Background Spontaneous supratentorial intracerebral haemorrhage accounts for 20% of all stroke- related sudden neurological deficits, has the highest morbidity and mortality of all stroke, and the role of surgery rema...Background Spontaneous supratentorial intracerebral haemorrhage accounts for 20% of all stroke- related sudden neurological deficits, has the highest morbidity and mortality of all stroke, and the role of surgery remains controversial. We undertook a prospective randomised trial to compare early surgery with initial conservative treatment for patients with intracerebral haemorrhage. Methods A parallel- group trial design was used. Early surgery combined haematoma evacuation (within 24 h of randomisation) with medical treatment. Initial conservative treatment used medical treatment, although later evacuation was allowed if necessary. We used the eight- point Glasgow outcome scale obtained by postal questionnaires sent directly to patients at 6 months follow- up as the primary outcome measure. We divided the patients into good and poor prognosis groups on the basis of their clinical status at randomisation. For the good prognosis group, a favourable outcome was defined as good recovery or moderate disability on the Glasgow outcome scale. For the poor prognosis group, a favourable outcome also included the upper level of severe disability. Analysis was by intention to treat. Findings 1033 patients from 83 centres in 27 countries were randomised to early surgery (503) or initial conservative treatment (530). At 6 months, 51 patients were lost to follow- up, and 17 were alive with unknown status. Of 468 patients randomised to early surgery, 122 (26% ) had a favourable outcome compared with 118 (24% ) of 496 randomised to initial conservative treatment (odds ratio 0.89 [95% CI 0.66- 1.19], p=0.414); absolute benefit 2.3% (- 3.2to 7.7), relative benefit 10% (- 13 to 33). Interpretation Patients with spontaneous supratentorial intracerebral haemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment.展开更多
PURPOSE: Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to re currence, and factors predicting recurrence of thrombosed ...PURPOSE: Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to re currence, and factors predicting recurrence of thrombosed external hemorrhoids a fter conservative or surgical management. METHODS: Two hundred and thirty-one c onsecutive patients with thrombosed external hemorrhoids treated from 1990 to 20 02 were identified. Recurrence was defined as complete resolution of the index l esion with subsequent return of a thrombosed external hemorrhoid and did not inc lude patients with chronic symptoms. Data were gathered retrospectively. Multipl e potential risk factors were reviewed. RESULTS: The index thrombosed external h emorrhoid was managed conservatively in 51.5 percent of cases and surgically in 48.5 percent. There were no differences between groups in gender, age, or race, and 44.5 percent of all patients had a prior history of thrombosed external hemo rrhoid. A prior history was less common in the conservative group than in the su rgical group (38.1 percent vs. 51.3 percent; P < 0.05). The frequency of pain or bleeding as the primary complaint was higher in the surgical group (P< 0.001 and P< 0.002) . In addition, the surgical group was more likely to report all three symptoms o f pain, bleeding, and a lump (P< 0.005). Mean follow-up was 7.6 months, with th e range extending to 7 years. Time to symptom resolution averaged 24 days in the conservative group vs. 3.9 days in the surgical group (P< 0.0001). The overall incidence to recurrence was 15.6 percent-80.6 percent in the conservative group vs. 19.4 percent in the surgical group. The rate of recurrence in the conservat ive group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 perc ent of the surgical patients had recurrence (P < 0.0001). Mean time to recurrenc e was 7.1 months in the conservative group vs. 25 months in the surgical group ( P < 0.0001). Survival analysis for time to recurrence of thrombosed external hem orrhoid indicated that time to recurrence was significantly longer for the surgi cal group (P < 0.0001). Logistic regression analysis of multiple factors (includ ing diverticular disease, constipation, straining, benign prostatic hypertrophy, diarrhea, skin tags, history of travel, anoreceptive sex, anal fissures, intern al hemorrhoids, and obesity) was performed to determine the outcome of each grou p. None of these variables were significant predictors of recurrence. CONCLUSION S: Patients whose initial presentation was pain or bleeding with or without a lu mp were more like to be treated surgically. Surgically treated patients had a lo wer frequency of recurrence and a longer time interval to recurrence than conser vatively treated patients. None of the variables analyzed were significant predi ctors of a particular treatment, except for a prior history of thrombosed extern al hemorrhoids, which may represent patient choice. Although most patients treat ed conservatively will experience resolution of their symptoms, excision of thro mbosed external hemorrhoids results in more rapid symptom resolution, lower inci dence of recurrence, and longer remission intervals.展开更多
Objective: To determine whether patients with moderate to severe acne who were treated with isotretinoin experienced significant increases in depressive symptoms over a 3- to 4- month period compared with patients who...Objective: To determine whether patients with moderate to severe acne who were treated with isotretinoin experienced significant increases in depressive symptoms over a 3- to 4- month period compared with patients who received conservative acne therapy. Design: Cohort study. Setting: Hospital- affiliated and community- based clinics in St Louis, Mo. Participants: One hundred thirty- two subjects aged 12 to 19 years with moderate to severe acne. Main Outcome Measures: Depressive symptoms were assessed using the Center for Epidemiological StudiesDepressionScale(CES- D),astandardizedself- reported instrument. Mean CES- D scores were compared between treatment groups, as were the prevalence and incidence of scores suggestive of clinically significant depression (CES- D score >16). Results: A total of 101 subjects completed the study. At follow- up, CES- D scores (adjusted for baseline CES- D score and sex of patient) suggestive of clinically significant depression were no more prevalent in the isotretinoin group than in the conservative therapy group. Similarly, the incidence (new onset) of depressive symptoms suggestive of clinical significance also was not significantly different between the treatment groups. Conclusions: The use of isotretinoin in the treatment of moderate- severe acne in adolescents did not increase symptoms of depression. On the contrary, treatment of acne either with conservative therapy or with isotretinoin was associated with a decrease in depressive symptoms.展开更多
Purpose To evaluate the long-term pr ognosis of visual function in patients with orbital cavernomas after conser-vative and surgical treatment.Design Interventional case series.Methods The authors describ e the outcom...Purpose To evaluate the long-term pr ognosis of visual function in patients with orbital cavernomas after conser-vative and surgical treatment.Design Interventional case series.Methods The authors describ e the outcome of 20patients with cavernous hemangioma s of the orbit treated in their departments between 1988and 2003.This prospec-tive study included five cases follo wed by clinical and ra-diologic observation and 15cases of symptomatic tumors that were completely removed by mean s of a frontotemporal or by means of a transconjunctival ap proach.The clinical characteristics of orbital cavernomas were analyzed together with their appropriate treatment.F urthermore,the authors present the unusual case of a patient suffering from pro-gressive visual deterioration from a cerebral cavernoma compressing the optic nerve.Results The follow up period was between 3and 10years.All orbita l cavernomas in the group of conservatively managed patients remained stable.The transconjunctival excision of a medially located lesion was uncomplicated.The frontotemporal approach was cho-sen for large tumors situated in the p roximity of the orbital apex and was associated with a higher number of compli-cations.A good overall outcome of visual function and patient satisfaction was achieved i n 11of 14cases operated on by craniotomy.Conclusion The com bination of clinical signs and magnetic resonance imagin g(MRI )is highly sensitive and specific for the diagn osis of orbital caver-nomas.In the presence of visual dete rioration clearly at-tributable to the tumor we recommend immediate surgery,while lesions producing solely exop hthalmos can safely be followed by observation.The transc ranial approach offers excellent exposure and a rewarding c osmetic result and may be considered for large lesions superior and medial to the optic nerve,especially if they involve the orbital apex.展开更多
文摘Background Spontaneous supratentorial intracerebral haemorrhage accounts for 20% of all stroke- related sudden neurological deficits, has the highest morbidity and mortality of all stroke, and the role of surgery remains controversial. We undertook a prospective randomised trial to compare early surgery with initial conservative treatment for patients with intracerebral haemorrhage. Methods A parallel- group trial design was used. Early surgery combined haematoma evacuation (within 24 h of randomisation) with medical treatment. Initial conservative treatment used medical treatment, although later evacuation was allowed if necessary. We used the eight- point Glasgow outcome scale obtained by postal questionnaires sent directly to patients at 6 months follow- up as the primary outcome measure. We divided the patients into good and poor prognosis groups on the basis of their clinical status at randomisation. For the good prognosis group, a favourable outcome was defined as good recovery or moderate disability on the Glasgow outcome scale. For the poor prognosis group, a favourable outcome also included the upper level of severe disability. Analysis was by intention to treat. Findings 1033 patients from 83 centres in 27 countries were randomised to early surgery (503) or initial conservative treatment (530). At 6 months, 51 patients were lost to follow- up, and 17 were alive with unknown status. Of 468 patients randomised to early surgery, 122 (26% ) had a favourable outcome compared with 118 (24% ) of 496 randomised to initial conservative treatment (odds ratio 0.89 [95% CI 0.66- 1.19], p=0.414); absolute benefit 2.3% (- 3.2to 7.7), relative benefit 10% (- 13 to 33). Interpretation Patients with spontaneous supratentorial intracerebral haemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment.
文摘PURPOSE: Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to re currence, and factors predicting recurrence of thrombosed external hemorrhoids a fter conservative or surgical management. METHODS: Two hundred and thirty-one c onsecutive patients with thrombosed external hemorrhoids treated from 1990 to 20 02 were identified. Recurrence was defined as complete resolution of the index l esion with subsequent return of a thrombosed external hemorrhoid and did not inc lude patients with chronic symptoms. Data were gathered retrospectively. Multipl e potential risk factors were reviewed. RESULTS: The index thrombosed external h emorrhoid was managed conservatively in 51.5 percent of cases and surgically in 48.5 percent. There were no differences between groups in gender, age, or race, and 44.5 percent of all patients had a prior history of thrombosed external hemo rrhoid. A prior history was less common in the conservative group than in the su rgical group (38.1 percent vs. 51.3 percent; P < 0.05). The frequency of pain or bleeding as the primary complaint was higher in the surgical group (P< 0.001 and P< 0.002) . In addition, the surgical group was more likely to report all three symptoms o f pain, bleeding, and a lump (P< 0.005). Mean follow-up was 7.6 months, with th e range extending to 7 years. Time to symptom resolution averaged 24 days in the conservative group vs. 3.9 days in the surgical group (P< 0.0001). The overall incidence to recurrence was 15.6 percent-80.6 percent in the conservative group vs. 19.4 percent in the surgical group. The rate of recurrence in the conservat ive group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 perc ent of the surgical patients had recurrence (P < 0.0001). Mean time to recurrenc e was 7.1 months in the conservative group vs. 25 months in the surgical group ( P < 0.0001). Survival analysis for time to recurrence of thrombosed external hem orrhoid indicated that time to recurrence was significantly longer for the surgi cal group (P < 0.0001). Logistic regression analysis of multiple factors (includ ing diverticular disease, constipation, straining, benign prostatic hypertrophy, diarrhea, skin tags, history of travel, anoreceptive sex, anal fissures, intern al hemorrhoids, and obesity) was performed to determine the outcome of each grou p. None of these variables were significant predictors of recurrence. CONCLUSION S: Patients whose initial presentation was pain or bleeding with or without a lu mp were more like to be treated surgically. Surgically treated patients had a lo wer frequency of recurrence and a longer time interval to recurrence than conser vatively treated patients. None of the variables analyzed were significant predi ctors of a particular treatment, except for a prior history of thrombosed extern al hemorrhoids, which may represent patient choice. Although most patients treat ed conservatively will experience resolution of their symptoms, excision of thro mbosed external hemorrhoids results in more rapid symptom resolution, lower inci dence of recurrence, and longer remission intervals.
文摘Objective: To determine whether patients with moderate to severe acne who were treated with isotretinoin experienced significant increases in depressive symptoms over a 3- to 4- month period compared with patients who received conservative acne therapy. Design: Cohort study. Setting: Hospital- affiliated and community- based clinics in St Louis, Mo. Participants: One hundred thirty- two subjects aged 12 to 19 years with moderate to severe acne. Main Outcome Measures: Depressive symptoms were assessed using the Center for Epidemiological StudiesDepressionScale(CES- D),astandardizedself- reported instrument. Mean CES- D scores were compared between treatment groups, as were the prevalence and incidence of scores suggestive of clinically significant depression (CES- D score >16). Results: A total of 101 subjects completed the study. At follow- up, CES- D scores (adjusted for baseline CES- D score and sex of patient) suggestive of clinically significant depression were no more prevalent in the isotretinoin group than in the conservative therapy group. Similarly, the incidence (new onset) of depressive symptoms suggestive of clinical significance also was not significantly different between the treatment groups. Conclusions: The use of isotretinoin in the treatment of moderate- severe acne in adolescents did not increase symptoms of depression. On the contrary, treatment of acne either with conservative therapy or with isotretinoin was associated with a decrease in depressive symptoms.
文摘Purpose To evaluate the long-term pr ognosis of visual function in patients with orbital cavernomas after conser-vative and surgical treatment.Design Interventional case series.Methods The authors describ e the outcome of 20patients with cavernous hemangioma s of the orbit treated in their departments between 1988and 2003.This prospec-tive study included five cases follo wed by clinical and ra-diologic observation and 15cases of symptomatic tumors that were completely removed by mean s of a frontotemporal or by means of a transconjunctival ap proach.The clinical characteristics of orbital cavernomas were analyzed together with their appropriate treatment.F urthermore,the authors present the unusual case of a patient suffering from pro-gressive visual deterioration from a cerebral cavernoma compressing the optic nerve.Results The follow up period was between 3and 10years.All orbita l cavernomas in the group of conservatively managed patients remained stable.The transconjunctival excision of a medially located lesion was uncomplicated.The frontotemporal approach was cho-sen for large tumors situated in the p roximity of the orbital apex and was associated with a higher number of compli-cations.A good overall outcome of visual function and patient satisfaction was achieved i n 11of 14cases operated on by craniotomy.Conclusion The com bination of clinical signs and magnetic resonance imagin g(MRI )is highly sensitive and specific for the diagn osis of orbital caver-nomas.In the presence of visual dete rioration clearly at-tributable to the tumor we recommend immediate surgery,while lesions producing solely exop hthalmos can safely be followed by observation.The transc ranial approach offers excellent exposure and a rewarding c osmetic result and may be considered for large lesions superior and medial to the optic nerve,especially if they involve the orbital apex.
