Main Clinical Situations Research Articles

Clinical decision of centric relation.

Centric relation (CR) was used in the complete dentures for edentulous jaws firstly. Then, CR was gradually applied in the clinical diagnosis and treatment of dentate jaws. Regarding the application of CR in dentate jaws, there are many doubts about its rationality. For instance, should CR be the core of diagnosis and treatment of temporomandibular disorders? Should CR be used as the jaw position of establishing occlusion in occlusal reconstruction? Should CR serve as the target jaw position in orthodontic treatment? Meanwhile, varieties of CR clinical applications are objective. According to the existing evidence, this paper summarizes the applicable conditions of several main clinical situations with little controversy. We preliminarily put forward the decision tree for the clinical application of CR, which can be used as a reference in clinical practice.

Ovarian Causes of Pseudomyxoma Peritonei (PMP)-A Literature Review.

Pseudomyxoma peritonei (PMP) is a rare, progressive, slowly growing, inadequately understood neoplasm with a 5-year progression-free survival rate of as low as 48%. It is characterized by varying degrees of malignancy and the production of mucinous and gelatinous structures. Typically, the development of pseudomyxoma peritonei is associated with the rupture of appendiceal mucinous tumors and other gastrointestinal or ovarian mucinous tumors. The goal of our literature review was to identify various aspects that characterize the ovarian causes of pseudomyxoma peritonei. The authors performed an extensive literature search between 1 February 2024 and 2 March 2024 on the following databases: Pubmed, Scopus, Oxford Journals, and Reaxys, and the findings were summarized into seven main clinical and paraclinical situations. According to our research, the main instances in which pseudomyxoma peritonei can be triggered by an ovarian cause are the following: (1) mucinous cystadenoma; (2) mucinous ovarian cancer; (3) colon cancer with ovarian metastasis; (4) malignant transformation of an ovarian primary mature cystic teratoma; (5) appendiceal mucocele with peritoneal dissemination mimicking an ovarian tumor with peritoneal carcinomatosis; (6) mucinous borderline tumor developing inside an ovarian teratoma; and (7) the association between a mucinous bilateral ovarian cancer and a colonic tumor. In our study, we aimed to provide a comprehensive overview of the ovarian causes of pseudomyxoma peritonei, including its epidemiology, imagery characteristics, symptoms, current treatment, and promising future therapies, in the hopes of finding feasible solutions, as a lack of understanding of this mucus-secreting malignant disease increases the risk of delayed diagnosis or uncontrolled deterioration.

Cardiotoxicity during and after oncological treatment − role of cardio-magnetic resonance

The purpose of this review article is to inform practicing cardiologists about the manifestations of cardiotoxicity in patients on or after antitumor therapy and about the potential of cardiac magnetic resonance imaging (CMR) in the diagnosis and follow-up of these patients. The definitions and classification of cardiotoxicity associated with antitumor treatment, the mechanisms of cardiac and vascular damage of some of the important groups of antitumor drugs, and the potential CMR findings are reviewed. The main clinical situations related to manifestations of cardiotoxicity in which CMR has or is expected to have a leading role are outlined.

Which imaging in patients with low back pain ?

Low back pain is a major public health problem, with a significant physical and psychosocial impact. Inappropriate use of diagnostic imaging is one of the main factors contributing to the costs of these conditions. In addition, there is evidence to suggest that imaging and the accompanying report are risk factors for chronicity. This article reviews the main clinical situations that clinicians face and summarizes the good clinical practice recommendations for each of them.

Les traitements de la dépression en psychiatrie de liaison : de la théorie à la pratique

Treatments for depression include an adapted lifestyle, physical activity, psychotherapies, antidepressant and mood stabilizing drugs, neuromodulation, chronotherapy, spa treatments. Drug treatments used for major depressive episode are antidepressants and mood stabilizers. For a mild episode, psychotherapy is indicated. It should be combined with an antidepressant (serotonin reuptake inhibitor) for moderate and severe episodes. Suicide risk assessment is essential throughout the depressive episode. It is recommended to monitor at the start of antidepressant treatment for suicidal behavior, a change in mood suggesting an underlying bipolar disorder. The effectiveness of the treatment is evaluated after 4 to 8 weeks. The total duration of antidepressant treatment for an EDC is between 6 months and 1 year after remission, in order to prevent relapses. The use of liaison psychiatry, a real healthcare system within the general hospital, is strongly recommended for better screening and treatment of depression, thus reducing the length of hospital stays, improving the prognosis of depression. The aim of this article is to provide clinicians with a summary of validated data on the efficacy/tolerance of treatment for depression, and to suggest practical action to be taken on the main daily clinical situations: treating comorbid conditions, taking into account interactions drugs, manage the serotonin syndrome, lead to withdrawal from antidepressants, manage treatment in the elderly.

Options for surgical treatment of cicatrical stenosis of the middle (folded) larynx

Aim of the study: to develop a tactic of surgical treatment of cicatrical lesion of the middle larynx depending on the localization and length of stenosis.Materials and methods: from 2014 to 2019, 43 patients with cicatrical stenosis of the folded larynx underwent surgery. The average age of the patients was 39 years and ranged from 18 to 78 years. Depending on the clinical situation, patients were divided into 4 groups, in which different methods of surgical treatment were applied – removal of scars of the middle larynx using CO2-laser and additional application of keel-shaped implant (n = 21), microflaps in the area of commissure (n = 10) and intraretynoid region (n = 4), endoprosthesis covered with xenopericord (n = 8).Results: in the postoperative period endoscopic examination of the larynx was carried out in dynamics during the period up to 1 year. Patients were examined daily while in hospital, then monthly. In addition to endoscopic examination, the study of voice function was carried out by the method of determining the time of maximum fonation. The estimation of respiratory and voice rehabilitation was carried out and stable positive effect was received in 90% in the first group, 70% - in the second, 75% - in the third, 75% – in the fourth. The obtained data allow to develop an individual approach to surgical treatment of cicatrical stenosis of the larynx depending on the localization and extent of cicatrical lesion.Discussion: the optimal method of treating cicatrical lesion of the middle larynx is to create conditions that prevent the contact of wound surfaces and their separation. For this purpose, methods that are individually addressed to the main clinical situations in this problem have been developed. In addition, the use of CO2-laser in the surgical treatment of cicatrical lesions of the middle larynx significantly expands operational capabilities due to high accuracy and low level of damage to surrounding tissues.Conclusions: in case of cicatrical lesion of the middle larynx up to 4 mm in length, in the absence of a tracheostoma an effective method of restoration of respiratory and vocal function of the larynx is the use of microflaps formed by microsurgery with th e help of CO2-laser; stenoses in the area of middle larynx commissure of more than 4 mm require additional stenting for the period of epithelization of the wound surface and remodeling of the scar, which is 3–4 weeks. In the presence of a tracheostoma in patients with prolonged stenosis of the middle laryngeal commissiure, an implant coated with xenopericardium and chlorhexidine ionic-covalent immobilization, which helps to avoid inflammatory changes during the period of stenting, has proved to be a good choice.

Encare clínico de las dislipemias

In daily clinical practice the management of patients with dyslipidemias implies knowledge of relevant clinical scientific evidence, common sense, as respect of patient preferences.There is strong evidence that treatment of dyslipidemias mainly with statins reduces morbidity and mortality in a wide group of patients with few side effects. A critical step in management of this individuals is to make the decision of whether statin treatment is indicated or not. There are patients that have a clear indication of statin use without any further cardiovascular risk calculation. Such is the case in secondary prevention, patients with extremely high low density lipoprotein cholesterol levels (190 mg/dl) and diabetics between 40 and 75 years-old. In all other patients, statin indication should start with a formal cardiovascular risk evaluation. American guidelines suggest using the Pooled Cohort Risk Equations and European guidelines prefer Heartscore. Both scoring systems stratify risk in four categories according to risk intensity. The absolute cardiovascular risk reduction obtained with treatment increases in parallel with the basal cardiovascular risk. This explains the recommendation that both treatment intensity and magnitude of low density lipoprotein cholesterol lowering should increase as the risk of the patient increases. Recommendations provided by American and European guidelines do not always coincide. Thus, besides basal cardiovascular risk estimation, potential adverse drug effects and patient preferences should always be considered in the context of a clinician-patient frank discussion.Ezetimibe first andPCSK9inhibitors eventually (currently limited by costs and availability) appear as the great allies of statins, when adequate doses are not tolerated or the target is not reached.We will tackle the subject through five cases that illustrate the main clinical situations in which physicians have to adopt specific therapeutic decisions.

Stereotactic radiotherapy in targeted therapy treated oligo-metastatic oncogene-addicted (non-small-cell) lung cancer

While the prognosis of metastatic non-small-cell lung cancer has shown significant progress these last years, notably with the discovery of oncogen-driven subtypes and the development of targeted therapies, significant improvements are still needed. More recently, numerous authors studied the oligo-metastasis concept, where the metastasis are limited in number and sites involved, and that could benefit from an aggressive approach of these lesions, for instance with the help of stereotactic radiotherapy. Nevertheless, there is no clear consensus existing for the time being for the treatment of these tumors. Three main clinical situations can be distinguished: oligo-metastasis state de novo at diagnosis (synchronous) or as first metastatic event of an initially locally limited affection (metachronous); oligo-progression during systemic treatment of a pluri-metastatic disease; and finally oligo-persistence of some remaining metastatic lesions at the nadir of the systemic therapy effect. In this review, we will discuss the place of stereotactic radiotherapy in the treatment of non-small-cell oligo-metastatic oncogene-addicted cancers treated with targeted therapies, differentiating these three main clinical situations. In all these indications, this technique could provide a benefit in terms of local control, possibly even in specific survival, when associated with targeted therapy continuation, related to local control of the oligo-metastatic cerebral or extracerebral lesions.

Outcomes of equinus/varus foot surgery in patients with spastic paresis: A retrospective study on 126 patients

Equinovarus foot is the most frequent complication in patients suffering from spastic paresis. Surgical treatment of equinovarus spastic foot includes different kinds of surgery, such as: selective tibial neurotomy, lengthening of the gastrocnemii, soleus, or Achilles tendon, tendon transfer, or rear- and midfoot arthrodesis. So far, there is a lack of precise guidelines about the surgery to consider, for these patients according to their clinical situation. To describe the outcome and complications of equinovarus foot surgery. We performed an analytic, retrospective, single centre study. We included all patients with spastic paresis acquired after 18 years who were operated for an equinovarus foot, on a 12-year period. Four time points were studied: the preoperative situation, postoperative at 3 and 12 months, and the last assessment during follow-up. Considering three main clinical situations (dynamic equinus, fixed equinus and fixed rear and midfoot deformities), we described the surgical procedures and their outcomes. From 200 patients who underwent surgery, 126 feet were included. Forty-eight percent of patients presented with a dynamic equinus foot and had a neurotomy; in such cases 10% of surgery failed, whereas only 6% failed in fixed equinus. The rate of subjective success (assessed by the patients) was 86%. Thirty percent of patients experienced a revision surgery, and 15% presented with complications. Fifteen percent of patients had claw toes after surgery in each group. Five patients had bone surgery because of a fixed varus. The occurrence of postoperative neuropathic pain, was associated with neurotomy of the plantar nerve ( P < 0.01). Equinus/equinovarus foot is a complex situation in patients with spastic paresis. Several clinical pictures can be identified. An important variety of surgical procedures is performed in these patients. The predictive factors of failure and complications of such surgeries can be suggested from this study.

Avoiding Pitfalls in the Interpretation of Gadoxetic Acid–Enhanced Magnetic Resonance Imaging

Gadoxetic acid is extensively used in the following 3 main clinical situations: characterization of small nodules in patients with cirrhosis, preoperative staging of liver metastases, and characterization of incidentally discovered focal liver lesions. Owing to the rapid entry of gadoxetic acid into hepatocytes, the traditional features of liver tumors are modified on magnetic resonance (MR) imaging, especially during delayed phase sequences. Thus, although the added value of gadoxetic acid for the detection and characterization of focal liver lesions is now clear, its unique pharmacokinetics as well as the presence of mimicking and atypical lesions may lead to misdiagnoses. The goal of this article is to illustrate common and uncommon pitfalls associated with the use of gadoxetic acid-enhanced MR imaging. Moreover, additional MR imaging features that can help establish a correct diagnosis are described.

How to treat severe infections in critically ill neutropenic patients?

Severe infections in neutropenic patient often progress rapidly leading to life-threatening organ dysfunction requiring admission to the Intensive Care Unit. Management strategies include early adequate appropriate empirical antimicrobial, early admission to ICU to avoid any delay in the diagnostic and therapeutic management of organ dysfunction. This review discusses the main clinical situations encountered in critically ill neutropenic patients. Specific diagnostic and therapeutic approaches have been proposed for acute respiratory failure, shock, neutropenic enterocolitis, catheter-related infections, cellulitis and primary bacteriemia. Non anti-infectious agents and recent advances will also be discussed. At present, most of large-scale studies and recommendations in neutropenic patients stem from hematological patients and will need further validation in ICU patients.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-512) contains supplementary material, which is available to authorized users.

LABORATORY EXAMINATION FOR TOXOPLASMOSIS: INDICATIONS, METHODS AND RESULTS' INTERPRETATION

Toxoplasmosis is a wide-spread disease with a strongly pronounced polymorphism of clinical manifestations. A lot of lab tests are used in the diagnostics of this disease. The main clinical situations regarding the selection of lab tests and its using for the diagnosis of toxoplasmosis,interpretation of the results, occurring in the practice of the family doctor are discussed in the article

127IN - Can Pet Imaging Help Individualize the Treatment of Colorectal Cancer Patients?

ABSTRACT While the science of medicine tries to understand the rules and hidden laws behind diseases and their management, the art of medicine aims to treat individual patients by matching clinical observations and existing knowledge. The ambiguity between the art and the science of medicine has never been so obvious than in our attempts to tailor cancer treatment to individual patients: the growing evidence of tumor heterogeneity makes understanding a patient's disease increasingly complex, especially when one considers the inadequacy of current assessment tools, which is becoming more apparent each day. In the setting of advanced colorectal cancer (aCRC), three main clinical situations coexist: metastasis that is immediately resectable with curative intent, borderline resectable disease and definitively non-resectable disease. Despite broad parameters within which to treat disease, clinicians lack tools that can rapidly and reliably point out treatment inefficiency in order to allow a therapeutic strategy to be quickly stopped or adapted. The usual endpoints of prospective randomized trials, which form the basis of the science of medicine, are seldom usable at the bedside to exercise the art of medicine. Death (overall survival) and progression (progression-free survival) both occur too long after the beginning of a treatment, and quality of life is much too subjective. The RECIST-based response rate is more readily available and relatively well standardized, but careful analysis reveals a definite but only small correlation with survival outcome in the aCRC setting. Several alternates for tumor response assessment have been studied: plasma tumor markers, circulating tumor cells, and functional imaging, notably the FDG-PET scan. However, few data from well-structured studies are available, and they are sometimes discordant. Among these alternatives, metabolic imaging by FDG-PET appears to be the most promising, bearing the highest and the most reproducible negative predictive value. This means that it could become useful both in the daily clinic and to develop new concepts for clinical trials. The aim of this review is to present the available evidence, point out areas of weakness, and consider how current findings might shape the future development of both FDG-PET techniques and study designs. Disclosure The author has declared no conflicts of interest.

Vitreous Analysis in the Management of Uveitis

A correct diagnosis of uveitis is often challenging, given the wide range of possible underlying conditions and the lack of typical phenotypes. Management decisions may be difficult in view of the risk of visual loss with either inappropriate or delayed therapy. Analysis of the vitreous may therefore be used to provide the clinician with valuable information. In this paper, we describe the main clinical situations in which vitreous sampling is indicated and provide some guidance to clinicians for tailoring their requests. These situations include suspected intraocular infection and suspected intraocular malignancy. We describe the principal tests carried out on vitreous samples, including cultures, polymerase chain reaction-based testing, and cytokine analysis. Limitations of the tests used are likely to become less as more advanced testing methods are introduced. The importance of selecting the appropriate investigations to support a clinical suspicion is emphasised, as is the interpretation of test results within a clinical context.

Estudios de Laboratorio - Parte III

In this third issue of EVIDENCIA, we describe the main indications and clinical situations where certain lab tests areclearly useful: blood culture, urinalisis, sputum culture, Clostridium difficile culture, allergy specific tests, ANCA; andantiphospholipid, anticardiolipin, anti-DNA, antithyroid antibodies.

Radiographies de l’épaule : les incidences utiles en pratique courante

The purposes of this paper are: 1) to review the different radiographic projections commonly used to explore shoulder pathology; 2) to propose a practical approach for radiographic evaluation of the shoulder, adapted to the main clinical situations; 3) to recognize the different imaging features of the most frequent shoulder diseases.

Magnesium in disease: a review with special emphasis on the serum ionized magnesium.

This review deals with the six main clinical situations related to magnesium or one of its fractions, including ionized magnesium: renal disease, hypertension, pre-eclampsia, diabetes mellitus, cardiac disease, and the administration of therapeutic drugs. Issues addressed are the physiological role of magnesium, eventual changes in its levels, and how these best can be monitored. In renal disease mostly moderate hypermagnesemia is seen; measuring ionized magnesium offers minimal advantage. In hypertension magnesium might be lowered but its measurement does not seem relevant. In the prediction of severe pre-eclampsia, elevated ionized magnesium concentration may play a role, but no unequivocal picture emerges. Low magnesium in blood may be cause for, or consequence of, diabetes mellitus. No special fraction clearly indicates magnesium deficiency leading to insulin resistance. Cardiac diseases are related to diminished magnesium levels. During myocardial infarction, serum magnesium drops. Total magnesium concentration in cardiac cells can be predicted from levels in sublingual or skeletal muscle cells. Most therapeutic drugs (diuretics, chemotherapeutics, immunosuppressive agents, antibiotics) cause hypomagnesemia due to increased urinary loss. It is concluded that most of the clinical situations studied show hypomagnesemia due to renal loss, with exception of renal disease. Keeping in mind that only 1% of the total body magnesium pool is extracellular, no simple measurement of the real intracellular situation has emerged; measuring ionized magnesium in serum has little added value at present.