Conventional Protocol Group Research Articles

Efficacy of an eye drop mixture for pupillary dilatation: A randomized comparative study

PurposePupillary dilatation with three types of eye drops is used regularly in the clinic; however, a mixture of these drops in a single bottle may be more beneficial in reducing workloads and resources. This study compared the efficacy in pupillary dilatation between two protocols of dilating drop instillation. MethodsThis prospective, randomized, comparative study included 30 eligible Thai patients. The patients randomly received preoperative pupillary dilatations by either the conventional protocol (1% tropicamide (T), 10% phenylephrine (P) and 0.1% diclofenac (D) in three separate bottles) or the fixed combination (TPD) protocol which had the three types of eye drops mixed in a single bottle in a ratio of 4:3:3. The chi-square test and independent t-test were used to analyze the data. ResultsThe conventional protocol group and TPD protocol group each had 15 patients. Sixty minutes after the initial instillation, all patients in the TPD protocol and 13 patients (86.7%) in conventional protocol achieved at least 6mm in the shortest diameter. The mydriatic rate between protocols showed no difference. In patients who received the TPD protocol, the systemic effects on the mean arterial blood pressure and pulse rate decreased over time. ConclusionThe mixture of tropicamide, phenylephrine and diclofenac had a comparable efficacy for a pupillary dilatation to the conventional dilating drops in separate bottles. The systemic complications on blood pressure and arterial pulse of the TPD mixture were less than the conventional protocol. Trial registrationTCTR20130325001.

A modified ultra-long pituitary downregulation protocol improved endometrial receptivity and clinical outcome for infertile patients with polycystic ovarian syndrome.

There are currently various protocols for in vitro fertilization (IVF). For patients with polycystic ovarian syndrome (PCOS), an optimized protocol for the downregulation of pituitary follicle stimulating hormone and luteinizing hormone via gonadotropin-releasing hormone agonist (GnRHa) remains a challenge. In the present study, the primary endpoint of an ultra-long and a conventional long GnRHa protocol for intracytoplasmic sperm injection/IVF treatments of patients with PCOS was retrospectively compared. In the modified ultra-long protocol group, endometrial thickness, morphology, and blood flow were significantly improved, as compared with in the conventional long protocol group. Furthermore, the serum progestogen (P) concentrations and P/estrogen (E2) [(Px1,000/E2)] ratio on the day of human chorionic gonadotrophin administration were significantly decreased in the modified ultra-long downregulation group, whereas the pregnancy and implantation rates were significantly higher. There were no significant differences in the average number of obtained oocytes, good quality embryo rates, cancel rates, fertilization rates, abortion rates, serious ovarian hyperstimulation syndrome incidences, ectopic pregnancy rates or gonadotropin (Gn) dosages between the two groups. These results suggest that the modified ultra-long protocol plus human menopausal Gn medication may be superior to the conventional long protocol, and may lead to improved implantation and pregnancy outcomes for infertile patients with PCOS.

Clomiphene based ovarian stimulation in a commercial donor program.

OBJECTIVE:This study was conducted to compare an extended clomiphene-based ovarian stimulation regimen with the conventional antagonist protocol in donor-recipient cycles.MATERIALS AND METHODS:A total of 170 (N) donors were stimulated between January 2013 and December 2013. Conventional antagonist protocol (group I) was employed in (n1 = 31) cycles, and clomiphene was used in (n2 = 139) donor cycles (group II). 50 mg clomiphene was given simultaneously with gonadotropins from day 2 of the cycle until the day of trigger. The analysis was performed retrospectively for oocytes retrieved, fertilization rates, cycle cancelation, blastocyst formation, and pregnancy rates. The dosages, cost, and terminal E2 (estradiol) were also compared between the two groups.RESULTS:The donor age groups were comparable in both the groups. There were no unsuccessful egg retrievals with clomiphene. The pregnancy rate (positive beta human chorionic gonadotropin) was significantly higher in the clomiphene group (odds ratio: 2.453; P = 0.02). Similarly, fertilization rate was significantly higher in the clomiphene group (59.5/50.5, P = 0.04). Eggs retrieved were similar in both groups, but the terminal E2 was significantly higher in the clomiphene group (P = 0.001). Average gonadotropin used was also significantly lower in clomiphene group (P < 0.001).CONCLUSION:Clomiphene can effectively prevent luteinizing hormone surge and limit the dose of gonadotropins thus bringing down the costs and its negative impact on the endometrium and oocyte quality.

Accelerated dobutamine stress testing: Feasibility and safety in patients with moderate aortic stenosis

Abstract Objective A continuous infusion of a single high dose of dobutamine was suggested as a simple protocol of dobutamine stress echocardiography (DSE). The present study explores the feasibility and safety of an accelerated DSE protocol in patients with calcific moderate valvular aortic stenosis undergoing DSE for evaluation of suspected coronary artery disease. Methods Eligible patients (n = 100) were prospectively enrolled. They were randomly assigned to undergo either the accelerated (group A, 50 patients) or the conventional protocol (group B, 50 patients). Group A received a continuous infusion of 40 μg/kg/min ± 1–2 mg atropine. Patients were monitored for adverse drug effects. Test duration was recorded. Patients with positive stress results underwent coronary angiography (CA). Results Mean age of the study cohort was 62.29 ± 9.8 years, 62 (62%) being males. Mean pressure gradient across the aortic valve was recorded (group A: 32.2 mmHg and group B: 31.16 mmHg, P Conclusion In patients with calcific moderate aortic stenosis undergoing DSE; adopting the described accelerated protocol is associated with shorter test duration, lower weight-adjusted cumulative dobutamine dose for target heart rate achievement and fewer adverse effects, while maintaining a comparable diagnostic value.

Postoperative emesis after laparoscopic pyloromyotomy in infantile hypertrophic pyloric stenosis

This study aimed to determine the causes of postoperative emesis (PE) in neonates with infantile hypertrophic pyloric stenosis (IHPS) after laparoscopic pyloromyotomy (LP). Retrospective review of the hospital database for infants with IHPS managed between 2000 and 2010 was performed. Relevant data were collected from the clinical records in the Medocs(®) system and used for statistical analysis. During the 10-year period, 95 patients with IHPS were identified and 43 (36 boys and seven girls) fulfilled the inclusion criteria. PE occurred in 21 infants (48.8%), of which nine presented with manifestations of enteric infections, with confirmed diagnosis in four. PE was significantly higher in the fast track feeding protocol (FTFP) group 12/15 compared with the conventional slow feeding protocol (CSFP) group 8/21 (p = 0.019). Gastro-oesophageal reflux (GER) confirmed by 24-h impedance monitoring was responsible for PE in three. Operative revision for suspected incomplete pyloromyotomy was performed in five infants. However, incomplete myotomy could only be confirmed in two infants during surgery. Postoperative emesis in IHPS after LP requires careful evaluation as it can be a result of enteric viral infections, aggressive feeding protocols or GER. Decisions to perform reoperations for incomplete myotomy after LP due to PE are challenging.

A simple tissue-handling technique performed in the endoscopy suite improves histologic section quality and diagnostic accuracy for serrated polyps

Surveillance intervals after colonoscopic resection of serrated polyps are partially predicated on the histology of the polyp(s) removed during the index exam. Histologic discrimination between sessile serrated adenomas/polyps (SSA/P) and hyperplastic polyps is challenging. We devised and tested a simple tool--an envelope--that gastroenterologists can integrate into routine colonoscopy practice to address this problem. In the "modified protocol," immediately after polypectomy each serrated polyp was flattened and enclosed in a paper envelope before being placed in formalin. In the pathology laboratory, each polyp was sectioned after processing. A two-site, prospective, randomized, single-blinded trial was performed to compare this modified protocol with the conventional protocol. Serrated polyps located proximal to the splenic flexure and 5-20 mm in diameter were included. A novel orientation score that measured the number of well-oriented crypts per unit area of polyp (higher orientation score = better orientation) was validated. Orientation score, SSA/P diagnosis rate, and inter-pathologist agreement were measured. A total of 375 polyps were enrolled, of which 264 were identified for analysis. The mean orientation scores in the modified and conventional protocol groups were 3.11 and 1.13, respectively (P < 0.0001). SSA/Ps were diagnosed in 103/135 cases (76.3%) in the modified protocol group vs. 54/129 (41.9%) in the conventional protocol group (P < 0.0001). Inter-pathologist agreement was higher with the modified than the conventional protocol (77.0% vs. 62.8%; P = 0.015). Standard polyp handling techniques may be sub-optimal for interpretation of serrated polyps resected at colonoscopy, and may lead to inadvertent histologic "under-grading" of many lesions. Our intervention improved histopathologic interpretation and increased the SSA/P diagnosis rate.

A Modified Surgical Schedule for Primary Management of Cleft Lip and Palate in Developing Countries

In developing countries cleft lip and palate (CLP) patients arrive late, and there is a risk of drop out for functionally important palatoplasty after lip repair. Patients may be underweight, anemic, and prone to recurrent infections. To repair cleft palate at an appropriate time and secondly to avoid the drop out after the first surgery. A new surgical protocol has been designed for patients with CLP in whom the cleft palate is first repaired at 6 to 9 months of age or whenever the patient presents at the clinic. The cleft lip is repaired 3 to 6 months after the first surgery. When cleft lip repair was performed before palate repair (conventional protocol group) in 89 patients with CLP, the median interval between first and second surgery was 290 days. However, when the modified protocol was followed in 330 patients over 13 years, the median interval was 193 days (p < .0002). The reduction in the interval is statistically significant. In eight patients cleft palate fistula encountered after palatoplasty was repaired during cleft lip repair thus avoiding a third surgery. The compliance for two surgeries in CLP has improved. Apart from achieving the main aim of the new protocol, a number of advantages were noticed. The palate repair was easier in the presence of an unrepaired cleft lip. The anterior palate repair was more dependable with reduced incidence of anterior palatal or alveolar fistula.

Can MR fluoroscopic triggering technique and slow rate injection provide appropriate arterial phase images with reducing artifacts on gadoxetic acid‐DTPA (Gd‐EOB‐DTPA)‐enhanced hepatic MR imaging?

To evaluate whether using MR fluoroscopic triggering technique and slow rate injection improves the quality of arterial phase images in gadoxetic acid-DTPA-enhanced (Gd-EOB-DTPA) MR imaging because of proper acquisition timing and reduction of artifacts. Two hundred sixteen patients undergoing examination for liver diseases were retrospectively reviewed. All MR images were obtained with two Gd-EOB-DTPA injection protocols: (i) a combination protocol, in which the MR fluoroscopic triggering technique and slow rate injection (1 mL/s) were used; and for comparison, (ii) a conventional protocol, in which adjusted fixed scan delay and ordinary rate injection (2 mL/s) were adopted. Signal-to-noise ratio (SNR) of aorta, portal vein, and liver parenchyma on arterial phase images were calculated. Two blinded readers independently evaluated the obtained arterial phase images in terms of acquisition timing and degree of artifacts. The SNRs of aorta and portal vein on arterial phase images were significantly higher in the combination protocol group (aorta/portal: 221.9 +/- 91.9/197.1 +/- 89.8) than that in the conventional protocol group (aorta/portal: 169.8 +/- 97.4/92.7 +/- 48.5) (P < 0.05). The acquisition timing for arterial phase images with the combination protocol was significantly better than that with the conventional protocol (P < 0.01). The image quality of the combination protocol was significantly higher than that of the conventional protocol (P < 0.01). The occurrence rate of moderate or severe degree of artifacts in the conventional protocol (38.0%) was more prominent than that in the combination protocol (18.5%). The combination of the MR fluoroscopic triggering technique and slow rate injection provides proper arterial phase images and reduces the artifacts in Gd-EOB-DTPA MR imaging.

Análise morfológica do arco superior de portadores de fissura labiopalatal submetidos a diferentes protocolos de expansão rápida maxilar: avaliação das alterações maxilares

INTRODUÇÃO: em portadores de malformações labiopalatais, a boa conformação do arco superior constitui um dos principais requisitos para a obtenção de uma oclusão adequada e para o aperfeiçoamento estético e funcional. Para tanto, a expansão ortopédica da maxila é frequentemente necessária, uma vez que é alta a incidência de colapso dos segmentos. OBJETIVOS: analisar, por meio de modelos de gesso, as dimensões do arco superior de 15 portadores de fissura transforame incisivo unilateral, com deficiências transversal e anteroposterior da maxila, submetidos à expansão com dois diferentes protocolos de ativação. MÉTODOS: um grupo foi submetido à Expansão Rápida da Maxila (ERM) com protocolo de ativação convencional (Grupo 1), enquanto no outro grupo foi utilizado o protocolo de ativação preconizado por Liou e Tsai em 2005, com expansões e contrações alternadas (Grupo 2), sendo ambos submetidos posteriormente à protração maxilar com máscara de tração reversa. Os modelos foram obtidos em dois momentos: antes da cimentação do disjuntor do tipo Haas modificado (T1) e após 24 semanas de tratamento (T2). As distâncias transversais entre os primeiros pré-molares superiores (região anterior) e a distância entre os primeiros molares superiores (região posterior) foram registradas com um paquímetro digital. Os dados obtidos foram submetidos ao teste t de Student. RESULTADOS E CONCLUSÕES: os dois protocolos de ativação mostraram-se igualmente efetivos na expansão maxilar, não havendo diferença entre os grupos em relação ao aumento transversal obtido.

Two-dose steroid combined with two-dose daclizumab and tacrolimus regimen in liver transplant recipients

To investigate the efficiency and safety of two-dose steroid combined with two-dose daclizumab and tacrolimus (FK506) regimen in liver transplant recipients. There were 74 patients who treated in the First Affiliated Hospital of Sun Yat-Sen University from September 2006 to March 2008. Expect for 7 patients who didn't measure up, 67 adult liver transplant recipients were randomized into two groups: conventional protocol group (n = 35) in which steroid was withdrawn in 3 months after operation, and two-dose steroid group (n = 32). Comparison of rejection, infection (bacteria, fungal and cytomegalovirus) and metabolic complications rates were studied between two groups. There were significant differences between two groups in the rate of early postoperation hyperglycemia, the average dosage of insulin consumption among hyperglycemia recipients as well as the rate of diabetes mellitus, hypertension and infection during the follow-up period (P < 0.05). The rate of hypertension in early postoperation period, hyperlipemia and rejection rate during the follow-up period were similar in two groups (P > 0.05). Two-dose steroid combined with two-dose daclizumab and tacrolimus would be a safe and efficient immunosuppression strategy without increase the acute rejection rate hazard, that could reduce post-transplant infection and other complications from side-effect of long-term usage of steroid.

The optimization of 64-MDCT brain and neck angiography

Sixty patients who underwent brain and neck CT angiograpby (CTA) were randomly divided into two groups: conventional protocol group and optimizing protocol group with 30 in each. The images were evaluated by two radiologists independently. The images of optimizing group avoided the artifact disturbance of the brachiocephalic vein effectively and greatly improved the imaging quality of arteria carotis communis and arteria vertebralis initial segment. Compared with the conventional group the differences were statistically significuat(P <0.05). The optimization of 64-MDCT brain and neck CTA is feasible and effective. Key words: Tomography,spiral computed; Angiography

Modified vancomycin dosing protocol for treatment of diabetic foot infections

The clinical efficacy of a modified vancomycin dosing protocol with a conventional regimen for managing patients with diabetic foot infections caused by methicillin-resistant Staphylococcus aureus (MRSA) was evaluated. This prospective study was conducted from January 2002 to December 2004 at the diabetic ward of Chang Gung Memorial Hospital--Linkou in Taiwan. All diabetic patients with MRSA-related diabetic foot infections confirmed by wound cultures were enrolled in this study. Patients treated with the conventional protocol (from 2002 to 2003) received vancomycin 10-15 mg/kg (up to 1 g) over 60 minutes every 12 hours if their serum creatinine (SCr) concentration was 0.4-1.4 mg/dL according to the estimation of creatinine clearance (CL(cr)). Patients treated with the modified vancomycin dosing protocol (from 2003 to 2004) received vancomycin according to their SCr level, age, and concurrent gentamicin dosage. Data analyzed included patients' age, sex, body weight, SCr level, CL(cr), serum vancomycin peak and trough levels, vancomycin dosage, treatment period, and duration of hospital stay. A total of 85 patients were enrolled in this study. The conventional protocol group achieved substantially higher serum vancomycin levels than those recommended by the British National Formulary (BNF). Although the vancomycin dosage in the modified protocol was lower than that in the conventional protocol, trough and peak vancomycin levels remained within the range recommended by the BNF. The duration of hospitalization and treatment did not significantly differ between the two groups. A modified vancomycin dosing protocol for treating diabetic foot infections caused by MRSA was superior to the conventional dosing regimen in achieving therapeutic serum levels of vancomycin.

Management of Kell isoimmunization — evaluation of a Doppler‐guided approach

To assess the role of peak systolic velocity in the middle cerebral artery (MCA-PSV) in the management of pregnancies complicated by Kell isoimmunization. Sixteen fetuses were monitored by conventional protocol (Group 1) and eight fetuses by an MCA-PSV-guided protocol (Group 2). The conventional protocol included a weekly ultrasound evaluation and measurement of maternal anti-Kell titers every 4-6 weeks. In Group 2 Doppler assessment of the MCA-PSV was performed at intervals of 4 to 7 days and MCA-PSV>1.5 multiples of the median (MoM) was considered as an indication for fetal blood sampling (FBS). No parameter emerged as a reliable predictor of isoimmunization severity in Group 1. In Group 2, no FBS was necessary in one case since the MCA-PSV values obtained during the follow-up were <1.29 MoM. In two cases the first FBS was already indicated after 1 week of follow-up, but five other fetuses were followed for 3-9 weeks before FBS was indicated. All fetuses with MCA-PSV>1.5 MoM prior to intrauterine transfusion (IUT) had severe fetal anemia on FBS. In fetuses with severe anemia on the first FBS, the MCA-PSV values 7 days before the first FBS were <1.29 MoM (four cases), between 1.29 and 1.5 MoM (two cases) and >1.55 MoM (one case). In the management of Kell isoimmunization invasive procedures may be avoided by implementing MCA-PSV measurements. Delineation of appropriate intervals between reassessments, the reliability of MCA-PSV following repeated IUTs, and cut-off values for FBS await further study.

Opioid detoxification using high doses of buprenorphine in 24 hours: A randomized, double blind, controlled clinical trial

In recent years, interest in shortening of opioid detoxification has increased with the rising demands to find more cost-effective approaches for treatment of opioid dependence. This study was designed to evaluate the efficacy of administration of high doses of buprenorphine during 24 h in the management of acute opioid withdrawal. A total of 40 treatment-seeking opioid dependents were admitted and randomly assigned to two groups in a double blind, parallel trial. Buprenorphine was administered intramuscularly. Twenty patients received 12 mg buprenorphine in 24 h and the remaining 20 patients treated with conventional doses of buprenorphine tapered down over 5 days. Variables that were assessed included retention in treatment, rates of successful detoxification, the Subjective Opiate Withdrawal Scale (OOWS) scores, the Objective Opiate Withdrawal Scale (SOWS) scores, intensity of craving, drug side effects, and levels of hepatic enzymes (ALT and AST). There was no significant difference between the two groups on most variables. The main difference was in the time that maximal withdrawal symptoms occurred, which in the experimental protocol group appeared early while in the conventional protocol group appeared later during the detoxification period. Moreover, the experimental protocol was not only tolerated well but also accompanied with significantly less elevation in the ALT levels compared to the conventional treatment. However, patients in this group used more indomethacin and trazodone for symptom palliation. This study suggests that administration of high doses of buprenorphine in 24 h may be a reasonable approach for shortening of opioid detoxification. However, a larger study to confirm our results is warranted.