A case of nonpharmacologic conservative management of suspected uncomplicated subacute appendicitis in an adult male.
J Altern Complement Med. 2011 Mar;17(3):275-7. Epub 2011 Mar 9. PMID: 21417813
Nathan Gershfeld, Peter Sultana, Alan Goldhamer
BACKGROUND: Appendicitis is an acute condition of the abdomen that is treated with surgical intervention. Conservative treatment of appendicitis currently involves intravenous antibiotics. While conservative care is a useful tool in apprehensive patients, in conditions such as appendicitis, delays in proper treatment can be life threatening. In spite of this, some patients will still refuse surgical and pharmacologic intervention, which can significantly limit the physician's therapeutic options.
SUBJECT: Sonographic evidence is presented of appendicitis in a patient who strongly desired to avoid pharmacologic or surgical intervention.
RESULTS: The patient underwent a medically supervised water-only fast followed by a plant-based, low-fat, low-sodium diet and achieved a significant reduction and eventual elimination of symptoms.
CONCLUSIONS: This case demonstrates the need for further research on the effects of medically supervised water-only fasting and careful refeeding in cases of uncomplicated appendicitis.
Article Published Date : Mar 01, 2011
Natural history of gallstone disease: Expectant management or active treatment? Results from a population-based cohort study.
J Gastroenterol Hepatol. 2010 Apr;25(4):719-24. PMID: 20492328
Davide Festi, Maria Letizia Bacchi Reggiani, Adolfo F Attili, Paola Loria, Paolo Pazzi, Eleonora Scaioli, Simona Capodicasa, Ferdinando Romano, Enrico Roda, Antonio Colecchia
BACKGROUND AND AIMS: The knowledge of natural history is essential for disease management. We evaluated the natural history (e.g. frequency and characteristics of symptoms and clinical outcome) of gallstones (GS) in a population-based cohort study.
METHODS: A total of 11 229 subjects (6610 men, 4619 women, age-range: 29-69 years, mean age: 48 years) were studied. At ultrasonography, GS were present in 856 subjects (338 men, 455 women) (7.1%). GS were followed by means of a questionnaire inquiring about the characteristics of specific biliary symptoms.
RESULTS: At enrollment, 580 (73.1%) patients were asymptomatic, 94 (11.8%) had mild symptoms and 119 (15.1%) had severe symptoms. GS patients were followed up for a mean period of 8.7 years; 63 subjects (7.3%) were lost to follow up. At the end of the follow up, of the asymptomatic subjects, 453 (78.1%) remained asymptomatic; 61 (10.5%) developed mild symptoms and 66 (11.4%) developed severe symptoms. In subjects with mild symptoms, the symptoms disappeared in 55 (58.5%), became severe in 23 (24.5%), remained stable in 16 (17%); in subjects with severe symptoms, the symptoms disappeared in 62 (52.1%), became mild in 20 (16.8%) and remained stable in 37 (31.1%). A total of 189 cholecystectomies were performed: 41.3% on asymptomatic patients, 17.4% on patients with mild symptoms and 41.3% on patients with severe symptoms.
CONCLUSIONS: This study indicates that: (i) asymptomatic and symptomatic GS patients have a benign natural history; (ii) the majority of GS patients with severe or mild symptoms will no longer experience biliary pain; and (iii) a significant proportion of cholecystectomies are performed in asymptomatic patients. Expectant management still represents a valid therapeutic approach in the majority of patients.
Article Published Date : Apr 01, 2010
Spontaneous reduction of intracranial arachnoid cysts: a complete review.
Br J Neurosurg. 2008 Oct;22(5):626-9. PMID: 19016115
N Russo, M Domenicucci, M Rojas Beccaglia, A Santoro
The aetiopathology, clinical features and treatment of arachnoid cysts (AC) are still extremely controversial topics. The posterior fossa is the second most common site of these lesions, since they are often detected in the cerebellar or cerebellar-cistern region. Despite this, almost all the cases of non-surgical reduction of an AC reported in literature concern cysts of the middle fossa, whereas only two cases of spontaneous reduction of a posterior fossa AC has been described in literature. A complete review of the literature regarding this topic has been collected and discussed. The authors present a case of spontaneous reduction of an arachnoid cyst situated along the midline of the posterior cranial fossa with regression of all neurological symptoms. This 43-year-old man presented increasing nuchal headache with vomiting and nausea, simulating subarachnoid haemorrhage. CT and MRI documented an arachnoid cyst along the midline of the posterior fossa compressing the mesencephalon. The patient did not present any family history of this pathology nor had suffered head trauma. The patient was only given analgesics to relieve painful symptoms. After 30 days, spontaneous resolution of all the neurological symptoms took place. A 2 months, MRI control documented marked reduction of the cyst without any evident brain compression. The feasibility of a wait and see policy in such cases is discussed.
Article Published Date : Oct 01, 2008
Bacterial conjunctivitis in children: antibiotic eye drops only if eye washing is ineffective.
Prescrire Int. 2007 Jun;16(89):120-1. PMID: 17585426
[No authors listed]
(1) Acute infectious conjunctivitis in children is often due to bacterial infection. (2) Systematic use of local antibiotic therapy may not be needed. A systematic review and two recent trials conducted in the primary care setting provide interesting results. (3) The results of several trials, and specifically of a study of children (excluding neonates) with uncomplicated conjunctivitis in primary healthcare, show that about 50% of patients recover within four days without antibiotic therapy. Antibiotic therapy seems to hasten recovery by less than half a day. (4) A trial involving adults and children at least one year of age compared immediate antibiotic eye drop therapy versus antibiotic eye drops given only when symptoms persisted for three days. A control group received no antibiotic treatment. Immediate antibiotic therapy hastened recovery by slightly more than half a day in comparison with delayed treatment. (5) In practice, when a child presents with conjunctivitis, it is reasonable to wait and see how the symptoms evolve before prescribing local antibiotics.
Article Published Date : Jun 01, 2007
Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment.
Pediatrics. 2005 Jun;115(6):1455-65. PMID: 15930204
David P McCormick, Tasnee Chonmaitree, Carmen Pittman, Kokab Saeed, Norman R Friedman, Tatsuo Uchida, Constance D Baldwin
OBJECTIVE: The widespread use of antibiotics for treatment of acute otitis media (AOM) has resulted in the emergence of multidrug-resistant pathogens that are difficult to treat. However, it has been shown that most children with nonsevere AOM recover without ABX. The objective of this study was to evaluate the safety, efficacy, acceptability, and costs of a non-ABX intervention for children with nonsevere AOM.
METHODOLOGY: Children 6 months to 12 years old with AOM were screened by using a novel AOM-severity screening index. Parents of children with nonsevere AOM received an educational intervention, and their children were randomized to receive either immediate antibiotics (ABX; amoxicillin plus symptom medication) or watchful waiting (WW; symptom medication only). The investigators, but not the parents, were blinded to enrollment status. Primary outcomes included parent satisfaction with AOM care, resolution of symptoms, AOM failure/recurrence, and nasopharyngeal carriage of Streptococcus pneumoniae strains resistant to ABX. Secondary outcomes included medication-related adverse events, serious adverse events, unanticipated AOM-related office and emergency department visits and telephone calls, the child's absence from day care or school resulting from AOM, the parent's absence from school or work because of their child's AOM, and costs of treatment. Subjects were defined as failing (days 0-12) or recurring (days 13-30) if they experienced a higher AOM-severity score on reexamination.
RESULTS: A total of 223 subjects were recruited: 73% were nonwhite, 57% were<2 years old, 47% attended day care, 82% had experienced prior AOM, and 83% had not been fully immunized with heptavalent pneumococcal vaccine. One hundred twelve were randomized to ABX, and 111 were randomized to WW. Ninety-four percent of the subjects were followed to the 30-day end point. Parent satisfaction with AOM care was not different between the 2 treatment groups at either day 12 or 30. Compared with WW, symptom scores on days 1 to 10 resolved faster in subjects treated with immediate ABX. At day 12, among the immediate-ABX group, 69% of tympanic membranes and 25% of tympanograms were normal, compared with 51% of normal tympanic membranes and 10% of normal tympanograms in the WW group. Parents of children in the ABX group gave their children fewer doses of pain medication than did parents of children in the WW group. Subjects in the ABX group experienced 16% fewer failures than subjects in the WW group. Of the children in the WW group, 66% completed the study without needing ABX. Immediate ABX resulted in eradication of S pneumoniae carriage in the majority of children, but S pneumoniae strains cultured from children in the ABX group at day 12 were more likely to be multidrug-resistant than strains from children in the WW group. More ABX-related adverse events were noted in the ABX group, compared with the WW group. No serious AOM-related adverse events were observed in either group. Office and emergency department visits, phone calls, and days of work/school missed were not different between groups. Prescriptions for ABX were reduced by 73% in the WW group compared with the ABX group. Costs of ABX averaged $47.41 per subject in the ABX group and $11.43 in the WW group.
CONCLUSIONS: Sixty-six percent of subjects in the WW group completed the study without ABX. Parent satisfaction was the same between groups regardless of treatment. Compared with WW, immediate ABX treatment was associated with decreased numbers of treatment failures and improved symptom control but increased ABX-related adverse events and a higher percent carriage of multidrug-resistant S pneumoniae strains in the nasopharynx at the day-12 visit. Key factors in implementing a WW strategy were (a) a method to classify AOM severity; (b) parent education; (c) management of AOM symptoms; (d) access to follow-up care; and (e) use of an effective ABX regimen, when needed. When these caveats are observed, WW may be an acceptable alternative to immediate ABX for some children with nonsevere AOM.
Article Published Date : Jun 01, 2005
Regression of low-grade squamous intra-epithelial lesions in young women.
Lancet. 2004 Nov 6-12;364(9446):1678-83. PMID: 15530628
Anna-Barbara Moscicki, Stephen Shiboski, Nancy K Hills, Kimberly J Powell, Naomi Jay, Evelyn N Hanson, Susanna Miller, K Lisa Canjura-Clayton, Sepidah Farhat, Jeanette M Broering, Teresa M Darragh
BACKGROUND: The aim of this study was to assess the probability of low-grade squamous intra-epithelial lesion (LSIL) regression in young women, and to examine the factors associated with this regression. METHODS: In a longitudinal study of human papilloma virus (HPV) infection, female adolescents aged 13-22 years were examined every 4 months by cytology, colposcopy, and HPV DNA status. Both prevalent and incident LSIL cases were included in the analysis, with regression defined as at least three consecutive normal Pap smears. FINDINGS: Median follow-up time from baseline (defined as the time of first LSIL diagnosis) for the 187 women with LSIL was 61 months (IQR 34-80). Median time they had been sexually active at diagnosis was 3.2 years (2.6-6.5). Probability of regression for the entire cohort was 61% (95% CI 53-70) at 12 months and 91% (84-99) at 36 months of follow-up. No associations were found between LSIL regression and HPV status at baseline, sexual behaviour, contraceptive use, substance or cigarette use, incident sexually transmitted infection, or biopsy. Multivariate analysis showed that only HPV status at the current visit was associated with rate of regression, whether infection was caused by one or more viral types (relative hazard=0.3 [95% CI 0.21-0.42], and 0.14 [0.08-0.25], respectively). INTERPRETATION: The high rate of regression recorded in this study lends support to observation by cytology in the management of LSIL in female adolescents. Negative HPV status was associated with regression, suggesting that HPV testing could be helpful in monitoring LSIL.
Evaluation of a national cryptococcal antigen screening program for HIV-infected patients in Uganda: A cost-effectiveness modeling analysis.
PLoS One. 2019;14(1):e0210105
Authors: Rajasingham R, Meya DB, Greene GS, Jordan A, Nakawuka M, Chiller TM, Boulware DR, Larson BA
BACKGROUND: Cryptococcal meningitis accounts for 15% of AIDS-related mortality. Cryptococcal antigen (CrAg) is detected in blood weeks before onset of meningitis, and CrAg positivity is an independent predictor of meningitis and death. CrAg screening for patients with advanced HIV and preemptive treatment is recommended by the World Health Organization, though implementation remains limited. Our objective was to evaluate costs and mortality reduction (lives saved) from a national CrAg screening program across Uganda.
METHODS: We created a decision analytic model to evaluate CrAg screening. CrAg screening was considered for those with a CD4<100 cells/μL per national and international guidelines, and in the context of a national HIV test-and-treat program where CD4 testing was not available. Costs (2016 USD) were estimated for screening, preemptive therapy, hospitalization, and maintenance therapy. Parameter assumptions were based on large prospective CrAg screening studies in Uganda, and clinical trials from sub Saharan Africa. CrAg positive (CrAg+) persons could be: (a) asymptomatic and thus eligible for preemptive treatment with fluconazole; or (b) symptomatic with meningitis with hospitalization.
RESULTS: In the base case model for 1 million persons with a CD4 test annually, 128,000 with a CD4<100 cells/μL were screened, and 8,233 were asymptomatic CrAg+ and received preemptive therapy. Compared to no screening and treatment, CrAg screening and treatment in the base case cost $3,356,724 compared to doing nothing, and saved 7,320 lives, for a cost of $459 per life saved, with the $3.3 million in cost savings derived from fewer patients developing fulminant meningitis. In the scenario of a national HIV test-and-treat program, of 1 million HIV-infected persons, 800,000 persons were screened, of whom 640,000 returned to clinic, and 8,233 were incident CrAg positive (CrAg prevalence 1.4%). The total cost of a CrAg screening and treatment program was $4.16 million dollars, with 2,180 known deaths. Conversely, without CrAg screening, the cost of treating meningitis was $3.09 million dollars with 3,806 deaths. Thus, despite the very low CrAg prevalence of 1.4% in the general HIV-infected population, and inadequate retention-in-care, CrAg screening averted 43% of deaths from cryptococcal meningitis at a cost of $662 per death averted.
CONCLUSION: CrAg screening and treatment programs are cost-saving and lifesaving, assuming preemptive treatment is 77% effective in preventing death, and could be adopted and implemented by ministries of health to reduce mortality in those with advanced HIV disease. Even within HIV test-and-treat programs where CD4 testing is not performed, and CrAg prevalence is only 1.4%, CrAg screening is cost-effective.
PMID: 30629619 [PubMed - in process]