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Surgical Therapy (surgical + therapy)
Selected AbstractsRisk of Ablative Therapy for "Elevated Firm Growing" Lesions: Merkel Cell Carcinoma Diagnosed After Laser Surgical TherapyDERMATOLOGIC SURGERY, Issue 6 2009CLIFF ROSENDAHL MBBS First page of article [source] Bariatric surgery vs. advanced practice medical management in the treatment of type 2 diabetes mellitus: rationale and design of the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently trial (STAMPEDE)DIABETES OBESITY & METABOLISM, Issue 5 2010Sangeeta R. Kashyap Obesity and Type 2 diabetes mellitus (T2DM) are closely interrelated, and are two of the most common chronic, debilitating diseases worldwide. Surgical approaches to weight loss (bariatric surgery) result in marked improvement of T2DM, however randomized trials directly comparing the efficacy of surgical and medical approaches are lacking. The Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial was designed to evaluate the efficacy of two bariatric surgery procedures involving gastric restriction only (laparascopic sleeve gastrectomy) and gastric bypass (Roux-en-Y) to advanced medical therapy in patients with T2DM with modest obesity with BMI of 27,42 kg/m2. This single site, prospective, randomized controlled trial will enroll 150 subjects who will be followed. The primary end point will be the rate of biochemical resolution of T2DM at 1 year as measured by HbA1c < 6%. The safety and adverse event rates will also be compared between the three arms of the study. [source] High-resolution MRI Enhances Identification of Lesions Amenable to Surgical Therapy in Children with Intractable EpilepsyEPILEPSIA, Issue 8 2004Monisha Goyal Summary:,Purpose: Many children with refractory epilepsy can achieve better seizure control with surgical therapy. An abnormality on magnetic resonance imaging (MRI), along with corroborating localization by other modalities, markedly increases chances of successful surgical outcome. We studied the impact of high-resolution MRI on the surgical outcome of intractable epilepsy. Methods: High-resolution MRI using four-coil phased surface array was obtained as part of the comprehensive presurgical protocol for children with focal onset intractable seizures evaluated by our epilepsy center during the first half of 2002. Results: Thirteen consecutive children, ages 5 to 18 years, entered this prospective study. For four patients with a lesion on a recent MRI examination with a standard head coil, management did not change with high-resolution MRI. Standard MRI in the other nine patients did not identify a lesion. However, high-resolution MRI with the phased-array surface coil found previously undiagnosed focal abnormalities in five of nine patients. These abnormalities included hippocampal dysplasia, hippocampal atrophy, and dual pathology with frontal cortical dysplasia. In four of nine patients, no identifiable lesion was identified on the high-resolution MRI. All patients underwent invasive monitoring. In three of five patients, newly diagnosed lesions correlated with EEG abnormalities, and resection was performed. Conclusions: In our center, high-resolution MRI identified lesions not detected by standard MRI in more than half the children (56%). Technical advances such as four-coil phased surface array MRI can help identify and better delineate lesions, improving the diagnosis of patients who are candidates for surgical treatment of refractory epilepsy. [source] Eleven-Year Experience in Diagnosis and Surgical Therapy of Right Atrial MassesJOURNAL OF CARDIAC SURGERY, Issue 1 2007Nezihi Kucukarslan M.D. A review of surgical experience with right atrial tumors in 11 patients from our institution has been presented in this article. Methods: Eleven cases, operated for a tumor mass in the right atrium in our institution between January 1993 and December 2004, were retrospectively reviewed for their clinical presentation, diagnostic workup, method of surgical procedure, and histopathologic findings. Electrocardiogram, transthoracic, and transesophageal echocardiography, computerized tomography, and nuclear magnetic resonance imaging were available for all patients during the diagnostic evaluation. Surgical procedure notes, photos, and file recordings were reviewed when available. The surgeons were also interviewed when necessary. Results: Right atrial tumors were diagnosed in 11 patients (6 males and 5 females). The average age of the patients was 34 ± 11 years (ranging between 21 and 65 years). The histopathological examination of the surgically removed specimen revealed a benign tumor in eight patients (73%), and a malignant process in three (23%). In eight patients with a benign tumor, atrial myxoma was the leading cause in half of the cases. Hydatid cyst (n = 2), lipoma (n = 1), and right atrial thrombus (n = 1) were detected in the remaining four patients. One patient died of heart failure after surgery. The diameters of the excised masses were 2 ± 0.5 cm versus 7 ± 1 cm. Conclusions: Tumors of the right atrium are rarely seen, and necessitate a unique attention during the process of diagnosis and surgical treatment. We present our surgical experience of 11 patients with right atrial mass. The differentiation of the right atrial tumors with the diagnostic tools before surgery, the determination of the spreading, and the structural properties of the mass may designate surgical approach and prognosis. [source] Surgical therapies for vitiligo and other leukodermas, part 1: minigrafting and suction epidermal graftingDERMATOLOGIC THERAPY, Issue 1 2001Rafael Falabella ABSTRACT: Vitiligo and other disorders of hypopigmentation are common cutaneous dermatoses that can give rise to considerable aesthetic concerns. In some patients these leukodermas are treated successfully with medical therapies such as topical corticosteroids and PUVA therapy. However, not all patients and not all lesions respond and as a result, surgical therapies are often required to restore normal pigmentation. The two most common and simple procedures, minigrafting (implantation of 1.0,1.2 mm grafts) and suction epidermal grafting (transfer of only epidermis harvested via negative pressures), are described in detail. Repigmentation with these two techniques, if carried out properly, yields good to excellent results with minor or no side effects. The most important factors for success are stability of the depigmenting process, an appropriate technique, and careful patient selection. Surgical interventions for stable vitiligo and other types of stable leukoderma are usually not first-line options, but when medical treatments fail, they represent the best available therapies. [source] Surgical therapies, part II: flip-top transplants in vitiligoDERMATOLOGIC THERAPY, Issue 1 2001Thomas W. McGovern ABSTRACT: The flip-top transplantation (FTT) method provides an important option for the treatment of depigmentation. It enables any physician to treat stable areas of depigmentation using equipment that is readily available and easy to use. To date, this method has resulted in the spread of pigmentation from each graft and has caused no visible scarring. FTT is best suited for treating localized areas of stable depigmentation where the cosmetic result is a priority. [source] Surgical therapy for Barrett's esophagus: prevention, protection and excision,DISEASES OF THE ESOPHAGUS, Issue 2 2002T. R. DeMeester First page of article [source] New Insights into the Clinical Management of Partial EpilepsiesEPILEPSIA, Issue S5 2000Prof. Edouard Hirsch Summary The diagnosis, treatment, and prognosis of seizure disorders depend on the correct identification of epileptic syndromes. Partial epilepsies are heterogeneous and can be divided into idiopathic, cryptogenic, and symptomatic epilepsies. The most common of the idiopathic localization-related epilepsies is benign epilepsy with rolandic or centrotemporal spikes (BECTS). Seizures remain rare and the use of antiepileptic drug (AED) treatment in all patients does not appear justified. Children who present with some of the electroclinical characteristics of BECTS may also display severe unusual neurologic, neuropsychological, or atypical symptoms. In some cases, carbamazepine has been implicated as a triggering factor. Primary reading epilepsy and idiopathic occipital lobe epilepsies with photosensitivity are examples of an overlap between idiopathic localization-related and generalized epilepsies and respond well to sodium valproate. Autosomal dominant nocturnal frontal lobe epilepsy and benign familial infantile convulsions are recently described syndromes, differing in several ways from classical idiopathic localization-related epileptic syndromes. In cryptogenic or symptomatic epilepsy, the topography of the epileptogenic zone might influence drug efficacy. An individualized approach to AED selection, tailored to each patient's needs, should be used. Resistance of seizures to antiepileptic therapy may be due to diagnostic and/or treatment error or may be the result of noncompliance. Increasing the dosage, discontinuation or replacement of a drug, or addition of a second drug is indicated in truly resistant cases. The use of more than two AEDs rarely optimizes seizure control, and in some cases reduction of treatment may improve seizure control while lessening side effects. EEG-video assessment of patients with refractory epilepsy is important. Indications for and timing of epilepsy surgery should be reconsidered. Surgical therapy should probably be used more often and earlier than it is at present. [source] A Comparative Study of Community- and Nursing Home-Acquired Empyema ThoracisJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2007Ali A. El Solh MD OBJECTIVES: To compare the clinical presentation, microbiological features, and outcomes of patients with community-acquired empyema (CAE) with those of patients with nursing home-acquired empyema (NHAE). DESIGN: A retrospective observational study. SETTING: Three tertiary care centers. PARTICIPANTS: One hundred fourteen patients admitted from the community and 55 patients transferred from nursing homes. MEASUREMENTS: Baseline sociodemographic information, activities of daily living, Charlson Comorbidity Index score, and clinica, and microbiologic data were obtained. Outcome was assessed at hospital discharge and 6 months postdischarge. RESULTS: Patients admitted from nursing homes had a delayed presentation, with dyspnea, weight loss, and anemia as the predominant manifestation. Patients with CAE presented more acutely, with fever, cough, and chest pain. Anaerobic organisms were more commonly isolated from patients with NHAE. The success rate of nonsurgical intervention was significantly lower for the NHAE patients than for the CAE group (39% vs 63; P=.01). In-hospital mortality was not significantly different between the two groups (NHAE, 18%; CAE, 8%; P=.09). In a Cox regression analysis, preadmission functional status (hazard ratio (HR)=1.26, 95% confidence interval (CI)=1.19,1.4; P<.001) and surgical intervention (HR=0.47, 95% CI=0.24,0.92; P=.03) were the only variables highly correlated with long-term outcome. CONCLUSION: Patients admitted with NHAE have distinctly different clinical and microbiological presentation from that of patients with CAE. Because of the delayed presentation in patients with NHAE, medical treatment alone may be associated with higher rate of failure. Surgical therapy should be considered for selected cases, with the aim of improving long-term survival. [source] The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth with furcation involvement after an observation period of at least 5 years: a systematic reviewJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 2 2009Guy Huynh-Ba Abstract Objective: To systematically review the survival rate and incidence of complications of furcation-involved multirooted teeth following periodontal therapy after at least 5 years. Material and methods: Electronic and manual searches were performed up to and including January 2008. Publication selection, data extraction and validity assessment were performed independently by three reviewers. Results: Twenty-two publications met the inclusion criteria. Because of the heterogeneity of the data, a meta-analysis could not be performed. The survival rate of molars treated non-surgically was >90% after 5,9 years. The corresponding values for the different surgical procedures were: Surgical therapy: 43.1% to 96%, observation period: 5,53 years. Tunnelling procedures: 42.9% to 92.9%, observation period: 5,8 years. Surgical resective procedures including amputation(s) and hemisections: 62% to 100%, observation period: 5,13 years. Guided tissue regeneration (GTR): 83.3% to 100%, observation period: 5,12 years. The most frequent complications included caries in the furcation area after tunnelling procedures and root fractures after root-resective procedures. Conclusions: Good long-term survival rates (up to 100%) of multirooted teeth with furcation involvement were obtained following various therapeutic approaches. Initial furcation involvement (Degree I) could be successfully managed by non-surgical mechanical debridement. Vertical root fractures and endodontic failures were the most frequent complications observed following resective procedures. [source] Meta-analysis of the effect of scaling and root planing, surgical treatment and antibiotic therapies on periodontal probing depth and attachment lossJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2002Hsin-Chia Hung Abstract Objective: This paper reports a meta-analysis of studies that have investigated the effect of scaling and root planing on periodontal probing depth and attachment loss. Material and methods: The criteria used for inclusion of studies were as follows: root planing and scaling alone was one of the primary treatment arms; patients or quadrants of each patient were randomly assigned to study groups; 80% of patients enrolled were included in first year follow-up examinations; periodontal probing depth and attachment loss were reported in mm; the sample size of each study and substudy was reported. Sample size was used to weight the relative contribution of each study since standard errors were not reported by many studies and sample size is highly correlated with standard error and therefore statistically able to explain a substantial portion of the standard error on studies that use similar measures. Results: The meta-analysis results show that periodontal probing depth and gain of attachment level do not improve significantly following root planing and scaling for patients with shallow initial periodontal probing depths. However, there was about a 1-mm reduction for medium initial periodontal probing depths and a 2-mm reduction for deep initial periodontal probing depths. Similarly, there was about a 0.50-mm gain in attachment for medium initial periodontal probing depth measurements and slightly more than a l-mm gain in attachment for deep initial periodontal probing depth measurements. Surgical therapy for patients with deep initial probing depths showed better results than scaling and root planing in reducing probing depths. When patients were followed up over 3 years or more, these differences were reduced to less than 0.4 mm. Antibiotic therapy showed similar results to scaling and root planing. However, a consistent improvement in periodontal probing depth and gain of attachment is demonstrated when local antibiotic therapy is combined with root planing and scaling. Zusammenfassung Metaanalyse des Effekts von Scaling und Wurzelglätten, chirurgischer Behandlung und Antibiotikatherapien auf parodontale Sondiertiefe und Attachment-Verlust Zielsetzung: Der vorliegende Artikel beschreibt eine Metaanalyse von Studien, in denen die Wirkung von Scaling und Wurzelglätten auf parodontale Sondiertiefe und Attachment-Verlust untersucht wurden. Material und Methodik: Die Kriterien für die Aufnahme in die Studie waren wie folgt: 1) Wurzelglätten und Scaling allein war einer der primären Behandlungsverfahren; 2) Patienten oder Quadranten einzelner Patienten wurden auf Studiengruppen zufallsverteilt; 3) 80% der aufgenommenen Patienten waren in den Follow-up-Untersuchungen nach einem Jahr eingeschlossen; 4) parodontale Sondiertiefe und Attachment-Verlust wurden in mm berichtet; und 5) der Probenumfang jeder einzelnen Studie und Unterstudie wurde berichtet. Der Probenumfang wurde zur Gewichtung des relativen Beitrages jeder einzelnen Studie herangezogen, da von vielen Studien keine Standardabweichungen berichtet wurden und der Probenumfang mit der Standardabweichung stark korreliert ist. Daher lässt sich auf dem Weg über den Probenumfang ein wesentlicher Teil der Standardabweichung bei Studien mit ähnlichen Messparametern statistisch erklären. Ergebnisse: Die Ergebnisse der Metaanalyse zeigten, dass die parodontale Sondiertiefe und die Zunahme des Attachment-Niveaus nach Scaling und Wurzelglätten bei Patienten mit ursprünglich geringen Sondiertiefen keine signifikanten Verbesserungen liefern. Bei ursprünglich mittleren parodontalen Sondiertiefen konnte jedoch eine Reduktion von 1 mm, bei ursprünglich tiefen parodontalen Sondiertiefen eine Reduktion von 2 mm beobachtet werden. Dementsprechend wurde eine Zunahme des Attachment-Niveaus bei ursprünglich mittleren parodontalen Sondiertiefen von 0,5 mm eine sowie eine Zunahme von etwas mehr als 1 mm bei ursprünglich tiefen parodontalen Sondiertiefen verzeichnet. Die chirurgische Behandlung bei Patienten mit ursprünglich beträchtlicher Sondiertiefe lieferte bei der Reduktion der Sondiertiefe bessere Ergebnisse als Scaling und Wurzelglätten. Wenn sich Patienten über 3 Jahre oder länger einem Follow-up unterzogen, liessen sich diese Differenzen auf unter 0,4 mm reduzieren. Darüber hinaus kann jedoch eine konsistente Verbesserung der parodontalen Sondiertiefe und Zunahme des Attachment-Niveaus erreicht werden, wenn eine lokale Antibiotikatherapie mit Scaling und Wurzelglätten kombiniert wird. Résumé Méta-analyse de l'influence du détartrage et du surfaçage radiculaire, du traitement chirurgical et des traitements antibiotiques sur la profondeur de poche au sondage et la perte d'attache But: Ce rapport présente une méta-analyse des études qui ont porté sur l'influence du détartrage et du surfaçage radiculaire sur la profondeur de poche au sondage et la perte d'attache. Matériaux et méthodes: Les critères d'inclusion dans les études étaient les suivants: 1) le détartrage et le surfaçage radiculaire constituaient l'un des premiers moyens de traitement utilisés; 2) les patients ou les quadrants de chaque patient ont été répartis dans les groupes d'étude de façon aléatoire; 3) 80% des patients enrôlés ont fait l'objet d'examens de suivi durant un an; 4) la profondeur de poche au sondage et la perte d'attache ont été mesurés en mm; 5) la taille de l'échantillon a été relevée pour chaque étude et sous-étude. La taille de l'échantillon a été utilisée pour évaluer la contribution relative de chaque étude. En effet, de nombreuses études ne mentionnaient pas les erreurs standard, alors qu'il existe une corrélation étroite entre la taille de l'échantillon et l'erreur standard et qu'elle permet donc d'expliquer statistiquement une part substantielle de l'erreur standard dans les études qui se basent sur des mesures similaires. Résultats: Les résultats de la méta-analyse montrent que la profondeur de poche au sondage et le gain d'attache ne s'améliorent pas de façon significative suite au détartrage et surfaçage radiculaire chez les patients dont les profondeurs de poche au sondage initiales étaient faibles. Il y avait toutefois une réduction d'environ 1 mm des profondeurs de poche au sondage initiales moyennes, et une réduction de 2 mm des profondeurs de poche au sondage initiales élevées. De façon similaire, on a observé un gain d'attache d'environ 0,50 mm pour les mesures des profondeurs de poche au sondage initiales moyennes et un gain d'attache légèrement supérieur à 1 mm pour les mesures des profondeurs de poche au sondage initiales élevées. Chez les patients à profondeur de poche au sondage initiale élevée, le traitement par chirurgie s'est avéré plus efficace que le détartrage et le surfaçage radiculaire pour réduire la profondeur au sondage. Lorsque les patients faisaient l'objet d'un suivi durant trois ans ou plus, ces différences s'abaissaient jusqu'à moins de 0,4 mm. Le traitement antibiotique a donné des résultats similaires à ceux obtenus par détartrage et surfaçage radiculaire. Une amélioration régulière de la profondeur de poche au sondage et du gain d'attache a toutefois été observée lorsque le traitement antibiotique local est combiné au détartrage et surfaçage radiculaire. [source] The clinical presentation and prognostic factors for intrahepatic and extrahepatic cholangiocarcinoma in a tertiary care centreALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2010A. G. SINGAL Aliment Pharmacol Ther,31, 625,633 Summary Background, The incidence of cholangiocarcinoma is rising. Accurate predictors of survival at diagnosis are not well defined. Aim, To clarify the clinical presentation and prognostic factors of intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma in a contemporary cohort of patients. Methods, Records for consecutive patients at the University of Michigan hospital diagnosed with cholangiocarcinoma between January 2003 and April 2008 were reviewed. Results, In all, 136 patients had cholangiocarcinoma (79 intra- and 57 extrahepatic cholangiocarcinoma). Median survival was 27.3 months,25.8 months for intrahepatic cholangiocarcinoma and 30.3 months for extrahepatic cholangiocarcinoma. Independent predictors of mortality at presentation on multivariate analysis were elevated bilirubin level (HR 1.04, 95%CI 1.01,1.07), CA 19-9 levels >100 U/mL (HR 1.90, 95%CI 1.17,3.08) and stage of disease (HR 1.51, 95%CI 1.16,1.96). After adjusting for baseline prognostic factors, surgical therapy was associated with improved survival (HR 0.48; 95% CI 0.26,0.88). There were no significant differences regarding clinical presentation, disease stage (P = 0.98), and survival (P = 0.51) between intra- and extrahepatic cholangiocarcinoma. Conclusions, Survival for cholangiocarcinoma remains poor with no significant difference in outcomes between intra- and extrahepatic cholangiocarcinoma. Stage of disease, bilirubin level and CA 19-9 level are important prognostic factors at presentation. Surgical therapy provides similar efficacy for both tumours when adjusted for other prognostic variables. [source] Fluorescence Bronchoscopy for Selection of Surgical Procedure in Patients With Early Staged Endobronchial CarcinomaARTIFICIAL ORGANS, Issue 4 2005Yoshio Tsunezuka Abstract:, Background: It is sometimes difficult to determine the extent of resection in patients with endobronchial carcinoma because preoperative white-light bronchoscopic (WLB), examination, is, not, sensitive, enough, to, examine, the extent fully. Light-Induced Fluorescence Endoscopy (LIFE) is recognized as a useful modality for the diagnosis of early staged bronchial carcinoma, but there have been no reports of its significance in surgical treatment. We have studied the influence of LIFE upon the selection of surgical procedures or other treatments in patients with endobronchial carcinoma preoperatively. Methods: Conventional WLB and LIFE were performed within 7 days of operation. Biopsy specimens were taken from the marginal regions of the areas that were suspicious for malignancy on LIFE examination and WLB. We decided the resection line before operation and kept the resected central margin 1 cm apart from the area revealed as suspicious by LIFE. Results: From January 1999 to March 2003, 75 patients underwent LIFE. LIFE was performed to decide the surgical procedures for 12 patients (16.0%). Surgical therapy was performed in 8 (66.7%). LIFE findings dramatically changed the surgical procedures for 3 patients, lobectomy changed to sleeve lobectomy in 2 and laser therapy to segmentectomy in 1. LIFE revealed larger abnormal areas of bronchial cancer compared to WLB in 7 (58.3%). Conversely, WLB overestimated the extent of abnormal area in 1 (8.3%). WLB revealed the same cancer area as LIFE in 4. In all patients, the resected bronchial margins were cancer free intraoperatively and postoperatively. Conclusion: LIFE can be more sensitive than WLB and be more beneficial for judging the extent of neoplastic bronchial changes for some patients. LIFE may be a useful modality for the preoperative selection of surgical procedures, especially whether sleeve resection is needed or not, for some centrally located superficial endobronchial carcinoma. [source] 3416: Surgical therapy of macular edemaACTA OPHTHALMOLOGICA, Issue 2010CJ POURNARAS Purpose Persistent macular oedema (ME) is the main cause of poor visual outcome during the evolution of retinal ischemic microangiopathies and traction related macular distortion. Among multiples treatment approaches, vitreoretinal surgery is applied with the goal to achieve the release of a traction related component of macular oedema . Methods Vitrectomy with peeling of the posterior hyaloid, epiretinal membranes, vitreoretinal tractions and/or internal limiting membrane removal, were studied in numerous nonrandomized cases series. Results Pars plana vitrectomy has been shown to reduce macular oedema with significant change in best corrected visual acuity, in epiretinal membranes, vitreoretinal traction syndrome and ischemic microangiopathies related macular thickening central, hemiretinal, branch retinal vein occlusion and diabetic macular edema). Evidence to date does not support any therapeutic benefit from radial optic neurotomy and arteriovenous crossing sheathotomy for BRVO and CRVO related macular oedema. Conclusion In the era of intravitreal injection of steroids and anti VEGF substances, vitrectomy seems to have a beneficial effect in traction related, selected pathologies associated to chronic macular edema. [source] Review article: pain and chronic pancreatitisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2009J. G. LIEB II Summary Background, Pain in chronic pancreatitis chronic pancreatitis is a frustrating and challenging symptom for both the patient and clinician. It is the most frequent and most significant symptom. Many patients fail the currently available conservative options and require opiates or endoscopic/surgical therapy. Aim, To highlight the pathophysiology and management of chronic pancreatitis pain, with an emphasis on recent developments and future directions. Methods, Expert review, utilizing in addition a comprehensive search of PubMed utilizing the search terms chronic pancreatitis and pain, treatment or management and a manual search of recent conference abstracts for articles describing pain and chronic pancreatitis. Results, Pancreatic pain is heterogenous in its manifestations and pathophysiology. First-line medical options include abstinence from alcohol and tobacco, pancreatic enzymes, adjunctive agents, antioxidants, and non-opiate or low potency opiate analgesics. Failure of these options is not unusual. More potent opiates, neurolysis and endoscopic and surgical options can be considered in selected patients, but this requires appropriate expertise. New and better options are needed. Future options could include new types of pancreatic enzymes, novel antinociceptive agents nerve growth factors, mast cell-directed therapy, treatments to limit fibrinogenesis and therapies directed at the central component of pain. Conclusions, Chronic pancreatitis pain remains difficult to treat. An approach utilizing conservative medical therapies is appropriate, with more invasive therapies reserved for failure of this conservative approach. Treatment options will continue to improve with new and novel therapies on the horizon. [source] A prospective longterm study of primary chronic angle closure glaucomaACTA OPHTHALMOLOGICA, Issue 2 2004Ramanjit Sihota Abstract. Purpose:, To prospectively evaluate the longterm outcome of therapy for chronic primary angle closure glaucoma (PACG) and to assess the efficacy of medical and surgical treatment in terms of intraocular pressure (IOP) and visual field stabilization. Methods:, Seventy consecutive patients with chronic PACG, whose IOP remained > 21 mmHg despite a patent iridotomy, had their IOP controlled by medications or trabeculectomy performed without antimetabolites. They were followed over a 6-year period. Best corrected visual acuity, IOP (mean of annual diurnal variation readings), cup : disc ratio and visual fields were recorded. A trabeculectomy was performed if the IOP was not adequately controlled on maximal tolerable medical therapy or if there was a progression of the glaucomatous defect. Data from one eye of each patient were analysed; if both eyes met the inclusion criteria, one was randomly selected for the analysis. The baseline parameters were compared with those at the end of 6 years. Results:, A total of 46 eyes (65%) were controlled medically throughout the 6-year follow-up period, while 24 eyes (35%) required surgery. The mean IOP was 25.4 ± 4.9 mmHg at baseline and 15.6 ± 4.6 mmHg at 6 years follow-up (p < 0.001). Stereoscopic evaluation of the cup : disc ratio did not show a significant change from a mean of 0.6 ± 0.18 at baseline to a mean of 0.64 ± 0.2 at 6 years (p = 0.12). Progression of visual field defects was seen in seven eyes (10%), which had statistically larger cup : disc ratios (p = 0.04) and more extensive visual field deficits at the initial assessment (p = 0.04), and which also maintained higher levels of IOP (p = 0.03) over the 6 years of follow-up. Conclusions:, Stable visual fields and good longterm IOP control were seen in 90% of chronic primary angle closure glaucoma eyes on medical/surgical therapy over 6 years. [source] Treatment of Vitiligo on Difficult-to-Treat Sites Using Autologous Noncultured Cellular GraftingDERMATOLOGIC SURGERY, Issue 1 2009SANJEEV V. MULEKAR MD BACKGROUND Because of the limitations of medical treatment, various surgical therapies have been developed and are being accepted to treat vitiligo. However, certain areas such as the fingers and toes, palms and soles, lips, eyelids, nipples and areolas, elbows and knees, and genitals are considered difficult-to-treat areas. OBJECTIVE To evaluate data pertaining to individual sites considered to be difficult to treat and highlight that noncultured melanocyte,keratinocyte transplantation (MKT) does not require any special precautions to treat these anatomical sites. METHODS AND MATERIALS Forty patients (13 male and 27 female) with bilateral vitiligo and nine (4 male and 5 female) with unilateral vitiligo were treated using noncultured MKT, for "difficult-to-treat" sites at the National Center for Vitiligo and Psoriasis, Riyadh, Saudi Arabia, and were analyzed for response according to region. Repigmentation was graded as excellent with 95% to 100% pigmentation, good with 65% to 94%, fair with 25% to 64%, and poor with 0% to 24% of the treated area. RESULTS For bilateral vitiligo, more than 50% of patients treated for difficult sites showed more than 65% repigmentation of the treated areas. For unilateral vitiligo, all of the patients except for two treated for the eyelids showed more than 65% repigmentation of the treated area. CONCLUSIONS The concept of a "difficult-to-treat site" is a relative term and depends upon the technique used. The noncultured MKT does not require any special precautions to treat these anatomical sites. This review may help physicians to change the concept of "difficult-to-treat site." [source] Medical and surgical therapies for alopecias in black womenDERMATOLOGIC THERAPY, Issue 2 2004Valerie D. Callender ABSTRACT:, Hair loss is a common problem that challenges the patient and clinician with a host of cosmetic, psychological and medical issues. Alopecia occurs in both men and women, and in all racial and ethnic populations, but the etiology varies considerably from group to group. In black women, many forms of alopecia are associated with hair-care practices (e.g., traction alopecia, trichorrhexis nodosa, and central centrifugal cicatricial alopecia). The use of thermal or chemical hair straightening, and hair braiding or weaving are examples of styling techniques that place African American women at high risk for various "traumatic" alopecias. Although the exact cause of these alopecias is unknown, a multifactorial etiology including both genetic and environmental factors is suspected. A careful history and physical examination, together with an acute sensitivity to the patient's perceptions (e.g., self-esteem and social problems), are critical in determining the best therapy course. Therapeutic options for these patients range from alteration of current hair grooming practices or products, to use of specific medical treatments, to hair replacement surgery. Since early intervention is often a key to preventing irreversible alopecia, the purpose of the present article is to educate the dermatologist on all aspects of therapy for hair loss in black women,including not only a discussion of the main medical and surgical therapies but also an overview of ethnic hair cosmetics, specific suggestions for alterations of hair-care practices, and recommendations for patient education and compliance. [source] Surgical therapies for vitiligo and other leukodermas, part 1: minigrafting and suction epidermal graftingDERMATOLOGIC THERAPY, Issue 1 2001Rafael Falabella ABSTRACT: Vitiligo and other disorders of hypopigmentation are common cutaneous dermatoses that can give rise to considerable aesthetic concerns. In some patients these leukodermas are treated successfully with medical therapies such as topical corticosteroids and PUVA therapy. However, not all patients and not all lesions respond and as a result, surgical therapies are often required to restore normal pigmentation. The two most common and simple procedures, minigrafting (implantation of 1.0,1.2 mm grafts) and suction epidermal grafting (transfer of only epidermis harvested via negative pressures), are described in detail. Repigmentation with these two techniques, if carried out properly, yields good to excellent results with minor or no side effects. The most important factors for success are stability of the depigmenting process, an appropriate technique, and careful patient selection. Surgical interventions for stable vitiligo and other types of stable leukoderma are usually not first-line options, but when medical treatments fail, they represent the best available therapies. [source] A "cure" for Parkinson's disease: Can neuroprotection be proven with current trial designs?MOVEMENT DISORDERS, Issue 5 2004Carl E. Clarke BSc Abstract Current medical and surgical therapies for Parkinson's disease provide symptomatic control of motor impairments rather than slowing or halting the progression of the disease. Previous clinical trials examining drugs such as dopamine agonists and selegiline for neuroprotective effects used "surrogate" outcomes, including clinical measures (rating scales, time to require levodopa), neuroimaging techniques (,-CIT single photon emission computed tomography; fluorodopa positron emission tomography), and mortality tracking. These studies failed to provide conclusive results because of design faults such as failing to control for symptomatic effects, small sample size, and not accounting for the possible effects of drugs on radionuclide tracer handling. Lessons must be learned from these failed neuroprotection trials. This review summarises the problems with previous neuroprotection studies and makes recommendations for future trial design. It is concluded that the primary outcome of explanatory trials should continue to be clinical measures such as the Unified Parkinson's Disease Rating Scale (UPDRS). It should be assumed that all agents have a symptomatic effect, which necessitates evaluation after a prolonged drug washout period. To achieve the evaluation after a prolonged drug washout period more effectively, trials must be performed in early disease and over a short period (6,12 months) so that symptomatic therapy is not required. To achieve adequate statistical power, these trials will need to include thousands of patients. Radionuclide imaging can only be used in such trials after considerable methodological work has been performed to establish its validity and reliability. To be affordable, such large explanatory trials need more streamlined designs with fewer hospital visits, fewer outcome measures, and rationalised safety monitoring. The clinical effectiveness of promising compounds from explanatory trials will need to be established in large long-term pragmatic trials using outcome measures such as quality of life, cost-effectiveness, and mortality. Such pragmatic trials could be continuations of the explanatory trials: after the primary outcome of the explanatory study (e.g., UPDRS) has been reported in an interim analysis, the trial could be continued for a further 5 to 10 years to report on quality of life and health economics outcomes. © 2004 Movement Disorder Society [source] Structural and functional changes in spastic skeletal muscle,MUSCLE AND NERVE, Issue 5 2004Richard L. Lieber PhD Abstract This review summarizes current information regarding the changes in structure or function that occur in skeletal muscle secondary to spasticity. Most published studies have reported an increase in fiber size variability in spastic muscle. There is no general agreement regarding any shift in fiber type distribution secondary to spasticity. Mechanical studies in whole limbs as well as in isolated single cells support the notion of an intrinsic change in the passive mechanical properties of muscle after spasticity in addition to the more widely reported neural changes that occur. Evidence is presented for changes within both the muscle cell and extracellular matrix that contribute to the overall changes in the tissue. Taken together, the literature supports the notion that, although spasticity is multifactorial and neural in origin, significant structural alterations in muscle also occur. An understanding of the specific changes that occur in the muscle and extracellular matrix may facilitate the development of new conservative or surgical therapies for this problem. Muscle Nerve 29: 615,627, 2004 [source] Targeting Allograft Injury and Inflammation in the Management of Post-Lung Transplant Bronchiolitis Obliterans SyndromeAMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2009A. G. N. Robertson Chronic allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is the major cause of morbidity and mortality in human lung transplant recipients. While alloimmunity has a definite role, there is increasing interest in overall allograft injury and subsequent inflammation and remodeling. This review deals with nonalloimmune factors that may potentiate alloimmune injury. We discuss infection and reflux/aspiration as examples of allograft injury, which may lead to chronic loss of graft function and BOS. Surgical and nonsurgical treatments aimed at preventing these insults and improving survival are considered. The need for further evidence, including randomized-controlled trials, to evaluate the role of medical and surgical therapies is emphasized by the current literature. [source] Right ventricular involvement in hypertrophic cardiomyopathy: A case report and literature reviewCLINICAL CARDIOLOGY, Issue 1 2001Dariush Mozaffarian M.D. Abstract Although hypertrophic cardiomyopathy (HCM) is classically considered a disease of the left ventricle, right ventricular (RV) abnormalities have also been reported. However, involvement of the right ventricle in HCM has not been extensively characterized. The literature regarding prevalence, genetics, patterns of involvement, histologic findings, symptoms, diagnosis, and treatment of RV abnormalities in HCM is reviewed. To highlight the salient points, a case is presented of apical HCM with significant RV involvement, with an RV outflow tract gradient and near obliteration of the RV cavity, in the absence of a left intraventricular gradient. Right ventricular involvement in HCM appears to be as heterogeneous as that of the left ventricle. The spectrum extends from mild concentric hypertrophy to more unusual severe, obstructive disease. While in some cases the extent of RV involvement correlates with left ventricular (LV) involvement, predominant RV disease can be seen as well. While the genetics of RV involvement have not been well characterized, histologic findings appear to be similar to those in the left ventricle, suggesting similar pathogenesis. Significant RV involvement may result in RV outflow obstruction and/or reduced RV diastolic filling, with potentially increased incidence of severe dyspnea, supraventricular arrhythmias, and pulmonary thromboembolism. The optimal treatment for patients with significant RV disease is unknown. Medical and surgical therapies have been attempted with variable success; experience with newer techniques such as percutaneous catheter ablation has not been reported. Further characterization of RV involvement in HCM is necessary to elucidate more clearly the clinical features and optimal treatments of this manifestation of HCM. [source] Trichloroacetic Acid Matricectomy in the Treatment of Ingrowing ToenailsDERMATOLOGIC SURGERY, Issue 6 2009SU-HAN KIM MD BACKGROUND Ingrowing toenails can be treated with conservative therapy or surgery, but frequent relapse can be a problem in conservative therapy and surgical therapy without matricectomy. Thus, permanent nail ablation by partial matricectomy is now accepted as the treatment of choice. OBJECTIVE To evaluate the efficacy and safety of trichloroacetic acid (TCA) matricectomy in the treatment of ingrowing nail. MATERIALS AND METHODS Forty ingrowing toenail edges in 25 patients were enrolled. TCA matricectomy with 100% trichloroacetic acid after partial nail avulsion was performed. For a few weeks after surgery, postoperative complications such as pain, discharge, and infection were assessed. After a mean follow-up period of 22.9 months, recurrence rate and cosmetic outcomes were investigated to evaluate the effects of the surgery. RESULTS The wounds almost always healed within 2 weeks without prolonged exudative discharge. Pain was mild and transient. A case of secondary infection occurred. Recurrence was found in only two nails of one patient, and the success rate was 95%, with good cosmetic results. CONCLUSION TCA matricectomy showed a low recurrence rate with minimal side effects and was easy to perform in outpatient clinic. Therefore, it may be a good alternative treatment of ingrowing toenails. [source] The medical and surgical therapy of pseudofolliculitis barbaeDERMATOLOGIC THERAPY, Issue 2 2004Sharon Bridgeman-Shah ABSTRACT:, Pseudofolliculitis barbae (PFB) is a common, chronic, inflammatory skin disorder seen mainly in individuals with curly hair. This condition is seen most frequently in black men who shave their beards but may also be seen in women of all races who wax or shave the axillary and pubic skin. The etiology of PFB is multifactorial, and heretofore a cure has been considered impossible for those desiring a clean-shaven face. The following article serves to discuss the current medical and surgical therapies available for this condition. Medical treatments for this condition include various combinations of topical antibiotics, corticosteroids, and retinoids. In the surgical arena, laser therapy has revolutionized the treatment of PFB and has enabled cure for the first time for those plagued by this disorder and for whom a beardless face is acceptable. [source] Does gastroesophageal reflux contribute to the development of chronic sinusitis?DISEASES OF THE ESOPHAGUS, Issue 6 2006A review of the evidence SUMMARY., Although recent studies suggest that gastroesophageal reflux disease (GERD) may contribute to a variety of ear, nose and throat and pulmonary diseases, the cause-and-effect relationship for the vast majority remains far from proven. In this article, the evidence supporting a possible causal association between GERD and chronic sinusitis has been reviewed. The evidence would suggest that: (i) a higher prevalence of GERD and a different esophagopharyngeal distribution of the gastric refluxate occurs in patients with chronic sinusitis unresponsive to conventional medical and surgical therapy compared to the general population; (ii) a biologically plausible pathogenetic mechanism exists whereby GERD may result in chronic sinusitis; and (iii) clinical manifestations of chronic sinusitis respond variably to antireflux therapy. While these findings suggest that GERD may contribute to the pathogenesis of chronic sinusitis in some patients, it is apparent that the quality of the evidence supporting each of these three lines of evidence is low and therefore does not conclusively establish a cause-and-effect relationship. A number of unresolved issues regarding prevalence, pathophysiological mechanism, diagnosis and treatment exist that deserve further investigation in order to solidify the relationship between GERD and chronic sinusitis. In conclusion, given the possible relationship between GERD and chronic sinusitis, until more convincing data are available, it may be prudent to investigate for GERD as a potential cofactor or initiating factor in patients with chronic sinusitis when no other etiology exists, or in those whose symptoms are unresponsive to conventional therapies. [source] Progress of Untreated Massive Cardiac Echinococcosis,Echocardiographic Follow-UpECHOCARDIOGRAPHY, Issue 9 2006Serdar Soydinc M.D. A 56-year-old man was admitted with chest pain and dyspnea. Echocardiographic evaluation revealed a giant cystic cardiac mass with multiple loculations at interventricular septum extended to inferoposterior region protruding inside the cavity. The patient refused surgical therapy. His complaints persisted without significant changes after 5 months. Second echocardiographic evaluation revealed conjugation of previous multiple cyst to gigantic intramyocardial cyst and minimal pericardial effusion. We intend to illustrate herein an unusual echocardiographic appearance and progress of an untreated massive "cardiac echinococcosis." If cardiac hydatid cyst is left untreated it may transform to large cavity with a high risk of rupture. [source] High-resolution MRI Enhances Identification of Lesions Amenable to Surgical Therapy in Children with Intractable EpilepsyEPILEPSIA, Issue 8 2004Monisha Goyal Summary:,Purpose: Many children with refractory epilepsy can achieve better seizure control with surgical therapy. An abnormality on magnetic resonance imaging (MRI), along with corroborating localization by other modalities, markedly increases chances of successful surgical outcome. We studied the impact of high-resolution MRI on the surgical outcome of intractable epilepsy. Methods: High-resolution MRI using four-coil phased surface array was obtained as part of the comprehensive presurgical protocol for children with focal onset intractable seizures evaluated by our epilepsy center during the first half of 2002. Results: Thirteen consecutive children, ages 5 to 18 years, entered this prospective study. For four patients with a lesion on a recent MRI examination with a standard head coil, management did not change with high-resolution MRI. Standard MRI in the other nine patients did not identify a lesion. However, high-resolution MRI with the phased-array surface coil found previously undiagnosed focal abnormalities in five of nine patients. These abnormalities included hippocampal dysplasia, hippocampal atrophy, and dual pathology with frontal cortical dysplasia. In four of nine patients, no identifiable lesion was identified on the high-resolution MRI. All patients underwent invasive monitoring. In three of five patients, newly diagnosed lesions correlated with EEG abnormalities, and resection was performed. Conclusions: In our center, high-resolution MRI identified lesions not detected by standard MRI in more than half the children (56%). Technical advances such as four-coil phased surface array MRI can help identify and better delineate lesions, improving the diagnosis of patients who are candidates for surgical treatment of refractory epilepsy. [source] AAN-EFNS guidelines on trigeminal neuralgia managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 10 2008G. Cruccu Several issues regarding diagnosis, pharmacological treatment, and surgical treatment of trigeminal neuralgia (TN) are still unsettled. The American Academy of Neurology and the European Federation of Neurological Societies launched a joint Task Force to prepare general guidelines for the management of this condition. After systematic review of the literature the Task Force came to a series of evidence-based recommendations. In patients with TN MRI may be considered to identify patients with structural causes. The presence of trigeminal sensory deficits, bilateral involvement, and abnormal trigeminal reflexes should be considered useful to disclose symptomatic TN, whereas younger age of onset, involvement of the first division, unresponsiveness to treatment and abnormal trigeminal evoked potentials are not useful in distinguishing symptomatic from classic TN. Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should be offered as first-line treatment for pain control. For patients with TN refractory to medical therapy early surgical therapy may be considered. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. Microvascular decompression may be considered over other surgical techniques to provide the longest duration of pain freedom. The role of surgery versus pharmacotherapy in the management of TN in patients with multiple sclerosis remains uncertain. [source] Salvage treatment for recurrent oropharyngeal squamous cell carcinomaHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 8 2010Christof Röösli MD Abstract Background. This study evaluates the oncological outcome of patients with recurrent oropharyngeal squamous cell carcinoma (OPSCC) after primary radiation therapy ± chemotherapy, primary surgical therapy, and surgical therapy followed by radiation therapy ± chemotherapy. Methods. A total of 156 patients (36%) of a cohort of 427 treated for OPSCC between 1990 and 2006 developed recurrent disease. Fifty-one patients (12%) qualified for salvage treatment. Study endpoints were 5-year overall survival (OS) and disease-specific survival (DSS). Results. The 5-year OS and DSS rates after salvage treatment were 29% and 40%; after initial primary radiation therapy, 25% and 40%; after initial surgery followed by radiation therapy, 40% and 40%; and after initial surgery alone, 20% and 40%. Conclusions. Patients with an advanced OPSCC have a considerable risk for recurrence. Despite poor ultimate outcome, salvage treatment should be attempted in patients with resectable disease, good performance status, and absence of distant metastases. © 2009 Wiley Periodicals, Inc. Head Neck, 2010 [source] | |||||||||||||||||||||||||||||||||||||