What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis?

BACKGROUND

Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement.

QUESTIONS/PURPOSES

The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management?

METHODS

The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05.

RESULTS

Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001).

CONCLUSION

FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Psychiatric morbidity and different treatment modalities in children with chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) is a potentially life-threatening condition leading to various psychosocial problems associated with different treatment modalities in addition to their medical advantages and disadvantages. The aim of this study was to evaluate the psychiatric morbidity in children with CKD in terms of different treatment modalities in comparison to healthy peers. In addition, parental attitudes and psychiatric symptoms in this group of mothers were examined.

POPULATION AND METHODS

A matched cohort study including 66 children with CKD (21 renal transplantation, 27 dialysis, 18 conservative treatment) and 37 healthy age- and sex-matched controls were evaluated. Children filled out the Children's Depression Inventory, the State-Trait Anxiety Inventory, and the Parental Attitude Scale, and the mothers filled out the Symptom Checklist-90-R. The Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version was used for psychiatric diagnosis.

RESULTS

The overall depression scores in children and the mothers' overall symptom severity index were significantly higher in the CKD group: 40.9% of children in the CKD group were diagnosed with a psychiatric disorder, while the corresponding figure for the control group was 16.2%. The in-group comparison of the CKD group failed to detect any significant difference between the three treatment modalities.

CONCLUSION

The results support the findings of research showing that CKD has high psychiatric morbidity. It is important to include psychosocial and psychiatric assessments in the evaluation processes of different treatment modalities in CKD.

Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review

BACKGROUND

Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management.

METHODS

Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale.

RESULTS

Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms.

CONCLUSIONS

Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.

Is there a Reason Why Obese Patients Choose Either Conservative Treatment or Surgery?

BACKGROUND

The effects of bariatric surgery on excess weight loss (EWL) and comorbidities are proven. Still, a significant number of patients prefer conservative therapy (ConsP).

OBJECTIVES

The goal of this study was to examine why ConsP and patients awaiting bariatric surgery (SurgP) choose which therapy, and to define the differences in their expectations.

SETTING

Prospective study, 1 university hospital, 1 general hospital, Germany.

METHODS

ConsP and SurgP were asked to complete a questionnaire. Statistical analysis including all patients and a BMI-matched cohort was performed using the chi-square and Wilcoxon rank-sum test.

RESULTS

Overall, 151 patients participated in this study (50 ConsP, 101 SurgP, 69.4% females). The mean age was 41.1 years (SD ± 12.2 years). ConsP had a significant lower body mass index (BMI, 44.7 kg/m² vs. 49.3 kg/m², p < 0.01). The educational level was significantly higher in ConsP. SurgP suffered significantly more often from depression (21.6% vs. 36.6%, p = 0.02) and joint pain (45.1% vs. 68.7%, p = 0.02). ConsP completed significantly more diets that were supervised by physicians or considered well-structured (56.3% vs. 31.0%, p = 0.04). SurgP considered their chosen therapy a last resort significantly more often (p < 0.01). A BMI-matched analysis between ConsP and SurgP revealed no significant differences in the prevalence of comorbidities but showed that fear of surgery plays a major role in the decision-making processes of obese patients.

CONCLUSION

A higher BMI and a greater prevalence of comorbidities had driven patients to seek a more radical solution for their obesity, i.e., surgery. The BMI-matched analysis suggests that fear of surgery is a relevant factor in why obese patients do not decide to undergo bariatric surgery lightly.

Treatment Decision Regret Among Long-Term Survivors of Localized Prostate Cancer: Results From the Prostate Cancer Outcomes Study

Purpose To determine the demographic, clinical, decision-making, and quality-of-life factors that are associated with treatment decision regret among long-term survivors of localized prostate cancer. Patients and Methods We evaluated men who were age ≤ 75 years when diagnosed with localized prostate cancer between October 1994 and October 1995 in one of six SEER tumor registries and who completed a 15-year follow-up survey. The survey obtained demographic, socioeconomic, and clinical data and measured treatment decision regret, informed decision making, general- and disease-specific quality of life, health worry, prostate-specific antigen (PSA) concern, and outlook on life. We used multivariable logistic regression analyses to identify factors associated with regret. Results We surveyed 934 participants, 69.3% of known survivors. Among the cohort, 59.1% had low-risk tumor characteristics (PSA < 10 ng/mL and Gleason score < 7), and 89.2% underwent active treatment. Overall, 14.6% expressed treatment decision regret: 8.2% of those whose disease was managed conservatively, 15.0% of those who received surgery, and 16.6% of those who underwent radiotherapy. Factors associated with regret on multivariable analysis included reporting moderate or big sexual function bother (reported by 39.0%; OR, 2.77; 95% CI, 1.51 to 5.0), moderate or big bowel function bother (reported by 7.7%; OR, 2.32; 95% CI, 1.04 to 5.15), and PSA concern (mean score 52.8; OR, 1.01 per point change; 95% CI, 1.00 to 1.02). Increasing age at diagnosis and report of having made an informed treatment decision were inversely associated with regret. Conclusion Regret was a relatively infrequently reported outcome among long-term survivors of localized prostate cancer; however, our results suggest that better informing men about treatment options, in particular, conservative treatment, might help mitigate long-term regret. These findings are timely for men with low-risk cancers who are being encouraged to consider active surveillance.

[Conservative treatment of chronic diseases of lower limb veins: major risks of poor patient compliance]

Presented herein are the results of the Russian part of the International Research Programme 'VEIN ACT' aimed at studying approaches to conservative treatment of chronic vein diseases in the Russian Federation, assessing its efficacy and safety, as well as monitoring the patient compliance. Also discussed are the regimen and results of conservative therapy, depending on patients' gender, age and body mass index, as well as the level of adherence to various methods of treatment in the cohorts concerned. High efficacy of conservative therapy in all patients was confirmed. However, the regimen of drug therapy needs to be adjusted depending on the disease severity, especially in patients of a more advanced age and those with obesity. The lowest patient compliance was observed in relation to compression treatment. The existing situation may be improved by be means of appropriate recommendations and a possible decrease of the level and degree of compression. This should of course be done carefully and attentively, with obligatorily taking into consideration the patients' age and body mass index.

[Pathogenetically targeted method for conservative treatment of obesity and overweight correction]

This review of literature presents modern pathogenetic treatment options for obesity and overweight correction including the optimization of the motor function, nutrition education, drug therapy, surgical techniques and psychotherapy. The need for a multidisciplinary approach to the development of combined treatment programs is underlined taking into account the multifactorial pathogenesis of obesity. A combination of optimal physical activity and diet therapy with active personal involvement in the process of recovery is accentuated among the priority areas of excess body weight correction, as well as the treatment and prevention of obesity. It is shown that the physical rehabilitation should focus on the individualization of the physical exertion, its adequate dosing and intensity control using heart rate monitors to ensure the safety and effectiveness of the training sessions. The article also presents data on the effectiveness of rational medical and other types of treatment of obesity when the adjustment of physical activities and nutrition is insufficient. In particular, the results of the world's largest observation program of safe weight loss for the treatment of patients with alimentary obesity held in Russia from 2012 to 2015 are described.