Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis.

BACKGROUND: Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment. METHODS: A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points). RESULTS: The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I(2)=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33). CONCLUSIONS: Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined.

A eficácia entre duas intervenções na Síndrome do Canal Cárpico

A Síndrome do Canal Cárpico (SCC) é a neuropatia compressiva mais comum do membro superior, causada pela compressão direta sobre o nervo mediano no interior do canal cárpico.Os resultados deste estudo mostram em cada um dos grupos, após a intervenção, uma melhoria estatisticamente significativa da sintomatologia no G-AFN (p=0,02) e no GTRN/ EAA (p=0,004) e uma melhoria estatisticamente significativa do estado funcional no G-AFN (p=0,022). Verificamos também em cada um dos grupos, após a intervenção, uma melhoria estatisticamente significativa na “Força de preensão” (p=0,005), na “Pinça polegar/dedo indicador” (p=0,021), na “Pinça polegar/dedo médio” (p=0,026) e “Pinça polegar/dedo anular” (p=0,026) no G-AFN, e uma melhoria estatisticamente significativa na “Pinça polegar/indicador” (p=0,016), na “Pinça polegar/dedo médio” (p=0,035), na “Pinça polegar/dedo anular” (p=0,010), na “Pinça trípode” (p=0,005) e na “Pinça lateral” (p=0,051) no G-TRN/EAA. Após a intervenção, não verificamos diferenças estatisticamente significativas nos valores das escalas de gravidade de sintomas (p=0,853) e de estado funcional (p=0,148) entre os grupos, mas diferenças estatisticamente significativas nos valores dos testes neurofisiológicos (p=0,047) e força de preensão da mão (p=0,005). Do estudo, concluímos que a utilização da intervenção articular/fascial/neural (AFN) e a intervenção com tala de repouso noturna e exercícios de auto alongamento (TRN/EAA), beneficia os indivíduos com SCC não severa, como nos casos incipientes, ligeiros ou moderados. Os indivíduos com esta condição clínica apresentam sintomatologia caraterística de dor, parestesia, especialmente noturna e disfunção muscular da mão. Tais manifestações originam perda funcional com implicações nas áreas de desempenho ocupacional, nomeadamente, nas atividades da vida diária, produtivas e de lazer. O tratamento conservador na SCC não severa, como nos casos incipientes, ligeiros e moderados, apesar de controverso, é recomendado. O tema suscita o nosso interesse, razão pela qual nos propomos realizar um estudo experimental em indivíduos com o diagnóstico clínico de SCC não severa e aplicar num grupo a intervenção articular, fascial e neural (AFN) e noutro grupo a intervenção com tala de repouso noturna e exercícios de auto alongamento (TRN/EAA). O estudo tem como principais objetivos, por um lado, verificar o impacto das intervenções em cada um dos grupos e, por outro lado, comparar o seu impacto entre os grupos, no que respeita à gravidade de sintomas, ao estado funcional, à força de preensão da mão e força de pinças finas. Fomos também comparar os resultados dos testes neurofisiológicos (Velocidade de Condução Motora) antes e depois da intervenção AFN e da intervenção com TRN/EAA, e averiguar o seu impacto nos valores da latência motora distal e da velocidade de condução sensitiva, entre os grupos. Identificamos também quais as variáveis sócio demográficas e as que caraterizam a patologia que estão relacionadas com o problema em estudo e com os valores obtidos com as escalas do Boston Carpal Tunnel Questionnaire (BCTQ), no grupo articular, fascial e neural (G-AFN) e no grupo com tala de repouso noturna e exercícios de auto alongamento (G-TRN/EAA). Para a concretização do estudo, recorremos a uma amostra de 23 indivíduos de ambos os sexos do Hospital Curry Cabral, Empresa Pública Empresarial -Centro Hospitalar de Lisboa Central (HCC, EPE -CHLC).

The deterioration of Circular Mausoleum, Roman Necropolis of Carmona, Spain

The Circular Mausoleum tomb in the Roman Necropolis of Carmona was carved on a calcarenite sequence in an ancient quarry located in the town of Carmona, Southern Spain. This rock-cut tomb, representative of Roman burial practices, currently suffers from serious deterioration. A detailed survey over several years permitted the identification of the main tomb's pathologies and damaging processes, which include loss of material (scaling, flaking, granular disintegration), surface modifications (efflorescences, crusts and deposits) and extensive biological colonization. The results obtained in this study indicated that anthropogenic changes were largely responsible and enhanced the main alteration mechanisms observed in the Circular Mausoleum. Based on the deterioration diagnosis, effective corrective actions were proposed. This study shows that any conservative intervention in the interior of the tomb should be preceded by accurate in situ measurements and laboratory analyses to ascribe the source of the deterioration damages and thus designing effective treatments.

Minimal intervention dentistry: part 5. Ultra-conservative approach to the treatment of erosive and abrasive lesions.

The therapeutic management of tooth wear lesions does not require the removal of diseased tissue. Nevertheless, diverse etiological factors may be associated with the condition and they could be difficult to eliminate; this has to be considered when planning therapy. Interceptive procedures should be reserved for such situations while regular monitoring is recommended for other cases, in accordance with advice provided for using the Basic Erosive Wear Examination (BEWE). Direct and indirect adhesive procedures with composite resins allow treatment of most clinical situations, including even extensive restorations. The possibility of managing subsequent interventions should be considered when planning the initial therapeutic approach.

Treatment of proximal interphalangeal joint flexion contracture: Combined static and dynamic orthotic intervention compared with other therapy intervention: randomized controlled trial

Purpose To test the effectiveness of static and dynamic orthoses using them as an exclusive treatment for proximal interphalangeal (PIP) joint flexion contracture compared with other hand therapy conservative treatments described in the literature. Methods 60 patients who used orthoses were compared with a control group that received other hand therapy treatments. Clinical assessments were measured before the experiment and 3 months after and included active PIP joint extension and function. Results A significant improvement in the extension active range of motion at the PIP joint in the second measurement was found in both groups, but it was significantly greater in the experimental group. Improvement in function (Disabilities of the Arm, Shoulder, and Hand score) between the first and second assessment was similar in the control and experimental groups. Conclusions Using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension, but the improvement did not correlate with increased function as perceived by the patient.

A randomized controlled trial protocol testing a decision support intervention for older patients with advanced kidney disease

Aim To assess the effectiveness of a decision support intervention using a pragmatic single blind Randomized Controlled Trial. Background Worldwide the proportion of older people (aged 65 years and over) is rising. This population is known to have a higher prevalence of chronic diseases including chronic kidney disease. The resultant effect of the changing health landscape is seen in the increase in older patients (aged ≥65 years) commencing on dialysis. Emerging evidence suggests that for some older patients dialysis may provide minimal benefit. In a majority of renal units non-dialysis management is offered as an alternative to undertaking dialysis. Research regarding decision-making support that is required to assist this population in choosing between dialysis or non-dialysis management is limited. Design. A multisite single blinded pragmatic randomized controlled trial is proposed. Methods Patients will be recruited from four Queensland public hospitals and randomizd into either the control or intervention group. The decision support intervention is multimodal and includes counselling provided by a trained nurse. The comparator is standard decision-making support. The primary outcomes are decisional regret and decisional conflict. Secondary outcomes are improved knowledge and quality of life. Ethics approval obtained November 2014. Conclusion This is one of the first randomized controlled trials assessing a decision support intervention in older people with advance chronic kidney disease. The results may provide guidance for clinicians in future approaches to assist this population in decision-making to ensure reduced decisional regret and decisional conflict.

Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions

As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients.

Clinical Relevance: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Conservative treatment of patellar tendinopathy

Patellar tendinopathy disrupts athletic careers in several sports and is resistant to many forms of conservative treatment. Outcome after conservative treatment has been minimally investigated, and the effect of these treatments on the pathology of overuse tendinopathy are not well understood.

The clinical assessment of patellar tendinopathy appears straightforward, but evidence suggests that the importance of imaging and palpation in diagnosis and ongoing assessment may be overestimated. There is a lack of clinically relevant research on which to base treatment. However, the principles of management for patellar tendinopathy derived from clinical experience include load modification, musculotendinous rehabilitation, and intervention to improve the shock absorbing capacity of the limb. The role of electrophysical agents, massage, and stretching in the treatment of patellar tendinopathy are also discussed. The progression of treatment is based on clinical grounds due to a lack of reliable subjective and objective tools to assess recovery.

The failure of some conservative programs could be due to either athlete compliance or practitioner expertise. The management of patellar tendinopathy is complex, and if the physiotherapist addresses all the principles of treatment, the chance of success could be increased.

Conservative discourse at the time of the Korean War. 1950-52

This thesis identifies the rhetorical strategies by which the Menzies government reconciled acceptance of full employment, the welfare state and government intervention with a defence of liberalism. It argues that the Korean War offered the Menzies government an opportunity to reconstitute these key aspects of the postwar state as "liberal" rather than social democratic.

Frequency of excisions and yields of malignant skin tumors in a population-based screening intervention of 360 288 whole-body examinations

Objective To explore the frequency of excisions and yields of histopathologically confirmed skin cancer.

Design A population-based skin cancer screening intervention (the SCREEN project) in the German state of Schleswig-Holstein (July 1, 2003, to June 30, 2004).

Setting Physician offices. Participants could choose between nondermatologist physicians and dermatologists for their initial whole-body skin examination. All screening physicians received a mandatory 8-hour training course.

Participants Inhabitants of Schleswig-Holstein 20 years or older with statutory health insurance (N = 360 288).

Main Outcome Measures Frequency of excisions and yields of malignant skin tumors (malignant melanomas [MMs], basal cell carcinomas [BCCs], and squamous cell carcinomas [SCCs]), stratified by sex and age.

Results Overall, 15 983 excisions were performed (1 of 23 screenees). A total of 3103 malignant skin tumors were diagnosed in 2911 persons: 585 MMs, 1961 BCCs, 392 SCCs, and 165 other malignant skin tumors. Overall, 116 persons (3103 of 360 288) had to be screened to find 1 malignant tumor, with 1 of 620 for MM, 1 of 184 for BCC, and 1 of 920 for SCC. Twenty excisions were performed to find 1 melanoma in men 65 years and older, but more than 50 excisions were required to find 1 melanoma in men aged between 20 and 49 years.

Conclusions The results of SCREEN suggest a high yield of malignant skin tumors in a large-scale population-based screening project. We found that a high number of excisions was performed in the youngest screenees with an associated low yield, suggesting a need in screener training to emphasize a more conservative attitude toward excisions in young screenees.

Conservative management of severe intrusion in a primary tooth: A 4-year follow-up

The purpose of this report was to describe the case of an 18-month-old boy who was referred to the pediatric clinic of the School of Dentistry of Araçatuba, São Paulo State University, Araçatuba, São Paulo, Brazil, 3 days after sustaining severe trauma that led to the complete intrusion of the primary maxillary right lateral incisor, a crown fracture of the primary maxillary right central incisor without pulp involvement, and disruption of the superior labial frenum. Four months later, spontaneous re-eruption was observed in the intruded tooth and no endodontic intervention was necessary in either traumatized teeth. Four years after the trauma, a morphological change in the germ of the permanent successor was noted. Clinical follow-up and periodic radiographies are necessary after traumatic intrusion of primary teeth to monitor possible sequelae in the permanent successors.

[Diabetes update: preventing type 2 diabetes. Individualized stepwise therapy (oral antidiabetic agents). Multifactorial intervention]

Preclinical disorders of glucose metabolism should be systematically included in the high-risk group for diabetes mellitus and affected individuals provided with preventive measures. Their underlying insulin resistance is determined with the help of a checklist and a method called homeostasis model assessment (HOMA). Patients with impaired fasting glucose (IFG) must change their lifestyles. If this does not lead to a response or the patient is unable to modify behavior, medication is required. In the case of manifest type 2 diabetes mellitus, a graded schedule is used for differential management, which should be based on nutritional and exercise therapy. Oral medication with metformin is probably the drug of choice in both obese and non-obese patients. It is crucial not to delay raising the level of treatment until HbA1c has fallen to within an unsatisfactory range (wait-and-see strategy). Rather, the level should be intensified when persistent exacerbation starts to become apparent (proactive therapy). In diabetes mellitus, the same guidelines for secondary prevention apply to the associated cardiovascular risk factors as with coronary heart disease. An intensified and, especially, early treatment is to be preferred over a conservative, wait-and-see approach, in this case as well.

Incorporating nerve-gliding techniques in the conservative treatment of cubital Tunnel syndrome

Objective: To discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The rationale for the addition of nerve-gliding techniques will be highlighted. Clinical Features: Two months after onset, a 17-year-old female nursing student who had a traumatic onset of cubital tunnel syndrome still experienced pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were present which were regarded as contributing factors hindering natural recovery. Intervention and Outcomes: After 6 sessions consisting of nerve-gliding techniques and segmental joint manipulation and a home exercise program consisting of nerve gliding and light free-weight exercises, a substantial improvement was recorded on both the impairment and functional level (pain scales, clinical tests, and Northwick Park Questionnaire). Symptoms did not recur within a 10-month follow-up period, and pain and disability had completely resolved. Conclusions: Movement-based management may be beneficial in the conservative management of cubital tunnel syndrome. As this intervention is in contrast with the traditional recommendation of immobilization, comparing the effects of both interventions in a systematic way is an essential next step to determine the optimal treatment of patients with cubital tunnel syndrome.

Evaluation of a mentored self -help intervention for the management of psychotic symptoms

Cognitive behavioral therapy has been shown to be promising for the treatment of individuals experiencing psychotic symptoms, who are often diagnosed with schizophrenia. Using a non-random non-equivalent comparison group design (n = 26), this study explores whether an individually mentored self-help and self-paced intervention based upon cognitive behavioral approaches to auditory hallucinations or "hearing voices" makes a significant positive difference for individuals with major mental disorder diagnoses and psychotic symptoms who are residing in the community and receiving community mental health services. The mentored self-help intervention uses a workbook (Coleman & Smith, 1997) that stemmed from the British psychiatric survivor and "voice hearers"' movements and from cognitive behavioral approaches to treating psychotic symptoms. Thirty individuals entered the study. Pre- and post-intervention assessments of 15 participants in the intervention group and 11 participants in the comparison group were carried out using standardized instruments, including the Rosenberg Self-Esteem Scale, the Brief Psychiatric Rating Scale, and the Hoosier Assurance Plan Inventory - Adult. Four specific research questions address whether levels of self-esteem, overall psychotic symptoms, depression-anxiety, and disruption in life improved in the intervention group, relative to the comparison group. Pre- and post-assessment scores were analyzed using repeated measures analysis of variance. Results showed no significant difference on any measure, with the exception of the Brief Psychiatric Rating subscale for Anxious Depression, which showed a statistically significant pre-post difference with a strong effect size. A conservative interpretation of this single positive result is that it is due to chance. An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by participants. If so, this is particularly important given high levels of depression and suicide among individuals diagnosed with schizophrenia. This alternative interpretation supports further research on the intervention utilized in this study. ^

Conservative management for female urinary incontinence and pelvic organ prolapse review 2013 : summary of the 5th International Consultation on Incontinence

Aims The objective of the 5th International Consultation on Incontinence (ICI) chapter on Adult Conservative Management was to review and summarize the new evidence on conservative management of urinary incontinence (UI) and pelvic organ prolapse (POP) in order to compile a current reference source for clinicians, health researchers, and service planners. In this paper, we present the review highlights and new evidence on female conservative management. Methods Revision and updates of the 4th ICI Report using systematic review covering years 2008–2012. Results Each section begins with a brief definition and description of the intervention followed by a summary, where possible, of both the state and level of evidence for prevention and treatment, and ends with a “grade of recommendation.” The paper concludes with areas identified as requiring further research. Conclusions For UI, there are no prevention trials on lifestyle interventions. There are, however, few new intervention trials of lifestyle interventions involving weight loss and fluid intake with improved levels of evidence and grade of recommendation. Outside of pre- and post-natal pelvic floor muscle training (PFMT) trials for the prevention of female UI, there is a dearth of PFMT prevention trials for women with UI. PFMT remains the first-line treatment for female UI with high levels of evidence and grades of recommendation. Bladder training levels of evidence and grades of recommendation are maintained. For POP, new evidence supports the effectiveness of physiotherapy in the treatment of POP and there are now improved levels of evidence and grades of recommendation.