Level Of Improvement In Symptoms Research Articles

Transoral Robotic Surgery for Eagle Syndrome: A Systematic Review.

Objectives: Transoral robotic surgery (TORS) is gaining popularity and has been introduced for the treatment of Eagle syndrome. This review aims to evaluate the safety and efficacy of TORS for the treatment of Eagle syndrome. Methods: A systematic review of the English language literature using multiple databases was completed for studies describing TORS for Eagle syndrome. The quality of studies and risk of bias were evaluated using the MINORS scoring system. Results: Out of 1495 articles screened, 4 studies met criteria for inclusion in the final analysis. Across all studies, there was a 100% surgical success rate. In total, every patient had some level of symptom improvement with 84% of patients having complete symptom improvement and 16% having partial improvement. Reported estimated blood loss averaged 12.5 mL. A total of 94.7% of patients had no surgical complications and no cases were complicated by postoperative bleeding. Operative time averaged 65 minutes. The average length of stay was 2.1 days. A total of 92% of patients resumed their diet on postoperative day 1, with the remainder resuming on postoperative day 2. MINORS criteria scoring suggested moderate risk of bias in all studies. Conclusion: Based on limited quality evidence, this review suggests that TORS is a safe and effective surgical approach in the treatment of Eagle syndrome with low complication rates. Further large-scale prospective studies are warranted.

Treatment of benign positional paroxysmal vertigo in clinical settings in India: a cross sectional pilot survey

Background: The usage pattern and effectiveness of various treatment strategies for benign positional paroxysmal vertigo (BPPV) have not been widely reported in routine clinical settings in India. The aim of the study was to understand treatment patterns and level of symptom improvement in Indian patients presenting with symptoms of BPPV in clinical practice.Methods: A cross-sectional pan-India survey was conducted with leading neurologists and otolaryngologists. A detailed questionnaire was shared with specialists which was followed by semi-structured telephonic interviews to gather a deeper understanding of their treatment practices. The obtained data was analyzed using appropriate statistical methods.Results: A total of 5 neurologists and 8 ENT specialists completed the survey. Physicians reported that age, but not gender, was an important factor when selecting appropriate treatment. Specialists reported that in their clinical practice symptom improvement is better with betahistine plus maneuvers compared to betahistine only alone (97% verses 90% cure rate) and is comparable with maneuvers (97% verses 98% cure rate, respectively). Dix Hallpike and supine roll test using videonystagmography were the most recommended tests used to diagnose BPPV. Betahistine plus maneuvers was the most commonly prescribed treatment for BPPV, and clinicians observed greater decrease in the severity of BPPV symptoms with betahistine plus maneuvers versus betahistine alone or maneuvers. The Visual analog scale (VAS) was the most widely used scale for assessing severity of BPPV symptoms.Conclusions: These findings indicate that betahistine plus maneuvers provides better control over symptom severity in patients with BPPV.

Predictors of Improvement After Fasciotomy for Treatment of Chronic Exertional Compartment Syndrome of the Lower Extremity.

Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating chronic exertional compartment syndrome (CECS). However, not all patients have demonstrated the same level of symptom improvement. Specific patient variables will lead to enhanced functional improvement after fasciotomy for CECS of the lower extremity. Case series. Level 4. A review of patients undergoing fasciotomy of the lower extremity for treatment of CECS by a single surgeon from 2009 to 2017 was performed. Pre- and postoperative measures of Foot and Ankle Ability Measure-Sports subscale (FAAM-Sports), FAAM-Sports Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected at a minimum of 12 months postoperatively. The primary outcomes of change in FAAM-Sports, FAAM-Sports SANE, and VAS during sporting activities were calculated by taking the difference of post- and preoperative scores. Generalized multiple linear regression analyses was performed to determine independent predictors of functional and pain improvement. A total of 61 patients (58% response rate) who underwent 65 procedures were included in this study, with postoperative outcome measures obtained at mean duration of 57.9 months (range, 12-115 months) after surgery. Patients had a mean ± SD improvement in FAAM-Sports of 40.4 ± 22.3 points (P < 0.001), improvement in FAAM-Sports SANE of 57.3 ± 31.6 points (P < 0.001), and reduction of VAS pain of 56.4 ± 31.8 points (P < 0.001). Multiple linear regression analysis revealed deep posterior compartment involvement, younger age, a history of depression, and male sex to be significant independent predictors of enhanced improvement after fasciotomy. Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater functional improvement. Male patients, younger patients, patients with depression, and patients with deep posterior compartment involvement may serve to benefit more with fasciotomies for treatment of CECS.

Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis.

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

Predictors of Improvement in Patient Outcomes after Fasciotomy for Chronic Exertional Compartment Syndrome of the Lower Leg

Category:Sports; OtherIntroduction/Purpose:Chronic exertional compartment syndrome (CECS) of the lower leg is the result of increased pressure in intramuscular compartments that occurs during repetitive physical activity. Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating CECS. However, not all patients have the same level of symptom improvement or ability to return to sport. The purpose of this study was to determine if any independent patient variables were predictive of outcomes following fasciotomy for CECS of the lower leg.Methods:A retrospective review of patients undergoing fasciotomy of the lower leg for treatment of CECS by a single fellowship-trained orthopaedic surgeon from 2009 to 2017 was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing using the Pedowitz criteria. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process or underwent revision fasciotomy were excluded. Preoperative measures of Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport single assessment numeric evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected. Patients with at least 12 months of follow-up were included. The primary outcomes of change (delta, Δ) in FAAM-Sport, FAAM-Sport SANE, and VAS during sporting activities were calculated. To determine significant predictors of outcomes, a generalized multivariate linear regression model developed based on univariate analysis and clinical experience was used. Statistical significance was set at p<0.05.Results:In total, 61 patients underwent 65 procedures, with outcome measures obtained on average 57.9 (range, 12-115) months postoperatively. Median age was 22, median BMI was 24.4, and 59.0% of the cohort was female. Of the 65 fasciotomies, 39 (60.0%) were simultaneous bilateral, 6 procedures (9.2%) performed on 3 patients were staged bilateral, and 18 (27.7%) wereunilateral. There were 16 four-compartment fasciotomies performed (24.6%), while 49 (75.4%) involved 2 compartments. Twenty- two procedures involved deep posterior compartment pressures meeting the Pedowitz criteria. Patients had mean (+- standard deviation) improvement in FAAM-Sport of 40.4 +- 22.3 points (p<0.001), improvement in FAAM-Sport SANE of 57.3 +- 31.6 (p<0.001), and reduction of VAS pain of 56.4 +- 31.8 (p<0.001). Multivariate linear regression results are listed in Table 1.Conclusion::Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater improvement. Independent predictors of improvement of FAAM-Sport SANE following surgery included younger age, history of depression, and male sex. A history of depression was an independent predictor of greater VAS pain reduction following fasciotomy. Patients with deep posterior compartment pressure testing meeting the Pedowitz criteria was an independent predictor of increased improvement in FAAM-Sport. To our knowledge, this is the first study to investigate and identify independent patient variables predictive of greater functional improvement following fasciotomy for CECS.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

Impact of personality disorder comorbidity on cognitive-behavioral therapy outcome for mood and anxiety disorders: results from a university training clinic

This study examined the impact of co-occurring personality disorder (PD) pathology on mood and anxiety symptom improvement in response to non-manualized, short-term, cognitive-behavioral therapy (CBT) delivered by trainees. The sample comprised 305 adult outpatients treated individually for mood (unipolar depression) and anxiety disorders [generalized anxiety disorder (GAD), panic disorder, social anxiety disorder (SAD), specific phobia, obsessive-compulsive disorder (OCD)] by doctoral students within a university training clinic. After comprehensive assessment of psychopathology, symptom-specific measures were administered at pre- and end-treatment. Both magnitude of disorder-specific mood and anxiety symptom change, as well as treatment outcome classification (via reliable change and clinical significance indices) were utilized to assess treatment response. Results indicated that patients treated for depression, GAD, panic disorder, SAD, and specific phobias evidenced significant reductions in symptoms, irrespective of PD presence, and there was no interaction between PD comorbidity and level of symptom improvement. Among patients treated for OCD, PD pathology negatively impacted OCD symptom improvement. When treatment outcome was determined categorically, PD presence had a deleterious effect on clinical recovery only among patients treated for GAD. Neither the number of PD diagnoses nor PD cluster type moderated results. In conclusion, in most instances (with the exception of GAD and OCD patients), individuals with PDs treated by graduate student trainees within a university training clinic experienced significant mood and anxiety symptom improvement in response to short-term CBT, and these improvements were comparable to those without co-occurring PDs.

The treatment of venous malformations with percutaneous sclerotherapy at a single academic medical center.

We report a retrospective analysis of venous malformation patients treated with percutaneous sclerotherapy, describing their clinical manifestations, therapeutic outcomes and procedural complications. We reviewed our Vascular Anomalies database for all patients who underwent percutaneous sclerotherapy for venous malformation between January 2005 and July 2011 and retrieved 186 patients, out of which 116 were included in the final analysis. The majority of patients were treated using 100% alcohol (72%) and the rest were treated with <100% alcohol, Sodium Tetradecyl Sulfate or combination of these therapies. The most common location was the lower extremity in 67 patients (58%), followed by the head and neck in 27 (23%) and the upper extremity in 11 (9%). Retrospective review of medical records was performed. Outcomes were classified on an improvement scale based on clinical therapeutic effects. Two-hundred and forty-five sclerotherapy procedures were performed in 116 patients, of which 52 patients (45%) underwent a single procedure, 32 (28%) had two procedures and 32 (28%) underwent ≥3 procedures. Median follow-up period from the last procedure was 2.5 months (interquartile range of 2.0 to 6.75 months). Significant improvement was seen in 37 patients (32%), moderate improvement in 31 (27%), mild improvement in 20 (17%), no improvement in 21 (18%) and worse than before in 7 (6%) patients. Major post-procedural complications were nerve injuries in 6 patients (5%), deep vein thrombosis in 5 (4%), muscle contracture in 2 (2%), infection in 3 (3%), skin necrosis in 4 (3%) and other complications in 3 (3%). Our study demonstrated that 76% of our patients with venous malformation had some level of improvement in symptoms with majority (72%) undergoing only one or two percutaneous sclerotherapy procedure/s. Although major complications occurred in 20% of the patients, majority (74%) of the complications either resolved spontaneously or were successfully treated.

Self-narrative reconstruction after dilemma-focused therapy for depression: A comparison of good and poor outcome cases

Objective: The aim of this study is to improve the understanding of self-changes after an intervention for depression focused on implicative dilemmas, a type of cognitive conflict related to identity. As recent research has highlighted the relevance of identity-related dilemmas in clients with depression, we sought to assess the way in which clients resolve such inner conflicts after a tailored dilemma-focused intervention and how this is reflected in the clients’ self-narratives. Method: We used three instruments to observe differences between good (n = 5) and poor (n = 5) outcome cases: (i) the Repertory Grid Technique to track the resolution of dilemmas, (ii) the Change Interview to compile clients’ accounts of changes at posttreatment, and (iii) the Innovative Moments Coding System to examine the emergence of clients’ novelties at the Change Interview. Results: Groups did not differ in terms of the number and relevance of client-identified significantly helpful events. However, between-group differences were found for the resolution of dilemmas and for the proportion of high-level innovative moment (IM) types. Furthermore, a greater self-narrative reconstruction was associated with higher levels of symptom improvement. Conclusions: Good outcome cases seem to be associated with the resolution of conflicts and high-level IMs.

More data are needed to use BTX A as first-line treatment

Dr. Steele succinctly summarizes the efficacy and safety of Botulinum toxin A (BTX A) – a point which is not in debate.1 However, the use of BTX A as a primary modality of treatment for OAB has never been reported. While it is likely that BTX A will be able to control overactivity in anticholinergic naive patients, it is unclear what side effects, such as urinary retention, will be seen in such a group. Research into patient preferences and decision-making as it relates to the weighted value of the invasiveness of intervention and side effects balanced with overall levels of improvement in symptoms would yield insight. A randomized trial between BTX A and an anti-cholinergic medication in patients with moderate to severe OAB with detrusor overactivity who are naive to treatment may be reasonable to address this issue, especially in the subset of neurogenic OAB who are already intermittently catheterizing. For the time being, there is no data to support the use of BTX A as a primary treatment for OAB. The long-term success beyond 10 years of BTX A for OAB is unknown. Thus, patients should continue to be treated in a stepwise fashion beginning with lifestyle and behavioural changes, and oral pharmacotherapy.

FDA: Gene Tests Need Premarket Approval

severe symptoms. William R. McFarlane, MD, director of the Center for Psychiatric Research at theMaineMedicalCenter inPortland, presented preliminary results from the Portland Identification and Early Referralprogram. In thiseffort,100at-risk individuals from the Portland area were randomly assigned to either FamilyAided Assertive Community Treatment (FACT) or a comparison group, which includedfamilyeducationandfamilycrisis intervention. Most patients in both groupshad fewsymptomsat2years and reported improved family function, but therewaslittledifferencebetweengroups in terms of the level of improvement in symptoms. McFarlane said in an interview after the meeting the result may indicate thatverysimpleandcost-effective behavioral interventions may be effective. McFarlane and his colleagues already have a large multisite trial under way,withfundingfromtheRobertWood Johnson Foundation. McFarlane explained that familytargeted therapies, may be effective in this population, which had a median age of 16.5 years, because they can help protect these at-risk individuals who appear to be very vulnerable to stress. “The family’s role is to buffer the individual from stresses in the community,” he said. Addington emphasized that such interventions are still in the research phase and that further studies are needed. Patrick D. McGorry, PhD, of the Center for Youth Mental Health at the University of Melbourne in Australia, and his colleagues have argued that future large clinical trials of early interventions for patients at risk of psychotic illnesses should follow a clinical staging model. “Simple and safe treatments first,” he said in a follow-up interview by e-mail, stepping up to more intensive treatments for individuals who do not improve. Until further studies are completed, McGorry suggested that when encountering patients who may be at risk, physicians should engage such patients, monitor their condition, and provide support. He and Addington suggested that physicians focus on treating problems these individuals may already be experiencing, such as depression or anxiety. They also agreed that antipsychotics, which can have serious adverse effects such as tardive dyskinesia and metabolic problems, should not be used in patients who may be at risk. Lieberman suggested reserving antipsychotics for those experiencing a psychotic episode. “Treat what is already a problem and do not use antipsychotics!” McGorry said.

Anal stenosis: use of an algorithm to provide a tension‐free anoplasty

Anal stenosis is a debilitating condition that often is iatrogenic in cause. Various surgical procedures to manage this problem have been described. The present study evaluates the use of different anoplasty techniques in a series of 11 patients with anal stenosis. To the best of the authors' knowledge, this is the first study to provide a stepwise algorithm for the anoplasty techniques used. A series of 11 patients were evaluated for presenting symptoms, cause of anal stenosis, type of anoplasty used, complications and post-operative success in relieving symptoms. All operations were performed by one surgeon in three hospitals, and were followed up by the same surgeon and by a surgical registrar. The most common presenting symptoms were constipation and decreasing calibre of stool. The main causes of anal stenosis were previous surgery, neoplasia and fissure. Transverse closure, Y-V and diamond advancement flaps were used in an escalating manner to deal with increasing severity of stenosis. All 11 patients had some level of improvement in symptoms post-operatively. There were no long-term complications. Anoplasty is a safe and successful option in the treatment of anal stenosis, and this stepwise algorithm takes the guesswork out of choosing the most appropriate procedure for each patient.

Reversals of Sudden Gains Made During Cognitive Therapy with Depressed Adults: A Preliminary Investigation

This study investigated sudden reversals during cognitive therapy (CT), through the comparison of "in-session" activity and "out-of-session" life events. The sample comprised 20 clients who experienced sudden gains during CT for depression: 10 who subsequently suffered a reversal of this gain and 10 matched clients who maintained progress. Measures of client resistance and therapist responses were scored by judges from session transcripts and clients completed measures of life events and depression at each session. This enabled the Reversal and Non-Reversal groups to be compared during pre-sudden gain, pre-reversal or matched sessions. No differences were apparent between the Reversal and Non-reversal groups or between the pre-gain and pre-reversal sessions in terms of client or therapist "in-session" activities. In the Reversals group, 6 out of 10 clients recovered their level of symptom improvement, following the reversal. Therapists showed higher levels of reflection and self-disclosure with clients who did not recover their symptom gain following the Reversal than with clients who did recover their symptom gain following the Reversal. The study is discussed in terms of the manner by which reversals can be more effectively measured and researched.

Complementary and alternative medicine use and cost in functional bowel disorders: a six month prospective study in a large HMO.

BackgroundFunctional Bowel Disorders (FBD) are chronic disorders that are difficult to treat and manage. Many patients and doctors are dissatisfied with the level of improvement in symptoms that can be achieved with standard medical care which may lead them to seek alternatives for care. There are currently no data on the types of Complementary and Alternative Medicine (CAM) used for FBDs other than Irritable Bowel Syndrome (IBS), or on the economic costs of CAM treatments. The aim of this study is to determine prevalence, types and costs of CAM in IBS, functional diarrhea, functional constipation, and functional abdominal pain.Methods1012 Patients with FBD were recruited through a health care maintenance organization and followed for 6 months. Questionnaires were used to ascertain: Utilization and expenditures on CAM, symptom severity (IBS-SS), quality of life (IBS-QoL), psychological distress (BSI) and perceived treatment effectiveness. Costs for conventional medical care were extracted from administrative claims.ResultsCAM was used by 35% of patients, at a median yearly cost of $200. The most common CAM types were ginger, massage therapy and yoga. CAM use was associated with female gender, higher education, and anxiety. Satisfaction with physician care and perceived effectiveness of prescription medication were not associated with CAM use. Physician referral to a CAM provider was uncommon but the majority of patients receiving this recommendation followed their physician's advice.ConclusionCAM is used by one-third of FBD patients. CAM use does not seem to be driven by dissatisfaction with conventional care. Physicians should discuss CAM use and effectiveness with their patients and refer patients if appropriate.

Responsiveness of the Adult Attention-Deficit/Hyperactivity Disorder Quality of Life Scale (AAQoL)

This study examined responsiveness of the Adult Attention-Deficit/Hyperactivity Disorder Quality of Life Scale (AAQoL), which was developed to assess health-related quality of life (HRQL) among adults with attention-deficit/hyperactivity disorder (ADHD). Adults with ADHD completed the AAQoL, Conners' Adult ADHD Rating Scale (CAARS), SF-36, and Endicott Work Productivity Scale (EWPS) at baseline and week 8 of a randomized, placebo-controlled trial of atomoxetine. Clinicians rated symptom severity and improvement (CGI-ADHD-S, CGI-ADHD-I). Responsiveness was examined through effect sizes and association with change in the measures listed previously (Spearman correlations, GLMs). Analyses included 328 patients (58.8% male; mean age = 36.9 years). All AAQoL scales reflected significant improvement from baseline to week 8 (P < 0.0001). AAQoL change scores were significantly correlated with change in the CGI-ADHD-S (r = -0.37 to -0.50), EWPS (r = -0.43 to -0.63), and CAARS (r = -0.35 to -0.62) (all P < 0.001). AAQoL change scores significantly discriminated among patients with various levels of symptom improvement. AAQoL effect sizes (-0.67 to -1.11) were larger than effect sizes for the SF-36 (0.15 to -0.39). The AAQoL was responsive to change in symptoms of ADHD, and it appears to be a useful outcome measure for treatments of ADHD in adults.

What is a Clinically Important Level of Improvement in Symptoms of Attention-Deficit/Hyperactivity Disorder?

To compare the desired and actual reduction in scores on a parent reported behaviour rating scale in a naturalistic sample of children and adolescents who had been treated with psychostimulant medication, referenced to global ratings of treatment benefit. Forty-five parents reporting poor global response to psychostimulant treatment, 44 reporting moderate response, and 49 reporting a high response retrospectively completed Conners rating scales describing their child prior to treatment, the child currently, and how the parent hoped the child would be following treatment. Percentage actual improvement in behaviour rating scales from baseline ranged from around 25% for the poor responders to above 50% for the high responders. Desired improvement was above 50%, with no significant difference between the groups on level of expectation. Percentage cut points used to indicate clinical improvement reported in previous controlled trials of psychostimulant medication are probably too low, and could lead to an overestimate of treatment effect. Expectation of treatment benefit is unlikely to contribute to variation in treatment response.

What is a clinically important level of improvement in symptoms of attention-deficit/hyperactivity disorder?

What is a clinically important level of improvement in symptoms of attention-deficit/hyperactivity disorder?