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The authors report the case of a patient with spinal abscess in whom operation was withheld because of severe concomitant medical problems. Conservative management resulted in apparent cure.
The prevalence and duration of secondary hyperparathyroidism in 42 renal transplant recipients, and the sequelae of this condition, were studied. Immediately before transplantation, an elevated PTH-value was recorded in 76% of the patients, postoperatively there was a marked drop. Early after successful transplantation, 57% of the patients had hypercalcemia. At follow-up 3 years later, moderate hypercalcemia persisted in half of the patients but only 3 patients had significantly elevated PTH. The quality of renal graft function was not inferior in the hypercalcemic patients. Subperiosteal bone resorption and soft tissue calcifications were more common among the hypercalcemic patients. Our data suggest that secondary hyperparathyroidism can be managed conservatively in most renal transplant recipients. If progressive bone changes occur, surgical removal of parathyroid tissue should be considered.
A comprehensive conservative management program for chondromalacia patella in athletes has been presented. The clinical manifestations and the efficacy of conservative treatment have been documented in the prospective study of 100 consecutive athletes. The over-all success rate was 82%, and 18% were considered to be failures of conservative treatment. Only 8 of these 100 athletes have required surgical treatment. It was concluded that this type of conservative management is effective in the majority of athletes with symptomatic patellofemoral syndromes, and that surgical treatment should be necessary for only the relative few who fail to respond to an adequate trial of conservative treatment.
INTRODUCTION: Renal stones are relatively uncommon in the pediatric population. This study aimed to evaluate the utility of conservative management of small renal stones in prepubertal children. PATIENTS AND METHODS: A retrospective chart review was conducted for children (≤12 years old) with small renal stones (3-10 mm) from 2016 to 2023 who underwent conservative management. Management included periodic renal ultrasonography, every 6 months, in addition to good hydration. Stones were confirmed by two consecutive ultrasounds. We recorded the patient's demographics and ultrasound findings (stone side, size, laterality, location, number, and associated hydronephrosis). Surgical intervention was indicated if recurrent loin pain, recurrent UTI, or worsening hydronephrosis (obstructing stone). Nephrolithiasis was considered resolved if stones were not visualized on 2 consecutive ultrasounds. Moreover, we evaluated conservative management outcomes for those presented during infancy (<12 months) versus later. RESULTS: We included 52 patients (65renal units) who presented at a median age of 46.1months (5.3-155.1). Seventy-five percent of patients had incidental renal stones. The median stone size was 4 mm (3-10). Forty-six percent of stones were in the lower calyx. The majority (70.8 %) had no hydronephrosis at presentation. During a median follow-up of 39months, 15patients with 17units (26.2 %) were documented stone-free. Ten patients (19.2 %) had symptomatic stone events, all measured ≥4 mm. Of them, 6 patients (6 units) underwent surgical interventions, and 4 patients (4 units) experienced complications. A ROC curve analysis identified a stone size cutoff of 4 mm (sensitivity 100 % and 29 % specificity) that could be associated with symptomatic stone events. Using a multivariate Cox regression model, stone size was the only significantly associated factor with subsequent surgical intervention (p = 0.007). 19 % (10patients,12units) presented during infancy. Notably, the incidence of stone-free rate was significantly higher during infancy compared to older children (58.3 % vs 18.9 %,respectively). DISCUSSION: During a 39-month follow-up, 4 patients developed complications (2recurrent pain and 2 experienced UTI), supporting the safety of conservative management of small renal stones. This study is limited due to its retrospective design and the reliance on ultrasound as the main imaging method. To minimize that, all ultrasound images were carefully reviewed by two pediatric urologists. Moreover, renal stones were confirmed using strict criteria, which required detection in two consecutive ultrasounds. CONCLUSION: Although 26.2 % of units had spontaneously resolved nephrolithiasis, surgical intervention was only required in 11.5%of patients, all of whom had renal stones≥4 mm. Infants had higher spontaneous resolutions without complications, suggesting that conservative management may be especially effective in this subgroup.
The conservative management of 60 patients suffering from renal tuberculosis is reported. Following chemotherapy, bacteriological conversion to negative was obtained in all patients. 2 patients (3-3%) relapsed due to failure to take adequate treatment. Evidence of ureteric obstruction was obtained in 30 patients (50%)--23 at the time of diagnosis, 6 during treatment and 1 at the time of relapse. Following corticosteroid treatment relief of obstruction was obtained in 72%. Nephrectomy was carried out in 4 patients (6-7%) but in only 1 of these was the operation carried out for reasons which we now consider valid.
Excellent results can be obtained with conservative therapy of intramural duodenal hematomas, and thus the radiologist plays a crucial role in their management and followup. Six children in in whom intramural duodenal hematoma was diagnosed, based on clinical, laboratory, and radiographic findings, were managed conservatively. Treatment consisted of restricted oral intake, intravenous infusion of fluids and electrolytes, and nasogastric suction when indicated. The satisfactory response of these patients to nonoperative therapy was demonstrated on serial upper gastrointestinal studies and by regression of clinical signs and symptoms.
The preliminary conservative management of juvenile fractures by closed reduction must be performed with due regard for the pressure of epiphyseal plates, the more rapid bone healing and the increased stimulation of growth. Malunited fractures are realigned by the normal process of bone remodeling, and results are better in young children. The management of shaft. metaphyseal and joint fractures by closed reduction is outlined. Late sequelae such as a diminished range of motion of the affected limb are rare, so that intensive physical therapy is not required.
Four cases are presented of the conservative treatment of the diabetic foot. Using the known principles of wound healing and of management of soft tissue infection, the obviously necrotic or infected tissue was debrided and the wounds were managed conservatively. The use of such debriding adjuncts as a pulsating jet lavage, topical antibacterials, and biological dressings, has controlled infections--so that the foot wounds could be closed then with sking grafts or local flaps. This resulted in the salvage of these feet, with maintenance of biped ambulation.
We report a case of gastrocolic fistula resulting from a benign gastric ulcer, diagnosed by barium meal and endoscopy. The fistula healed with conservative management and treatment with carbenoxolone sodium. To our knowledge this is the first reported case of successful conservative treatment of a benign gastrocolic fistula using carbenoxolone.
A study of 26 patients (thirty attacks) with central serous retinopathy was made in order to assess the results of conservative management, and the factors which might affect the incidence of residual symptoms. There were two groups, one given systemic steroids and one given no treatment. Comparison is made with two groups treated by laser coagulation and another given no treatment.
Chylothorax may be produced by superior vena cava (SVC) obstruction, a recognized complication of the Mustard operation for trasposition of the great arteries. The chylothorax may be reduced by keeping the subject in the upright position. Conservative management is an alternative to repeat operation. This syndrome must be recognized, as it can be confused with congestive heart failure. Severe chylothorax may develop insidiously because of progressive SVC obstruction after the immediate postoperative period.
With the apparent indefinite postponement of the release of chymopapain for lumbar disk disorders, it seems appropriate to review critically the proliferation of proposed methods of management of this common complaint, particularly the numerous exercise regimens which have been set forth as helpful. A critical review of these regimens quickly reveals that the majority are propounded with considerably more confidence than statistical proof of their efficacy. The following is a delineation of the results of a critical review of the literature, with emphasis on those few studies which have been statistically validated. The physician has an obligation to attempt conservative management of discogenic disease with methods of demonstrated efficacy before recommending invasive procedures such as laminectomy or chemonucleolysis.
This study reviews twenty years' experience at the University of Michigan with 500 consectutive patients suffering from symptoms of Méniére's disease. An especially strong tradition of medical therapy of Méniére's disease has prevailed at the University of Michigan because of the influence of Albert C. Furstenberg, who developed and promoted the Furstenberg regimen of a low-sodium diet and diuretics. It has been our distinct clinical impression over the years that the Furstenberg regimen has been quite satisfactory in relieving the most disturbing symptoms of Méniére's disease in the vast majority of cases and often in patients who have failed other treatment programs. This study quantifies, as much as possible, our extensive experience with this disease and confirms for us the efficacy of this treatment. Relatively few operative procedures have had to be performed for conservative treatment failures in our hands. The success of this conservative management program has been largely dependent upon the strict adherence by the patient to a professionally prescribed, low-sodium diet. Occasional patients with chronic symptoms which are refractory to medical management continue to be a problem, particularly since it is in this group of patients that bilateral involvement tends to ultimately occur.
Ovulation induced with human menopausal gonadotropin-human chorionic gonadotropin in a 27-year-old woman who had been amenorrheic for 7 years resulted in pregnancy. Although pretreatment neurologic evaluation was normal, significant loss of vision was found at 30 weeks' gestation, and a skull x-ray revealed enlargement and erosion of the sella turcica. As an attempt to delay surgery, 12 mg of dexamethasone daily arrested further visual deterioration, and the pregnancy continued uneventful for 36 weeks, when triplets were born. Five days after delivery the visual fields were normal. Trans-sphenoidal resection of a prolactin-secreting chromophobe adenoma of the pituitary was carried out 6 months later. It is suggested that when disturbance in visual perception due to a pituitary tumor occurs during pregnancy, a course of high-dose corticosteroids with frequent monitoring of visual fields and acuity might be tried before surgical intervention. Although further rapid deterioration in vision may dictate immediate surgical decompression, conservative management may result in stabilization, allowing the patient to carry the pregnancy to term and obviating the need for emergency surgery.
A philosophy of conservatism in regard to termination of gestations complicated by pregnancy-induced hypertension has been practiced at the University of Virginia Hospital for many years. The advent of improved methods to evaluate the intrauterine fetal status prompted retrospective review of 246 pre-eclamptic and 13 eclamptic patients managed during the antepartum period. Continuous magnesium sulfate infusion for periods up to 144 hours (265 grams) was the therapeutic measure used for prevention or control of convulsions. Average duration of predelivery hospitalization increased 8.7 days, and the incidence of neonates requiring intensive care increased 10.9% with the use of tests to evaluate intrauterine fetal status. Frequency of spontaneous onset of labor and vaginal delivery decreased 18.6%. The uncorrected perinatal mortality rate for all antepartum patients was 7.0%. The mortality rate for infants of mothers with superimposed, severe or convulsive disease was significantly less in pregnancies in which tests of fetoplacental status were employed (8.2%) compared to pregnancies in which they were not (15.2%). The only maternal death was a 41-year-old patient with severe pre-eclampus who suffered a cerebral vascular accident on the fifth hospital day. These data reiterate the value of conservative management with meticulous individualized care.
A method of conservative treatment of fingertip amputations, allowing for spontaneous healing of the defect, was evaluated in a one-year study involving 17 consecutive patients and 21 amputations. Six presented with exposed bone in the lesion. These injuries healed with excellent results in terms of maintenace of maximum finger length and minimization of cosmetic deformity and functional disability. Rapid retrun to work was possible in most cases and morbidity associated with surgery was avoided.
A 41-year-old agricultural sustained a lumbosacral fracture-dislocation when a tree fell across his back. The initial anterior displacement of half the depth of the body of L5 progressed to three-quarters of the body over a 2-year period. Neurological deficit was minimal and the management was conservative. Spontaneous arrest of the displacement occurred by anterior sacral buttressing and the patient has returned to his previous heavy work.
Acute superficial fissure-in-ano responds readily to conservative non-surgical treatment. For chronic deep fissures we recommend manual anal dilatation and the post-dilatation regimen but recognise that equally good results follow the simple procedure of subcutaneous lateral internal sphincterotomy. The recurrence rate following these minor procedures is less than 10 per cent and the incidence of poor flatus control and mucus leakage is even lower. It is never necessary to excise fissures nor sentinel piles although it may be desirable to excise large redundant skin tags to facilitate anal hygiene. Painless or atypically sited fissures should suggest the diagnosis of Crohn's disease. Treatment is rarely required for fissure-in-ano in this condition, although severe anal stenosis may need extremely gentle anal dilatation. Postoperative anal stenosis can also be managed successfully by manual dilatation under anaesthesia with a prolonged regimen of self dilatation until healing is complete. Radical or complicated plastic operations are rarely indicated for any patient with fissure-in-ano or stenosis and are strongly contraindicated in Crohn's disease.