Likelihood Of Treatment Success Research Articles

Use of Support Vector Machine(SVM) in Prediction of Success of Wart Treatment Methods

Abstract: Warts are common noncancerous benign tumors caused by the Human Papilloma Virus. They can be treated using various methods, including cryotherapy and immunotherapy. However, the success rates of these treatment methods are not consistent and can vary from patient to patient. To address this issue, we have developed a reliable machine learning model that can accurately predict the success of immunotherapy and cryotherapy for individual patients based on their demographic and clinical characteristics. By utilizing a dataset of 180 patients who received either immunotherapy or cryotherapy for their warts, we employed a support vector machine classifier with a radial basis function kernel for the immunotherapy treatment method (Nugroho et al., 2018) . This model takes into account factors such as sex, age, time, number of warts, type, area, and response to treatment to make predictions about the likelihood of treatment success. Through this model, healthcare professionals can have a better understanding of which treatment method is more likely to be effective for a specific patient. The accuracy of our machine learning model for predicting the success of immunotherapy and cryotherapy for warts is expected to be high, as previous studies using similar datasets have reported classification accuracies of up to 90 (Rahman et al., 2020). Our model builds upon previous research in the field, such as the fuzzy logic rule-based method developed by Khozeimeh et al and the AdaBoost with classification and regression tree and random forest algorithms employed by Putra et al. Using our machine learning model, healthcare professionals can make more informed decisions about the treatment approach for individual patients with warts, increasing the likelihood of successful outcomes and improving overall patient care. In conclusion, our machine learning model offers a promising approach to predict the success of immunotherapy and cryotherapy treatments for warts.

Tumor Control Probability and Small-Scale Monte Carlo Dosimetry: Effects of Heterogenous Intratumoral Activity Distribution in Radiopharmaceutical Therapy.

In radiopharmaceutical therapy, intratumoral uptake of radioactivity usually leads to heterogeneous absorbed dose distribution. The likelihood of treatment success can be estimated with the tumor control probability (TCP), which requires accurate dosimetry, estimating the absorbed dose rate per unit activity to individual tumor cells. Methods: Xenograft cryosections of the prostate cancer cell line LNCaP treated with [177Lu]Lu-PSMA-617 were evaluated with digital autoradiography and stained with hematoxylin and eosin. The digital autoradiography images were used to define the source in a Monte Carlo simulation of the absorbed dose, and the stained sections were used to detect the position of cell nuclei to relate the intratumoral absorbed dose heterogeneity to the cell density. Simulations were performed for 225Ac, 177Lu, and 90Y. TCP was calculated to estimate the mean necessary injected activity for a high TCP. A hypothetical case of activity mainly taken up on the tumor borders was generated and used to simulate the absorbed dose. Results: The absorbed dose per decay to tumor cells was calculated from the staining and simulation results to avoid underestimating the tumor response from low absorbed doses in tumor regions with low cell density. The mean of necessary injected activity to reach a 90% TCP for 225Ac, 177Lu, and 90Y was found to be 18.3 kBq (range, 18-22 kBq), 24.3 MBq (range, 20-29 MBq), and 5.6 MBq (range, 5-6 MBq), respectively. Conclusion: To account for the heterogeneous absorbed dose generated from nonuniform intratumoral activity uptake, dosimetry models can estimate the mean necessary activity to reach a sufficient TCP for treatment response. This approach is necessary to accurately evaluate the efficacy of suggested radiopharmaceuticals for therapy.

Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes

A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials. To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial. This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis. Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful. Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors. Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28). Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation. ClinicalTrials.gov Identifier: NCT02800785.

Implementing a Toolkit to Improve the Education of Patients on Home-Based Outpatient Parenteral Antimicrobial Therapy (OPAT)

Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. This article describes the study team's experience piloting an educational toolkit for patients on home-based OPAT. An OPAT toolkit was developed to address barriers such as unclear communication channels, rushed instruction, safe bathing with an intravenous (IV) catheter, and lack of standardized instructions. The research team evaluated the toolkit through interviews with home infusion nurses implementing the intervention, surveys of 20 patients who received the intervention, and five observations of the home infusion nurses delivering the intervention to patients and caregivers. Of surveyed patients, 90.0% were comfortable infusing medications at the time of discharge, and 80.0% with bathing with the IV catheter. While all practiced on equipment, 75.0% used the videos and the paper checklists. Almost all (95.0%) were satisfied with their training, and all were satisfied with managing their IV catheters at home. The videos were considered very helpful, particularly as reference. Overall, nurses adjusted training to patient characteristics and modified the toolkit over time. Shorter instruction forms were more helpful than longer instruction forms. Developing a toolkit to improve the education of patients on home-based OPAT has the potential to improve the safety of and experience with home-based OPAT.

A Rare Case of Giant Cell Tumor of the Extensor Hallucis Longus Tendon

Giant cell tumor is a benign tumour of the extremities that is more prevalent in the upper limbs and less common in the foot and ankle region. We present a case of a patient with a lobulated lesion on the dorsum of the foot that turned out to be a giant cell tumor of the extensor hallucis longus tendon sheath. The likelihood of treatment success is increased by doing a differential diagnosis of a "synovial cyst" in the foot and ankle, completing sufficient surgical planning, and using imaging tests such as nuclear magnetic resonance. Giant cell tumor of tendon sheath involving the foot and ankle region is a rare clinical entity, and good results can be expected after surgical excision

Factors Related to Successful Tuberculosis Treatment in Vulnerable Groups

Background/Aims: Although the incidence and mortality of tuberculosis are decreasing in South Korea, the number of applications for financial assistance with the cost of tuberculosis treatment made by individuals from vulnerable groups was 3.8 times higher in 2019 compared to 2017 (Tuberculosis Relief Belt Project, 2019).Methods: We analyzed the data of patients who received financial aid for tuberculosis treatment (in the period 2014-2018) from the Tuberculosis Relief Belt Project, which was designed to assist vulnerable groups. This study analyzed 137 subjects, and the independent variables included patient factors (age, gender, nationality, tuberculosis type, number of comorbidities, and place of residence) and treatment type (outpatient or inpatient). The dependent variable was the treatment outcome.Results: The likelihood of treatment success was significantly lower for patients with one (odds ratio [OR] 0.202), two (OR 0.147), or three or more (OR 0.070) comorbidities compared to those with no comorbidities. This was also the case for patients living alone (OR 0.097), and for those classified as homeless (OR 0.053). Korean patients (OR 8.512) had a significantly higher probability of a successful treatment outcome than foreigners.Conclusions: Appropriate community-based management of individuals with tuberculosis from vulnerable groups, including foreigners, people with comorbidities, people living alone, and people with an unstable residential situation or homeless status, is important.

Superior Postimplant Dosimetry Achieved Using Dynamic Intraoperative Dosimetry for Permanent Prostate Brachytherapy

PurposeLow-dose-rate brachytherapy is a highly effective treatment modality for prostate carcinoma, but postimplant dosimetry quality is essential and correlated with likelihood of treatment success. Registered ultrasound and fluoroscopy (iRUF) can facilitate real-time intraoperative monitoring and plan adaptation, with the aim of attaining superior dosimetric outcomes. The purpose of this research was to compare clinical postimplant dosimetric results of iRUF-guided brachytherapy against brachytherapy using standard ultrasound-guided intraoperative dosimetry methods. Methods and MaterialsWe analyzed postimplant dosimetry in 292 patients treated with Pd-103 between January 2007 and December 2018. All patients had postimplant dosimetry measured on day 0 to 1 using fused magnetic resonance/computed tomography assessment. Fifty-two patients were treated in 2 prospective clinical trials using iRUF intraoperative dosimetry, including 6 patients in a pilot study and 46 treated in a phase 2 study. Postimplant dosimetry in iRUF-treated patients was compared with dosimetry from 240 patients treated using standard (real-time ultrasound) intraoperative seed tracking. ResultsFor every parameter measuring dose coverage to the prostate, iRUF patients had significantly higher values, irrespective of adjustment for year of treatment. In adjusted analyses, parameters of dose to urethra and rectum were not significantly higher among iRUF-treated patients. ConclusionsUse of iRUF intraoperative dosimetry was associated with improved postimplant dose coverage in prostate, without associated increases in doses to urethra or rectum.

Decisional Involvement, Information Preferences, and Prognostic Optimism Among Patients with Hematologic Malignancies

Introduction: Understanding decisional involvement and information preferences in patients with hematologic malignancies may help to optimize physician-patient communication about treatment decisions and align the decision-making processes with patients' preferences. Exploring how patients perceive their length of life compared to an average person (prognostic optimism) may allow tailoring of conversations about treatment and prognosis. We described and examined factors associated with decisional involvement preferences, information preference, and prognostic optimism. Methods: In a multicenter observational study, we recruited patients with hematologic malignancies of any stage from 9/2003 to 6/2007. Patients were asked about: 1) Decisional involvement preference (Control Preferences Scale), 2) Information sources (including most useful source of information), 3) Preferences for types of information, 4) Preferences for presentation of treatment success information by their oncologists, and 5) Self-perceived length of life compared to patient estimates of an average person of the same disease type and stage (0-6 months, 6-12 months, 1-3 years, 3-5 years, 5-10 years, and >10 years); prognostic optimism was defined as present if patients perceived that they would live longer than their estimates of an average person with the same disease type and stage. We used multivariate logistic regressions to determine demographic and clinical factors associated with: 1) Decisional involvement preference, 2) Usefulness of information sources, and 3) Prognostic optimism. Results: Among 216 patients, median age was 55 years (range 22-79); 39% had lymphoma, 19% had acute leukemia, and 13% had multiple myeloma. In terms of decisional involvement preferences, patient-directed, shared, and physician-directed approaches were preferred in 34%, 38%, and 28% of patients, respectively (Figure 1a). On multivariate analysis, none of the demographics or clinical factors were associated with decisional involvement preferences. Common sources for patients to obtain information on disease or treatment options included their physician (98%), computer/internet (87%), print and broadcast media (71%), and family/friends/other patients/patient support group (78%). Utilization of computer/internet was higher among patients aged <60 years compared to those ³60 years (91.2% vs. 80.5%, P=0.02).. On multivariate analysis, patients with less than a college education (vs. postgraduate education) were less likely to perceive their physician as the most useful source [Adjusted Odds Ratio (OR) 0.46, p=0.05]. Patients with acute leukemia were more likely to perceive their physician as the most useful source (OR 2.49, p=0.03) compared to patients with other blood cancer Over 90% of participants indicated that they would like to discuss each of the following disease and treatment issues: treatment options, goals, impact of disease and treatment on lifestyle, likelihood of treatment success, average survival, physician recommendations for treatment, things they can do to help with recovery, and emotional response to the disease. When asked about their preferences for information presentation about treatment success rates, 70% had ≥1 preferred methods. Most participants (88%) preferred presentation in percentages, 59% wanted to hear about a previous patient that the physician had treated, 37% preferred qualitative descriptions and 30% preferred presentation in fractions. Compared to younger adults, older adults were less likely to prefer presentation in percentages (82% vs. 91%, p=0.04). Prognostic optimism occurred in 31% (Figure 1b). On multivariate analysis, only older age was associated with prognostic optimism (OR 1.05, p=0.03). Conclusions: Our study suggests that decisional involvement and information preferences vary among patients with hematologic malignancies and should be assessed explicitly as part of each decision-making encounter to ensure patients' needs are being met. In addition, approximately one-third of patients had prognostic optimism. Although most studies find that physicians follow the same script with their patients and present invariant information, given the heterogeneity of patient preferences, physicians need to tailor their encounters. Disclosures Loh: Seattle Genetics: Consultancy; Pfizer: Consultancy. Leblanc:Agios, AbbVie, and Bristol Myers Squibb/Celgene: Speakers Bureau; UpToDate: Patents & Royalties: Royalties; American Cancer Society, BMS, Duke University, NINR/NIH, Jazz Pharmaceuticals, Seattle Genetics: Research Funding; AbbVie, Agios, Amgen, AstraZeneca, CareVive, BMS/Celgene, Daiichi-Sankyo, Flatiron, Helsinn, Heron, Otsuka, Medtronic, Pfizer, Seattle Genetics, Welvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Research Funding. Lee:Pfizer: Consultancy, Research Funding; Incyte: Consultancy, Research Funding; AstraZeneca: Research Funding; Kadmon: Research Funding; Novartis: Research Funding; Takeda: Research Funding; Syndax: Research Funding; Amgen: Research Funding.

Pelvic organ prolapse management.

Pelvic organ prolapse describes the loss of support and subsequent descent of pelvic organs into the vagina. It is common, affecting up to 50% of parous women, and can be accompanied by a number of burdening symptoms. Prolapse has been thrown into the spotlight secondary to mesh-related complications. There are a number of effective treatment options to consider when managing pelvic organ prolapse and most do not require mesh. Patients' choice, comorbidities and likelihood of treatment success should be considered when making decisions about their care. Vaginal mesh surgery is currently on hold in the UK and even prior to this there has been a reduction both in the number of all prolapse surgeries and the number of women seeking surgery to manage their symptoms. This article reviews the current evidence for the management of pelvic organ prolapse, providing an update on the current state of mesh in prolapse surgery and summarises the key evidence points derived from the literature.

A qualitative examination of patient priorities and preferences during treatment decision-making for recurrent head and neck cancer.

Patients with recurrent head and neck cancer (HNC) may feel overwhelmed at the prospect of having to consider treatment options particularly if they recently completed treatment for their primary disease or when they have no options that may lead to long-term survival. The purpose of this study was to examine patient priorities and preferences during treatment decision-making for recurrent HNC. Individuals with newly diagnosed recurrent HNC were recruited at a National Cancer Institute-Designated Cancer Center. Participants were interviewed using a structured interview guide. Descriptive statistics were used to describe participants, and qualitative template analysis was used to analyze interview data. Participants (n = 38) considered information from healthcare providers, likelihood of treatment success, and other patient-specific factors in making their treatment decisions. Although patients with recurrent HNC endorse a myriad of decision-making factors, the recommendation of their healthcare provider and the likelihood of treatment success are of paramount importance. Future research should focus on methods to rapidly identify patient priorities at the time of diagnosed recurrence while respecting patient coping and communication styles.

Insight into the brain metastasis journey: Initial survey results from patients and caregivers.

2069 Background: Brain metastases (BM) are the most common central nervous system tumors in the US. Though the exact incidence is unknown, BM are estimated to occur in up to 10-20% of all cancers. Despite the high frequency, there is little systematic knowledge about how BM are typically diagnosed and treated. The American Brain Tumor Association (ABTA) seeks to understand the BM journey: symptoms, diagnosis, treatment, and end of life, through a survey of BM patients and caregivers. Methods: Two surveys were developed by the ABTA with vendor, PSB Research, after careful literature review. The surveys were reviewed by a panel of clinicians who treat BM patients. Online survey research was conducted between 8/13-9/16/18, with one survey for adults with BM (N = 237) and another for caregivers (N = 211). Respondents came from PSB’s panels and ABTA collaborators: LUNGevity, Melanoma Research Foundation and the Kidney Cancer Association. Results: Ninety percent of patients, and a similar number of caregivers, were surprised by the diagnosis, with only 20% of patients knowing about BM before diagnosis. Most caregivers were the adult child of a patient. The impact of the diagnosis was primarily emotional. Top concerns after diagnosis, for both patients and caregivers, were likelihood of treatment success and impact on quality of life. Although a majority of patients were happy with the quality of information given, they stated a need to receive a greater quantity of information about treatment success and options. Only 30% of patients were referred to a patient advocacy organization. When referred, information on treatment success rates and options was most sought. Conclusions: Direct patient and caregiver feedback provides valuable insight towards understanding the BM journey and resources needed to support patients and caregivers. A subsequent survey among oncologists and other clinicians, planned for spring of 2019, will add to these findings.

Cancer Communication Outside of the Physician-Patient Relationship: The Experience of Communicating and Understanding the Meaning of Prognosis.

How does the process of engagement and integration of sources of information outside patient-physician interaction affect how individuals with cancer interpret their treatment experience and prognosis? Studies of patient-physician communication of prognosis in oncology highlight areas where misunderstanding occurs: understanding consequences of treatment, likelihood of treatment success, probability of cure, status/progression of illness, and prognosis. Theories proposing mechanisms that underlie this discrepancy cannot account for all instances of misunderstanding, including when complete and direct physician disclosure occurs. Prior research focused on patient-physician communication event(s) and immediate antecedents and consequences. However, less is known about what happens to information once it has been communicated and how a patient's process to interpret the meaning of their experience affects their understanding of it. Our study explores this question by examining patient communication with sources of information other than treating physicians. We conducted 10 semi-structured qualitative interviews with individuals diagnosed with 4 types of cancer at different stages. The interviews were analyzed using inductive qualitative analysis. Participants in our sample consulted a variety of additional sources to give context and understanding to their communicated prognosis. These were important contributors to how they understood their prognosis and incorporated that understanding. They included family, friends/acquaintances, cancer survivors, support/survivor groups, secondary health-care staff, and relevant informational materials. Different motivations for seeking out these sources were also expressed. Participants expressed a link between their understanding of their prognosis and the variety of outside sources they enlisted for input and support.

Fundamentals of Pain Medicine, 1st ed

Pain is a unifying presenting symptom across many medical specialties. Nearly all physicians are routinely asked to provide quality care to patients whose primary request is assistance with pain control. However, most physicians feel ill-equipped to manage pain, especially in the chronic setting, which inevitably leads to increased patient suffering. In many cases, physicians without specialty training in pain are tasked with treating complex pain patients when pain physicians are not readily available. Fundamentals of Pain Medicine aims to level the playing field, so to speak, for physicians across varying fields who aspire to better treat their patients’ pain complaints. This text offers invaluable information regarding diagnosis, understanding, and treatment of both basic and complex pain states. Fundamentals of Pain Medicine is offered as a paperback text, as well as an eBook. The 359 pages of this book are easily viewed via the eBook platform, which also allows for zooming for improved visualization of the numerous figures used throughout to illustrate complex concepts. The 36 chapters are well organized in easy to manage sections that allow for quick reference to pertinent topics. The text covers 9 distinct topics: diagnosis of pain states, management of pain states, acute pain, chronic musculoskeletal pain, radicular pain, neuropathic pain, chronic visceral pain, headaches, and painful disease states in special populations (pediatrics, geriatrics, and the critically ill). The book is organized logically and with progressively more detail to allow for further investigation by the reader, as dictated by their interest. The sections can easily be referenced for rapid assistance in patient management, or the whole text can be taken in as a guide in the overarching themes of successful pain medicine. A strength of this text is its structure and ability to break pain states down by etiology, leading to improved clinical utility and more appropriate treatment plans. As is well known by pain physicians, the cause of the pain states often dictates the utility of various modalities and likelihood of success in treatment. In short, not all patients’ pain complaints can be treated using the same pharmacological and interventional techniques, and this text clarifies this concept and appropriate approaches. The chapters are broken down into etiologies of pain and their evidence-based treatment courses, which allows for improved patient response, particularly for physicians who may be less familiar with some of the rarer pain etiologies. For example, chapter 23 describes complex regional pain syndrome pathophysiology, epidemiology, diagnosis, and management. This chapter may prove quite valuable in directing the multimodal treatment of complicated, refractory pain patients seen by physicians who do not routinely treat complex regional pain syndrome patients. The author provides thorough details regarding levels of evidence, as well as a cogent summary of recommendations at the end of each chapter, allowing for improved understanding and more effective delivery of patient care. Fundamentals of Pain Medicine reads easily and functions as an excellent reference for those needing a quick refresher course on the nuts and bolts of pain medicine. In fact, many physicians in various fields could offer significantly improved pain management for their patients, namely those in primary care settings without immediate access to pain physicians, simply by consulting relevant chapters. This book may be especially useful for primary care physicians tasked with providing long-term care for patients with complicated, chronic pain conditions. For the trained pain physician, Fundamentals of Pain Medicine offers a concise, well-written summary and reference in a pinch but may fall short when it comes to in-depth analysis of physiological mechanisms of pain and more innovative, up-and-coming interventions. However, following the summary of each chapter, a comprehensive list of suggested readings offers an opportunity for a more detailed perusal into various topics as may pertain more so to specific patient populations, allowing for a more thorough understanding. For physicians of specialties outside the realm of pain management looking to improve efficacy of pain interventions in their patient populations, Fundamentals of Pain Medicine provides a concise overview of the physiological mechanisms, etiologies, and appropriate management of a multitude of pain states that is easy to read and comprehend. The text is extremely practical in its delivery of recommendations, including both pharmacological and more complementary and integrative techniques. This book serves as an excellent initial stepping stone in providing quality pain treatment for patients with common pain states and should be considered a staple desk reference for all physicians interested in improving their patients’ pain control. Caitlin D. Tourje, MDAmanda M. Kleiman, MDDepartment of AnesthesiologyUniversity of VirginiaCharlottesville, Virginia[email protected]

Neural correlates of tobacco cue reactivity predict duration to lapse and continuous abstinence in smoking cessation treatment.

It has been hypothesized that neural reactivity to drug cues in certain limbic/paralimbic regions of the brain is an indicator of addiction severity and a marker for likelihood of success in treatment. To address this question, in the current study, 32 participants (44 percent female) completed a functional magnetic resonance imaging cigarette cue exposure paradigm 2hours after smoking, and then enrolled in a 9-week smoking cessation treatment program. Neural activation to smoking cues was measured in five a priori defined limbic/paralimbic regions previously implicated with cue reactivity across substances. These included regions of the ventral striatum, anterior cingulate cortex and amygdala. Cox proportional hazard modeling was conducted to predict the number of days to first smoking lapse by using neural activation in these regions. Greater neural activation during pre-treatment exposure to smoking cues in the right ventral striatum, the left amygdala, and the anterior cingulate was associated with longer periods of abstinence following cessation. A similar pattern was present for continuous abstinence for the full duration of treatment. While baseline levels of nicotine dependence were strongly associated with treatment outcome, activation in the right ventral striatum predicted duration of abstinence beyond level of nicotine dependence. These results suggest that pre-treatment reactivity to smoking cues in areas associated with cue reactivity may be associated with successfully maintaining abstinence during treatment. This is consistent with models that propose that as addiction becomes more severe, motivational processing shifts from regions that subserve reward salience and learning to regions responsible motor behavior and habit learning.

Clots, Collaterals, and the Intracranial Arterial Tree

See related article, p 2061. Acute ischemic stroke is a story of two parts; a thrombus blocks anterograde blood flow within the intracranial arterial tree while tiny vessels called collaterals sustain the brain until the thrombus is cleared. The location, size, and type of thrombus along with the degree and extent of collaterals likely determine the patient’s clinical symptoms, the likelihood of treatment success and the patient’s prognosis. A major focus of acute stroke research has been to image and measure various thrombus and collateral characteristics that help predict patient outcomes. In vitro studies show that larger clots are less likely to lyse with thrombolytic agents, whereas clots with more surface area exposed to flowing blood are more likely to lyse early.1 This information can be used to create a theoretical framework for thrombus lysis within the intracranial arterial tree.2 Thrombi in proximal arteries such as the internal carotid or the M1 segment of the middle cerebral artery are likely to have greater volume than thrombi in smaller more distal arteries. Independent of thrombus volume, longer thrombi within the cylindrical framework of the intracranial arterial tree are likely to have less relative surface area (at the proximal and distal ends) exposed to blood flow. Poor collateral status is likely to result …

Off-label use of maraviroc in HIV-1-infected paediatric patients in clinical practice.

Maraviroc (MVC) is not approved for HIV-1-infected paediatric patients. This is the first assessment of the use of MVC-based salvage therapy in vertically HIV-1-infected paediatric patients in clinical settings. The results suggest that MVC-based salvage therapy is useful in children and adolescents with extensive resistance profile leading to maintained virological suppression in up to 88% of the patients with CCR5-tropic virus. The likelihood of treatment success might increase when MVC is combined with other active drugs.

Risk factors for acquisition of drug resistance during multidrug-resistant tuberculosis treatment, Arkhangelsk Oblast, Russia, 2005-2010.

Acquired resistance to antituberculosis drugs decreases effective treatment options and the likelihood of treatment success. We identified risk factors for acquisition of drug resistance during treatment for multidrug-resistant tuberculosis (MDR TB) and evaluated the effect on treatment outcomes. Data were collected prospectively from adults from Arkhangelsk Oblast, Russia, who had pulmonary MDR TB during 2005-2008. Acquisition of resistance to capreomycin and of extensively drug-resistant TB were more likely among patients who received <3 effective drugs than among patients who received >3 effective drugs (9.4% vs. 0% and 8.6% vs. 0.8%, respectively). Poor outcomes were more likely among patients with acquired capreomycin resistance (100% vs. 25.9%), acquired ofloxacin resistance (83.6% vs. 22.7%), or acquired extensive drug resistance (100% vs. 24.4%). To prevent acquired drug resistance and poor outcomes, baseline susceptibility to first- and second-line drugs should be determined quickly, and treatment should be adjusted to contain >3 effective drugs.

Optimal differentiated thyroid cancer management in the elderly.

The incidence of differentiated thyroid cancer is increasing worldwide across all age groups. While most patients with differentiated thyroid cancer have a good prognosis, aggressive disease is more common in the elderly and disease-specific mortality is higher. Treatment options for differentiated thyroid cancer include surgery, levothyroxine, radioactive iodine, external beam radiotherapy and kinase inhibitors. Rational and evidence-based management is particularly important in older individuals because they may experience greater toxicities from the therapeutic options. We advocate an explicit risk-benefit analytic approach to thyroid cancer care that emphasises individual patient factors, likely disease biology and progression, and age-dependent treatment characteristics to ensure optimal treatment. In particular, this risk-benefit approach should seek to identify patients with aggressive disease, and, within a multidisciplinary setting, balance the likelihood of treatment success with the probability of treatment-related adverse effects.

Assessment of motivating factors associated with the initiation and completion of treatment for chronic hepatitis C virus (HCV) infection

BackgroundInfection with hepatitis C virus (HCV) is associated with high morbidity and increased mortality but many patients avoid initiation of treatment or report challenges with treatment completion. The study objective was to identify motivators and barriers for treatment initiation and completion in a community sample of HCV-infected patients in the United States.MethodsSurvey methods were employed to identify factors reported by patients as important in their decision to start or complete HCV treatment. Study participants included 120 HCV-infected individuals: 30 had previously completed treatment with pegylated interferon/ribavirin (PR), 30 had discontinued PR, 30 were treated with PR at the time of the survey, and 30 were treatment‒naïve. Telephone interviews occurred between May and August of 2011 and employed a standardized guide. Participants assigned factors a rating from 1 (not at all important) to 5 (extremely important). Trained researchers coded and analyzed interview transcripts.ResultsOf 33 factors, expected health problems from not treating HCV infection was reported as most encouraging for treatment initiation and completion, while treatment side effects was most discouraging. Sixty-nine percent of participants reported that the ability to obtain information during treatment on the likelihood of treatment success (i.e., results of viral load testing) would motivate them to initiate therapy. Median preferred timing for learning about test results was 5 weeks (range: 1–23 weeks).ConclusionUnderstanding challenges and expectations from patients is important in identifying opportunities for education to optimize patient adherence to their HCV treatment regimen.

Lack of efficacy of ergocalciferol repletion

Introduction: Vitamin D has become an area of intensive scrutiny, both in medical and lay literature. However, there are limited data to suggest proper repletion regimens for those patients who have hypovitaminosis D. Consequently, various methods are used in clinical practice. The aim of this study was to assess the efficacy of various treatment strategies for hypovitaminosis D in an ambulatory internal medicine practice.Methods: A retrospective chart review between October 2005 and June 2010 of a suburban internal medicine practice was performed via query of the electronic medical record (Centricity, General Electric Healthcare, UK). Patients with a 25-hydroxyvitamin D concentration less than 32 mg/dl were identified and treated. Treatment success was defined as 25-hydroxyvitamin D concentrations greater than 32 mg/dl. Statistical analysis to assess changes in vitamin D level controlling for season, comorbidities, and demographics were used.Results: A total of 607 treatment episodes were identified, with 395 excluded due to lack of follow-up vitamin D level within 16 weeks, no treatment documented, topical treatment, doxercalciferol treatment, or non-compliance. Of the remaining patients, there were 212 treatment instances on 178 patients. Ergocalciferol 50,000 international units (IU) was used most frequently (71.4% of the time.). A higher initial vitamin D level was positively associated with treatment success (adjusted odds ratio = 1.11, p=0.002). Increased doses of ergocalciferol increased the likelihood of treatment success (p=0.0011). Seasonal variation was related to posttreatment 25-hydroxyvitamin D concentration as was body mass index (BMI) (p=0.003 and p=0.044).Conclusion: Pretreatment levels of 25-hydroxyvitamin D, BMI, season, and vitamin D dose are predictors of successful hypovitaminosis D treatment. Our data suggest that patients with initial 25-hydroxyvitamin D concentrations of <20 should be treated with a higher total dose of ergocalciferol than 50,000 IU for 8 weeks. Further studies, including prospective, randomized trials, are needed to determine an optimal treatment protocol to account for the numerous variables.