First-line Therapeutic Modality Research Articles

Remediating rigid rule-following in subclinical obsessive-compulsive disorder using a brief mindfulness task: A case-control pilot study

A pioneering experiment by Hayes et al. (1986a, b) demonstrated the influence of instructional control and rule-governed behaviour on sensitivity to alternating reinforcement schedules. Hassoulas et al. (2017) replicated the same experimental design in a sample of participants exhibiting obsessive-compulsive behavioural (OCB) traits, supporting the results reported by the original study but also providing further insights into the maintenance of rigid rule following in OCB. The current pilot study replicated the same experimental design and procedure once again, however in considering whether a brief mindfulness-based intervention would facilitate contact with schedule contingencies in a group of participants exhibiting OCB traits. A total of 78 participants were recruited, 38 of whom exhibited OCB traits as measured using the Maudsley Obsessive-Compulsive Inventory (MOCI). The results revealed a significant difference in sensitivity to changing schedules between the group of participants exhibiting OCB traits and those with few such traits (n = 40), dependent on the degree of instructional accuracy they were provided with. The findings of the current study provide insights into the proposed concomitant administration of mindfulness-based interventions, alongside traditional first-line therapeutic modalities currently administered in the management of obsessive-compulsive disorder.

Prosthetic Replacement of the Ocular Surface Ecosystem for Terrien Marginal Degeneration: A Case Series.

To assess outcomes of the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with advanced Terrien marginal degeneration (TMD). This is a retrospective case series of patients with advanced TMD who were assessed and fit with customized PROSE lenses. Data were collected on PROSE fitting details including visual acuity (VA) before and after PROSE, slit-lamp findings, and corneal tomography scans. Six eyes in four patients were included. All patients attempted at least one other contact lens (CL) modality before PROSE. Some patients had corneal comorbidities such as pseudopterygium and pseudobleb that contributed to intolerance to previous lenses and warranted extra considerations in the fitting process. With PROSE, VA improved in all six eyes. Patients with structural corneal comorbidities achieved improved vision, comfort, and lens tolerance with PROSE. Two eyes had noncorneal ocular comorbidities that limited PROSE efficacy. Another eye discontinued PROSE wear because of limbal stem-cell disease progression necessitating a limbal stem-cell transplant. PROSE treatment can be an effective option to improve vision and comfort for patients with advanced TMD who are intolerant to first-line therapeutic CL modalities, even in the presence of other corneal comorbidities.

Systemic Therapy for Hepatocellular Carcinoma: Current Updates and Outlook.

Hepatocellular carcinoma (HCC) has emerged the culprit of cancer-related mortality worldwide with its dismal prognosis climbing. In recent years, ground-breaking progress has been made in systemic therapy for HCC. Targeted therapy based on specific signaling molecules, including sorafenib, lenvatinib, regorafenib, cabozantinib, and ramucirumab, has been widely used for advanced HCC (aHCC). Immunotherapies such as pembrolizumab and nivolumab greatly improve the survival of aHCC patients. More recently, synergistic combination therapy has boosted first-line (atezolizumab in combination with bevacizumab) and second-line (ipilimumab in combination with nivolumab) therapeutic modalities for aHCC. This review aims to summarize recent updates of systemic therapy relying on the biological mechanisms of HCC, particularly highlighting the approved agents for aHCC. Adjuvant and neoadjuvant therapy, as well as a combination with locoregional therapies (LRTs), are also discussed. Additionally, we describe the promising effect of traditional Chinese medicine (TCM) as systemic therapy on HCC. In this setting, the challenges and future directions of systemic therapy for HCC are also explored.

A123 MINIMALLY INVASIVE ENDOSCOPIC RESECTION TECHNIQUE PERFORMANCE FOR PERI-APPENDICEAL COLORECTAL NEOPLASIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

BackgroundMinimally invasive endoscopic resection techniques, including endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) have revolutionized the management of peri-appendiceal colorectal neoplasia. However, questions remain about their comparative performance.AimsWe sought to evaluate the performance of EMR, ESD and EFTR for peri-appendiceal colorectal neoplasia.MethodsTwo authors independently searched MEDLINE, EMBASE and Cochrane Libraries (Jan 2000 – Aug 2021) for citations evaluating the performance of endoscopic resection techniques (EMR, ESD, EFTR) for peri-appendiceal colorectal neoplasia (defined as those involving or in close proximity to the appendiceal orifice). The incidence rates and 95% confidence intervals (95% CI) of technical success (complete removal of all neoplastic tissue at index procedure), clinically significant post-endoscopic resection bleeding (CSPEB), delayed perforation, recurrence and referral to surgery were assessed using random-effects modelling.Results12 studies were included in the analysis (479 patients: 185 EMR, 171 ESD, 123 EFTR). Technical success was achieved in 93.5% (95% CI 90.9%-95.4%, EMR 93.5%, ESD 94.1%, EFTR 92.7%). Clinically significant post-endoscopic resection bleeding occurred in 1.3% (95% CI 0.4%-4.3%, EMR 3.8%, ESD 1.2%, EFTR 0%). Delayed perforation occurred in 1.9% (95% CI 0.9%-3.9%, EMR 0%, ESD 2.4%, EFTR 2.4%). Recurrence occurred in 5.7% (95% CI 2.3%-13.8%, EMR 14.3%, ESD 0.2%, EFTR 12.2–14.3%). Referral to surgery occurred in 9.0% (95% CI 6.7%-12.0%, EMR 8.1%, ESD 9.5%, EFTR 9.8%).ConclusionsMinimally invasive endoscopic resection techniques including EMR, ESD and EFTR demonstrate high frequencies of technical success with comparable adverse event profiles. They should now be viewed as first-line therapeutic modalities for the management of peri-appendiceal colorectal neoplasia.Funding AgenciesNone

Reduction of the Vertebral Bone Mineral Density in Patients with Hodgkin Lymphoma Correlates with Their Age and the Treatment Regimen They Received.

Simple SummaryHodgkin lymphoma (HL) is considered a largely curable disease (~80%). The young patient age at diagnosis and their long life expectancy make quality-of-life issues, including osteopenia, exceedingly important. This study aimed to assess treatment-related bone mineral density (BMD) changes that are overlooked in this young population. BMD was measured using PET/CT scans. Among 213 patients (median age 29 years), post-treatment BMD reduction of >15% was significantly more common in those aged ≥30 years and was also associated with a cumulative dose of steroids used. At 6 months post-therapy, BMD recovery was observed in ABVD (adriamycin/bleomycin/vinblastine/dacarbazine) treated patients, while individuals receiving EB (bleomycin/etoposide/adriamycin/cyclophosphamide/oncovin/procarbazine/prednisone) regimens demonstrated persistent BMD loss and higher rates of osteopenia. Our findings suggest that steroid use should be minimized and highly gonadotoxic drugs like procarbazine should be substituted with less toxic ones, due to their deleterious effect on BMD. Adequate vitamin D levels should be maintained.Nowadays, Hodgkin lymphoma (HL) has become highly curable. The young age at diagnosis and long life expectancy emphasize the importance of preventing long-term treatment side effects, including bone mineral density (BMD) loss, in these patients. We aimed to evaluate the effects of first-line therapeutic modalities on BMD dynamics in HL patients, intending to identify individuals at risk for osteopenia. Demographics, HL risk factors, treatment, including cumulative steroid doses, and BMD of 213 newly-diagnosed HL patients (median age 29 years), treated at Rambam between 2008–2016, were analyzed. The main chemotherapy regimens applied were: ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) and escalated BEACOPP (EB; bleomycin, etoposide, adriamycin, cyclophosphamide, oncovin, procarbazine, prednisone). BMD was measured using PET/CT scans. BMD loss >15% was revealed in 48% of patients at therapy completion, with osteopenia prevalence of 4% and 14% at baseline and post-therapy, respectively. Cumulative hydrocortisone equivalent doses >3400 mg/m2 correlated with significant BMD reduction. Multivariate analysis at 6 months post-therapy identified age ≥30 years and EB-regimens as significant risk factors for BMD decrease >15%. Therapy-related BMD loss is common in HL patients. Its persistence is associated with age ≥30 years and EB treatment. Reduction of cumulative steroid doses and switch to non-gonadotoxic drugs should be considered.

Combination Immunotherapy for Hepatocellular Carcinoma: Where Are We Currently?

The past decade has seen a rise in the availability of breakthrough therapeutic strategies for treatment of hepatocellular carcinoma (HCC). A tumor microenvironment in HCC is regulated by various immunotolerance mechanisms; therefore, therapeutic strategies aiming at disrupting tumor immune tolerance are becoming attractive curative options in HCC. Immune checkpoint inhibitors have demonstrated impressive effectiveness in HCC, including in sorafenib-unresponsive patients. Synergistic approaches with checkpoint inhibitors (anti-PD-1/PD-L1 and CTLA-4) and antiangiogenic drugs are burgeoning as first-line treatment therapeutic modalities in HCC.

Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks.

Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.

Challenges and updates in the management of eosinophilic esophagitis.

Eosinophilic esophagitis (EE) is a chronic T helper cell-2 mediated inflammatory condition and is considered as a primary cause of dysphagia and foregut symptoms. There are many challenges regarding the treatment options of EE. Different therapeutic approaches are best at meeting different endpoints. There are unresolved questions such as whether the goal for treatment should be to control esophageal eosinophilia and inflammation or to achieve symptomatic improvement. Still, proton pump inhibitors are used in differential diagnosis, along with their anti-inflammatory and anti-acid properties. Conducted trials continue to recommend the use of topical corticosteroids and empiric food elimination diets as first-line therapeutic modalities. The growing knowledge on the pathogenesis of EE has allowed further progression of encouraging targeted biologic therapies. However, the guidelines for EE management should be updated accordingly in the coming years, including fast evolving data on non-invasive diagnostic strategies, new treatment modalities, and the long-term prognosis of the disease.

A review article on gastric varices with focus on the emerging role of endoscopic ultrasound-guided angiotherapy.

Gastric varices (GV) manifest in almost one-fifth of the patients with portal hypertension. Although primary pharmacological prevention of esophageal varices has been identified, there are limited therapeutic options that are optimal for GV bleeding. Recently, the use of endoscopic ultrasound (EUS)-guided angiotherapy [cyanoacrylate (CA) and coils] was introduced for the treatment of GV. Although CA injection is the recommended first-line therapeutic modality, it is associated with systemic, life-threatening embolization as well as technical instrumental challenges. Recently, EUS-guided coiling for GV was used with high safety profile. This is a review of the current literature on the treatment of GV, focusing on the role of EUS-guided angiotherapy in the treatment of GV. We performed a Medline/PubMed search, and 37 relevant studies were extracted and examined. EUS-guided angiotherapy has shown a consistent favorable result among the several reports throughout the literature, with better safety and efficacy profile toward EUS-guided coiling; however, a combination treatment with EUS-guided coiling followed by glue injection has shown as well to reduce the embolization adverse events associated with glue injection. EUS-guided angiotherapy and specifically EUS-guided coiling is an emerging promising technique and should be considered as a first-line therapeutic option for bleeding GV.

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis.

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome). We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with≥10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model. Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I 2=15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I 2=50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P=0.51). WPR for AE was 13% (9, 20%), (I 2=64%). AE were 10% more in WON as compared to PP (P=0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I 2=50%). Pooled MD for number of endoscopic sessions was -0.84 (-1.69, 0.01). LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

Low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet improves symptoms in adults suffering from irritable bowel syndrome (IBS) compared to standard IBS diet: A meta-analysis of clinical studies.

BackgroundIrritable bowel syndrome (IBS) and functional digestive tract disorders, e.g. functional bloating, carbohydrate maldigestion and intolerances, are very common disorders frequently causing significant symptoms that challenge health care systems. A low Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAP) diet is one of the possible therapeutic approaches for decreasing abdominal symptoms and improving quality of life.ObjectivesWe aimed to meta-analyze data on the therapeutic effect of a low-FODMAP diet on symptoms of IBS and quality of life and compare its effectiveness to a regular, standard IBS diet with high FODMAP content, using a common scoring system, the IBS Symptom Severity Score (IBS-SSS).MethodsA systematic literature search was conducted in PubMed, EMBASE and the Cochrane Library as well as in the references in a recent meta-analysis. Adult patients diagnosed with IBS according to the Rome II, Rome III, Rome IV or NICE criteria were included in the analysis.Statistical methodsMean differences with 95% confidence intervals were calculated from studies that contained means, standard deviation (SD) or mean differences and SD of differences and p-values. A random effect model was used because of the heterogeneity (Q test (χ2) and I2 indicator). A p-value of less than 0.05 was chosen to indicate a significant difference.ResultsThe literature search yielded 902 publications, but only 10 were eligible for our meta-analysis. Both regular and low-FODMAP diets proved to be effective in IBS, but post-diet IBS-SSS values were significantly lower (p = 0.002) in the low-FODMAP group. The low-FODMAP diet showed a correlation with the improvement of general symptoms (by IBS-SSS) in patients with IBS.ConclusionsThis meta-analysis provides high-grade evidence of an improved general symptom score among patients with irritable bowel syndrome who have maintained a low-FODMAP diet compared to those on a traditional IBS diet, therefore showing its superiority to regular IBS dietary therapy. These data suggest that a low-FODMAP diet with dietitian control can be a candidate for first-line therapeutic modality in IBS. Because of a lack of data, well-planned randomized controlled studies are needed to ascertain the correlation between improvement of separate key IBS symptoms and the effect of a low-FODMAP diet.

Surgical management of psoas abscess in the Human Immunodeficiency Virus era

Thai aims of this study were to provide an epidemiological and microbiological analysis of psoas abscess in the human immunodeficiency virus (HIV)-infected population, and to describe the optimal investigative and management approach of this condition. A retrospective chart analysis of 20 patients with a diagnosis of psoas abscess admitted to a regional academic hospital from January 2012 to December 2014 was performed. Twenty patients with psoas abscess were identified, of which 14 were HIV positive (70%) and five HIV negative (25%). One patient remained untested (5%). The mean CD4 count was 402 cells/mL (range 150-796 cells/mL, median 367 cells/mL). Acid fast bacilli were positive in psoas abscess aspirates in 13 cases (65%). Staphylococcus aureus and Escherichia coli were identified in 15% of cases. The radioisotope bone scan showed increased vertebral uptake in 10 patients (62.5%), with the lumbar spine (L1-L4) being most commonly involved (31%). There was a statistically significant increase in radioisotope uptake in the lumbar vertebrae in tuberculous psoas abscess than in pyogenic psoas abscess (p=0.003). Ultrasound-guided percutaneous drainage was used in 16 patients (80%) with a success rate of 87.5%; only two cases required repeat drainage (12.5%). Open drainage was used in four patients (30%) with a 100% success rate. There were no mortalities at 30-day follow-up. Tuberculous psoas abscess from underlying vertebral osteomyelitis is more common than pyogenic psoas abscess. Ultrasound has high diagnostic accuracy and guides percutaneous drainage with excellent success rates. Ultrasound-guided percutaneous drainage should be regarded as the first-line therapeutic modality.

Role of oral propranolol in the treatment of infantile subglottic hemangioma.

To determine the efficacy of oral propranolol for the treatment of infantile subglottic hemangioma. 17 children (13 females and 4 males) with a median age at onset of treatment of 5 months were included in this study. Propranolol was administered after the presence of subglottic hemangioma was confirmed by laryngoscopy and a CT scan of the trachea with contrast. Propranolol was started at 1 mg/kg per day divided into 3 doses. Heart rate and blood pressure were monitored during treatment. If no side effects were observed, then the dose was increased to 1.5 mg/kg per day on the second day. 14 patients (82%) showed clinical improvement within 1 week of treatment initiation. In each of these patients, the diameter of the subglottic stenosis caused by the hemangioma decreased, and the hemangioma became lighter in color. Two children with cutaneous hemangiomata also exhibited significant improvements in their cutaneous lesions after treatment. One patient's treatment was stopped after 2 weeks for personal reasons (family issue). After treatment cessation, this patient's respiratory symptoms recurred and increased in severity over the next 2 weeks. The patient was restarted on propranolol, and the symptoms disappeared. One patient only partially responded to propranolol. One patient continued with a tracheostomy for 15 months due to the diffuse nature of the lesion and was just recently decannulated. One patient initially did not respond to propranolol and developed residual disease after open resection; this patient finally responded to propranolol after 6 months of therapy and was recently weaned off the drug. Oral propranolol is a safe and effective treatment for infantile subglottic hemangiomata and may be used as a first-line therapeutic modality.

Retrospective Comparison of the Effectiveness of Various Treatment Modalities of Extragastric MALT Lymphoma: A single center analysis

We have performed a retrospective analysis of all patients with extragastric mucosa-associated lymphoid tissue (MALT) lymphoma treated at our institution to compare the efficacy of first-line therapeutic modalities including surgery, radiation, systemic therapy, and antibiotics. One hundred eighty-five patients with extragastric MALT lymphoma with a median age of 63 (interquartile range (IQR) 50-74) years and a median follow-up time of 49 (IQR 18-103) months were retrospectively analyzed. Time to progression and time to next therapy were used as surrogate endpoints for efficacy. Patients having either surgery (100 %), chemo/immunotherapy (85.5 %), or radiation (80 %) had significantly (p = 0.01) higher response rates than patients treated with antibiotics (33.3 %). Patients who were irradiated had significantly more progressive disease, but also the longest follow-up time. Stage, elevated LDH, anemia, elevated beta-2 microglobulin, plasmacytic differentiation, monoclonal gammopathy, or autoimmune disease did not influence the rate of disease progression nor did complete remission or partial remission from initial therapy influence time to and rate of progression. There was no significant difference in the median time to progression (p = 0.141), but the estimated time to progression (p = 0.023) as well as the estimated time to next therapy (p = 0.021) was significantly different among the various cohorts favoring surgery, chemo/immunotherapy, and radiation. Our results suggest extragastric MALT lymphoma as a potential systemic disease irrespective of initial stage. Radiation, surgery, and chemo/immunotherapy seem to be equally effective in achieving remissions and prolonged progression free survivals, but a curative potential is questionable. Localized MALT lymphomas affecting the thyroid gland or the lungs have excellent long-term progression-free survivals with surgical treatment only.

Retrospective comparison of the effectiveness of various treatment modalities of extragastric MALT lymphoma: a single-center analysis

We have performed a retrospective analysis of all patients with extragastric mucosa-associated lymphoid tissue (MALT) lymphoma treated at our institution to compare the efficacy of first-line therapeutic modalities including surgery, radiation, systemic therapy, and antibiotics. One hundred eighty-five patients with extragastric MALT lymphoma with a median age of 63 (interquartile range (IQR) 50-74) years and a median follow-up time of 49 (IQR 18-103) months were retrospectively analyzed. Time to progression and time to next therapy were used as surrogate endpoints for efficacy. Patients having either surgery (100 %), chemo/immunotherapy (85.5 %), or radiation (80 %) had significantly (p = 0.01) higher response rates than patients treated with antibiotics (33.3 %). Patients who were irradiated had significantly more progressive disease, but also the longest follow-up time. Stage, elevated LDH, anemia, elevated beta-2 microglobulin, plasmacytic differentiation, monoclonal gammopathy, or autoimmune disease did not influence the rate of disease progression nor did complete remission or partial remission from initial therapy influence time to and rate of progression. There was no significant difference in the median time to progression (p = 0.141), but the estimated time to progression (p = 0.023) as well as the estimated time to next therapy (p = 0.021) was significantly different among the various cohorts favoring surgery, chemo/immunotherapy, and radiation. Our results suggest extragastric MALT lymphoma as a potential systemic disease irrespective of initial stage. Radiation, surgery, and chemo/immunotherapy seem to be equally effective in achieving remissions and prolonged progression free survivals, but a curative potential is questionable. Localized MALT lymphomas affecting the thyroid gland or the lungs have excellent long-term progression-free survivals with surgical treatment only.

Efficacy of intratympanic steroid therapy for idiopathic sudden sensorineural hearing loss: comparison with systemic steroid therapy and combined therapy

Conclusion: Intratympanic steroid therapy (IT-S) was as effective as systemic steroid therapy (SST) or combined therapy (CT) and could be considered a first-line therapeutic modality for idiopathic sudden sensorineural hearing loss (SSNHL). Due to its known safety and efficacy, IT-S will be particularly suitable for patients with SSNHL who have chronic diseases such as diabetes mellitus, hypertension, or chronic renal failure. Objectives: Systemic high dose steroid therapy is the main therapeutic modality for SSNHL. Comparable therapeutic efficacies for IT-S and CT with SST and IT-S for SSNHL have been reported recently. We compared the efficacy of IT-S, SST, and CT for treating SSNHL. Methods: A retrospective, multicenter study investigating the therapeutic efficacy of SST, IT-S, and CT for SSNHL was designed and involved 735 patients with idiopathic SSNHL who were diagnosed and treated at seven tertiary referral medical centers of the Catholic University of Korea between 2007 and 2011. Patients were divided into three groups according to the treatment methods they received: IT-S group, SST group, and CT group (SS plus IT-S). Hearing was evaluated by pure tone audiogram performed before initial treatment and at 4 weeks following the final treatment. More than a 10 dB HL decrease in average air conduction threshold of hearing at 500, 1000, 2000, and 3000 Hz was defined as improved hearing. Results: Among 735 patients with SSNHL, 94 were included in the IT-S group, 444 in the SST, and 197 in the CT group. Age, gender, interval from disease onset to start of treatment, and initial hearing level were not different among the three groups. Patients who had concomitant medical disorders such as diabetes mellitus, hypertension, or chronic renal failure were more frequently treated with IT-S. No difference in the level of hearing gain or ratio of hearing improvement was observed among the three groups (p = 0.147 and p = 0.067, respectively).

Treatment of infantile subglottic hemangioma with oral propranolol

To observe the efficacy of oral Propranolol in the treatment of infantile subglottic hemangioma. Eleven children (6 females and 5 males) with a median age at onset of treatment being 4 months were included in this study. Propranolol was given after laryngoscopy and a CT scan with contrast of the trachea confirming the presence of a subglottic hemangioma. The starting dose of Propranolol was 0.5 mg/kg per day, given in 2 or 3 divided doses. Heart rate and blood glucose were monitored during the treatment. If no side effects occurred, the dose was increased to 1 mg/kg per day at the third day and to 2 mg/kg per day at the sixth day. Treatment was continued at home after 10 days of inpatient treatment and the children were reevaluated monthly. After 24 - 48 hours of treatment, all of the children had improvement in their airway obstruction which was confirmed by fibro-laryngoscopy. The diameter of the subglottic stenosis from the hemangioma decreased from 3.9 - 5.0 mm to 1.5 - 2.0 mm,and the color was also lighter than before. In 3 children with cutaneous hemangioma, there was also significant improvement in the cutaneous lesions after treatment, with the color becoming lighter. There were no significant ECG, blood pressure or blood biochemical changes during the treatment. Two of the children had hypoglycemia at the first dose, but improved after blood transfusion and changing their diet. In five children, the treatment was stopped after 6 to 11 months when the obstructive symptoms improved. None of the children in this group had any evidence of recurrence. In the 5 children who stopped treatment, the obstructing mass in the subglottis was less than 10% of the diameter. Oral propranolol is a safe and effective treatment for infantile subglottic hemangioma. It may be used as a first-line therapeutic modality.

Primary Stenting for Stroke

With great interest we read the early electronic publication of the interim results from “Midterm Clinical and Angiographic Follow Up for the First FDA-approved Prospective, Single-arm Trial of Primary Stenting for Stroke: SARIS (Stent-Assisted Recanalization for acute Ischemic Stroke)” by Levy et al.1 The authors used the Wingspan stent (Stryker, former Boston Scientific, Freemont, California), a self-expandable stent used as a first-line therapeutic modality to recanalize an occluded cerebral artery. In our experience2 with a smaller cohort of 7 patients, the Enterprise stent (Cordis, Miami Lakes, Florida), a closed-cell design, partially retrievable stent was used as a rescue therapy where other techniques failed (intravenous tissue plasminogen activator, IV tissue plasminogen activator, Penumbra aspiration system, balloon angioplasty). Obtaining Thrombolysis in Myocardial Infarction (TIMI) 2 and 3 in all the patients. The stent was retrieved in 5 patients and permanently implanted in 2. The median modified Rankin scale was 3 at 1 month and the median National Institutes of Health Stroke Scale improved from 16 to 11 at 24 hours. We obtained TIMI 2 in 3 patients and TIMI 3 in 4 patients. Our results are similar to others, Castano et al3 and Roth et al4 using a different self-expandable stent (Solitaire AB, EV3 Plymouth, Minnesota) and also retrieved after the vessel was recanalized obtaining TIMI 2 and 3 in 90% in both series. Regarding the inclusion criteria, Levy's study limits this technique to a clot burden of <14 mm; this is a disadvantage of using an open-celled stent. With a retrievable device, it can be partially deployed, retrieved, and then deployed on a more proximal or distal location based on the specific need. The theoretical advantage of using the Wingspan stent because of its higher radial force did not seem to offer a clinical advantage since the recanalization rates were similar to ours and previously published with the Solitaire stent.3,4 Temporary stent deployment does not have to carry the risk of developing intrastent stenosis that has been reported as high as 50% additionally prevents the requirement of using long-term antiplatelet agents. We commend the authors for pursuing a prospective Food and Drug Administration study addressing the use of self-expandable stent on cerebral revascularization and presenting angiographic follow-up of the target vessel, which is unique because no other revascularization paper has it. Finally, we agree that prospective randomized trials are required to determine the real value of this new therapeutic modality. Disclosure The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

Imaging After Radiofrequency Ablation of Hepatic Tumors

Radiofrequency ablation (RFA) is now increasingly used as a first-line therapeutic modality for small malignant hepatic tumors in many parts of the world. The importance of radiological imaging at follow-up to assess therapeutic effectiveness, presence of complications, and recurrences cannot be overemphasized, as RFA treatment is minimally invasive and locally applied. A broad spectrum of imaging findings obtained by the use of various modalities has been reported by many investigators. In this review, we describe findings, including chronologic changes of the ablation zones, both local and remote recurrences, and complications that occur after RFA of the liver as well as the advantages and disadvantages of the use of each imaging modality for a specific situation.

Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi

Objectives. The efficacy, safety, feasibility, and outcome of in situ treatment applied to select proximal ureteral calculi was assessed and analyzed with a view to avoiding auxiliary interventions and providing high clearance rates in the shortest possible time. We studied the impact of several clinically important variables, including power index, degree of hydroureteronephrosis (HDUN), stone size, and composition on the efficacy of sequential in situ boosted extracorporeal shock wave lithotripsy (ESWL) in a select group. The power index requirement for the in situ boosted protocol and the impact of the stone size/composition, degree of HDUN, and clearance rates were also analyzed. Methods. An in situ (no instrumentation) boosted protocol was applied to 130 primary unimpacted proximal ureteral calculi with no prior intervention. A typical session with the Siemens Lithostar Plus comprised 3000 shock waves, in installments of 500, deployed at a power setting of 1 to 4 kV with a gradual stepwise escalation. Sequential boosted additional sessions of ESWL were administered on days 2, 7, and 14, tailored to the degree of fragmentation, clearance status, and amount of residual stone bulk. Several parameters (shock waves, kilovolts used, fluoroscopy time, number of sessions, stone size, composition, fragmentation, clearance, and HDUN) were recorded and the results analyzed statistically. Results. The results were excellent in 83.8%, with a mean duration to complete clearance of 11.3 days. In situ ESWL failed in 7.69%, and the auxiliary intervention rate was 10.7%. Pre-ESWL HDUN was present in 78.3%, the mean power index was 184.6/session/case, and the average stone burden was 8.9 mm 2. Calcium oxalate monohydrate was the most common stone (56%). Renal colic was the most common side effect observed. The power index, fragmentation at the first session, and stone size were found to be the most favorable significant variables affecting stone clearance. The degree of HDUN, number of sessions, and stone composition did not significantly impact the clearance rates. Conclusions. In situ boosted ESWL should be the first-line therapeutic modality in select unimpacted primary proximal ureteral stones.