Alternative Treatment Modality Research Articles

Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP)

Background: The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of “elective” interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures. Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic. Objectives: The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques. Methods: The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge. Results: The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included emergent, urgent, and elective procedures. Examples of emergent and urgent procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, urgent procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives. Limitations: COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance. Conclusion: The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus. Key words: Coronavirus, COVID-19, interventional pain management, COVID risk factors, elective surgeries, interventional techniques, chronic pain, immunosuppression

Letter: Safety Instructions for Neurosurgeons During COVID-19 Pandemic Based on Recent Knowledge and Experience.

To the Editor: Here, we ask for the opinion of 4 worldwide-known neurosurgeons from 3 different continents and review the evidence from literature and from major relevant societies to provide a guide for the safety of surgical personnel and to reorganize neurosurgical practice during the COVID-19 pandemic and in the subsequent phase. Moreover, we retrieved relevant information from PubMed and from national and international organizations, including Robert-Hooke Institute, Germany, World Health Organization, German Society of Neurosurgery, and World Society of Virology, to develop guidelines. PROPOSED RECOMMENDATIONS FOR THE MANAGEMENT OF EMERGENCY NEUROSURGICAL PATIENTS DURING THE COVID-19 PANDEMIC All efforts should be utilized to perform certain emergency procedures under local anaesthesia. Endovascular treatment, if possible, especially in neurovascular diseases, should be considered as priority. Alternate treatment modalities, such as radiosurgery in certain neuro-oncological conditions, should be considered. To avoid any ethical issues, the urgent neurosurgical cases in all neurosurgical subspecialties should be triaged and treated. PROPOSED MANAGEMENT OF NEUROSURGICAL PATIENTS DURING COVID-19 WITH COVID-19 INFECTION All patients in emergency rooms (ERs) may be potential carriers of the virus and at least all unconscious patients should be treated as infected. Only 1 case from China and 1 from Japan with COVID-19 meningitis have been reported in the news. In literature, however, there is no single report on COVID-19 meningitis and the presence of virus in the cerebrospinal fluid. Moreover, some patients may present with neurological symptoms (eg, confusion) as the virus may cause hypoxia but still not provoke hyperventilation to compensate. Therefore, we still recommend the surgical personnel to take complete measures due to the presence of the virus in the blood. Urgent surgical procedures on COVID-19 positive patients should be performed only in dedicated operation rooms. To date there has been no single central nervous system complication reported that needed a neurosurgical procedure, but it is still highly possible that neurosurgical patients who need emergency surgery are COVID-19 positive with a high virus load. We propose the following safety measures for the surgeon and surgical staff during neurosurgical approaches. PROPOSED PRECAUTIONS DURING SURGICAL APPROACH During the pandemic, all neurosurgical procedures should be highly standardized to reduce the operation room time. Use of new materials or instruments and clinical studies should be postponed until the end of the pandemic. Whole surgical team should wear the FFP2/FFP3 (FPP stands for “Filtering Face Piece”) mask, eye protection glasses, double gloves, surgical suits, and shoe covers. Experienced neurosurgeons beyond their learning curve should perform the surgeries to reduce total exposure time. If possible, only a single surgeon should perform the surgery to avoid exposure to the assistant. Special care should be taken during craniotomy and drilling (irrigation with heat) to avoid aerosol dispersal and prevent them from reaching nose and eyes. Any dispersal of blood during drilling procedures should be avoided. Electrocautery power setting or the use of bipolar should be minimized to reduce aerosol dispersal. The surgical wound should be covered at the end of surgery. Special care should be taken and the powered air-purifying respirator (PAPR) mask should be worn during the endonasal surgery because COVID-19 is known for settling down in the nasopharyngeal room. SARS-CoV-2 negative (negative history of COVID-19, negative swab (2 times within 24 h) OR negative CT chest: FFP3 mask and safety glasses should be worn. SARS-CoV-2 positive: PAPR mask should be worn. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Funding support was received from EANS to Dr Muhammad.

Drug-Coated Balloon Treatment in Symptomatic Intracranial High Grade Stenosis : A Retrospective Study of 33Patients.

Endovascular therapy (EVT) represents an alternative treatment modality for symptomatic intracranial high-grade atherosclerotic stenosis (sICAS); however, periprocedural complication rates as well as midterm restenosis rates represent relevant limitations of EVT. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) may overcome some of these shortcomings. The aim of this study was to assess feasibility and safety as well as the stroke recurrence rate in 33patients. Aretrospective, monocentric cohort study of sICAS patients treated with DCB-PTA. Outcome measures were the periprocedural intracranial complication rate, the recurrent stroke rate and mortality during follow-up. This cohort study included 33patients with 35sICAS treated with DCB-PTA. The median age was 72years (interquartile range, IQR 66-77 years); median clinical and mean radiological follow-up time was 9months (IQR 3-22 months). Median preprocedural degree of stenosis (WASID) was 80% (IQR 73-80%) and median postprocedural residual stenosis degree (WASID) was 50% (IQR 33-60%). Intracranial periprocedural complications occurred in 2 (6%) patients. The overall restenosis rate was 15% (n = 5). In four patients asymptomatic ischemic re-event occurred within 7months after the initial treatment. None of the patients died. This DCB-PTA cohort study showed arelatively low intracranial complication rate of 6% with asymptomatic recurrence rate of 12%. Larger trials are needed to validate these promising observations.

Vim stereotactic radiosurgical thalamotomy for drug-resistant idiopathic Holmes tremor: a case report

We share our experience with stereotactic gamma knife thalamotomy (GKT) for medically refractory Holmes tremor (HT). A 22-year-old patient underwent gamma knife thalamotomy at ventrointermediate nucleus for disabling HT of the right upper limb. A single 4-mm isocenter was used to target the ventral intermediate nucleus with 130Gy radiation. At 4months follow up, we observed 84% improvement in his Fahn-Tolosa-Marin (FTM) rating scale with significant improvement in the right upper limb dystonic tremor. There was only subtle improvement in the ataxic component of the right lower limb. At 1year after stereotactic GKT, there was sustained neurological improvement with no side effect, We present the stereotactic GKT as a treatment modality for drug-resistant HT. Moreover, it may be considered an alternate treatment modality especially in patients reluctant or contraindicated for any invasive surgical technique. CLINICAL TRIAL REGISTRATION NUMBER: Not required.

Prosthetic rehabilitation of an edentulous mandible by two implants-retained Mandibular Overdenture: A case report

Conventionally, complete denture therapy has been considered as the standard of care for prosthetic management of edentulous jaws. However, it is very well recognized that not all patients are able to tolerate or adapt themselves to the prosthesis and frequently complain of discomfort, lack of retention, stability and inability to chew food. Such problems are more pronounced with mandibular dentures due to the anatomy of the mandible, faster resorption rates and close proximity of the residual alveolar ridge to the various muscle attachments which often interferes with the formation of adequate peripheral seal at the denture borders. With the recent developments in the dental implantology, Implant- Retained Mandibular Overdentures have emerged as an alternate treatment modality for prosthetic rehabilitation of edentulous mandibles and have achieved encouraging results in terms of enhanced retention, support and stability contributing to greater patient acceptance and hence improvement in their quality of life. This article describes a case report where a Implant- Retained Overdenture was planned for a patient with edentulous mandible by placement of two endosseous implants.

Excellent Hemodynamic Performance After Aortic Valve Neocuspidization Using Autologous Pericardium

Aortic valve neocuspidization (AVNeo) for trileaflet aortic valve reconstruction using autologous pericardium (Ozaki procedure) offers an alternative treatment modality to overcome drawbacks of conventional prosthetic aortic valve replacement. Between October 2016 and April 2019, 103 patients underwent surgery. Mean follow-up was 426 ± 270 days. Aortic stenosis was the leading diagnosis in 80 patients (77.7%) and aortic regurgitation in 23 (22.3%), respectively. Mean age was 54.0 ± 16.4 years (range, 13.8-78.5). A bicuspid valve was found in 81 patients (78.6%). Transthoracic echocardiography was performed at discharge and at 6 to 12 months after surgery. During AVNeo surgery valve sizing for an Abbott/St Jude Trifecta bioprosthesis (virtually implanted Trifecta bioprosthesis; St Jude Medical, St Paul, MN) was performed to compare pressure gradients and effective orifice area with published data. Trileaflet aortic valve reconstruction was achieved in all patients. In 38 patients neocommissures were created (36.9%). Mean cross-clamp time was 135 ± 20 minutes. Four patients underwent reoperation; the overall freedom from reoperation was 96.1%. Echocardiographic 6- to 12-months follow-up after surgery was available in 93.8% of patients and did not show any change in hemodynamic parameters compared with discharge. Comparison between AVNeo and virtually implanted Trifecta Bioprosthesis revealed a significantly lower mean pressure gradient (8.5 ± 3.7 mm Hg vs 10.2±2.0 mm Hg, P < .001) and higher mean effective orifice area (2.2 ± 0.7 cm2 vs 2.1 ± 0.4 cm2, P= .037) for AVNeo. AVNeo shows low reoperation rates after surgery within the first 2 years. The hemodynamic performance is excellent, and the effective orifice area and mean pressure gradient remain stable within the first year.

Inflammation, Immunity and Immunogenetics in COVID-19: A Narrative Review.

The novel Coronavirus Disease 2019 (COVID-19), that began in Wuhan Province, China was labelled as an International Public Health Emergency on January 30, 2020 and later was declared a pandemic by the World Health Organisation (WHO) on March 11, 2020. The causative agent, SARS-CoV-2 was the third coronavirus responsible for causing major disease outbreaks in human population after Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) caused by SARS-CoV and MERS-CoV respectively. The patients of COVID-19 present with a clinical feature resembling mild form of viral pneumonia which in certain cases progress to a severe form characterised by adult respiratory distress syndrome (ARDS) and/or multiorgan failure leading to death. The transition from mild to severe form of COVID-19 is affected by a lot of factors like age, co-morbidities etc. In the absence of an absolute cure, it is essential to explore the molecular pathogenesis of the disease to identify people at risk of developing severity so that alternative treatment modalities may be planned. The aim of this review is to provide an update on the general characteristics of SARS-CoV-2 and highlight the inflammatory changes and immune dysregulation that may help in identification of molecular predictors of disease severity.

Mo1292 EFFICACY AND OUTCOMES OF ENDOSCOPIC MUCOSAL RESECTION IN T1B ESOPHAGEAL ADENOCARCINOMA: CAN ESOPHAGECTOMY BE AVOIDED IN SELECT PATIENTS?

The incidence of esophageal adenocarcinoma (EAC) has continued to increase over the past several decades. While endoscopic mucosal resection (EMR) is highly effective for intramucosal EAC (T1a lesions), there is limited data on outcomes of patients following EMR with T1b EAC in the era of modern chemoradiation and cryotherapy modalities. While the current standard of care for T1b EAC relies on esophagectomy, with its high risk of morbidity and mortality, it remains uncertain whether select patients with T1b EAC can be definitively treated with EMR along with chemoradiation or additional endoscopic therapies. The aim of this study is to evaluate the outcomes of patients with T1b EAC after initial EMR. A retrospective cross-sectional study was performed using a prospective electronic endoscopy database at a tertiary care academic medical center. All patients who underwent esophageal EMR for T1b EAC between February 2015 and September 2019 were included. Data on patient and disease characteristics were collected. The primary outcome was presence of residual disease (local or metastatic) during follow-up. A total of 13 patients with T1b EAC who underwent EMR were identified. The mean age was 71 years and 85% were male. Seven of these patients (54%) underwent esophagectomy while 6 patients had endoscopic and clinical surveillance. Patients who underwent esophagectomy and endoscopic surveillance had similar characteristics except that patients who underwent esophagectomy had a lower Charlson comorbidity index (5.7 vs. 7.8, P = 0.04). In patients who underwent endoscopic surveillance, 67% were deemed too high-risk for surgery, while 33% refused surgery. Among the 6 patients who underwent endoscopic surveillance after EMR, 3 were additionally treated with cryotherapy, 1 was treated with radiofrequency ablation (RFA) and 1 underwent chemoradiation. One of these 6 patients was found to have residual disease at a mean follow-up of 478 days. Among the 7 patients who underwent esophagectomy after EMR, 3 (43%) had residual tumor on surgical pathology, however none of these 7 patients underwent chemoradiation prior to surgery. Of all 13 T1b EAC patients who underwent EMR, 69.2% (N = 9) had no evidence of subsequent residual disease with a follow-up of 739 days. None of the patients with residual disease underwent prior chemoradiation. These results suggest that select patients with T1b EAC who are at high-risk for esophagectomy may be successfully managed with local therapy of EMR followed by the addition of chemoradiation and alternative endoscopic treatment modalities. Further prospective studies are needed to validate these findings and guide optimal patient selection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Robotic-assisted laparoscopic pyeloplasty as management for recurrent ureteropelvic junction obstruction: a comparison study with primary pyeloplasty.

BackgroundTo analyze the perioperative parameters and outcomes of robotic-assisted laparoscopic pyeloplasty (RALP) for recurrent ureteropelvic junction obstruction (UPJO) and compare them with our series of RALP for primary UPJO. Secondary pyeloplasty can be a challenging procedure because of ureteral devascularization, fibrosis and dense stricture formation. Robotic approach could be adjunct to these repairs.MethodsBetween August 2015 to March 2019, 96 patients in our hospital underwent RALP, with 32 patients as secondary intervention for recurrent UPJO. We compared the perioperative parameters of RALP for both primary UPJO and recurrent UPJO. Patient demographics, perioperative parameters, postoperative outcomes and complications from both groups were analyzed and compared.ResultsRALP was successfully performed for all cases in both groups. The median operating time was longer for secondary RALP than for primary RALP [125 (108.5–155) vs. 151 (120–190) minutes, P=0.004]. There were no conversions to open surgery or significant perioperative complications. No difference in blood loss, transfusion rate and perioperative complication rates was noted between the two groups. The success rates were 98.44% (63/64) and 96.88% (31/32) at a median follow up of 32 and 20 months (P=0.001) for the primary and secondary groups, respectively.ConclusionsSecondary RALP is associated with significantly longer operative time as compared to primary RALP, especially during the exposure of the UPJO, however it is a safe surgical modality for recurrent UPJO with durable outcome. RALP should be an alternative treatment modality for recurrent UPJO whenever the facility and expert are available.

Proposition of standardized protocol for photodynamic therapy for vulvar lichen sclerosus

Background Photodynamic therapy (PDT) is an alternative treatment modality for vulvar lichen sclerosus (VLS) which is a chronic inflammatory mucosal condition. In literature, no consensus of optimal parameters of PDT for VLS is reached so far. Objectives The aim of this narrative review is to develop a standardized treatment protocol for PDT in VLS. Methods A systematic literature search was conducted to identify studies reporting on PDT in VLS and used treatment parameters, side-effects, and clinical outcomes were summarized. Results Thirteen studies used 5-aminolevulinic acid (5-ALA) with concentrations of 20%, 10%, 5% and three studies used methyl aminolevulinate (MAL). Generally, the light source was red light (median 630 nm). Light dose varied between 9 and 180 J/cm2 and light intensity between 40 and 700 mW/cm2. Incubation period with the photosensitizer ranged from 2 to 6 h. All studies showed a substantial improvement in VLS-related pruritus, burning and pain. Conclusions Based on a literature review, we suggest the following protocol for PDT in VLS: 5% 5-ALA as a photosensitizer applied for 3 h under occlusion before irradiation at the dose of 120 J/cm2 with red light (590–760 nm) and intensity of 204 mW/cm2.

0893 Myofunctional Therapy in Children With Mild Obstructive Sleep Apnea: A Meta-Analysis

Abstract Introduction OSA affects 2-4% of children and untreated OSA can have adverse behavior and quality of life outcomes. 40% of children can have residual obstructive sleep apnea (OSA)despite first line treatment (adenotonsillectomy). Alternative modalities of treatment for OSA are limited. Myofunctional therapy comprises of exercises targeting upper airway muscles that can improve facial growth and have been shown to treat OSA in adults. There is paucity of data on the role of myofunctional therapy (MT) in children. The objective of this study was to systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for OSA in children and to perform a meta-analysis on the polysomnographic and mouth breathing data. Methods Medline, Embase, CINAHL, Scopus, Web of Science and Cochrane were searched from inception through October 1st, 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. Results Eight studies (91 patients) reported polysomnography and/or mouth breathing outcomes. The pre- and post-MT apnea hypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 3.75± 3.14/h to 2.08 ± 2.48/h, mean difference (MD) -1.6 [95% confidence interval (CI) -2.42, -0.78], P =0.0001. Mean oxygen saturations improved from 96.03 ± 1.1% to 96.67 ± 0.95%, MD 0.42 (95% CI 0.21, 0.63), P &amp;lt;0.0001. Lowest oxygen saturations improved from 86.6 ± 7.3% to 90.94 ± 3.05%, MD 1.01 (95% CI 0.25, 1.77), P = 0.009. Mouth breathing decreased in all three studies reporting subjective outcomes. Conclusion Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 45% in children with mild obstructive sleep apnea. Mean oxygen saturations, lowest oxygen saturations and mouth breathing outcomes improved in children. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments. Support None

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic.

BackgroundCOVID‐19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel.MethodsThe MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular.RecommendationsEach subsite is presented separately with disease‐specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred.ConclusionThese guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID‐19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

Radioimmunotherapy of methicillin-resistant Staphylococcus aureus in planktonic state and biofilms.

Implant associated infections such as periprosthetic joint infections are difficult to treat as the bacteria form a biofilm on the prosthetic material. This biofilm complicates surgical and antibiotic treatment. With rising antibiotic resistance, alternative treatment options are needed to treat these infections in the future. The aim of this article is to provide proof-of-principle data required for further development of radioimmunotherapy for non-invasive treatment of implant associated infections. Planktonic cells and biofilms of Methicillin-resistant staphylococcus aureus are grown and treated with radioimmunotherapy. The monoclonal antibodies used, target wall teichoic acids that are cell and biofilm specific. Three different radionuclides in different doses were used. Viability and metabolic activity of the bacterial cells and biofilms were measured by CFU dilution and XTT reduction. Alpha-RIT with Bismuth-213 showed significant and dose dependent killing in both planktonic MRSA and biofilm. When planktonic bacteria were treated with 370 kBq of 213Bi-RIT 99% of the bacteria were killed. Complete killing of the bacteria in the biofilm was seen at 185 kBq. Beta-RIT with Lutetium-177 and Actinium-225 showed little to no significant killing. Our results demonstrate the ability of specific antibodies loaded with an alpha-emitter Bismuth-213 to selectively kill staphylococcus aureus cells in vitro in both planktonic and biofilm state. RIT could therefore be a potentially alternative treatment modality against planktonic and biofilm-related microbial infections.

Fractionated Radiation Therapy for Large and Giant Cavernous Sinus Hemangioma: A Retrospective Study.

Purpose: Surgical resection has been traditionally used as a treatment for cavernous sinus hemangioma (CSH). However, this is usually difficult due to tumor vascularity and results in complications especially in large and giant CSH (volume >20 cm3). Previous studies have reported that radiotherapy (RT) provides an alternative treatment modality for hemangiomas. However, the optimized dose and fractions which control CSH and also protect the cognitive function remain unclear. This study reports our experience in the management of symptomatic large and giant CSH.Methods: Fifty-four patients with symptomatic large (20 cm3 <tumor volume ≤ 40 cm3, 3–4 cm in diameter) and giant (tumor volume>40 cm3, >4 cm in diameter) CSH were enrolled in a retrospective study between January 2007 and December 2018. The prescription dose to the target margin was 50 Gy in 25 fractions.Results: The mean pre-RT tumor volume was 60.9 cm3 which ranged from 20.2 to 230.5 cm3. The clinical data obtained was analyzed retrospectively following a mean follow-up period of 35.0 months which ranged from 1 to 140 months. All patients experienced tumor shrinkage within 3 months after radiotherapy. There was an average mean tumor reduction of 79.7% (range, 48.4–98.5%) with no patients experiencing tumor progression and recurrence. All the 54 patients experienced symptomatic improvement within 1 month to 12 months after radiotherapy. Within the entire follow up period, no patients experienced any form of permanent complications or symptomatic radiation toxicity. Neurocognitive impairment studies were conducted before and after radiotherapy on 28 patients while the studies were conducted after the last follow up in 40 patients. The cognitive function of all the participants had normal MoCA-scores of 28.25 pre-radiotherapy. The post-treatment MoCA-scores were also clinically stable (28.04, p = 0.78), and the average MoCA-score did not show any decline until the last follow-up (27.61, p = 0.13).Conclusion: The optimal dose and fractions of radiotherapy treatment for symptomatic large and giant cavernous sinus hemangioma remain unclear. This study, therefore, used a marginal dose of 50 Gy in 25 fractions in radiotherapy and this was proven to be effective and relatively safe in the treatment of symptomatic large and giant CSHs.

The Use of Inhaled Nitric Oxide in Congenital Diaphragmatic Hernia.

Congenital diaphragmatic hernia (CDH) is a complex congenital defect of the diaphragm that allows abdominal contents to herniate into the chest cavity, altering pulmonary development, and leading to pulmonary hypoplasia and hypertension. Patient presentation is variable in severity, making management difficult. Many common management strategies have improved the survival rate of infants with CDH, including gentle ventilation and permissive hypercapnia. Inhaled nitric oxide (iNO) is a potent, pulmonary vasodilator that has shown to improve oxygenation while decreasing pulmonary pressure in infants with pulmonary hypertension. While many institutions utilize iNO in the treatment of pulmonary hypertension, the role of iNO as a treatment for CDH is controversial. The purpose of this literature review is to establish a better understanding of CDH including embryology, patient presentation, and management strategies, and to analyze the use and effect of iNO on patients in this population. A systemic search of PubMed, CINHAL, and Medline was performed to identify research articles studying the use of iNO on patients with pulmonary hypertension secondary to CDH. Three studies were utilized in this review to assess the current use and effectiveness of iNO in patients with CDH. This review summarized the pathophysiology, embryology, patient presentation, and management strategies, as well as reviewed literature on the effectiveness of iNO on pulmonary hypertension secondary to CDH. Further research is indicated to determine alternative treatment modalities and establish evidence-based practice protocols to standardize care in infants with CDH.

Implementation and Evaluation of a Platelet-Rich Plasma Multimedia Patient Education Tool for Patients With Androgenetic Alopecia

ABSTRACT Androgenetic alopecia (AGA) is a chronic, progressive hair loss disorder affecting both men and women. It is the most common form of alopecia. Platelet-rich plasma (PRP) is an alternative treatment modality that provides individuals with AGA with a safe and effective treatment option. A practice improvement needs assessment was conducted within a private dermatology practice in South Florida to evaluate the need for a patient education tool for patients with AGA. Upon the completion of this needs assessment, dermatology providers discovered that there is a need for a PRP education tool to aid in patient comprehension of the PRP procedure. This clinical practice improvement study examined the impact of a brief multimedia educational intervention on patient comprehension of PRP for the treatment of AGA. A commercially produced PRP patient education video was viewed by 10 patients with AGA within this practice. Postintervention, the teach-back method was utilized to measure patient comprehension of the PRP procedure. On the basis of the study results, it can be concluded that the utilization of a PRP multimedia patient education tool may provide dermatology providers with a standardized patient education method for patients with AGA and improve patient comprehension of PRP for the treatment of AGA.

Identifying optimal candidates for liver resection or transarterial chemoembolisation in patients with unresectable hepatocellular carcinoma.

BackgroundRecommended as the first-line treatment for advanced unresectable hepatocellular carcinoma (HCC), sorafenib has been shown to prolong median overall survival (OS) for patients. However, advanced HCC sees high heterogeneity across patient groups. Recently, a growing number of studies have indicated surgical resection and transarterial chemoembolisation (TACE) to perform well in patients with portal vein tumor thrombosis (PVTT). The aim of this study was to compare the outcomes of liver resection and TACE and to identify prognostic factors related to OS for BCLC stage C patients with performance status (PS) 1 who have a single tumor but no vascular invasion or extrahepatic spread.MethodsA total of 323 consecutive patients in BCLC stage C with PS 1 who had only one tumor and no vascular invasion or extrahepatic spread were enrolled in this retrospective study, regardless of tumor size. Survival analyses were performed using the Kaplan-Meier analysis, and statistical differences between the TACE and sorafenib groups were examined by the log-rank test. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.ResultsBased on the Kaplan-Meier curves, patients treated with surgical resection showed a better OS than those who underwent TACE, with OS at 1, 3, and 5 years (85.7%, 48.8%, and 33.3% vs. 66.6%, 21.8%, and 13.4%, respectively; log-rank P<0.001). Univariate and multivariate analyses demonstrated that tumor size, albumin, bilirubin, Child-Pugh score, and treatment method were significant prognostic factors for OS. According to the subgroup analyses based on tumor size, there were significant differences in OS among overall subsets between patients who underwent hepatectomy and those who underwent TACE therapy.ConclusionsLiver resection had a better prognostic performance than TACE and should be put forward as an alternative treatment modality to TACE for BCLC stage C patients with PS 1 who have a single tumor and no vascular invasion or extrahepatic spread.

Analysis of the clinical efficacy of liver resection combined with adjuvant microwave coagulation for patients with hepatocellular carcinoma.

BackgroundLiver resection has been widely applied as a curative measure in the treatment of hepatocellular carcinoma (HCC) patients. However, the high rate of postoperative recurrence observed following liver resection proposes a problem, the solution for which is yet to be well established. Microwave coagulation is a therapy that was recently proposed as an adjuvant tool. In this study, we intended to evaluate the effectiveness of microwave coagulation as an auxiliary therapeutic method for patients undergoing liver resection.MethodsA total of 236 consecutive patients classified as Barcelona Clinic Liver Cancer (BCLC) stage A who had only one tumor were enrolled in this retrospective study, regardless of tumor size. Survival analyses were performed using the Kaplan-Meier method, and the statistical differences between patients who underwent liver resection with and without adjuvant microwave coagulation were examined by the log-rank test. To investigate the prognostic factors for OS, we carried out univariate and multivariate Cox regression analyses.ResultsBased on the Kaplan-Meier curves, patients who underwent surgical resection with intraoperative adjuvant microwave coagulator had prolonged recurrence-free survival time and showed better overall survival (OS) than those who underwent surgical resection alone, with OS at 1, 3, and 5 years of 77.8%, 33.2%, 12.6% vs. 58.2%, 15.5%, 9.7%, respectively (log-rank P<0.001). The univariate and multivariate analyses demonstrated that tumor size, albumin, bilirubin, Child-Pugh score, and treatment method had significant prognostic power for both PFS and OS. According to the subgroup analyses based on the tumor size, there were significant differences in PFS and OS among overall subsets between the liver resection with adjuvant microwave coagulator and liver resection only groups.ConclusionsLiver resection combined with intraoperative adjuvant microwave coagulation had a better prognostic performance than treatment with liver resection alone. Adjuvant microwave coagulation should be suggested as an alternative treatment modality for BCLC stage A patients with a single tumor, regardless of its size.

Comparison of radiofrequency ablation combined with sorafenib or sorafenib alone in patients with ECOG performance score 1: identifying optimal candidates.

BackgroundSorafenib has been recommended as the first-line treatment and shown to prolong the median overall survival (OS) of patients with advanced unresectable hepatocellular carcinoma (HCC). Recently, a growing number of earlier studies showed the application of radiofrequency ablation (RFA) plus sorafenib in patients diagnosed at the advanced-stage HCC. This study aimed to compare the outcomes of RFA plus sorafenib versus sorafenib alone and identify prognostic factors related to OS for BCLC stage C patients with PS 1 but without vascular invasion or extrahepatic spread.MethodsA total of 276 consecutive patients in BCLC stage C with PS 1 but without vascular invasion or extrahepatic spread were enrolled in this retrospective study. Survival analyses were performed using the Kaplan-Meier analysis, and the log-rank test examined the statistical differences between the transarterial chemoembolization (TACE) and sorafenib groups. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.ResultsBased on the Kaplan-Meier curves, patients treated with RFA plus sorafenib showed better OS than those undergoing sorafenib, with respective OS at 1, 3 and 5 years (84.0%, 43.1%, 22.8% vs. 55.6%, 29.6%, 4.8%, Log-rank P<0.001). The univariate analysis and multivariate analysis showed that tumor size, tumor number, treatment method, albumin, bilirubin, and the Child-Pugh score were associated with OS. According to the subgroups analyses based on the tumor size and tumor number, there were significant differences in OS among overall subsets except in patients with tumor number ≥4 between RFA plus sorafenib and sorafenib therapy.ConclusionsRFA plus sorafenib provided better prognostic performance than sorafenib, which should be suggested as an alternative treatment modality compared with sorafenib for BCLC stage C patients with PS 1 but without vascular invasion or extrahepatic spread.

Identifying optimal candidates of transarterial chemoembolization (TACE) vs. sorafenib in patients with unresectable hepatocellular carcinoma.

BackgroundSorafenib has been recommended as the first-line treatment and shown to prolong median overall survival (OS) of patients with advanced unresectable hepatocellular carcinoma (HCC). Recently, a growing amount of research has supported the application of transarterial chemoembolization (TACE) in patients with advanced-stage HCC. The aim of this study was to compare the outcomes of TACE and sorafenib and identify the prognostic factors related to OS for Barcelona Clinic Liver Cancer (BCLC) stage C patients with PS 1 but without vascular invasion or extrahepatic spread.MethodsA total of 323 consecutive patients in BCLC stage C with PS 1 but without vascular invasion or extrahepatic spread were enrolled in this retrospective study. Survival analyses were performed using the Kaplan-Meier analysis, and the statistical differences between the TACE and sorafenib groups were examined by the log-rank test. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.ResultsBased on the Kaplan-Meier curves, patients treated with TACE showed a better OS than those undergoing sorafenib, with respective OS at 1, 3, and 5 years (67.7%, 41.5%, 23.2% vs. 55.6%, 29.6%, 4.8%; log-rank P=0.002). The univariate analysis indicated that tumor size, tumor number, and treatment method, along with platelet (PLT), white blood cell (WBC), and α-fetoprotein (AFP) count, were associated with OS. The multivariate analysis demonstrated that tumor size, tumor number, and treatment method were significant prognostic factors for OS. According to the subgroups analyses based on the tumor size and tumor number, there were significant differences in OS among overall subsets between TACE and sorafenib therapy.ConclusionsTACE provided better prognostic performance than sorafenib and should be suggested as an alternative treatment modality to sorafenib for BCLC stage C patients with PS 1 but without vascular invasion or extrahepatic spread.