Controversial Treatment Research Articles

Beware of Paid “Patient Influencers” Promoting Controversial Treatments in Medicine and the Media

Beware of Paid “Patient Influencers” Promoting Controversial Treatments in Medicine and the Media

How Contralateral Prophylactic Mastectomy Does the Body, or Why Epistemology Alone Cannot Explain this Controversial Breast Cancer Treatment.

Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the "epistemology problem" in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.

Indonesian health minister under fire for pushing his own controversial stroke treatment

Indonesian health minister under fire for pushing his own controversial stroke treatment

Updates on COVID-19

Authors discuss the use of dexamethasone, mathematical models in predicting COVID, hydroxychloroquine as a controversial treatment, immunity after contracting COVID, and association of COVID with neurological symptoms.

Controversial treatment using coloured overlays in visual processing disorders

Controversial treatment using coloured overlays in visual processing disorders

Alternating view in controversial treatment of osteoarthritis of knee (Restoknee vs TKR)

The osteoarthritis of knee is a wide spread condition worldwide and specially in country like India where the routine life is such where knee joint arthritis occurs at an early age. The widely used treatment option for knee arthritis is total knee replacement which have its own complication and once the complication like infection sets in we are left with nothing but to do arthrodesis or revision knee after controlling infection which cause a lot of problem for the patient as well as doctors. And moreover if total knee replacement done at an early age predisposes the patient to revision surgery as the life of the joint used is not more than life expectancy of the patient this puts a surgical toll over patient as well as financial load. Here we have compared our technique of treating osteoarthritis wherein we are preserving the natural joint and no implant are used in our technique which in itself reduced the major complications and even if by any chance complication occurs we are left with many options to give functional knee to the patient rather than going for arthrodesis which is not very well accepted by many patients. In this article we have compared pros and cons of our technique with total knee replacement.

Hepatopancreatoduodenectomy –a controversial treatment for bile duct and gallbladder cancer from a European perspective

BackgroundHepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. MethodMembers of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. ResultsIn total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. ConclusionHPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

Pelviureteric junction obstruction and crossing vessels: pro "vascular hitch"

The vascular hitch procedure for pelviureteric junction obstruction caused by crossing lower-pole vessels is a controversial treatment option. Since this minimally-invasive technique has been introduced in patients with aberrant lower-pole vessels, multiple publications have reported successful short, intermediate and long-term outcomes. Success rates of > 90 % are similar to those of Anderson-Hynes pyeloplasty. In general, an associated intrinsic stenosis seems to be rare. Histological evidence of muscular hypertrophy may simply indicate a compensatory mechanism and may be reversible to a certain degree. To differentiate between those patients who are eligible for a vascular hitch procedure and those who should receive an initial Anderson-Hynes pyeloplasty, an intraoperative diuretic test should be performed (volume bolus plus intravenous administration of furosemide). An associated intrinsic stenosis seems to be unlikely in a funnel-like and otherwise normal-looking pelviureteric junction, decreasing hydronephrosis after mobilisation of renal pelvis and crossing vessels and effective peristalsis of the renal pelvis after intraoperative diuretic testing. The vascular hitch technique is less demanding than laparoscopic Anderson-Hynes pyeloplasty and less time-consuming with regard to the duration of the surgical procedure and anaesthesia. Further advantages are: no risk of urinary leakage or anastomotic stricture and no need for intra-luminal stenting. Therefore, in a selected group of patients with solely extrinsic pelviureteric junction obstruction, the vascular hitch procedure is a valuable alternative to classic Anderson-Hynes pyeloplasty with seemingly long-term efficiency.

A Simple and Inexpensive Management for Peroneus Longus Dislocation

Introduction:Peroneal longus dislocation is an uncommon sports injury and commonly misdiagnosed. Imaging measure includes plain radiography, ultrasonography, and MRI examination. Treatment strategies include controversial nonoperative treatment with a significant failure rate and several surgical procedures were reported. We reporting a chronic peroneal longus dislocation case in our hospital.Material and methods:Twenty-two years old male presented with a painful snapping lateral ankle suffered 3-month prior surgery. He played futsal and suddenly he felt popped on his ankle followed by pain and swelling. Dynamic ultrasound examination shows dislocation of peroneal longus tendon and convex shape of the retromalleolar groove. A five-centimeter long incision is made posterior to the lateral malleolus and during exploration we confirmed the ultrasound findings. We perform retromalleolar groove deepening by making bone flap medially, curette the cancellous bone and tamper back the bone flap, followed by superior peroneal retinaculum (SPR) reconstruction to the medial aspect of lateral cortex of the lateral malleolus to provide smooth gliding surface. We immobilize the ankle with a cast for six weeks for soft tissue healing.Result:After six weeks he can perform the almost full range of motion of the ankle without pain. Followed by further physiotherapy to regain full range of motion of the ankle. He returns to sport six months after surgery. Ultrasound examination shows the stability of the peroneal longus tendon.Conclusion:Dynamic ultrasound examination and retromalleolar groove deepening with SPR reconstruction are simple and inexpensive management for peroneal longus dislocation

Mild Hyperventilation in Traumatic Brain Injury—Relation to Cerebral Energy Metabolism, Pressure Autoregulation, and Clinical Outcome

Hyperventilation is a controversial treatment in traumatic brain injury (TBI). Prophylactic severe hyperventilation (below 3.3 kPa/25 mm Hg) is generally avoided, due to the risk of cerebral ischemia. Mild hyperventilation (arterial pCO2 within 4.0-4.5 kPa/30-34 mm Hg) in cases of intracranial hypertension is commonly used, but its safety and benefits are not fully elucidated. The aim of this study was to evaluate the use of mild hyperventilation and its relation to cerebral energy metabolism, pressure autoregulation, and clinical outcome in TBI. This retrospective study was based on 120 patients with severe TBI treated at the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Data from cerebral microdialysis (glucose, pyruvate, and lactate), arterial pCO2, and pressure reactivity index were analyzed for the first 3 days post-injury. Mild hyperventilation, 4.0-4.5 kPa (30-34 mm Hg), was more frequently used early and the patients were gradually normoventilated. Low pCO2 was associated with slightly higher intracranial pressure and slightly lower cerebral perfusion pressure (P < 0.01). There was no univariate correlation between low pCO2 and worse cerebral energy metabolism. Multiple linear regression analysis showed that mild hyperventilation was associated with lower pressure reactivity index on day 2 (P= 0.03), suggesting better pressure autoregulation. Younger age and lower intracranial pressure were also associated with lower pressure reactivity index. These findings support the notion that mild hyperventilation is safe and may improve cerebrovascular reactivity.

Corrigendum: The Effect of Low-Dose Naltrexone on Medication in Inflammatory Bowel Disease: A Quasi Experimental Before-and-After Prescription Database Study.

Background and aims Low-dose naltrexone [LDN] is a controversial off-label treatment used by many Crohn's disease [CD] and ulcerative colitis [UC] patients. A small number of preliminary studies indicate that LDN might be beneficial in CD, but evidence is too scarce to demonstrate efficacy. We sought to examine whether initiation of LDN therapy by patients with inflammatory bowel disease [IBD] was followed by changes in dispensing of relevant medication. Methods We performed a quasi-experimental before-and-after study following a sudden increase in LDN use in the Norwegian population in 2013. IBD patients were identified from among all the patients who had at least one LDN prescription recorded in the Norwegian Prescription Database [NorPD] in 2013. Drug dispensing 2 years before and after the first LDN prescription was compared. Results We identified 582 IBD patients who had received LDN. Of the 256 patients who became persistent LDN users, there were reductions in the number of users for [i] all examined drugs [-12%], [ii] intestinal anti-inflammatory agents [-17%], [iii] other immunosuppressants [-29%], [iv] intestinal corticosteroids [-32%] and [v] aminosalicylates [-17%]. In subgroups of identified CD and UC patients, there were significant reductions in the number of users of intestinal corticosteroids [CD: -44%, UC: -53%] and systemic corticosteroids [UC: -24%]. No significant differences in cumulative defined daily doses were observed. Conclusions Our findings imply that the initiation of LDN in IBD is followed by reduced dispensing of several drugs considered essential in the treatment of CD and UC.

Non-functional paraganglioma of urinary bladder managed by transurethral resection.

ABSTRACTPurpose As a rare bladder tumor, paraganglioma of the urinary bladder (PUB) is frequently misdiagnosed as bladder cancer, particularly for the non-functional type. To date, transurethral resection remains a controversial treatment for non-functional PUB. This study aimed to identify the clinical features, pathological characteristics, prognosis, and safe/effective treatment of non-functional PUB using transurethral resection of the bladder tumor (TURBT).Materials and Methods The clinical records, radiological data, pathological characteristics and follow-up times were retrospectively reviewed in 10 patients with clinically and pathologically proven non-functional PUB in our hospital from January 2008 to November 2016. All patients underwent TURBT treatment.Results The incidence of non-functional PUB in patients with bladder cancer was 0.17%. The mean age at diagnosis was 44.5 ± 13.6 years (range, 29-70 years), and the patient population had a female: male ratio of 3: 2. No patients had excess catecholamine (CA) whilst four patients had painless hematuria. All neoplasms were completely resected via TURBT. The majority of samples were positive for immunohistochemical markers including chromogranin A (CgA) and Synaptophysin (Syn), but were negative for cytokeratins (CKs). Only a single recurrence was observed from the mean follow-up period of 36.4 ± 24.8 months.Conclusion Complete TURBT is a safe and efficient treatment that serves both diagnostic and therapeutic purposes. Histopathological and immunohistochemistry examinations are mandatory for diagnostic confirmation. Long-term follow-up is recommended for patients with non-functional PUB.

Mandibular condyle fractures: A diagnosis with controversial treatment.

Over the years, the treatment to be chosen for the resolution of condylar fractures has been discussed with great concern. Treatment depends on the type and location of the fracture, as well as other associated factors such as facial injuries and concurrent diseases. The aim of the study was to make a review of the different criteria to establish a diagnosis and treatment to resolve mandibular condyle fractures, according to the evolution of the years and what this entails. Management of condylar fractures remains controversial among surgeons. However, as time goes by and as comparative and analytical studies are carried out within the issue, parameters and criteria are established to facilitate the decisions taken regarding the management and treatment of condylar fractures. Condylar fractures must be managed according to the clinical and case presentation.

Intra-articular Hyaluronan Therapy for Symptomatic Knee Osteoarthritis

Intra-articular hyaluronan therapy (IAHA) is a common but controversial nonsurgical treatment of symptomatic knee osteoarthritis. The overall treatment effect of IAHA for osteoarthritis pain is substantial, but the majority of this benefit is mediated by the placebo effect. Despite the large overall benefit of IAHA when the effect of the hyaluronan is combined with the placebo effect, there is only a small benefit of questionable clinical significance of IAHA compared with intra-articular placebo. Compared with intra-articular corticosteroids, however, IAHA most likely is comparable for long-term pain relief and possibly slightly inferior for short-term pain relief.

Update: Twins who were face of controversial rare disease treatment have died

Update: Twins who were face of controversial rare disease treatment have died

Spread through air spaces (STAS) is a predictor of poor outcome in atypical carcinoids of the lung.

Spread through air spaces (STAS) have been recently recognized as a prognostic factor for adenocarcinoma and squamous cell carcinoma of the lung. Pulmonary neuroendocrine neoplasms (NENs) include tumors with different morphology and a heterogeneous clinical behavior. Among atypical carcinoids (ACs), new prognostic factors able to refine prognosis are needed. In the present study, a retrospective series of 91 surgically resected ACs was investigated, in parallel with 191 control cases of typical carcinoids (TCs) and of high-grade small- and large-cell neuroendocrine carcinomas, to assess the presence and potential prognostic role of STAS. STAS was defined by the presence of neoplastic nests or single cells in air spaces beyond the tumor edge. Clinicopathological parameters and survival were correlated by univariate and multivariate analyses. STAS was identified in 48% of ACs (44/91) compared to 20.5% of TCs and 71-88% of high-grade large- and small-cell carcinomas in the control group. In the carcinoid group, presence of STAS was significantly correlated with unfavorable parameters, such as high tumor stage, positive nodal status, high Ki-67 index, presence of angioinvasion, and with adverse disease outcome, shorter overall survival, and time to progression. In conclusion, the presence of STAS is an additional relevant adverse prognostic factor in pulmonary AC that currently has the most unpredictable outcome and the most controversial treatment strategy.

A Bioengineered In Vitro Osteoarthritis Model with Tunable Inflammatory Environments Indicates Context-Dependent Therapeutic Potential of Human Mesenchymal Stem Cells

Recently, intra-articular injections of mesenchymal stem cells (MSCs) have been used as a treatment for early osteoarthritis (OA) due to the known immunomodulatory effects of these cells. However, MSC therapy has shown variable clinical outcomes. This variability in efficacy likely reflects the interplay of a range of factors, which influence MSC immunoregulatory capacity. In particular, joint inflammatory state may impact MSC treatment efficacy due to the known dependence of the anti-inflammatory MSC phenotype on the levels of pro-inflammatory cytokines in the surrounding environment. To gain insight into the potential role of joint inflammatory state on MSC immunomodulatory effects, we first expanded a previously validated 3D in vitro model of OA to allow for tunable inflammatory conditions. We then utilized our expanded in vitro OA model to assess the therapeutic potential of MSCs in “high” (high-OA) versus “low” (low-OA) inflammatory contexts. The addition of MSCs to high-OA conditions stimulated significantly lower production of IL-1β, IFN-γ, MMP-9, and MMP-13 by osteoarthritic chondrocytes (OACs) and reduced macrophage activation. In contrast, the addition of MSCs to low-OA conditions increased OAC expression of OA-related markers IL-6 and IL-8 and induced a wound healing-like phenotype in macrophages. In addition to these results, we also assessed if MSCs primed with pro-inflammatory factors IFN-γ and TNF-α could improve MSC treatment efficacy in low-OA conditions. No improvements in MSC anti-inflammatory effects were observed for low-OA after priming. These findings suggest a key role for the inflammatory environment and MSC “activation” state in determining MSC immunomodulatory effects. If further validated, this knowledge could potentially be used to tailor the phenotype of injected MSCs to improve clinical outcomes. The inflammatory environment surrounding joint tissues is believed to underlie OA pathogenesis and may therefore hold a key to treatment. This work developed a system with control of inflammatory levels to assess OA therapies outside of living organisms. We then used this system to help study the therapeutic potential of mesenchymal stem cells (MSCs), an emergent yet controversial OA treatment. Our results suggest that MSC efficacy is context-dependent and sheds light on some of the specifics of these contexts. If further validated, this knowledge could potentially be used to screen patients and/or tailor the injected MSCs, improving clinical outcomes. Future work will be focused on the further development and validation of this model system towards its use as a discovery/development tool for OA therapies.

Towards reaching consensus on hyaluronic acid efficacy in knee osteoarthritis.

Intra-articular injection of hyaluronic acid (HA) is a controversial treatment for knee osteoarthritis (OA). While clinical efficacy of HA relative to saline injections has been demonstrated in many studies, these results are of limited value in real-world clinical practice since saline injection is not a knee OA treatment. Instead, rigorous postmarket comparative studies of HA versus approved knee OA treatments are encouraged. The conduct of such studies is particularly important given the paucity and heterogeneous nature of current evidence regarding nonsurgical knee OA treatment. KEY POINTS: • Societal guidelines recommend nonsteroidal anti-inflammatory drugs and corticosteroid injections, but not hyaluronic acid injections, for knee osteoarthritis (OA) despite inconsistent supportive data. • This article encourages rigorous comparative post-approval studies to clarify the role of nonsurgical treatments used in clinical practice for knee OA.

Development and Validation of the Achieving Effective & Safe Opioid Prescribing–Advanced Practice Registered Nurse (AESOP-APRN) Survey: A Pilot Study

BackgroundAdvanced practice registered nurses (APRNs) are essential partners in the management of pain, both in primary care and in pain specialty practices. One of the more controversial treatment practices surrounds the use of opioid analgesic medication for the relief of pain in persons with chronic pain. Although several guidelines have been developed, the extent and impact of APRN knowledge, attitudes, and values about pain management and opioid prescribing practices are not known. In addition, regulatory mandates may encumber APRN scope of pain management practice. AimsThis manuscript describes the development and pilot testing of the Achieving Effective & Safe Opioid Prescribing–APRN (AESOP-APRN) Survey conceptualized to address these topics. DesignInstrument development. Participants/SubjectsAdvanced practice registered nurses. MethodsPhase I addressed development, content validity determination, and survey refinement. APRN-focused discussion groups, expert review, and analysis of content were conducted. In phase II, pilot testing was conducted to determine reliability. ResultsAPRNs are aware of regulatory restrictions to practice and potential implications on patient outcomes. The Initial Content Validity Index suggested refinement of survey questions. After content revision, final ratings were acceptable. A sample of APRNs (N = 23) completed the survey. Cronbach's α range (.65-.91) suggests acceptable internal consistency for a new survey. ConclusionsEven at this initial phase, the newly developed AESOP-APRN Survey accurately represents the underlying thematic concepts of interest; however further psychometric analyses are required, and instrument refinement is possible. Additional study should include analysis of members from a variety of health care disciplines, as was the intention of the development of the Core Competencies for Pain Management from which many items were derived.

Understanding and management of gestational trophoblastic disease.

Gestational trophoblastic disease or neoplasia covers a spectrum of benign and malignant conditions arising from pregnancies with highly abnormal development of trophoblastic tissue. In this brief review, we discuss the different features of these different conditions and their origins and risk factors and introduce some of the more novel and controversial treatment options currently being explored.