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Optimal Treatment Strategy (optimal + treatment_strategy)
Selected AbstractsHepatitis C virus-related extra-hepatic disease , aetiopathogenesis and managementALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2004J. Medina Summary Hepatitis C virus infection is often associated with extra-hepatic manifestations, secondary to the elicitation of autoimmune reactions, generalized deposition of immune complexes and lymphoproliferative disorders. The most clearly established associations are those linking chronic hepatitis C with mixed cryoglobulinaemia (and the related glomerulonephritis and cutaneous vasculitis), as well as with the presence of autoantibodies. Less well-documented disorders include non-Hodgkin's lymphoma, thrombocytopenia, sialadenitis, thyroid disease, lichen planus, porphyria cutanea tarda, rheumatoid disorders and neurological disorders. Extra-hepatic manifestations are most frequent in patients of female sex, advanced age, long-lasting infection and cirrhosis. Optimal treatment strategies should be based on the predominant manifestation of the disease. In the case of autoimmune disorders not clearly attributable to the viral infection, corticosteroids may be the most effective option. Interferon-, alone or in combination with ribavirin may be indicated for those disorders related to immune complex deposition, such as mixed cryoglobulinaemia, although relapses of extra-hepatic signs often occur on discontinuation of treatment. In some cases, interferon-, may induce or exacerbate some extra-hepatic manifestations. [source] Management of Multivessel Coronary Disease after ST Elevation Myocardial Infarction Treated by Primary AngioplastyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 1 2008Ph.D., STEFANO RIGATTIERI M.D. Background: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. Methods: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. Results: Group 1 patients underwent staged PCI 5.9 ± 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 ± 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. Conclusions: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure. [source] A Clinical Review of Infected Wound Treatment with Vacuum Assisted Closure® (V.A.C.®) Therapy: Experience and Case SeriesINTERNATIONAL WOUND JOURNAL, Issue 2009Allen Gabriel ABSTRACT Over the last decade Vacuum Assisted Closure® (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult-to-treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.® Therapy and V.A.C. Instill® with either GranuFoamÔ or GranuFoam SilverÔ Dressings. The panel reviewed infected wound treatment methods within the context of evidence-based medicine coupled with experiential insight using V.A.C.® Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state-of-practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.® Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.® Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies. [source] Gender Differences in Various Types of Idiopathic Ventricular TachycardiaJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 7 2002MIKIKO NAKAGAWA M.D. Gender Differences in Idiopathic VT.Introduction: The aim of this study was to evaluate gender differences in the incidence and age distribution of various types of idiopathic ventricular tachycardia (VT). Methods and Results: We conducted a search of the medical literature on idiopathic VT. According to their site of origin, we divided the VTs into three types: right ventricular outflow tract (RVOT-VT), left ventricular outflow tract (LVOT-VT), and left ventricular (LV) septum (LV-VT). We reviewed 68 articles and a total of 748 patients. Among RVOT-VT patients, there were more females than males (311 vs 153, male/female ratio 0.49). In LV-VT, males prevailed over females (175 vs 52, male/female ratio 3.37), whereas LVOT-VT was distributed almost equally between males (n = 33) and females (n = 24). To determine the age distribution, we assessed 419 patients from 51 studies. In both males and females, the highest incidence of RVOT-VT occurred in the third to fifth decade of life (males, mean 43.5 ± 18.7; females, mean 40.9 ± 13.8 years). LV-VT occurred at a younger age in both males and females than did RVOT-VT (mean 33.0 ± 13.9 and 25.7 ± 12.0 years, respectively, P < 0.0001 vs RVOT-VT). LV-VT occurred at a younger age in females than males (P < 0.005). Conclusion: Gender-specific differences exist in the incidence and age distribution of the various types of idiopathic VT. Studies on gender-specific differences in arrhythmia will lead to a better understanding of its mechanism(s) and provide valuable information for the development of optimal treatment strategies. [source] Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapyCANCER, Issue 10 2003An analysis of 1225 patients Abstract BACKGROUND Prognostic factors for patients with soft-tissue sarcoma who are treated with conservative surgery and radiation are documented poorly. METHODS The clinicopathologic features and disease outcome for 1225 patients with localized sarcoma who were treated with conservative surgery and radiation were reviewed retrospectively. Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for local control, metastatic recurrence, and disease specific survival. RESULTS The median follow-up of surviving patients was 9.5 years. The respective local control rates at 5 years, 10 years, and 15 years were 83%, 80%, and 79%. Factors predictive of local recurrence were positive or uncertain resection margins; tumors located in the head and neck and the deep trunk; presentation with local recurrence; patient age > 64 years; malignant fibrous histiocytoma, neurogenic sarcoma. or epithelioid sarcoma histopathology; tumor measuring > 10 cm in greatest dimension; and high pathologic grade. Freedom from metastasis at 5 years, 10 years, and 15 years was 71%, 68%, and 66%, respectively. Factors that were predictive of metastatic recurrence were high tumor grade; large tumor size (> 5 cm); and leiomyosarcoma, rhabdomyosarcoma, synovial sarcoma, or epithelioid sarcoma. The respective disease specific survival rates at 5 years, 10 years, and 15 years were 73%, 68%, and 65%. Adverse factors for disease specific survival were high tumor grade; large tumor size (> 5 cm); tumors located in the head and neck and deep trunk; rhabdomyosarcoma, epithelioid sarcoma, or clear cell sarcoma; patient age > 64 years; and positive or uncertain resection margins. CONCLUSIONS Soft-tissue sarcoma comprises a heterogeneous group of diseases. Prognostic factors for local recurrence, metastatic recurrence, lymph node recurrence, disease free survival, and disease specific survival are different, and optimal treatment strategies need to take this complexity into account. Cancer 2003;10:2530,43. © 2003 American Cancer Society. DOI 10.1002/cncr.11365 [source] Characteristics of patients with coronary artery disease and hypertension: A report from INVESTCLINICAL CARDIOLOGY, Issue S5 2001Serap Erdine M.D. Abstract In all, 22,599 patients with coexisting hypertension and coronary artery disease (CAD) from around the world are enrolled in the INternational VErapamil SR/trandolapril STudy (INVEST). As a result, much will be learned regarding the use of treatment strategies using verapamil SR and atenolol with and without trandolapril and/or hydrochlororthiazide in patients with hypertension and CAD, all of whom are at high risk for adverse cardiovascular outcomes. This trial will provide meaningful data on optimal treatment strategies for hypertension, especially among patients who are elderly, have diabetes, have left ventricular hypertrophy, or who are dyslipidemic. This trial will be the first to use Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) guidelines as blood pressure goals to determine the relative benefits of a calcium antagonist versus a beta-blocker strategy in reducing morbidity and mortality. In addition, women and Hispanic patients participating in INVEST will provide the largest controlled experience in the management of hypertensive patients with CAD, facilitating the development of future guidelines. [source] Brain metastases from testicular germ cell tumors: A retrospective analysisINTERNATIONAL JOURNAL OF UROLOGY, Issue 11 2009Norio Nonomura Objectives: To review our series of testicular germ cell tumors with brain metastases and to establish an optimal treatment strategy for them. Methods: Twenty-seven cases of testicular germ cell tumors from three institutions were retrospectively reviewed. Results: Twenty-six were non-seminomatous tumors and only one was a seminoma. Based on the International Germ Cell Consensus Classification, two cases were classified as good prognosis, seven as intermediate prognosis and 18 as poor prognosis. Chemotherapy was carried out in all patients. Additionally, whole-brain radiotherapy was performed in 10 cases, stereotactic radiosurgery in six, whole-brain radiotherapy combined with stereotactic radiosurgery in three and complete surgical resection in five. Three patients received chemotherapy only. Cancer-specific 5- and 10-year survival rates were both 35.9%. The prognosis of those with brain metastases at the time of diagnosis tended to be better than those developing brain metastases during treatment. Those with a single brain metastasis showed significantly better survival than those with multiple brain metastases. No other significant prognostic factor was found at multivariate analysis. Conclusion: Testicular germ cell tumors with brain metastases can be managed with the combination of whole-brain radiotherapy, stereotactic radiotherapy, and/or surgical resection in combination with chemotherapy. [source] Autologous stem cell transplantation as treatment modality in a patient with relapsed pancreatoblastoma,PEDIATRIC BLOOD & CANCER, Issue 3 2010Amir Ali Hamidieh MD Abstract Pancreatoblastoma (PB) is a rare malignant neoplasm of the pancreas, which occurs mostly during childhood. Presently, the optimal treatment strategy is neither clear nor uniform for patients in advanced stages, in particular those with metastasis, inoperable, or recurrent tumors. To our knowledge, until now, only one patient with PB has been treated with hematopoietic stem cell transplantation (HSCT) following aggressive chemotherapy and surgical resection. Here we report the second case of PB who was treated with aggressive chemotherapy combined with autologous peripheral blood stem cell transplantation. Pediatr Blood Cancer. 2010;55:573,576. © 2010 Wiley-Liss, Inc. [source] A Generalized Estimator of the Attributable Benefit of an Optimal Treatment RegimeBIOMETRICS, Issue 2 2010Jason Brinkley Summary For many diseases where there are several treatment options often there is no consensus on the best treatment to give individual patients. In such cases, it may be necessary to define a strategy for treatment assignment; that is, an algorithm that dictates the treatment an individual should receive based on their measured characteristics. Such a strategy or algorithm is also referred to as a treatment regime. The optimal treatment regime is the strategy that would provide the most public health benefit by minimizing as many poor outcomes as possible. Using a measure that is a generalization of attributable risk (AR) and notions of potential outcomes, we derive an estimator for the proportion of events that could have been prevented had the optimal treatment regime been implemented. Traditional AR studies look at the added risk that can be attributed to exposure of some contaminant; here we will instead study the benefit that can be attributed to using the optimal treatment strategy. We will show how regression models can be used to estimate the optimal treatment strategy and the attributable benefit of that strategy. We also derive the large sample properties of this estimator. As a motivating example, we will apply our methods to an observational study of 3856 patients treated at the Duke University Medical Center with prior coronary artery bypass graft surgery and further heart-related problems requiring a catheterization. The patients may be treated with either medical therapy alone or a combination of medical therapy and percutaneous coronary intervention without a general consensus on which is the best treatment for individual patients. [source] Cost-effectiveness analysis of immediate radical cystectomy versus intravesical Bacillus Calmette-Guerin therapy for high-risk, high-grade (T1G3) bladder cancer,CANCER, Issue 23 2009Girish S. Kulkarni MD Abstract BACKGROUND: Although both radical cystectomy and intravesical immunotherapy are initial treatment options for high-risk, T1, grade 3 (T1G3) bladder cancer, controversy regarding the optimal strategy persists. Because bladder cancer is the most expensive malignancy to treat per patient, decisions regarding the optimal treatment strategy should consider costs. METHODS: A Markov Monte-Carlo cost-effectiveness model was created to simulate the outcomes of a cohort of patients with incident, high-risk, T1G3 bladder cancer. Treatment options included immediate cystectomy and conservative therapy with intravesical Bacillus Calmette-Guerin (BCG). The base case was a man aged 60 years. Parameter uncertainty was assessed with probabilistic sensitivity analyses. Scenario analyses were used to explore the 2 strategies among patients stratified by age and comorbidity. RESULTS: The quality-adjusted survival with immediate cystectomy and BCG therapy was 9.46 quality-adjusted life years (QALYs) and 9.39 QALYs, respectively. The corresponding mean per-patient discounted lifetime costs (in 2005 Canadian dollars) were $37,600 and $42,400, respectively. At a willingness-to-pay threshold of $50,000 per QALY, the probability that immediate cystectomy was cost-effective was 67%. Immediate cystectomy was the dominant (more effective and less expensive) therapy for patients aged <60 years, whereas BCG therapy was dominant for patients aged >75 years. With increasing comorbidity, BCG therapy was dominant at lower age thresholds. CONCLUSIONS: Compared with BCG therapy, immediate radical cystectomy for average patients with high-risk, T1G3 bladder cancer yielded better health outcomes and lower costs. Tailoring therapy based on patient age and comorbidity may increase survival while yielding significant cost-savings for the healthcare system. Cancer 2009. © 2009 American Cancer Society. [source] Matrix metalloproteinase-2 expression in stromal tissues is a consistent prognostic factor in stage II colon cancerCANCER SCIENCE, Issue 5 2009Yoshiko Inafuku For patients with stage II colon cancer, the usefulness of adjuvant chemotherapy remains controversial. Therefore, it is important to identify high-risk indicators. The biological prognostic factors for recurrence might allow further insight into the optimal treatment strategy for patients with node-negative disease. Matrix metalloproteinase-2 seems to be one of the essential factors for tumor invasion and lymph node metastasis. In this study, we analyzed the expression of cyclooxygenase-2 and matrix metalloproteinase-2 by immunohistochemical staining in 109 patients with stage II colon cancer. A positive correlation was observed between tumor cyclooxygenase-2 and tumor matrix metalloproteinase-2 expression (P = 0.0006) and between tumor cyclooxygenase-2 and stromal matrix metalloproteinase-2 expression (P < 0.0001). Stromal matrix metalloproteinase-2 expression was associated with disease-free survival (P = 0.0095) and was shown to be an independent risk factor for recurrence by multivariate analysis. In addition, we carried out an invasion assay in vitro to investigate whether cyclooxygenase-2 and matrix metalloproteinase-2 affected the tumor-invasive potential of colon cancer cell lines. The invasion assay showed that every cancer cell line acquired invasive potential in coculture with stromal cell lines and the cyclooxygenase-2 inhibitor suppressed this phenomenon by downregulating the matrix metalloproteinase-2 expression of stromal cells. In conclusion, these findings suggest that matrix metalloproteinase-2 expression in stromal cells can be a high-risk indicator for recurrence in patients with stage II colon cancer. (Cancer Sci 2009; 100: 852,858) [source] | ||||||||||||||||||||||