

Introduction The incidence of acetabular fractures in the elderly population is ever increasing. While management of acetabular fractures in young patients following high-energy trauma is well described, treatment of the elderly patient subgroup is complex and requires a unique, individualized approach. A variety of treatment strategies including operative and non-operative approaches exists to manage this vulnerable patient group. Conservative management of acetabular fractures in the elderly continues to play an important role in treatment of both stable fracture patterns and those medically unfit for surgery. Aim This review assessing the current literature was undertaken with the purpose of summarising the challenges of management in this at-risk cohort as well as quantifying the role and outcomes following conservative management in the elderly. Conclusion Our recommendation is that conservative management of acetabular fractures in the elderly can be considered as a treatment option on a case-by-case basis accounting for patient, injury, and surgical factors. If it is to be pursued, we advise a multidisciplinary approach focused on early mobility, minimisation of risk and regular follow-up to optimise patient outcomes.

Item does not contain fulltext OBJECTIVE: The aim of the study was to obtain an updated overview of regression, persistence, and progression rates of conservatively managed cervical intraepithelial neoplasia grade 1 (CIN 1)/CIN 2/CIN 3. METHODS: Data sources were MEDLINE, Embase, and Cochrane (January 1, 1973-April 14, 2020). Two reviewers extracted data and assessed risk of bias. To estimate outcome rates, we pooled proportions of the individual study results using random-effects meta-analysis, resulting in point estimates and corresponding 95% CIs. Heterogeneity was quantified by the I2 and τ2 measures. RESULTS: Eighty-nine studies were included, 63 studies on CIN 1 (n = 6,080-8,767), 42 on CIN 2 (n = 2,909-3,830), and 7 on CIN 3 (n = 245-351). The overall regression, persistence, and progression to CIN 2 or worse and CIN 3 or worse rates for women with conservatively managed CIN 1 were 60% (95% CI = 55-65, I2 = 92%), 25% (95% CI = 20-30, I2 = 94%), 11% (95% CI = 8-13, I2 = 89%), and 2% (95% CI = 1-3, I2 = 82%), respectively. The overall regression, persistence, and progression rates for CIN 2 were 55% (95% CI = 50-60, I2 = 85%), 23% (95% CI = 19-28, I2 = 83%), and 19% (95% CI = 15-23, I2 = 88%), respectively. Finally, for CIN 3, these were 28% (95% CI = 17-41, I2 = 68%), 67% (95% CI = 36-91, I2 = 84%), and 2% (95% CI = 0-25, I2 = 95%), respectively. Cervical intraepithelial neoplasia grade 2 regression was significantly higher in women 30 years or younger and high-risk human papillomavirus-negative women (66%, 95% CI = 62-70, I2 = 76%; 94%, 95% CI = 84-99, I2 = 60%). Only 2/7,180 (0.03%) and 10/3,037 (0.3%) of the CIN 1 and CIN 2 cases progressed to cervical cancer. CONCLUSIONS: Most CIN 1/CIN 2 will regress spontaneously in less than 24 months, with the highest rates in high-risk human papillomavirus-negative and young women, whereas progression to cancer is less than 0.5%. Conservative management should be considered, especially in fertile women and with expected high compliance. Given the heterogeneity in regression rates of high-grade histology, this should be classified as CIN 2 or CIN 3 to guide management.

Many cultures have developed traditional practices around the management of the umbilical cord stump in the newborn. Treatment with hot water compress or fomentation is well-documented in sub-Saharan Africa but can result in thermal injuries in vulnerable neonatal skin. We report three cases of superficial partial thickness umbilical burns in infants following such treatment that presented to a paediatric burns unit in London, UK in 2020, all from a Nigerian background. In each case, the burn wound healed with conservative management only. This is a previously unreported cause of neonatal burn injury and we aim to raise awareness of the risks that traditional cord practices may pose to the newborn.

Odontoid fractures are considered a frequent pathology within elderly patients in relationship with degenerative bone changes in context of aging. Its management depends on the type of fracture according to Anderson and D’Alonzo classification. Type I and III fractures are susceptible of conservative management due to its high fusion rate. Treatment of type II fractures is controversial due to its high mortality and morbidity rates associated with the type of patients affected. We present the case of an octogenarian patient with a C1-C2 anterior spinal epidural hematoma due to type II odontoid fracture managed with urgent odontoidectomy and hematoma removal.

Acute great toe (Hallux) pain is a common complaint encountered by the primary care physician. Pathological conditions can vary from acute trauma to acute exacerbation of underlying chronic conditions. Delay in treatment or misdiagnosis can lead to debilitating loss of function and long-lasting pain. This review endeavors to discuss the pertinent history, physical exam findings, radiographic evidence, conservative treatment options, and surgical management for the musculoskeletal causes of acute and acute on chronic great toe pain in the adult population. The acute pathologies discussed in this review are hallux fractures and dislocations, turf toe, sand toe, and sesamoid disorders. The chronic pathologies discussed include hallux rigidus, hallux valgus, and chronic sesamoiditis.

Active surveillance for low-to-intermediate risk prostate cancer is a conservative management approach that aims to avoid or delay active treatment until there is evidence of disease progression. In recent years, multiparametric MRI (mpMRI) has been increasingly used in active surveillance and has shown great promise in patient selection and monitoring. This has been corroborated by publication of the Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation (PRECISE) recommendations, which define the ideal reporting standards for mpMRI during active surveillance. The PRECISE recommendations include a system that assigns a score from 1 to 5 (the PRECISE score) for the assessment of radiologic change on serial mpMRI scans. PRECISE scores are defined as follows: a score of 3 indicates radiologic stability, a score of 1 or 2 denotes radiologic regression, and a score of 4 or 5 indicates radiologic progression. In the present study, we discuss current and future trends in the use of mpMRI during active surveillance and illustrate the natural history of prostate cancer on serial scans according to the PRECISE recommendations. We highlight how the ability to classify radiologic change on mpMRI with use of the PRECISE recommendations helps clinical decision making.

Background: Placenta accrete occurs when there is abnormal attachment of the placenta to the uterine wall either partially or totally. Placenta accreta had many complications mainly intraoperative and postpartum including injury to local organs (e.g. bowel, bladder, ureters) and neurovascular structures in the retroperitoneum. The aim of the present study was to evaluate the uterine cavity after conservative management of placenta accreta by using hysteroscope. Materials and Methods: This is prospective study was carried on 40 pregnant at Tanta University Hospital with age >35 years, to detect Presence or absence of intra uterine changes after conservative management of placenta accrete by hysteroscopy, easiness of performing diagnostic hysteroscopy and Correlation between intrauterine changes and operative data. Results: Hysteroscopic examination of the participants showed that 30.0% with incidences of Cervical stenosis, 15.0% with uterine cavity irregularity, 15.0% with intrauterine adhesions, 10.0% with endometrial fibrosis, 5.0% with scar dehiscence and 5.0% with Remnant. There was a statistically significant positive correlation between development of cervical stenosis and endometrial thickness by US (correlation coefficient r = 0.323 with p value 0.042) .There was a statistically significant negative correlation between Endometrial fibrosis and scar thickness (correlation coefficient r = -0.538 with p value

Thyroid gland rupture in a child secondary to blunt trauma is an extremely rare occurrence. The number of published cases of thyroid gland injuries in children is very limited in the research literature. A case report of shattered thyroid gland in a child is presented. This case highlights potential life-threatening complications and reviews management of thyroid gland injuries. Based on this case and other published pediatric case reports, conservative management may be a reasonable approach in thyroid gland injuries from blunt neck trauma in children.

Interstitial pregnancy is a rare type of ectopic pregnancy with a high risk of massive hemorrhage on rupture as compared to ectopic on other sites. The mortality rate for the ruptured interstitial pregnancy is high. Therefore, early diagnosis of such pregnancy before the rupture occurs facilitates appropriate management and avoids life-threatening complications. With the advancement in diagnostic imaging modalities, early diagnosis and more conservative management for interstitial pregnancy have become possible. Here, we report a case of primigravida diagnosed with interstitial pregnancy with ultrasonography and successfully managed with a single dose of methotrexate.

The fifth metatarsal base fracture is the most common fracture of the forefoot. The aim of this study was to evaluate the short term results of comparison between surgical and conservative management of Jones fracture of base 5th metatarsal: This is a comparative study included forty patients, twenty patients were treated by percutaneous fixation using cannulated 4.0 mm screw and twenty patients were treated conservatively with below knee cast. The duration from injury to admission to the hospital ranged from 1 to 3 days with an average of 2 days. The average follow-up duration was 6 months (range from 4 to 12 months). The American Orthopedic Foot and Ankle Society (AOFAS) used as a clinical rating system to monitor improvement following injury was done at 6 weeks, 12 weeks and 6 months. Patients treated with percutaneous screw fixation all achieved full union and had AOFAS score ranged from 91 to 98 at end of follow up at 12 weeks, while patients treated conservatively by cast had AOFAS score ranged from 73 to 87 at end of follow up at 12 weeks . After calculating P value to compare both groups according to end of follow up AOFAS Score P value = 0.000665781, P value significant < 0.001 which is highly significant. Early screw fixation is safe and effective method for treatment of acute Jones fracture of base of 5th metatarsal.

Summary Cervical and root pain due to herniated disc is one a common cause of a visit to an orthopedic surgeon. It is important to know how to diagnose, treat and initially. What are the best options to treat a herniated disc nowadays? The present article reviews the literature and updates on the clinical and surgical treatment of cervical disc herniation. Resumo A dor cervical e radicular devido à hérnia de disco é uma causa comum de uma visita a um cirurgião ortopédico. É importante saber diagnosticar, tratar e inicialmente. Quais são as melhores opções para tratar a hérnia de disco hoje em dia? Este artigo faz uma revisão da literatura e atualização sobre o tratamento clínico e cirúrgico da herniação do disco cervical.

Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Radiofrequency ablation techniques targeting the genicular nerves have evolved as our understanding of the anatomy of the anterior knee joint capsule has become more defined. The article aims to review the basic anatomy of the anterior knee joint and both the traditional and revised approaches to nerve ablation.

An abdominal binder could be used effectively in a patient showing CSF leakage in the coccygeal area with post‐dural puncture headache, which is not controlled by conventional compressive dressing.

Purpose: To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis of internal derangement and to assess the complimentary role of MRI and clinical assessment in prognostication. To assess the role of MRI in demonstrating disc displacement and reduction. Methods: A total of 34 patients (28 cases and 6 controls) with clinical features of temporomandibular joint (TMJ) internal derangement underwent a dedicated MRI at our institution. MRI was assessed for disc displacement, morphology, and reduction on open-mouth imaging. For analysis, the patients were divided into those with disc displacement with reduction (WR) and those without reduction (WOR). Clinical and MRI grading of internal derangement were done in all patients and correlated with each other. Prognostication was attempted using the clinical and MRI features, and patients were followed up over a mean period of 6 months. Results: Most of the patients were females (n = 20 71%) in the child-bearing age group (third decade). MRI demonstrated disc displacement in all but two patients in whom disc was not visible. Fourteen (54%) patients were placed in WR group, whereas 10 (38%) were in WOR group. In two (8%) patients, stuck disc was diagnosed. Patients in WR group responded to conservative treatment alone while those in WOR group needed conservative management in some (n = 8 57%) and surgical intervention in others (n = 6 43%). Both patients with stuck disc failed conservative management. Conclusion: MRI is an essential component of TMJ evaluation and helps in diagnosing and staging internal derangement together with disc assessment. Patients with disc displacement WOR and those with higher grades of derangement on MRI including stuck disc require surgical intervention if conservative management fails.

Background During the Covid-19 pandemic, non‐operative management for acute appendicitis (AA) was implemented in the UK. The aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. Materials & Methods We conducted an observational study in a tertiary referral centre. Data was collected from all patients (≥16 years) with a diagnosis of AA between November 1, 2019 to March 10, 2020 (pre-COVID period) and March 10, 2020 to July 5, 2020 (COVID period). Results A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n = 50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n = 24) during the COVID period (p-value = 0.042). 72.5% (n = 66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n = 28) in the pre-COVID period (p-value

Mandibular fracture is the most common facial skeletal injury in pediatric population seen in hospital setting. Fracture management is complicated by the developing permanent tooth buds and continuous mandibular growth. However, healing capacity in children is faster. Hence, conservative management is most often the treatment of choice for bone fractures in children. This case report is about a 6-year-old female child who sustained mandibular fracture after a road traffic accident (RTA) which was conservatively managed with maxillomandibular fixation using brackets and elastics. Orthodontic brackets were placed on facial aspect of posterior teeth of both the arches and elastics were used for traction leading to immobilization and stabilization of fracture. Healing was uneventful with complete bony union as evident by three months follow up orthopantomogram. Maxillomandibular fixation using brackets and elastics is a simple and non-invasive closed fracture reduction technique giving excellent result. The present case report showed successful outcome of mandibular fracture management.

Context: Traumatic cerebellar hematomas are rare in comparison to nontraumatic cerebellar hematomas. Aims: The aim of this study is to evaluate the prognostic factors and outcome determining factors with regard to conservatively managed isolated traumatic cerebellar hematoma. Settings and Design: Retrospective cohort study. Materials and Methods: A retrospective study of 23 patients of conservatively managed isolated posterior fossa hematoma, admitted between August 2018 and May 2020, was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Each of the patients was evaluated in terms of age, sex, mode of injury, clinical presentation, comorbidity, the severity of injury, best motor response, Glasgow Coma Scale (GCS) at admission, computed tomography findings, and Glasgow Outcome Scale at discharge/death. Statistical Analysis: Chi-square test and unpaired t-test were used. P < 0.05 was deemed statistically significant. Results: Mean volume of posterior fossa contusion was 8.9 ml. The cerebellar hemispheric (60.9%) location of hematoma was more common. Age at presentation (P = 0.0086), best motor response (P < 0.0001), severity of injury (P = 0.0002), GCS at admission (P < 0.0001), effacement of basal cistern (P < 0.0001), fourth ventricular compression and intraventricular hemorrhage (P = 0.0008), presence of hydrocephalus (P = 0.0142), subarachnoid hemorrhage (P = 0.0008), and volume of posterior fossa contusion (P = 0.0002) were significantly associated with outcome of posterior fossa contusion. Conclusion: Traumatic cerebellar hematoma is rare. Conservatively managed cerebellar hematoma patients must be monitored closely for neurological and radiological status. Patients who show deterioration in neurological or radiological status require surgical intervention.

Background and objectives: The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report: This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion: The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself. Resumo: Justificativae objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.

Management of chylothorax after repair of late presenting congenital diaphragmatic hernia is debatable. Conservative management in the form of close monitoring of chylous output with nutritional support appears convincing to surgery.

Introduction Extracorporeal shock wave therapy (ESWT), first described in the eighties for the treatment of urolithiasis, has also been applied in other fields such as orthopaedics and chronic wound care. Recently it has also been used in the treatment of burns and its sequelae since several studies suggest it could be an important tool in the conservative management of these conditions. The aim of this article is to review the literature for published evidence on the use of ESWT for the treatment of acute burn patients and its sequelae and to elaborate a brief report on the current state of the matter. Material and methods We carried on a search on PUBMED database and Cochrane database with the following terms: (‘burns’ [title/abstract] OR ‘burn’ [title/abstract]) AND “shock wave” ([title/abstract]). For an optimal reporting of the studies found we followed the PRISMA statement. Results This search found 34 articles from which only 15 were actually related to the use of ESWT in burn patients. From these 15 articles, 7 involved the use of ESWT in the treatment of acute burns, 6 related to its application in post-burn scars, 1 in the treatment of heterotopic ossification and 1 was about the use of ESWT in skin-graft donor site. Except for the latter, all of them were carefully reviewed. Conclusion Scientific evidence on the use of ESWT for the treatment of burn patients is weak due to the paucity of studies and their low quality. However, ESWT seems to be a promising tool in this field and therefore more high-quality trials should be conducted.

Omental infarction is an unusual cause of abdominal pain presenting in both adults and children; though it is rare in both [1, 2]. The difficulty is in the initial diagnosis where it can present in a number of different ways and may mask an underlying surgical condition [3, 4]. Most cases are managed without surgery, however; continuing or worsening pain may push a surgical approach. We present 3 cases of omental infarction, all with characteristic radiological findings. One had accompanying radiological features of acute appendicitis, another continued abdominal pain and the third with symptoms responding well to analgesia. The first and second patients required laparoscopic intervention, while the third was managed conservatively.

At our hospital, an unusually high proportion of patients and families opted for conservative management of hip fractures. This study aimed to compare the mortality rates of patients with hip fractures treated conservatively to that of operatively managed patients in a dedicated hip fracture unit. Retrospective analysis was done for patients who were treated for hip fractures between January 2015 and October 2017 in a Hip Fracture Unit at a tertiary hospital. Patients were managed non-operatively or surgically after discussion with the multi-disciplinary team. 233 patients were treated conservatively and 781 underwent operative management for hip fractures. Patients managed non-operatively had a higher inpatient, 30-day and 1-year mortality rates. Inpatient mortality was 6.01% for conservatively managed compared to 0% for operative management. 30-day mortality for conservatively managed patients was 8.58% as compared to 0% for operatively managed patients, and 1-year mortality was 33.05% as opposed to 8.96%. There was an association seen with the type of management of hip fractures and that of inpatient death (p = 0.000), death in 30 days (p = 0.000) and death in 1 year (p = 0.000). The type of management was a predictive factor in 1-year mortality (p = 0.000). The average number of co-morbidities in conservatively managed patients was 5.2 compared to surgically managed patients of 4.0. Conservatively managed hip patients had a higher prevalence of stroke, chronic kidney disease and ischemic heart disease. Complications during hospital stay were comparable for both groups. The mean length of hospital stay was similar for both groups. Surgical intervention for hip fractures is associated with lower inpatient, 30-day and 1-year mortality rates. However, patient co-morbidities and pre-morbid conditions should also be considered. IV.

The presence of pelvic pain, a pelvic/paravaginal mass, and purulent vaginal discharge in primigravida should raise the possibility of obstructed hemivagina and uterine didelphys. Though conservative management could result in successful pregnancy outcomes, early excision of vaginal septum and adequate drainage offer a shorter course of management and complication avoidance.

Children of all ages have been reported to be susceptible to COVID-19 with no significant gender difference Clinical manifestations of paediatric patients are generally less severe than those of adult patients except for the children with co-morbidities We report a case of a COVID-19 positive child, 13 months old, with both parents positive and managed conservatively for symptoms of cough and loss of appetite Continuous monitoring and close follow-up in intensive care is the key to successful recovery in patients with Coronavirus infection without co-morbidities [ABSTRACT FROM AUTHOR] Copyright of Biomedica is the property of Knowledge Bylanes and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Intramedullary spinal cord metastasis (IMSCM) is a rare complication of malignancies still studied by case reports; although surgery is related with the best results, the management is still debated considering the risks and the low life expectancy; in fact, many authors prefer conservative management (radiotherapy, chemotherapy), and so less than 200 cases reported in the literature with patients IMSCM were treated surgically; reporting such cases will help to understand the pathology and elaborate a clear management protocol. We report three cases of IMSCM operated at our department; in those patients, the intramedullary lesions revealed the primary tumours.

This is a unique presentation of common injury in a young professional athlete. The sensitivity of typical acute clinical signs in athletes is not known. Adequate splinting and early graded mobilization are key for successful rehabilitation, which was shorter than reported in the literature.

There is currently a steep rise in the global prevalence of obesity. Pharmaceutical therapy is a valuable component of conservative obesity therapy. Herein, medications currently in the phase of preclinical or clinical testing are reviewed, along with an overview of the mechanisms that regulate energy intake and expenditure. In addition, the current and potential future directions of obesity drug therapy are discussed. Although the current arsenal of obesity pharmacotherapy is limited, a considerable number of agents that exert their actions through a variety of pharmacodynamic targets and mechanisms are in the pipeline. This expansion shapes a potential near future of obesity conservative management, characterized by tailored combined therapeutic regimens, targeting not only weight loss but also improved overall health outcomes. The progress regarding the elucidation of the mechanisms which regulate the bodily energy equilibrium has led to medications which mimic hormonal adaptations that follow bariatric surgery, in the quest for a “Medical bypass.” These, combined with agents which could increase energy expenditure, point to a brilliant future in the conservative treatment of obesity.

Achilles tendinopathy is a painful overuse injury that is extremely common in athletes, especially those who participate in running and jumping sports. In addition to pain, Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties, altered lower extremity function, and fear of movement. Cumulatively, these impairments limit sport participation and performance. A thorough evaluation and comprehensive treatment plan, centered on progressive tendon loading, is required to ensure full recovery of tendon health and to minimize the risk of reinjury. In this review, we will provide an update on the evidence-based evaluation, outcome assessment, treatment, and return-to-sport planning for Achilles tendinopathy. Furthermore, we will provide the strength of evidence for these recommendations using the Strength of Recommendation Taxonomy system.

Purpose The purpose of this study was to quantify the experience of five Italian centers on the diagnosis and management of isolated fallopian tube torsion (IFTT) in children. Methods We retrospectively reviewed the data of 20 patients aged 1–16 years of age with surgically diagnosed IFTT between 1991 and 2017 from five Italian centers of pediatric surgery. We analyzed common presenting signs, symptoms, and radiographic findings, as well as surgical interventions to describe management offering further insight into the diagnosis and treatment of this rare entity. Results Twenty cases of IFTT were collected. Median age was 13.1 years. Menarche was present in 14 cases. A clinical history of abdominal pain was present in 13 patients, whereas in 7 patients the clinical picture was an acute abdomen. Ultrasonography was the first diagnostic examination in 16 cases. Surgical approach was by laparoscopy in 16 cases and laparotomy in 4 cases. In 11 patients IFTT was associated with another pathologic condition. In 7 of the remaining 9 IFTT without pathologic association, the girls played sports. Salpingectomy was performed in 13 patients and de-torsion in 7. Conclusions IFTT is a rare condition that seems to occur in younger adolescents. Vague clinical presentation contributes to low preoperative suspicion. IFTT should be considered in girls with abdominal pain who practice sports with sudden body movements. Preoperative suspicion may be increased based on radiographic findings of an enlarged tubular/cystic structure with adjacent normal ovary. Conservative management is controversial but could be preferred in order to provide the best option for future fertility of these girls. Type of Study Treatment Study (Retrospective Study) – Level IV.

Background. Abnormally invasive placentation (AIP) is a clinical term that describes situation when placenta does not separate spontaneously after delivery and its manual removal causes excessive bleeding (1). Historically, the treatment of choice for this condition is hysterectomy. Lately, the new treatment option, conservative management of the AIP, has proven itself an effective alternative to hysterectomy in carefully selected patients (2). However, the use of conservative AIP management is limited in many countries, the reasoning being the lack of doctors’ experience in this procedure and concerns regarding a high postpartum infection rate. Case reports. We present the first two cases of conservative management of AIP in Latvia. Most of prenatally diagnosed AIP cases country-wide are referred to the Paul Stradinš University Hospital, which is a tertiary referral hospital. The annual rate of AIP in the hospital varies from five to ten cases. Two pregnant women were diagnosed with AIP prenatally, both of them refused hysterectomy and therefore went for the conservative management of AIP. During Caesarean section operation, placentas were left in situ after delivery of the baby. During the follow-up period of 12 and 14 weeks, both women developed infection complications, but complete placental tissue resolution was diagnosed in the end. Conclusion. These two cases demonstrate that conservative management of AIP can be safely applied in small countries/areas with small AIP rate and management experience.

Background and Objective: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing renal parenchymal infection. Traditional management of EPN with nephrectomy had a mortality of 40-50%. The purpose of this case series was to assess the management, biochemical factors, and outcome of EPN patients. Methods: In this retrospective study, patients admitted to The Indus Hospital, Karachi with a diagnosis of EPN from January 2010 to February 2019, were grouped according to the Huang Tseng Classification (HTC). Their biochemical parameters, sensorium states and outcomes were recorded and analysed. Results: Twenty patients were reviewed (9 males). No mortality was recorded. 11 patients (55%) were treated conservatively with only intravenous antibiotics and eight patients underwent an intervention: minimally invasive with drain placement in six patients, and invasive in four patients (two underwent subsequent nephrectomy, and two patients had nephrectomy only). One patient left against medical advice. All patients had decreased serum creatinine levels and total leucocyte counts on discharge. Conclusion: EPN can be successfully managed conservatively for HTC Grade-1 and 2. Conservative treatment may be tried in higher grades, but poor response should lead to prompt escalation of treatment. doi: https://doi.org/10.12669/pjms.36.ICON-Suppl.1728 How to cite this:Irfaan AM, Shaikh NA, Jamshaid A, Qureshi AH. Emphysematous Pyelonephritis: A single center review. Pak J Med Sci. Special Supplement ICON 2020. 2020;36(1):S83-S86 doi: https://doi.org/10.12669/pjms.36.ICON-Suppl.1728 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: This scoping review aimed to identify and synthesize existing research on active conservative management of primary spinal syringomyelia and associated symptoms and to discuss perspectives for clinical application using an activity-based approach.Methods: PubMed, Embase, Scopus, and Web of Science were systematically searched for empirical studies of conservative management or therapies of adults with primary spinal syringomyelia from inception to April 2021. In addition, abstracts from relevant conferences were searched. Study characteristics and key findings were extracted, and findings descriptively synthesized.Results: Of 1,186 studies screened, 7 studies met the eligibility criteria (4 single case studies and 3 cohort studies, a total of 90 individuals). The interventions were primarily physiotherapeutic, mostly by posture correction and exercises, and effects were alleviation of pain, improved physical function, improved activities of daily living and quality of life. Analysis of factors triggering symptoms and rationale for choice of intervention based upon these was limited.Conclusion: Evidence of active conservative management of primary spinal syringomyelia and associated symptoms is limited. Many variations and limitations in the existing research limit the conclusions. High-quality research is needed to enable healthcare professionals to apply evidencebased active conservative interventions. LAY ABSTRACTPeople with primary spinal syringomyelia and associated symptoms are often managed conservatively. In most cases, this means without active treatment. Pathophysiological knowledge and our own physiotherapeutic experience propose that the symptoms may be connected to specific active movements and activities of daily life. The aim of this study was to map existing evidence for active rehabilitation as a means of reducing symptoms and preventing syrinx progression. Only 7 low-quality research studies with different kinds of treatment were found. Mostly, physiotherapy was offered with exercises and focus on posture. Outcomes included alleviation of pain as well as improved physical function and quality of life. Unfortunately, analysis of symptominducing factors to guide the choice of intervention was limited. Future high-quality studies are needed to develop active conservative interventions for people with primary spinal syringomyelia.

ObjectivesTo define a consensual approach for the conservative treatment of patients C0s-C3.MethodThe project was structured into two phases. The first one involved a group of Italian specialists in angiology and/or vascular surgery with the aim to compare their therapeutic choices in the management of patients in CEAP C0s-C3. The second phase used a Delphi consensus in order to elaborate practical statements on the conservative management of these patients.ResultsThe first phase involved a group of 166 Italian specialists while the second phase involved a Steering Committee of 6 specialists and a panel of 20 specialists. At the end of the third round, a consensus >80% was reached on seven assertions.ConclusionSeven statements have been drafted by a group of Italian specialists to provide physicians with practical guidance for the conservative treatment of C0s-C3 patients. Outstanding issues on the management of these patients were identified, confirming the urgent need of further research.

Objectives: The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken. Background: A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof. Methods: We retrospectively evaluated “decisions not to operate” over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth–Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality. Results: Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score ( P < .001) and a poorer functional status ( P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively). Conclusions: Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.