Initial Treatment (initial + treatment)

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Distribution within Medical Sciences

Selected Abstracts

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

James R. Miner MD
Abstract Objectives:, The objective was to compare the time to medication administration, the side effects, and the analgesic effect at sequential time points after medication administration of an oral treatment strategy using oxycodone solution with an intravenous (IV) treatment strategy using morphine sulfate for the initial treatment of musculoskeletal pain in emergency department (ED) patients. Methods:, This was a prospective randomized clinical trial of patients >6 years old who were going to receive IV morphine sulfate for the treatment of musculoskeletal pain but did not yet have an IV. Consenting patients were randomized to have the treating physician order either 0.1 mg/kg morphine sulfate IV or 0.125 mg/kg oxycodone orally in a 5 mg/5 mL suspension as their initial treatment for pain. The time from the placement of the order to the administration of the medication was recorded. Pain was measured using a 100-mm visual analog scale (VAS) and recorded at 0, 10, 20, 30 and 40 minutes after drug administration. Results:, A total of 405 eligible patients were identified during the study period; 328 (81.0%) patients consented to be in the study. A total of 158 patients were randomized to the IV morphine sulfate treatment group, and 162 were randomized to the oral oxycodone treatment group. Of the patients who were randomized to IV therapy, 34 were withdrawn from the study prior to drug administration; leaving 125 patients in the IV group for analysis. Of the patients who randomized to oral therapy, 22 were withdrawn from the study prior to drug administration, leaving 140 patients for analysis. No serious adverse events were detected. There was a 12-minute difference between the median time of the order and the administration of oral oxycodone (8.5 minutes) and IV morphine (20.5 minutes). The mean percent change in VAS score was larger for patients in the IV therapy group than those in the oral therapy group at 10 and 20 minutes. At 30 and 40 minutes, the authors could no longer detect a difference. The satisfaction scale score was higher after treatment for the morphine group (median = 4; interquartile range [IQR] = 4 to 5) than for the oxycodone group (median = 4; IQR = 2 to 5; p = 0.008). Conclusions:, The oral loading strategy was associated with delayed onset of analgesia and decreased patient satisfaction, but a shorter time to administration. The oral loading strategy using an oxycodone solution provided similar pain relief to the IV strategy using morphine 30 minutes after administration of the drug. Oral 0.125 mg/kg oxycodone represents a feasible alternative to 0.1 mg/kg IV morphine in the treatment of severe acute musculoskeletal pain when difficult or delayed IV placement greater than 30 minutes presents a barrier to treatment. [source]

Metastatic squamous cell carcinoma of the neck from an unknown primary: Management options and patterns of relapse,

Shahrokh Iganej MD
Abstract Purpose Management of squamous cell carcinoma of undetermined primary tumors in the head and neck region is controversial. Here we report the Southern California Kaiser Permanente experience with these patients. Methods and Materials From January 1969 through December 1994, 106 patients were eligible for this retrospective analysis. Distribution of nodal staging was as follows: 14 N1, 27 N2A, 39 N2B, 2 N2C, and 24 N3. Initial treatment included excisional biopsy alone in 12, radical neck dissection alone in 29, radiotherapy alone in 24, excisional biopsy followed by radiotherapy in 15, and radical neck dissection plus postoperative radiation in 26 patients. Results Except for two patients, all patients have had a minimum follow-up of 5 years. Overall, 57 patients (54%) have had recurrences. Only two patients (3%) who had received radiotherapy as part of their initial treatment had an appearance of a potential primary site inside the irradiated field vs 13 patients (32%) who had not received radiotherapy (p = .006). Combined modality therapy resulted in fewer neck relapses, particularly in patients with advanced neck disease. Including salvage, surgery alone as the initial treatment resulted in 81% ultimate tumor control above the clavicle for patients with N1 and N2a disease without extracapsular extension. The 5-year survival for the entire population was 53%. Radiotherapy alone resulted in poor survival in patients with advanced/unresectable neck disease. No significant difference in survival based on the initial treatment was found. The statistically significant adverse factors in determining survival included advanced nodal stage and the presence of extracapsular extension. Conclusions Radiotherapy is very effective in reducing the rate of appearance of a potential primary site. However, in the absence of advanced neck disease (N1 and N2A without extracapsular extension), radiotherapy can be reserved for salvage. Radiotherapy alone results in poor outcomes in patients with advanced/unresectable neck disease, and incorporation of concurrent chemotherapy and cytoprotective agents should be investigated. © 2002 Wiley Periodicals, Inc. Head Neck 24: 236,246, 2002; DOI 10.1002/hed.10017 [source]

Upper digestive bleeding in cirrhosis.

HEPATOLOGY, Issue 3 2003
Post-therapeutic outcome, prognostic indicators
Several treatments have been proven to be effective for variceal bleeding in patients with cirrhosis. The aim of this multicenter, prospective, cohort study was to assess how these treatments are used in clinical practice and what are the posttherapeutic prognosis and prognostic indicators of upper digestive bleeding in patients with cirrhosis. A training set of 291 and a test set of 174 bleeding cirrhotic patients were included. Treatment was according to the preferences of each center and the follow-up period was 6 weeks. Predictive rules for 5-day failure (uncontrolled bleeding, rebleeding, or death) and 6-week mortality were developed by the logistic model in the training set and validated in the test set. Initial treatment controlled bleeding in 90% of patients, including vasoactive drugs in 27%, endoscopic therapy in 10%, combined (endoscopic and vasoactive) in 45%, balloon tamponade alone in 1%, and none in 17%. The 5-day failure rate was 13%, 6-week rebleeding was 17%, and mortality was 20%. Corresponding findings for variceal versus nonvariceal bleeding were 15% versus 7% (P = .034), 19% versus 10% (P = .019), and 20% versus 15% (P = .22). Active bleeding on endoscopy, hematocrit levels, aminotransferase levels, Child-Pugh class, and portal vein thrombosis were significant predictors of 5-day failure; alcohol-induced etiology, bilirubin, albumin, encephalopathy, and hepatocarcinoma were predictors of 6-week mortality. Prognostic reassessment including blood transfusions improved the predictive accuracy. All the developed prognostic models were superior to the Child-Pugh score. In conclusion, prognosis of digestive bleeding in cirrhosis has much improved over the past 2 decades. Initial treatment stops bleeding in 90% of patients. Accurate predictive rules are provided for early recognition of high-risk patients. [source]

Recurrent bile duct stones after transduodenal sphincteroplasty

HPB, Issue 2 2002
SMG Kibria
Background Transduodenal sphincteroplasty (TDS) offers permanent prophylaxis against further stones in the common bile duct (CBD) by allowing continuous free efflux of bile from the papilla. Patients and resultsIn a personal series of 267 consecutive operations, four patients underwent further treatment for recurrent CBD stones during a median follow-up of 12 years. Three of them received Roux-en-Y biliary diversion and had no further symptoms; the fourth patient remains well four years after endoscopic extraction of stones. Discussion Recurrent stone formation is rare after an adequate TDS and probably reflects retained food debris within the CBD. Initial treatment may be endoscopic, but biliary diversion is needed for those with recurrent symptoms. [source]

Long-term prognosis of crown-fractured permanent incisors.

The effect of stage of root development, associated luxation injury
Objectives. The aim of the present study was to investigate pulp healing responses following crown fracture with and without pulp exposure as well as with and without associated luxation injury and in relation to stage of root development. Patient material and methods. The long-term prognosis was examined for 455 permanent teeth with crown fractures, 352 (246 with associated luxation injury) without pulpal involvement and 103 (69 with associated luxation injury) with pulp exposures. Initial treatment for all patients was provided by on-call oral surgeons at the emergency service, University Hospital (Rigshospitalet), Copenhagen. In fractures without pulpal involvement, dentin was covered by a hard-setting calcium hydroxide cement (Dycal®), marginal enamel acid-etched (phosphoric acid gel), then covered with a temporary crown and bridge material. In the case of pulp exposure, pulp capping or partial pulpotomy was performed. Thereafter treatment was identical to the first group. Patients were then referred to their own dentist for resin composite restoration. Results. Patients were monitored for normal pulp healing or healing complications for up to 17 years after injury (x = 2·3 years, range 0·2,17·0 years, SD + 2·7). Pulp healing was registered and classified into pulp survival with no radiographic change (PS), pulp canal obliteration (PCO) and pulp necrosis (PN). Healing was related to the following clinical factors: stage of root development at the time of injury, associated damage to the periodontium at time of injury (luxation) and time interval from injury until initial treatment. Crown fractures with or without pulp exposure and no concomitant luxation injury showed PS in 99%, PCO in 1% and PN in 0%. Crown fractures with concomitant luxation showed PS in 70%, PCO in 5% and PN in 25%. An associated damage to the periodontal ligament significantly increased the likelihood of pulp necrosis from 0% to 28% (P < 0·001) in teeth with only enamel and dentin exposure and from 0% to 14% (P < 0·001) in teeth with pulp exposure. Conclusions. In the case of concomitant luxation injuries, the stage of root development played an important role in the risk of pulp necrosis after crown fracture. However, the primary factor related to pulp healing events after crown fracture appears to be compromised pulp circulation due to concomitant luxation injuries. [source]

Periodontal treatment of patients with Papillon,Lefèvre syndrome: a 3-year follow-up

T. Lundgren
Abstract Background/aim: Conventional mechanical periodontal treatment of Papillon,Lefèvre syndrome (PLS) has often been reported to fail. This study describes the outcome of a non-surgical periodontal therapy including antimicrobial treatment of nine patients diagnosed with PLS. The patients originate from a total of 15 children and adolescents with PLS for which clinical characteristics are presented. Methods: Clinical examination including conventional periodontal measurements. Initial treatment including oral hygiene instruction, scaling and root planing and systemic amoxicillin,metronidazole therapy for 6 weeks. After that the patients were enrolled in a 3-month recall maintenance program. In addition to this mechanical supportive maintenance treatment, tetracycline was prescribed and used continuously for 1.5 years. Results/Conclusion: On five patients who were showing acceptable standard of oral hygiene and also compliance with the antibiotic medication, development of periodontitis on erupting teeth was prevented and disease activity on the previously periodontally involved teeth controlled during a 3-year period. Poor results of treatment were observed for three patients, all siblings. These patients failed to comply with the medication and also failed to improve their oral hygiene. [source]

Epithelial salivary gland tumors of children and adolescents in west China population: a clinicopathologic study of 79 cases

Liu Laikui
Objective:, Determine the clinical and histopathologic features of epithelial salivary gland tumors of children and adolescents. Methods:, A total of 79 cases of epithelial salivary gland tumors of children and adolescents were retrieved from the files. Information about demographic, clinical, histopathologic characteristics, and follow-up status were analyzed. Results:, Sixty tumors (75.9%) were benign and 19 (24.1%) malignant. The most common tumor overall was pleomorphic adenoma (PA). The parotid was the most frequently involved site (43.0%). PA was the most common type of benign tumor. The most common malignant tumor was mucoepidermoid carcinoma. Five patients with parotid PA and two cases with palate myoepithelioma showed local recurrences. One patient with mucoepidermoid carcinoma showed local recurrences and died from the tumor 3 years after the initial treatment. One patient with adenocarcinoma presented local and neck recurrences, and died 4 years after initial treatment. Conclusions:, Our data showed that the salivary gland tumors in children and adolescents may be the higher incidence of benign tumors, especially of PA; the slightly higher tendency for female predominance; the higher incidence of parotid glands. Mucoepidermoid carcinoma was the most common malignant tumor, with majority of low grade. Initial treatment should be planned to excise the tumor completely with satisfactory margins. The neck dissections or postoperative radiotherapy were performed in patients with low differentiation malignancies, or patients who present nodal metastasis or with clinically suspicious regional metastasis. [source]

HPA-suppressive effects of aqueous clobetasol propionate in the treatment of patients with oral lichen planus

MA Gonzalez-Moles
Abstract Background, Oral topical corticosteroids have potential to produce inhibition of the hypothalamus,pituitary,adrenal (HPA) axis. Objective, To assess whether clobetasol propionate (CP) in aqueous solution causes HPA inhibition. Patients and methods, Sixty-two patients with oral lichen planus or oral lichenoid lesions presenting with severe lesions were treated with topical oral 0.05% CP plus 100 000 IU/cm3 nystatin in aqueous solution. Initial treatment of three 5-min mouthwashes (10 mL) daily was reduced, when the response was deemed complete or excellent, to a maintenance treatment of one 5-min mouthwash on alternate days for 6 months; treatment was then withdrawn and patients were followed up for 1 year. HPA function was assessed by plasma cortisol measurement and adrenocorticotropin (ACTH) stimulation at the end of the initial and maintenance treatment regimens. Results, The HPA axis was more frequently inhibited during initial (53/62; 85.5%) vs. maintenance (2/49; 4%) regimens of aqueous CP. Limitations, In patients with morning plasma cortisol levels between 3 and 18 ,g/dL, a normal result for the ACTH stimulation test only moderately reduces the possibility that a patient has secondary adrenal insufficiency. This can be considered a minor limitation in our study, as only three patients required additional assessment with the ACTH stimulation test. Conclusions, Hypothalamus,pituitary,adrenal inhibition is substantial during initial treatment with aqueous CP three times daily. [source]

Consequences of treatment withdrawal in type 1 autoimmune hepatitis

Aldo J. Montano-Loza
Abstract Background and Aims: Drug-related side effects are considered the major consequences of relapse and re-treatment in patients with autoimmune hepatitis. Our goals were to determine whether relapse is associated with disease progression and whether treatment end points can be refined. Methods: The outcomes of 132 patients with definite type 1 autoimmune hepatitis who had been treated comparably until remission were assessed retrospectively after drug withdrawal. Results: Patients who had relapsed repeatedly after initial treatment withdrawal developed cirrhosis more commonly than patients who sustained remission (18/48 vs 1/22, P=0.004), and those who relapsed once (18/48 vs 2/21, P=0.02). Hepatic death or the need for liver transplantation was also more frequent in the patients who had multiple relapses than those who sustained remission (13/64 vs 0/30, P=0.008) and those who relapsed once (13/64 vs 1/38, P=0.02). Patients who sustained their remission had a higher frequency of normal laboratory indices at drug withdrawal than patients who relapsed (88% vs 46%, P=0.003). Adverse outcomes after relapse did not distinguish patients until after 5 years of observation. Conclusions: Multiple relapses are associated with a poorer prognosis than sustained remission or single relapse episodes. Initial treatment to resolution of laboratory abnormalities may afford the greatest opportunity to prevent relapse. [source]

Natural history and outcome of optic pathway gliomas in children,

Gary Nicolin MD
Abstract Background The optimal management of optic pathway gliomas (OPGs) is complicated by their variable natural history, the association with neurofibromatosis type 1 (NF1) and difficulties in defining progression and response to treatment. Methods This study is a retrospective review of all children presenting to a single institution with an OPG between 1990 and 2004. Results Of the 133 children included, 78 (59%) had NF1; 87 (71 NF1) were observed initially, of whom 23 (11 NF1) subsequently required treatment. Forty-six patients received immediate treatment. Initial treatment, without or with an observation period, comprised chemotherapy alone (32, 11 NF1); debulking,+,chemotherapy (15, 4 NF1); gross total resection (6); radiotherapy (2); debulking,+,radiotherapy (3); and debulking only (12, 3 NF1). Overall, 16 patients were irradiated during the study period. Four children died (overall survival at 5 and 10 years was 97.6% and 94.6% for those who required treatment). Progression-free survival (PFS) for the 69 patients who needed treatment was 48%. There was no difference in PFS between chemotherapy versus chemotherapy,+,debulking or debulking alone. PFS for the NF1 patients who required treatment was similar to that of non-NF1 patients. Mean follow-up time was 9.0 (range 0.6,18.0, median 8.6) years. Conclusions The study confirms the complexity of OPGs and that NF1 is a major determinant of the resultant behavior of the tumor. Pediatr Blood Cancer 2009; 53:1231,1237. © 2009 Wiley-Liss, Inc. [source]

Laryngeal Cancer in the United States: Changes in Demographics, Patterns of Care, and Survival

FACS, Henry T. Hoffman MD
Abstract Background: Survival has decreased among patients with laryngeal cancer during the past 2 decades in the United States. During this same period, there has been an increase in the nonsurgical treatment of laryngeal cancer. Objective: The objectives of this study were to identify trends in the demographics, management, and outcome of laryngeal cancer in the United States and to analyze factors contributing to the decreased survival. Study Design: The authors conducted a retrospective, longitudinal study of laryngeal cancer cases. Methods: Review of the National Cancer Data Base (NCDB) revealed 158,426 cases of laryngeal squamous cell carcinoma (excluding verrucous carcinoma) diagnosed between the years 1985 and 2001. Analysis of these case records addressed demographics, management, and survival for cases grouped according to stage, site, and specific TNM classifications. Results: This review of data from the NCDB analysis confirms the previously identified trend toward decreasing survival among patients with laryngeal cancer from the mid-1980s to mid-1990s. Patterns of initial management across this same period indicated an increase in the use of chemoradiation with a decrease in the use of surgery despite an increase in the use of endoscopic resection. The most notable decline in the 5-year relative survival between the 1985 to 1990 period and the 1994 to 1996 period occurred among advanced-stage glottic cancer, early-stage supraglottic cancers, and supraglottic cancers classified as T3N0M0. Initial treatment of T3N0M0 laryngeal cancer (all sites) in the 1994 to 1996 period resulted in poor 5-year relative survival for those receiving either chemoradiation (59.2%) or irradiation alone (42.7%) when compared with that of patients after surgery with irradiation (65.2%) and surgery alone (63.3%). In contrast, identical 5-year relative survival (65.6%) rates were observed during this same period for the subset of T3N0M0 glottic cancers initially treated with either chemoradiation or surgery with irradiation. Conclusions: The decreased survival recorded for patients with laryngeal cancer in the mid-1990s may be related to changes in patterns of management. Future studies are warranted to further evaluate these associations. [source]

A prospective study of the time to evacuate acute subdural and extradural haematomas,

ANAESTHESIA, Issue 3 2009
D. Bulters
Summary We performed a prospective, single-centre study of times to treatment of patients with life-threatening, traumatic, extra- and subdural haematomas requiring surgical evacuation between May 2006 and May 2007. The mean time to surgical decompression was 5.0 h and 32% were performed within 4 h. Patients who initially presented to a district hospital and required transfer for neurosurgery were decompressed in 5.4 h vs 3.7 h for those admitted directly. The current standard of surgical evacuation of all haematomas within 4 h is not being met. Delays were identified in every stage in the management of these patients and no single step was identified as the major cause. Initial treatment in district hospitals led to delays greater than the added driving time. There may be time savings from carrying out treatment steps in parallel instead of in series. [source]

Combination therapy with fludarabine and rituximab followed by alemtuzumab in the first-line treatment of patients with chronic lymphocytic leukemia or small lymphocytic lymphoma

CANCER, Issue 6 2008
A phase 2 trial of the Minnie Pearl Cancer Research Network
Abstract BACKGROUND The purpose of the current study was to evaluate the efficacy and toxicity of the combination of fludarabine and rituximab, followed by alemtuzumab, as first-line treatment for patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). METHODS In a nonrandomized phase 2 trial, 41 patients who had previously untreated CLL or SLL and required treatment received 4 cycles of the fludarabine and rituximab combination followed 5 weeks later by 4 weeks (12 doses) of intravenous alemtuzumab therapy. The response to treatment was evaluated after completion of treatment with fludarabine and rituximab, and again after the completion of alemtuzumab consolidation. RESULTS Initial treatment with the combination of fludarabine and rituximab was well tolerated, and produced a 71% overall response rate (13% complete response). Thirty-four patients began treatment with intravenous alemtuzumab, but this drug was relatively poorly tolerated when given at a short interval after fludarabine and rituximab, and only 20 patients (49% of total) were able to complete the prescribed course. Five patients had an improvement in their response with alemtuzumab; the final complete response rate was 21%. The median progression-free survival for the entire group was 42 months. Toxicity with alemtuzumab included infusion-related toxicity, myelosuppression, and opportunistic infections. CONCLUSIONS The intravenous schedule of alemtuzumab employed in the trial was relatively poorly tolerated in this community-based trial. The relatively low complete response rates after treatment with the combination of fludarabine and rituximab and after the completion of treatment suggest that these abbreviated courses may compromise efficacy. The generalized use of alemtuzumab as consolidation therapy cannot yet be recommended for community practice. However, optimization of the route of administration, duration of treatment, and interval after completion of induction therapy may improve efficacy, and further investigation is ongoing. Cancer 2008. © 2008 American Cancer Society. [source]

Clinical management and outcome of papillary and follicular (differentiated) thyroid cancer presenting with distant metastasis at diagnosis,

CANCER, Issue 7 2007
Elliot Sampson BSc
Abstract BACKGROUND. Differentiated thyroid cancer has a good prognosis and only rarely presents with distant metastasis at diagnosis. The clinical outcome of this presentation was assessed with respect to survival and factors that may determine prognosis. METHODS. A retrospective review was undertaken of patients with stage M1 differentiated thyroid cancer at presentation (n = 49), referred from 1980,2000 at a single institution. RESULTS. The median age was 68 (range, 17,90), with 69% females. The initial site(s) of metastasis were lung only, 45%, bone only, 39%, other single site, 4%, and multiple sites, 12%. Histology: papillary, 51%, follicular, 49%. Initial treatment(s) included: thyroidectomy, 82%, radioactive iodine (RAI), 88%, excision of metastasis, 29%, radiotherapy, 47%, and chemotherapy, 6%. With a median follow-up time of 3.5 years, 25 patients are alive (51%) and 24 died (49%), with 3-year and 5-year actuarial survivals of 69% and 50%, respectively. Only a minority of patients (4/25, 16%) had no clinical evidence of disease at last follow-up. Most deaths (17/24, 71%) were due to progressive cancer. Prognosis was associated with age, site of metastasis, histology, and iodine avidity of the metastasis. Patients aged ,45 (n = 8) had a 3-year survival of 100%, versus 62% for those age > 45 years (P = .001). The 3-year survival for lung only versus bone only metastasis was 77% versus 56% (P = .02); for papillary versus follicular carcinoma, 75% versus 62% (P = .006); for iodine-avid disease (n = 29) versus not avid (n = 14), 82% versus 57% (P = .02), respectively. In multivariate analysis after adjusting for age, only histology and iodine avidity remained significant for survival. The hazard ratio for follicular histology was 3.7 (95% confidence interval [CI], 1.1,12.1, P = .03), and for tumors not avid for iodine, 3.4 (95% CI, 1.2,9.2, P = .02). CONCLUSIONS. The data support the aggressive management of patients presenting with stage M1 thyroid cancer, with thyroidectomy and RAI. Complete clinical eradication of disease was rarely seen, and 50% of patients survived for more than 5 years. Young patients with papillary tumors and/or iodine-avid disease have an even better prognosis. Cancer 2007. © 2007 American Cancer Society. [source]

Out-patient management of patients with a peritonsillar abscess

C. Al Yaghchi
Keypoints ,,In the United Kingdom, patients with a peritonsillar abscess are usually managed as inpatients. However, studies in other countries have shown successful management of these patients as outpatients. ,,We designed an evidence based protocol for the management of patients with a peritonsillar abscess. Diagnosis was by aspiration of pus. Initial treatment was with analgesia, 1.2 g co-amoxiclav and 4 mg dexamethasone intravenously. ,,Data were collected prospectively over 11 months on the management of all patients who had been confirmed by aspiration of pus to have a peritonsillar abscess. ,,Four of the 46 patients (9%) treated as per the protocol required admission, two immediately and two later on. Of the 44 patients initially treated as outpatients, 41 said they were happy to have been treated as outpatients and not admitted to hospital (93%). ,,Patients with a peritonsillar abscess can be managed successfully as outpatients with a high degree of patient satisfaction. [source]

An audit of the time to initial treatment in avulsion injuries

Betul Kargul
Good outcome requires education of the general public and non-dental professionals. Aim:, Retrospective observational survey of case records of avulsion injuries attending a dental hospital trauma clinic. Method:, Data collected included: hospital number, date of birth, gender, source of patient's referral, date of trauma, number of avulsed teeth, place of initial presentation, storage, hours till initial presentation, and initial treatment. Results:, One hundred and twenty teeth with avulsion were identified in 75 children. The mean age of the patients was 9.8 years (SD = 2.3 years) at the time of trauma with avulsions recorded in 44 (58.7%) boys and in 31 (41.3%) girls. Only 51 (42.5%) teeth were stored in an appropriate medium before attendance at any site and only 48 (40%) of the teeth were seen within 1 h. 83.3% received emergency treatment at general hospital, 89.7% in dental practice and 92.9% at dental hospital. Conclusions:, A minority of avulsion injuries were seen within the first hour and a minority were in appropriate storage medium at presentation. Geographical location plays a huge role in the time taken to reach secondary care. However, improving public and non-dental professional knowledge about tooth storage in avulsion injuries is critical to long-term prognosis of the teeth. [source]

Persistence and Improvement of Nasolabial Fold Correction with Nonanimal-Stabilized Hyaluronic Acid 100,000 Gel Particles/mL Filler on Two Retreatment Schedules: Results up to 18 Months on Two Retreatment Schedules

BACKGROUND Nonanimal-stabilized hyaluronic acid (NASHA) fillers are frequently used for facial soft tissue augmentation. Their long-term efficacy and the effects of different retreatment schedules are not well established. OBJECTIVE This is an 18-month interim analysis of a 30-month study to evaluate the efficacy and persistence of NASHA 100,000 gel particles/mL filler with two different retreatment schedules. METHODS This multicenter, randomized, evaluator-blinded study enrolled 75 patients with moderate to severe nasolabial folds. Patients were randomized to retreatment of one nasolabial fold at 4.5 months and the contralateral fold at 9 months after correction of both folds at the initial visit. RESULTS Wrinkle Severity Rating Scale scores improved significantly (p<.001) from baseline, with mean improvements ranging from 1.1 to 1.7 grades. Almost all patients (97%) responded satisfactorily, and the efficacy of the retreatment schedules did not differ significantly. Adverse events, primarily swelling and bruising, occurred in 33% of patients; none were serious. CONCLUSION The improvements seen after initial treatment with NASHA 100,000 gel particles/mL filler persisted for up to 18 months with one retreatment. The response was equivalent for retreatment at 4.5 and 9 months. [source]

Angiolymphoid Hyperplasia with Eosinophilia Successfully Treated with a Long-Pulsed Tunable Dye Laser

Thomas E. Rohrer MD
Background. To date, both surgical excision and laser treatments for angiolymphoid hyperplasia with eosinophilia (ALHE) have resulted in scarring. Objective. Based on the principle of selective photothermolysis, we considered employing the newer long-pulsed tunable dye laser in the treatment of ALHE, as less scarring would be expected and deeper blood vessels could be ablated. Methods. After punch biopsy specimens confirmed the diagnosis, the patient was treated on two separate occasions, 2 months apart with a long-pulsed tunable dye laser. Results. The lesions flattened after the initial treatment and resolved after a second treatment. No scarring was detectable and no recurrence was noted in follow-up after 1 year. Conclusion. We conclude that the long-pulsed tunable dye laser can be employed successfully to treat superficial lesions of ALHE, particularly in cosmetically sensitive areas. [source]

Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive-behavioural treatment one-and-a-half-year follow-up

J. Lidbeck
Objective:, The objective of this study was to evaluate the maintenance of treatment goals of a short cognitive-behavioural group treatment programme for the management of somatization disorders in primary care. Method:, In a previous controlled 6-month follow-up study, patients with somatization disorders (n=32) improved with respect to illness and somatic preoccupation, hypochondriasis, and medication usage. In the present report the same group of patients were also investigated one-and-a-half year after initial treatment. Results:, The long-term follow-up manifested maintained improvement with respect to hypochondriasis. There was additional reduction of anxiety and psychosocial preoccupation, whereas somatization and depression-anxiety scores improved progressively. Conclusion:, A short cognitive-behavioural group treatment of psychosomatic patients can be useful in primary care and may manifest maintained or progressive beneficial outcome. [source]

Sensitivity to sulphonylureas in patients with hepatocyte nuclear factor-1, gene mutations: evidence for pharmacogenetics in diabetes

E. R. Pearson
SUMMARY Introduction Maturity-onset diabetes of the young (MODY) is characterized by autosomal dominantly inherited, early-onset, non-insulin-dependent diabetes. Mutations in the hepatocyte nuclear factor (HNF)-1, gene are the commonest cause of MODY. Individual patients with HNF-1, mutations have been reported as being unusually sensitive to the hypoglycaemic effects of sulphonylurea therapy. We report three patients, attending a single clinic, with HNF-1, mutations that show marked hypersensitivity to sulphonylureas. Case reports In cases 1 and 2 there were marked changes in HbA1c on cessation (4.4% and 5.8%, respectively) and reintroduction (5.0% and 2.6%) of sulphonylureas. Case 3 had severe hypoglycaemic symptoms on the introduction of sulphonylureas despite poor glycaemic control and was shown with a test dose of 2.5 mg glibenclamide to have symptomatic hypoglycaemia (blood glucose 2 mmol/l) after 4 h despite eating. Conclusions HNF-1, MODY diabetic subjects are more sensitive to sulphonylureas than Type 2 diabetic subjects and this is seen in different families, with different mutations and may continue up to 13 years from diagnosis. This is an example of pharmacogenetics, with the underlying aetiological genetic defect altering the pharmacological response to treatment. The present cases suggest that in HNF-1, MODY patients: (i) sulphonylureas can dramatically improve glycaemic control and should be considered as initial treatment for patients with poor glycaemic control on an appropriate diet; (ii) hypoglycaemia may complicate the introduction of sulphonylureas and therefore very low doses of short acting sulphonylureas should be used initially; and (iii) cessation of sulphonylureas should be undertaken cautiously as there may be marked deterioration in glycaemic control. Keywords, genetics, HNF-1,, MODY, pharmacogenetics, sulphonylurea sensitivity [source]

Pseudoxanthoma elasticum with recurrent gastric hemorrhage managed by endoscopic mechanical hemostasis

Hitoshi Nishiyama
A 24-year-old-woman was admitted to our hospital for further examination of recurrent upper gastrointestinal tract hemorrhage. The characteristic xanthomatous papular rash, retinal angioid streaks, and stenosis of cardiac coronary artery confirmed the diagnosis of pseudoxanthoma elasticum. Upper gastrointestinal endoscopy revealed vascular dilation in the gastric body to fornix. The vessel showing conspicuous dilation covered with the discolored mucosa was suspected as the source of the bleeding. The vessel was identified as a dilated vein located in the submucosa by endoscopic ultrasonography and pulsed-wave Doppler ultrasonography. Abdominal angiography demonstrated aneurysmal dilation in the splenic artery, but not in the gastric artery. Endoscopic band ligation was chosen as an initial treatment for the prevention of recurrent bleeding. The procedure seemed to be successful, but rebleeding occurred on the next day, which was again treated with hemostatic clipping. There have been no further episodes of gastrointestinal hemorrhage during the 15-month follow up. [source]

Salvage esophagectomy after definitive chemoradiotherapy for synchronous double cancers of the esophagus and head-and-neck

R. Yoshida
SUMMARY Head-and-neck cancer is frequently associated with esophageal cancer. Because the operative procedures for these synchronous double cancers are too invasive, definitive chemoradiotherapy tends to be applied as an initial treatment. A salvage esophagectomy for either recurrent or residual disease after definitive chemoradiotherapy in patients with such double cancer has never been reported. We reviewed 21 patients with esophageal cancer who underwent a salvage esophagectomy after definitive chemoradiotherapy. Among them, the treatment course of five patients who underwent a salvage esophagectomy for patients with synchronous double cancers of the esophagus and head-and-neck region was analyzed. Because head-and-neck cancer was well controlled after chemoradiotherapy in all five patients, a salvage esophagectomy was indicated for either recurrent or residual esophageal cancer after definitive chemoradiotherapy. Anastomotic leakage developed in four patients; however, no other complications including pulmonary complications were recognized. All of them were discharged to home and three of them are still alive without any recurrence for 20,43 months. A salvage esophagectomy should be considered as a treatment option for either recurrent or residual esophageal cancer with well-controlled head-and-neck cancer after definitive chemoradiotherapy when complete resection of the esophagus is expected. [source]

Equine dental disease Part 4: a long-term study of 400 cases: apical infections of cheek teeth

P. M. Dixon
Summary Of 400 horses referred because of equine dental disease, 162 suffered from primary apical infections of their cheek teeth (CT), including 92 with maxillary CT infections and 70 with mandibular CT infections. Maxillary swellings and sinus tracts were more common (82 and 26% incidence, respectively) with infections of the rostral 3 maxillary CT, than with infections of the caudal 3 maxillary CT(39 and 5% incidence, respectively). Nasal discharge was more commonly present with caudal (95%) than rostral (23%) maxillary CT infections. Mandibular CT apical infections commonly had mandibular swellings (91%) and mandibular sinus tracts (59%) and these infections were closely related to eruption of the affected CT. A variety of treatments, including medical treatment, apical curettage, repulsion and oral extraction of affected teeth were utilised in these cases, with oral extraction appearing to be most satisfactory. Infections of caudal maxillary CT with a secondary paranasal sinusitis were most refractory to treatment, with a complete response to the initial treatment achieved in just 33% of these cases. Most other cases responded fully to their initial treatment. The long-term response to treatment was good in most cases. [source]

Recurrent pleomorphic adenoma of the parotid gland: Analysis of 108 consecutive patients

Claus Wittekindt MD
Abstract Background Surgery for recurrent parotid pleomorphic adenoma is a challenging problem. Methods One hundred eight patients who underwent 134 reoperations for recurrent parotid pleomorphic adenoma (follow-up, 22 years) were evaluated for histopathologic features and risk factors for recurrence. Results The number of reoperations for tumor recurrence ranged from 1 to 10. Twenty-seven patients (25%) developed permanent facial nerve weakness. The risks for clinically evident rerecurrence after 1, 5, and 15 years were 16%, 42%, and 75%, respectively. Female sex, young age at initial treatment, and enucleation instead of parotidectomy for treatment of the first recurrence were significant risk factors for rerecurrence. The mean number of recurrent tumor nodules was 26. Conclusions Surgery for recurrent parotid pleomorphic adenoma has a high rate of facial nerve morbidity. The chance of rerecurrence is high. Extended parotidectomy seems to be the best approach for the reoperation to reduce the risk of rerecurrence. © 2007 Wiley Periodicals, Inc. Head Neck 2007 [source]

Retropharyngeal node metastasis from papillary thyroid carcinoma

Naoki Otsuki MD
Abstract Background. Papillary thyroid carcinomas commonly metastasize to paratracheal and jugular lymph nodes. Metastasis to the retropharyngeal node is rare for this tumor. Methods. Five patients underwent surgical treatment for metastasis of thyroid papillary carcinoma to the retropharyngeal lymph nodes that presented as a parapharyngeal or retropharyngeal mass. All patients had a history of total or subtotal thyroidectomy as their initial treatment. Among them, 3 patients had undergone ipsilateral modified radical neck dissection at their initial treatment. The other 2 patients had a history of bilateral or ipsilateral modified neck dissection for their subsequent cervical lymph node metastases. Results. Metastatic retropharyngeal nodes were successfully resected via transcervical approach in all patients. Although aspiration and difficulty in swallowing were observed in 2 patients after surgical treatment for metastatic retropharyngeal nodes, these complications spontaneously resolved within a few months. Conclusions. This study suggests that neck dissection and/or metastatic cervical lymph nodes might alter the direction of lymphatic drainage to the retrograde fashion, resulting in the unusual metastasis to the retropharyngeal lymph nodes. Although the cases described here are rare, metastasis to the retropharyngeal node should be considered at the follow-up for thyroid papillary carcinoma. Because these metastases will be missed by routine ultrasonography of the neck, periodic CT scan or MRI is recommended for follow-up, especially for patients with a history of neck dissection. © 2006 Wiley Periodicals, Inc. Head Neck, 2007 [source]

Clinical relevance of three subtypes of primary sinonasal lymphoma characterized by immunophenotypic analysis

Gwi Eon Kim MD
Abstract Background. The purpose of this study was to investigate the clinical relevance of subtypes categorized by immunophenotypic analysis in primary sinonasal lymphomas. Methods. Eighty patients with localized non-Hodgkin's lymphoma involving the nasal cavity and/or paranasal sinuses were divided into three subtypes on the basis of their immunohistochemical findings: (A) B-cell lymphoma (n = 19), (B) T-cell lymphoma (n = 27), and (C) natural killer (NK)/T-cell lymphoma (n = 34). The clinicopathologic profiles, immunophenotypic data, patterns of treatment failure, and survival data among the three patient groups were retrospectively compared. Results. The nasal cavity was the predominant site of involvement in T-cell and NK/T-cell lymphoma, whereas sinus involvement without nasal disease was common in B-cell lymphoma. Systemic B symptoms were frequently observed in NK/T-cell lymphoma. Almost all patients with NK/T-cell lymphoma showed a strong association with the Epstein-Barr virus by in situ hybridization studies. Sixty-five patients (81%) patients achieved complete remission after initial treatment, but 36 (55%) of these subsequently experienced treatment failure. Although there were no significant differences in locoregional failure rates among the patients of the three groups, distant failure was far more common in B-cell or NK/T-cell lymphoma than in T-cell lymphoma (p = .005). Most B-cell lymphoma cases showed a predilection for sites of systemic failure in the nodal and extranodal sites below the diaphragm, such as the paraaortic lymph nodes or the gastrointestinal (GI) tract, whereas patients with NK/T-cell lymphoma showed an increased risk of systemic dissemination to the skin, testes, or GI tract, including the development of hemophagocytic syndrome. The 5-year actuarial and disease-free survival rates for all patients were 57% and 51%, respectively. Of the three subtypes of primary sinonasal lymphomas, T-cell lymphoma seemed to carry the most favorable prognosis and NK/T-cell lymphoma the worst. (The 5-year actuarial survival rate was 57% for B-cell lymphoma, 80% for T-cell lymphoma, 37% for NK/T-cell lymphoma; p = .02, log-rank.) By univariate and multivariate analyses, immunophenotype was identified as the most important prognostic factor. Conclusions. Our data indicate that the three subtypes of primary sinonasal lymphomas classified by immunohistochemical studies exhibit different clinical profiles, different patterns of failure, and different treatment outcomes. Given these observations, it is concluded that the recognition of these distinct subsets, diagnosed on the basis of immunophenotypic study, is very important and clinically relevant in predicting their potential behavior and prognosis. © 2004 Wiley Periodicals, Inc. Head Neck26: 584,593, 2004 [source]

Metastatic squamous cell carcinoma of the neck from an unknown primary: Management options and patterns of relapse,

Shahrokh Iganej MD
Abstract Purpose Management of squamous cell carcinoma of undetermined primary tumors in the head and neck region is controversial. Here we report the Southern California Kaiser Permanente experience with these patients. Methods and Materials From January 1969 through December 1994, 106 patients were eligible for this retrospective analysis. Distribution of nodal staging was as follows: 14 N1, 27 N2A, 39 N2B, 2 N2C, and 24 N3. Initial treatment included excisional biopsy alone in 12, radical neck dissection alone in 29, radiotherapy alone in 24, excisional biopsy followed by radiotherapy in 15, and radical neck dissection plus postoperative radiation in 26 patients. Results Except for two patients, all patients have had a minimum follow-up of 5 years. Overall, 57 patients (54%) have had recurrences. Only two patients (3%) who had received radiotherapy as part of their initial treatment had an appearance of a potential primary site inside the irradiated field vs 13 patients (32%) who had not received radiotherapy (p = .006). Combined modality therapy resulted in fewer neck relapses, particularly in patients with advanced neck disease. Including salvage, surgery alone as the initial treatment resulted in 81% ultimate tumor control above the clavicle for patients with N1 and N2a disease without extracapsular extension. The 5-year survival for the entire population was 53%. Radiotherapy alone resulted in poor survival in patients with advanced/unresectable neck disease. No significant difference in survival based on the initial treatment was found. The statistically significant adverse factors in determining survival included advanced nodal stage and the presence of extracapsular extension. Conclusions Radiotherapy is very effective in reducing the rate of appearance of a potential primary site. However, in the absence of advanced neck disease (N1 and N2A without extracapsular extension), radiotherapy can be reserved for salvage. Radiotherapy alone results in poor outcomes in patients with advanced/unresectable neck disease, and incorporation of concurrent chemotherapy and cytoprotective agents should be investigated. © 2002 Wiley Periodicals, Inc. Head Neck 24: 236,246, 2002; DOI 10.1002/hed.10017 [source]

A Community-Based Study of Helicobacter pylori Therapy Using the Strategy of Test, Treat, Retest, and Re-treat Initial Treatment Failures

HELICOBACTER, Issue 5 2006
Yi-Chia Lee
Abstract Background:, Although eradication of Helicobacter pylori infection can decrease the risk of gastric cancer, the optimal regimen for treating the general population remains unclear. We report the eradication rate (intention-to-treat and per protocol) of a community-based H. pylori therapy using the strategy of test, treat, retest, and re-treat initial treatment failures. Materials and methods:, In 2004, a total of 2658 residents were recruited for 13C-urea breath testing. Participants with positive results for infection received a standard 7-day triple therapy (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily), and a 10-day re-treatment (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) if the follow-up tests remained positive. Both H. pylori status and side-effects were assessed 6 weeks after treatment. Results:, Among 886 valid reporters, eradication rates with initial therapy were 86.9% (95% confidence interval [CI]: 84.7,89.1%) and 88.7% (95%CI: 86.5,90.9%) by intention-to-treat and per protocol analysis, respectively. Re-treatment eradicated infection in 91.4% (95%CI: 86,96.8%) of 105 nonresponders. Adequate compliance was achieved in 798 (90.1%) of 886 subjects receiving the initial treatment and in all 105 re-treated subjects. Mild side-effects occurred in 24% of subjects. Overall intention-to-treat and per protocol eradication rates were 97.7% (95%CI: 96.7,98.7%) and 98.8% (95%CI: 98.5,99.3%), respectively, which were only affected by poor compliance (odds ratio, 3.3; 95%CI, 1.99,5.48; p < .0001). Conclusions:, A comprehensive plan using drugs in which the resistance rate is low in a population combined with the strategy of test, treat, retest, and re-treat of needed can result in virtual eradication of H. pylori from a population. This provides a model for planning country- or region-wide eradication programs. [source]

Combination therapy with lamivudine and famciclovir for chronic hepatitis B,infected Chinese patients: A viral dynamics study

HEPATOLOGY, Issue 2 2000
George Ka Lau M.D.
In vitro studies have shown that lamivudine and penciclovir (the active metabolite of famciclovir) act synergistically to inhibit hepatitis B virus (HBV) replication. We compared the effectiveness of HBV viral suppression by lamivudine monotherapy versus lamivudine plus famciclovir combination therapy in Chinese patients with chronic HBV infection. Twenty-one Chinese hepatitis B e antigen (HBeAg)-positive patients, with detectable HBV DNA (Digene Hybrid Capture II), were randomized to receive either lamivudine 150 mg/d orally (group 1, 9 patients) or lamivudine 150 mg/d plus famciclovir 500 mg 3 times a day orally (group 2, 12 patients) for 12 weeks, with a follow-up period of at least 16 weeks. Serial serum HBV-DNA levels were determined and a mathematical model with provision for incomplete inhibition of virus production during therapy was applied to analyze the dynamics of viral clearance. The mean antiviral efficacy was significantly greater in group 2 than in group 1 (0.988 ± 0.012 vs. 0.94 ± 0.03, P = .0012). HBV DNA returned to pretreatment level within 16 weeks after the end of initial treatment in 4 patients (66.7%) in group 1 and none in group 2 (P = .08), who remained HBeAg positive and received no further treatment after week 12. Hence, in Chinese chronic HBeAg-positive patients, combination therapy using lamivudine and famciclovir was superior to lamivudine monotherapy in inhibiting HBV replication. Further studies of longer duration are needed to define whether combination therapy will increase the HBeAg seroconversion rate and decrease the rate of emergence of lamivudine-resistant variants. [source]

Determinants of response to first HAART regimen in antiretroviral-naïve patients with an estimated time since HIV seroconversion

HIV MEDICINE, Issue 1 2006
R Thiébaut
Objective To study the determinants of immunological and virological response to highly active antiretroviral therapy (HAART) in naïve patients, adjusting for time since HIV-1 seroconversion. Design Data from HIV-cohort studies where dates of seroconversion have been reliably estimated. Methods In previously untreated patients, short- and long-term marker responses from HAART initiation (three or more antiretroviral drugs) to the end of follow-up or any treatment modification were considered using mixed effects models accounting for undetectable HIV viral load and informative dropout. Results In total, 943 patients were treated with a first HAART regimen for a median of 29 months. In adjusted analyses, compared with a reference group of homosexual men without AIDS initiating treatment 4 years after seroconversion, injecting drug users (IDUs) were treated at similar CD4 and HIV RNA levels but had poorer short-term virological response (2.54 vs 2.13 log10 HIV-1 RNA copies/mL at 1.5 months, P=0.03) and poorer long-term immunological response (522 vs 631 cells/,L at 24 months, P<0.0001). Although individuals with AIDS at HAART initiation had lower CD4 counts (206 vs 382 cells/,L, P<0.0001), their immunological responses were similar to those of individuals without AIDS. Similarly, individuals further from seroconversion started HAART at lower CD4 counts (e.g. 311 vs 382 cells/,L at vs before 9 years from seroconversion, P<0.0001), but had similar CD4 responses. However, they experienced poorer long-term virological response (0.67 log10 copies/mL/year smaller decline, P<0.0001) compared to those treated before 9 years from seroconversion. Conclusion Taking into account the time elapsed since seroconversion, this study suggests that careful choices of initial treatment should be made and intensive follow-up carried out in high-risk subgroups such as IDUs who have poorer responses. [source]