Multimodal Management Approach Research Articles

Fluid management in chronic kidney disease: what is too much, what is the distribution, and how to manage fluid overload in patients with chronic kidney disease?

Assessment of fluid status to reach normovolemia in patients with chronic kidney disease (CKD) continues to be a tough task. Besides clinical observation, technological methods have been introduced, yet, the best approach is still uncertain. The present review looks at fluid overload in CKD from three perspectives: the critical fluid threshold leading to adverse cardiovascular outcomes, fluid distribution and its clinical correlates, and direct effect of fluid overload on vascular function related to disturbance of the sodium-skin axis and endothelial glycocalyx dysfunction. To determine fluid status, both the absolute and relative fluid overload is used as parameter in clinical practice. In addition, the definition of fluid overload is ambivalent and its relation to symptom burden has not been studied well. Studies on the impact of distribution of fluid are scarce and the limited evidence suggests differences based on the cause of CKD. So far, no standardized technologies are available to adequately determine fluid distribution. After discovering the 'third compartment' of total body sodium in skin and muscle tissue and its potential direct effect on vascular function, other biomarkers such as VEGF-C are promising. We propose a multimodal clinical approach for volume management in CKD. Because there are currently no studies are available demonstrating that correction of fluid overload in CKD will lead to better outcome, these are strongly needed.

Treatment Expectations Towards Different Pain Management Approaches: Two Perspectives.

PurposeAccumulating evidence suggests an association between patient expectations and treatment success across various types of pain treatments. Expectations among treatment caregivers, however, are often neglected. Despite international treatment guidelines, only a small minority of chronic pain patients undergo psychological interventions. Therefore, our aim was to explore expectations among treatment receivers and caregivers especially concerning their attitudes towards psychological pain treatments.MethodsTwo hundred ten (potential) treatment receivers (n=85 individuals suffering from chronic low back pain (CLBP); n=125 healthy controls) and 237 caregivers (n=75 physicians; n=64 psychotherapists; n=98 physiotherapists) provided ratings of expected treatment success for standardized vignettes describing patients suffering from CLBP and undergoing a pharmacological, psychological, or multimodal pain management program.ResultsIndividuals suffering from CLBP generally had lower treatment expectations than healthy controls. Both psychotherapists and physicians had higher treatment expectations from their own individual treatment approach. All participants expected the multimodal approach to be most effective. The psychological approach was expected to be more effective than the pharmacological approach – except for the physicians, who expected both treatment approaches to be equally effective.ConclusionThere is an urgent need to clarify, under which circumstances and how patient expectations can be altered among individuals suffering from CLBP. Our results appear to encourage the implementation of multimodal and psychological pain management approaches across various settings. We invite clinicians to reflect whether their own expectations are in line with the recommendations in international treatment guidelines.

Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain.

Purpose of ReviewEffective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30–50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU).Recent FindingsDexmedetomidine, a selective alpha2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU.SummaryPerioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

Multimodal Approach for Management of Retinal Angioma: A Case Series

Purpose: To evaluate outcomes of multi modal approach in management of Retinal Angioma. Material and Methods: Medical reports of 15 eyes of 12 patients having retinal angioma presented over a period of 12 years were retrospectively analyzed. Age, gender, presenting complaint, general physical examination and neurological examination findings, initial Visual Acuity, eye involved, tumor location, growth pattern, ocular complications were noted. Fundus photographs and FFA, OCT at initial visit as well as those taken during follow-up and final visual acuity were noted. CT/MRI brain and abdominal ultrasound reports were reviewed. Any pedigree association with von-Hipple-Lindau disease was recorded. Results: Records of 15 eyes of 12 patients with retinal angioma were reviewed including 7 males and 5 females. Mean age of presentation was 27.7 yrs. Initial vision was 6/6 –6/18 in 27%, 6/24 –6/60 in 20%, 5/60 –3/60 in 27%, <2/60 in 26%. Laser was given as initial treatment in 8 eyes in which 4 eyes received intravitreal anti VEGF along with laser. Cryotherapy was done in 2 eyes and VR surgery was done in 5 patients. At final follow-up all patients had stable tumor and resolution of exudates and macular edema and vision was better than 6/18 in 73% 6/18 - 6/60 in 7% and less than 3/60 in 7%. Conclusion: Early diagnosis and treatment of retinal angiomas with multimodal approach yields good visual outcome. If untreated the tumors may eventually have exudative RD and have a poor visual prognosis even with vitreoretinal surgery.

The Horse is at the Stable Door: Management of N1M0 Prostate Cancer

Pelvic lymph node involvement in prostate cancer is a significant poor prognostic factor with very little evidence on the optimal management options for these patients. It is estimated that lymph node-positive patients make up 12% of newly diagnosed prostate cancer and this figure is expected to rise with the advancement and increasing use of novel imaging. The controversy around this subgroup of patients is whether this is an intermediary stage before disseminated disease and hence amenable to curative treatment options. Systemic therapies have been the mainstay of treatment for these patients for decades, but in recent years, studies have emerged supporting the addition of local therapy. This review will focus on the current multimodal management approach for clinical and pathological lymph node-positive prostate cancer with a focus on radiotherapy options and aims to provide the rationale for a curative approach with a combination of local and systemic therapy.

12 A multimodal approach for piglet pain management after tail docking

Abstract Millions of piglets on commercial production farms are tail docked each year to reduce the incidence of tail biting. While this procedure is known to be painful, piglets in the United States are often not provided analgesia or anesthesia for pain relief. The objectives of this study were to assess a multimodal approach to managing tail docking pain in piglets, using 0.4 mg/kg meloxicam (MEL), 0.04 mg/kg buprenorphine (BUP), and Maxilene® (MAX). The effectiveness of each drug and drug combination was evaluated using behavioral indicators, vocalization, and facial grimace analysis. This study also assessed whether male and female piglets responded differently to pain or pain treatments. Four-day-old piglets from 14 litters (n = 165 total) were used and piglets within a litter were randomly assigned to one of six possible treatments: MEL, BUP, MEL + BUP, MEL + BUP + MAX, no treatment (tail docked control), or sham (non-tail docked control). Treatments were administered intramuscularly (MEL, BUP) or topically on the tail (MAX) 20 min prior to tail docking. Piglets administered MEL + BUP and BUP demonstrated significantly fewer pain behaviors than piglets in the MEL and no treatment group (p &lt; 0.05). MEL + BUP + MAX and BUP piglets also grimaced significantly less than piglets in the no treatment group (p &lt; 0.05). There were no significant differences in emitted vocalizations between the analgesia-treated piglets and the no treatment group, and both injection and tail docking elicited piglet vocalizations of similar frequency, power, and energy (P &gt; 0.05). There were no significant differences in behavior, facial grimacing or emitted vocalizations between male and female piglets. All treatment groups with buprenorphine were able to alleviate tail docking-associated pain, suggesting that opioid administration is highly effective for managing piglet pain.

Immersive Virtual Reality for Pediatric Procedural Pain: A Randomized Clinical Trial.

Pain management in children often is inadequate, and the single most common painful procedure in children who are hospitalized is needle procedures. Virtual reality (VR) is a promising and engaging intervention that may help to decrease anxiety and pain in children undergoing painful procedures. Our aim for this study is to investigate patient satisfaction and pain reduction by using a three-dimensional VR interactive game as a distraction. In this randomized clinical trial, we enrolled 64 children aged 7 to 16 years who were scheduled for venous cannulation. Patients assigned to the control group were adherent to our standard of care, including topical numbing cream, positioning, and distraction by a specialized pain nurse. In the study group, children were adherent to the standard of care and were distracted by an interactive VR game. Primary outcomes were patient satisfaction and the procedural pain assessed by using a visual analog score; secondary outcomes were the procedural time and any adverse events. We found a high level of patient satisfaction with using the VR custom-made three-dimensional interactive game. All children (28 of 28 [100%]) in the VR group answered that they would prefer VR as a distraction for a later procedure, a borderline significant result compared with that of the control group (26 of 31 [84.9%]). No significant difference was found in pain scores and procedural times between the 2 groups. The number of adverse effects was low, with no significant difference between the 2 groups. We found no difference in pain scores but higher satisfaction when using VR versus standard care as part of a multimodal approach for management of procedural pain in children.

Symptom correlates of dyspnea in advanced cancer patients using the Edmonton Symptom Assessment System.

Dyspnea is frequently experienced in advanced cancer patients and is associated with poor prognosis and functional decline. This study used the Edmonton Symptom Assessment System (ESAS) to characterize the relationship between dyspnea and concurrent symptoms experienced by advanced cancer patients. A prospective database was collected and analyzed to extract patient demographics and ESAS scores. Logistic regression analysis and generalized estimating equations (GEE) identified correlations of other ESAS symptoms in three categories: severity of dyspnea (none, mild, moderate, severe), moderate/severe dyspnea (ESAS ≥ 4), and presence of dyspnea (ESAS ≥ 1), at patients' first visit and over time, respectively. Multivariable analysis revealed drowsiness (p = 0.001), and anxiety (p = 0.01) and appetite loss (p = 0.02) were associated with increased severity of dyspnea at first visit. Over time, tiredness (p = 0.02), drowsiness (p = 0.04), nausea (p = 0.02), and anxiety (p = 0.0006) were more likely to experience increased dyspnea severity. Tiredness (p = 0.0003), depression (p = 0.03), and appetite loss (p = 0.003) were significant for moderate/severe dyspnea at first visit. Over multiple visits, tiredness (p < 0.0001), anxiety (p = 0.0008), and appetite loss (p = 0.0008) had higher probabilities of moderate/severe dyspnea. For the presence of dyspnea at the first visit, anxiety (p = 0.03) and drowsiness (p = 0.002) were significantly correlated with an increased frequency of dyspnea. Over time, anxiety (p < 0.0001) and drowsiness (p < 0.0001) remained significant with the addition of nausea (p = 0.0007). The highly interactive relationship between dyspnea and other common cancer symptoms necessitates the development of comprehensive symptom assessments and utilization of multimodal management approaches that consider concurrent symptoms for improved identification and treatment of dyspnea.

New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE. Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.

Successful multi-modality approach in management of human leukocyte antigen-B27 associated fulminant panuveitis - rare presentation

Objective: To report a multimodality approach in the management of human leukocyte antigen B27 (HLA-B27) associated fulminant posterior uveitis, an uncommon presentation, with good visual and anatomical recovery. Methods: A 33-year-old young male presented with HLA-B27 associated severe posterior uveitis, which is a relatively uncommon presentation. The patient had severe vitritis with papillitis, which was sequentially and stepwise managed with oral steroids, pars plana vitrectomy, immunosuppressive agents and sustained release intravitreal steroid implant. Results: The patient had a good recovery of vision with complete resolution of inflammation and without any long-term complication. Conclusion: HLAB27 positivity can be associated with an uncommon presentation of fulminant posterior uveitis that requires a judicious and stepwise multimodality approach in its management, and can have a good visual and anatomical outcome as demonstrated in our case.

A Contemporary Perspective on the Management of Post-Craniotomy Headache and Pain

This article discusses the etiology and management of post-craniotomy headache and pain. A review of available as well as investigatory treatment modalities is offered, followed by suggestions for optimal management of post-craniotomy headache. There is a dearth of evidence-based practice regarding the differential diagnosis, natural history, and management of post-craniotomy headache. The etiology of post-craniotomy headache is typically multifactorial, with patients' medical history, type of craniotomy, and perioperative management all playing a role. Post-craniotomy headaches are often undertreated, yet available evidence supports a multimodal approach for both prophylaxis and management. Many therapeutic techniques that aim to treat or prevent post-craniotomy headache require more robust validation than clinical evidence currently imparts. Pre- and intraoperative locoregional anesthesia should be the mainstay of prophylaxis; the role of opiates co-administered with analgesics, corticosteroids, and antiepileptic therapy in the acute perioperative phase is of paramount importance. Treatment of chronic PCH is less well-defined but should involve trials of analgesic, antineuropathic, and antiepileptic medications before enlisting experimental treatments. Comorbid psychiatric, musculoskeletal, or seizure disorders should be managed distinctly from post-craniotomy headaches. In patients failing all extant therapies, experimental approaches should be considered. These include subanesthetic ketamine infusion or surgical site injection with local anesthetics, corticosteroids, or botulinum toxin. Post-craniotomy headache is a complex phenomenon with many underutilized treatment options available, and many more under investigation. Nonetheless, further research is required to differentiate the efficacy of contemporary treatment strategies and to elucidate the applicability of novel therapies.

Hepatocellular carcinoma treatment: hurdles, advances and prospects.

Hepatocellular carcinoma (HCC) is one of the major causes of cancer-related mortality and is particularly refractory to the available chemotherapeutic drugs. Among various etiologies of HCC, viral etiology is the most common, and, along with alcoholic liver disease and nonalcoholic steatohepatitis, accounts for almost 90% of all HCC cases. HCC is a heterogeneous tumor associated with multiple signaling pathway alterations and its complex patho-physiology has made the treatment decision challenging. The potential curative treatment options are effective only in small group of patients, while palliative treatments are associated with improved survival and quality of life for intermediate/advanced stage HCC patients. This review article focuses on the currently available treatment strategies and hurdles encountered for HCC therapy. The curative treatment options discussed are surgical resection, liver transplantation, and local ablative therapies which are effective for early stage HCC patients. The palliative treatment options discussed are embolizing therapies, systemic therapies, and molecular targeted therapies. Besides, the review also focuses on hurdles to be conquered for successful treatment of HCC and specifies the future prospects for HCC treatment. It also discusses the multi-modal approach for HCC management which maximizes the chances of better clinical outcome after treatment and identifies that selection of a particular treatment regimen based on patients’ disease stage, patients’ ages, and other underlying factors will certainly lead to a better prognosis.

Enteral nutrition improves clinical outcome and reduces costs of acute mesenteric ischaemia after recanalisation in the intensive care unit

Little data evaluate the enteral nutrition (EN) for patients with acute mesenteric ischaemia (AMI) in the intensive care unit (ICU). This study assessed the outcomes of EN for recanalised AMI patients in the ICU. In this retrospective study, 183 AMI patients with mesenteric recanalisation admitted to two surgical ICUs were included. Patients were divided into EN (EN within first week, n=95) and total parenteral nutrition (TPN) group (TPN in 1st week, n=88). The etiology, outcomes and complications were compared. Nutritional, immunologic, inflammatory response and mesenteric reperfusion were evaluated. Subgroup analysis and cost-assessment were performed. No significant difference of demographics and illness severity at baseline were found. The rates of TPN for ≥6 months (7.4% vs. 18.2%, P<0.01), infectious complications (7.4% vs. 20.5%, P=0.01) and acute respiratory distress syndrome (4.2% vs. 13.6%, P<0.01) were lower in EN group. For patients with mesenteric infarction (n=101), EN was associated with earlier bowel continuity restoration (P<0.01) and lower 30-day mortality (7.3% vs. 26.1%, P=0.01). For patients without initial bowel resection (n=82), length of ICU and hospital stay was significantly shortened in EN group. The 1-year survival was 88.4% in EN group and 78.4% in TPN group (P=0.031). EN was cost-effective, with improved inflammatory response and elevated peak velocity of mesenteric flow. For recanalised AMI patients, EN starting within the first week represents a favourable alternative to TPN. A multicentre randomised controlled trial with high level of evidence is warranted in the future. Acute mesenteric ischaemia (AMI) is a catastrophic abdominal vascular emergency in the surgical intensive care unit (ICU), and the mortality of AMI remains unchanged despite significant progress of endovascular techniques. A multidisciplinary and multimodal management approach of AMI in the ICU has been recently proposed to improve patient's survival and prevent the intestinal failure. Post-recanalisation nutrition therapy may significantly improve the overall survival of AMI patients is quite underemphasised in the ICU. Definitive data comparing EN with TPN for this patient population are very lacking. This study provides the clinical data to suggest that early EN starting after ICU admission represents a favourable alternative to TPN for recanalised AMI patients. The nutrition therapy protocol in the ICU for this special cohort needs to be updated with more high-level evidence in the future.

Multimodality Approach in Management of Pressure Sore: A Systemic Review

Pressure sores are unyielding wounds proving a nightmare to treating physician and adding to financial burden and psychological distress of the patient and the care giver. Systemic multidisciplinary approach and multimodal intervention to treat the wound is essential to achieve favourable results. In our case report we highlight the various modalities of treatment that can be used for the treatment of such pressure sore and review other modalities that can be used to accelerate the wound healing process.

Multi-modal treatment approach in management of Sandhigata Vata w.s.r. to Osteoarthritis

The disease like Sandhigata Vata which is similar to modern disease entity Osteoarthritis, is a silent enemy of the physical ability of human beings. Besides other Vata provoking factors Jara (old age) is an important factor and hence the disease is prevalent more in aging population. The provoked Vata gets seated in the Sandhis (Joints) and damages the joint structure (Hantisandhin). Functional and structural deterioration is obvious in the disease. For effective management of the disease Multi-modal treatment approach is the need of time. Amapachana, Snehana, Swedana, Lekhana, Basti, Upnaha, Agnikarma, Shamana Yoga etc. treatment modalities are used in Sandhigata Vata according to the patient condition. Multi-modal approach in the management of Sandhigata Vata (osteoarthritis) is much useful to treat patient successfully.

Clinicopathologic characterization and outcomes for patients with renal medullary carcinoma: Results from the National Cancer Database.

456 Background: Renal medullary carcinoma (RMC) is a rare, aggressive malignancy for which relatively limited characterization exists to date. We evaluated clinicopathologic features, treatment patterns, and variables associated with outcomes for patients with RMC. Methods: We reviewed the National Cancer Database to identify patients diagnosed with RMC between 1998-2012. Overall survival (OS) was estimated using the Kaplan-Meier method. Clinicopathologic features associated with all-cause mortality (ACM) were assessed using Cox regression analysis. Results: We identified 153 patients with RMC, comprising approximately 0.04% of renal malignancies during this time period. Median age at diagnosis for RMC was 24 years (IQR 20, 31). The majority of RMC patients were black (135; 88%), male (108; 71%), and presented with unilateral, right-sided tumors (101; 66%). Notably, nearly half (72; 48.9%) presented with metastatic disease. A total of 92 (64.3%) patients underwent radical nephrectomy (RN), and 2 (1.3%) were treated with partial nephrectomy. Pathologic stage at nephrectomy was ≤pT2 in 30 patients (32.6%), pT3 in 43 (46.7%), pT4 in 7 (7.6%), and N+ in 50 (55.6%). Of the patients who underwent RN, 60 (65.2%) received multimodal therapy (MMT), including radiation (3; 3.3%), systemic therapy (49; 53.3%), and radiation + systemic therapy (8; 8.7%). Of the 59 patients who did not undergo surgical resection, the majority (46; 77.8%) presented with M1 disease. Median OS was 7.8 months for the entire RMC cohort, with 1- and 3-year OS of 34% and 11%, respectively. Notably, median OS for patients presenting with M1 and M0 disease was 5.2 months versus 11.2 months, respectively (p&lt; 0.01). On multivariable analysis, treatment with RN (HR 0.40; p=0.003) or RN+MMT (HR 0.44; p&lt;0.001) were associated with decreased ACM, whereas the presence of metastatic disease at diagnosis remained associated with an increased risk of ACM (HR 1.74; p=0.02). Conclusions: The prognosis for patients with RMC is dismal, with a median OS under 8 months. Further studies, including the development of novel therapies, are needed to establish the optimal multimodal management approach for these patients.

Renal Cell Carcinoma with Isolated Lymph Node Involvement: Long-term Natural History and Predictors of Oncologic Outcomes Following Surgical Resection

BackgroundRenal cell carcinoma (RCC) with isolated lymph node (LN) involvement has historically been associated with poor prognosis. However, a subset of patients may experience long-term survival. ObjectiveTo examine the natural history of RCC with isolated LN involvement following surgical resection with long-term follow-up, and to evaluate clinicopathologic features associated with disease progression and survival. Design, setting, and participantsA total of 138 patients with isolated pN1M0 RCC underwent partial or radical nephrectomy and LN dissection from 1980 to 2010. InterventionPartial or radical nephrectomy with LN dissection. Outcome measurements and statistical analysisMetastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) were estimated using the Kaplan-Meier method. Associations between clinicopathologic features and oncologic outcomes were evaluated using Cox regression models. Results and limitationsMedian follow-up among survivors was 8.5 yr. The 5-yr and 10-yr MFS, CSS, and OS rates were 16% and 15%, 26% and 21%, and 25% and 15%, respectively. The median time to development of metastases was only 4.2 mo. On multivariable analysis, symptoms at presentation (hazard ratio [HR] 2.40; p=0.03), inferior vena cava tumor thrombus (HR 1.99; p=0.003), clear cell (HR 2.21; p=0.01) and collecting duct/not otherwise specified (HR 4.28; p<0.001) histologic subtypes, pT4 stage (HR 2.64; p=0.005), and coagulative tumor necrosis (HR 2.51; p<0.001) were independently associated with development of metastases. MFS rates at 1 yr after surgery were 71%, 63%, 33%, and 7% for patients with one, two, three, and four to five adverse features, respectively. Limitations include surgical selection bias. ConclusionsAlthough isolated pN1 disease portends a poor prognosis, a small subset of patients experience durable long-term survival after surgical resection of isolated lymphatic metastases. Adverse prognostic features may enhance patient risk stratification and facilitate multimodal management approaches. Patient summaryAlthough isolated lymph node metastases portend a poor prognosis, a small subset of patients experience long-term survival following surgical resection.

A preliminary case series evaluating the safety and immediate to short-term clinical benefits of joint mobilization in hemophilic arthritis of the lower limb

Objectives: Arthritis resulting from recurrent intra-articular bleeding in individuals with hemophilia can be severely debilitating due to joint pain and stiffness with subsequent loss of mobility and function. Very limited studies have investigated the potential benefits of joint mobilization for this condition. This case series is a preliminary investigation of safety, as well as immediate and short-term clinical benefits, associated with gentle knee and ankle joint mobilization in people with hemophilic arthropathy.Methods: A single intervention of joint mobilization was applied to the affected knees and/or ankles of 16 individuals with severe or moderate hemophilia within a public hospital setting. Adverse events, as well as immediate (pain-free passive joint range, Timed Up and Go Test with maximum pain numerical rating scale) and short-term (Lower Extremity Functional Scale) effects of the intervention were evaluated with a repeated measures ANOVA.Results: There were no adverse events. An immediate significant increase was observed in pain-free passive ankle joint range of motion (p < 0.05) following the joint mobilization intervention.Discussion: The findings of this case series suggest that gentle joint mobilization techniques may be safely considered as part of a multimodal management approach for hemophilic arthropathy.

Active myofascial trigger points in head and neck muscles of patients with chronic tension-type headache in two primary health care units in Tshwane

Background: The management of patients presenting with chronic tension-type headache (CTTH) can be challenging for primary health care practitioners. As with most chronic pain disorders, a multimodal management approach is frequently required. It has been postulated that myofascial pain syndrome (MPS) and its hallmark myofascial trigger points (MTrPs) found in specific muscle tissues may play a role in the chronic pain experienced by patients with CTTH. Little is known about the prevalence of MTrPs in patients with CTTH, in primary health care settings on the African continent. This study therefore aimed to investigate the prevalence of active MTrP’s in specific head and neck muscles/muscle groups in patients with CTTH.Methods: A prospective, cross-sectional and descriptive study was done in two primary health care facilities situated in Tshwane, South Africa. The sample included 97 adult patients with CTTH. Five head and neck muscles/muscle groups were examined bilaterally for active MTrPs. Outcome measures were the prevalence and distribution of active MTrPs in these patients.Results: Active MTrPs were found in 95.9% of the patients, the majority (74.2%) having four or more active MTrPs. The temporalis muscles and suboccipital muscle group exhibited the highest number of active MTrPs (prevalence 87.6% and 80.4% respectively).Conclusion: Our study suggests a strong association between MPS and CTTH in patients, presenting in the primary health care setting. This indicates the importance of a musculoskeletal assessment of neck and pericranial muscles in patients with CTTH. This can assist in determining the most appropriate treatment strategy in these patients.

Evolving Use of Androgen Deprivation Therapy in Prostate Cancer Management.

Since its introduction more than 70 years ago, the use of androgen deprivation therapy (ADT) for prostate cancer has evolved to become part of a multimodal management approach. In this presentation from the NCCN 21st Annual Conference, James L. Mohler, MD, reviewed data that inform these strategies and gave his bottom-line recommendations on issues such as ADT plus radiotherapy, continuous versus intermittent ADT, ADT for positive nodes, and ADT plus docetaxel. He suggested that ADT plus radiation therapy should be used in patients at high risk, intermittent ADT is more appropriate for most patients than continuous ADT, and docetaxel should be given with ADT for high-volume metastatic disease.