Decidualized Endometrioma: Its Sonography and Optimal Clinical Management

Endometriosis is a condition which affects many reproductive age women. During pregnancy, an ovarian endometrioma may undergo decidualization, which may take on the sonographic appearance suggestive of malignancy. In this instance, a surgical approach for treatment may be deemed necessary. Three cases are presented with different outcomes, worthy of viewing the contrasting management. In case 1, a patient was diagnosed with a left ovarian cyst at her routine 20-week gestation sonogram. This sonographic examination was suggestive of an ovarian malignancy. The patient underwent laparoscopy with left salpingo-oophorectomy at 23 weeks gestational age, without complications. The pathologic diagnosis of the removed mass was a decidualized endometrioma. In case 2, a female patient presented with bilateral ovarian decidualized endometriomas that were demonstrated sonographically and had the appearance of malignancy. This patient was treated conservatively with serial follow-up sonograms during her pregnancy. At the 2-month post-partum follow-up sonogram demonstrated persistent bilateral endometriomas, without decidualization. However, in case 3, possible decidualization of an endometrioma was seen, and a follow-up sonogram revealed the presence of ovarian carcinoma. There is previously published support for watchful waiting when similar sonographic findings, in pregnancy, are seen.

Effectiveness of Surgical Approach of Insertion Ventilation Tubes (Tympanostomy) and Adenoidectomy in Comparison with Non-Surgical Approach (Watchful Waiting Approach) in Children at the Age between 1 and 6 and Who Suffer from Otitis Media with Effusion (OME) in 12-Month Period of Observation—The Retrospective Analysis

(1) Background: Otitis media with effusion (OME) is one of the most common diseases in childhood. The objective was to assess clinically the effectiveness of the surgical approach (tube insertion with adenoidectomy) in comparison with the non-surgical approach (watchful waiting) during a 12-month observation period. (2) Methods: This study was retrospective and obtained approval from the bioethics committee. The criteria of inclusion in the first group (surgical approach) were: (1) a diagnosis of chronic otitis media with effusion in children aged between 1 and 6 years; (2) their medical history showed that they had undergone adenoidectomy and tympanostomy with the insertion of ventilation tubes (VTs). The criteria for inclusion in the second group (non-surgery) were similar to the first group except that their medical history showed they had not undergone adenoidectomy or tympanostomy with the insertion of VTs. There were 422 children included in the surgical group and 50 children in the non-surgical group, and the period of observation was 12 months. (3) Results: For the entire surgical group, the number of healthy days ranged from 20 to 365, with a mean of 328.0 days (SD = 91.4).In the non-surgical group, the number of healthy days ranged from 13 to 365, with a mean of 169.2 days (SD = 127.3). The difference in the number of healthy days was statistically significant (p < 0.001). The certainty of treatment in the first group was higher than in the second group, and the number of days without recurrence was significantly higher than in the second group. In the first group, there were 71 recurrences from 422 children (16.8%), and, in the second subgroup, there were 40 recurrences of acute otitis media (AOM) from 50 children (80%). The RR was 0.21. (4) Conclusions: The surgical approach in children aged 1–6 years who have been diagnosed with otitis media with effusion is reasonable and beneficial for the child.

Management of Pulp Canal Obliteration—Systematic Review of Case Reports

Background and Objectives: This systematic review aimed to assess the literature focusing on the clinical management of traumatized teeth with Pulp Canal Obliteration (PCO) and propose an updated clinical decision-making algorithm. The present review follows the PRISMA guidelines and was registered on PROSPERO database (CRD42020200656). Materials and Methods: An electronic search strategy was performed in Pubmed, EBSCOhost and LILACS from inception to March 2021. Only anterior permanent teeth with PCO due to dental trauma were included. Regarding clinical approaches, only teeth managed with a “watchful waiting” approach, tooth bleaching or root canal treatment (RCT) were included. Quality assessment was performed using the JBI Critical Appraisal Tool for Case Reports. Results: Twenty case reports were selected, resulting in a total of 27 patients. The number of traumatized teeth diagnosed with PCO was 33. The “watchful waiting” approach was the most implemented clinical strategy. Discolored non-symptomatic PCO teeth were mostly managed with external bleaching. The prevalence of pulp necrosis (PN) was 36.4%. For teeth diagnosed with PN, non-surgical RCT was performed in 10 teeth and surgical RCT in one tooth. Guided endodontic technique was performed in six of those teeth. Conclusions: For discolored non-symptomatic PCO teeth, external bleaching is advocated and the RCT approach should not be implemented as a preventive intervention strategy. Symptomatic PCO teeth should follow regular endodontic treatment pathways. Clinical approach of teeth with PCO should follow a decision-making algorithm incorporating clinical and radiographic signs and patient-reported symptoms.

Results of watchful waiting of unruptured intracranial aneurysms in a Western patient population: a single-center cohort

BackgroundThe natural history of unruptured intracranial aneurysms (UIAs) in Western populations is still debated, especially for those <7 mm. Reporting data of a large single-center cohort managed with watchful waiting is therefore interesting.MethodsFrom January 2011 to June 2019, 662 UIAs were followed up by yearly MR angiography. Morphologically stable UIAs were managed conservatively while unstable UIAs were offered treatment. The patients’ clinical and radiological data were analyzed retrospectively.ResultsUIAs were ≤4 mm in 60%, 4.1–7.0 mm in 33%, and >7 mm in 7%. They were located on the anterior circulation in 90% of cases. The mean follow-up duration was 51.32 months for a total of 2831 aneurysm-years. During follow-up, 37 UIAs (5.5%) were treated because of an increase in size, and 8 UIAs were treated because of patient decision. Three aneurysms ruptured during follow-up for an annual risk of rupture of 0.1% (95% CI 0% to 0.24%). No risk factors for rupture were identified. The three ruptured cases made an excellent recovery. During follow-up, annual mortality from unrelated causes was 0.8% (95% CI 0.51% to 1.18%).ConclusionsThis single-center cohort evaluated our watchful waiting policy applied in two-thirds of all incidental UIAs. Morphological change of UIAs during follow-up led to treatment in 5.5% of cases. With such a management paradigm, we found a low rupture rate in these selected UIAs and the mortality was unrelated to aneurysms.

O18 LONG-TERM CROSSOVER RATE FROM WATCHFUL WAITING TO SURGERY OF INITIALLY MIDLY SYMPTOMATIC OR ASYMPTOMATIC INGUINAL HERNIAS IN MEN AGES 50 YEARS AND OLDER

Aim Inguinal hernia (IH) belongs to the most common surgical pathology worldwide. Approximately, one third of patients are asymptomatic. Watchful waiting (WW) has been regarded as a justifiable treatment option, but doubts still exist since high crossover (CO) rates to surgery may occur. The aim of this study is to assess the CO rates after 13-year follow-up of our randomized controlled trial (RCT). Material and Methods In our original study, 496 men with an asymptomatic or mildly symptomatic IH were randomly assigned to elective repair or WW. A retrospective review was conducted of patients initially assigned to WW. Primary outcome was CO rate to surgery. Secondary outcomes included reason for crossing over and time between initial randomisation and the CO to surgery. Results In the original RCT, 95 of 262 WW patients electively crossed over to surgery (35.4%) after 32.9 months. Currently, 212 of the 262 (81.0%) WW patients were reviewed, and 133/212 (62.7%) crossed over to surgery. Median follow-up was 13 years (range, 8-15 years). Mean time to CO was 35.2 months SD (40.8). Motivations for crossing over to surgery were predominantly due to progression of symptoms (83.5%), and in 8 (3.8%) cases due to an emergency event. Conclusions In the presented population, WW on the long-term remains a safe strategy, saving one third of patients an operation, although CO to surgery will likely occur. Insights into the natural course of untreated inguinal hernia that are valuable during patient counseling can be offered in the form of long-term CO rate due to progression of symptoms.

Factors that influence clinicians’ decisions to decrease active surveillance monitoring frequency or transition to watchful waiting for localised prostate cancer: a qualitative study

ObjectiveLittle is known about clinicians’ decision-making about decreasing active surveillance (AS) testing/converting patients to watchful waiting (WW), nor are there any guidelines. The objective of this study was to identify factors that clinicians consider when decreasing AS testing/converting to WW for men with prostate cancer.DesignExploratory qualitative study.SettingAll participants practiced in various institutions in the USA.ParticipantsEligible clinicians had to provide clinical care for patients with prostate cancer in the USA and speak English. Clinicians could be either urologists or radiation oncologists. Of the 24 clinicians, 83% were urologists representing 11 states, 92% were men and 62% were white.MethodsThis qualitative study used data from semi-structured interviews. Purposive sampling was used to ensure geographical variation in the USA. Data collection continued until thematic saturation was achieved. Framework analysis guided coding and identification of themes. Two researchers coded all transcripts independently, met to discuss and reached consensus.ResultsInterviews with clinicians demonstrated that testing or monitoring for AS or transitioning to WW is happening in practice, whether intentionally or unintentionally. Decisions to decrease AS were personalised and tailored to patients’ health status. Life expectancy was the dominant factor that influenced decision, but clinicians were generally hesitant to specify an age when they would decrease AS or transition to WW. Fear that poor adherence could lead to missed progression and concerns about the medico-legal issue of not doing enough were cited as barriers to decreasing AS.ConclusionsThese findings suggest that in certain situations, AS frequency is reduced or transitioned to WW, yet decisions appear to be inconsistent and there are no significant barriers. These findings could inform further areas to explore when drafting recommendations that consider patients’ values and preferences when making decisions about decreasing AS/converting to WW.