Multidisciplinary Treatment Of Patients Research Articles

Multidisciplinary Treatment in Patients With Persistent Pain Following Total Hip and Knee Arthroplasty

In a retrospective study, we evaluated the clinical outcome of multidisciplinary pain therapy (MPT) in a consecutive series of 40 patients with persistent unexplained pain following THA or TKA. Pain intensity, physical capability and psychological status were assessed before MPT (t1), after 3 weeks (t2) and at a mean follow-up of 32 months (t3). At t2, all scores demonstrated a significant improvement compared to the baseline value. At t3, pain intensity, physical capability, and depression levels deteriorated slightly but were still significantly better compared to baseline values. Anxiety scores deteriorated between t2 and t3 and showed no difference in the baseline value. The present study suggests that MPT has beneficial short-term and mid-term effects in this subgroup of patients and may avoid exploratory revision surgery.

AB0847-HPR Cognitive mechanisms of change in multidisciplinary treatment of patients with chronic wide spread pain: a prospective cohort study

BackgroundCognitive mechanisms of change in the multidisciplinary treatment of patients with chronic widespread pain (CWP) are only partially understood.ObjectivesTo evaluate the contribution of improvement in negative emotional cognitions, active cognitive...

Preoperative chemoradiation and IOERT for unresectable or borderline resectable pancreas cancer.

Pre-operative chemoradiation (preop CRT) plus intraoperative electron irradiation (IOERT) has been used in the multidisciplinary treatment for patients with locally advanced unresectable or borderline resectable pancreas cancer. This review was performed to evaluate survival, relapse patterns and prognostic factors in patients treated with curative intent. Between January 2002 and December 2010, 48 patients with locally advanced pancreatic ductal adenocarcinoma received preop CRT prior to an attempt at resection and IOERT. 31/48 (65%) patients proceeded to curative-intent surgical resection. Resection status prior to preop CRT was locally unresectable (20 patients) and borderline resectable (11 patients). Preop CRT (45-50.4 Gy/25-28 Fx in 27/31) was delivered with concurrent 5FU or gemcitabine-based regimens. Subsequent gross total resection was achieved in 16 patients (R0, 11; R1, 5). IOERT was delivered in 28 patients (dose, 10-20 Gy). 16 patients also received adjuvant post-operative systemic chemotherapy. Outcomes evaluated include survival, local failure in the EBRT field (LF), central failure in the IOERT field (CF), and distant metastases. Resection status was predictive for survival and for patterns of relapse. For patients with at least a gross total resection after preop CRT (R0/R1; n=16) vs. no resection (n=15), both median and overall survival were improved (median 23 vs. 10 months; 2-year, 40% vs. 17%; 3-year, 40% vs. 0%; P=0.002). Liver or peritoneal relapse was documented in 22/31 patients (71%); LF/CF in 5/26 (16%). Long term survival and disease control are achievable in select patients with borderline resectable or locally unresectable pancreas cancer when gross total surgical resection is achieved after preop CRT. Continued evaluation of curative-intent combined modality therapy is warranted in this high risk population, but additional strategies are needed to improve resectability and disease control.

415. Results of a Multidisciplinary Treatment in Patients with Locally Advanced Adenocarcinoma of the Pancreas in a Single Institution

Aim: Optimal management of patients with locally advanced pancreatic adenocarcinoma (LAAP) remains controversial. To evaluate the results of a radical multidisciplinary treatment in this patients at the Platform of Oncology.

Ectodermal dysplasia: aggressive treatment of oligodontia versus non-intervention?

Prosthodontists can serve as productive members of the craniofacial team and can help coordinate multidisciplinary treatment of patients with congenital anomalies. Often there are few, if any, evidence-based criteria to assist them in developing “correct” clinical protocols. When syndromes involve hypodontia, oligodontia, or anodontia, coordinating prosthetic treatment through phases of three-dimensional growth and development can be daunting. Early implant intervention with anodontia patients is acceptable in some treatment centers. Correcting previously untreated adolescent oligodontia can be extremely challenging and removal of strategic teeth with immediate implant placement is surely controversial. Understanding the morbidity of grafting in these patients and the questionable long-term survival of overdenture abutment teeth will lend to an active discussion of the advocated aggressive therapeutic approach.

Resectability and indication for chemotherapy in patients with colorectal liver metastases as assessed by medical oncologists and surgeons.

e14167 Background: Multidisciplinary treatment in patients with colorectal liver metastases (CRLM) is standard in modern oncology. However, for interdisciplinary discussion assessing complimentary disciplines' potential and changes in personal views is crucial. We evaluated experienced medical oncologists' (MO) and surgeons' (SG) assessment of resectability and indication for chemotherapy (CTx) in patients with CRLM. Methods: Thirty patients who underwent R0-resection of CRLM between 2001 and 2011 at our department were selected. Medical history and staging data were presented to MO (n=10) and SG (n=11) in a virtual tumor board (TB1). Standardized blinded TED-voting answers (9 options) included assessment of resectability and the indication for pre- and/or postoperative CTx. The virtual tumor board was followed by training in terms of state-of-the-art lectures on potential of CTx and surgery. Assessment was then repeated in a second virtual tumor board (TB2). Results: 630 (21x30) answers were obtained per tumor board. In TB1 resectability, borderline resectability and definite unresectability were expected in 433, 161 and 36 answers, respectively. Resectability was significantly more often expected by SG (p<0.001). In TB2 57% of answers were different from TB1 (p<0.001). Assessment shifted from borderline resectable to resectable CRLM in 81 of 161 and from unresectable to (borderline) resectable CRLM in 29 of 36 answers (p<0.001). The shift was significant in MO (p=0.012) and SG (p<0.001). Preoperative CTx was significantly more often indicated by MO (p=0.041) and included in 255 answers (44%) in TB1 compared to only 157 answers (27%) in TB2 (p<0.001). With 55% of answers voting for postoperative CTx remained stable in TB1 and TB2 without a significant difference between MO and SG in either TB1 (p=0.099) or TB2 (p=0.353). Conclusions: Resectability and indication for pre- but not postoperative CTx were discrepantly assessed by MO and SG. Training had a strong influence on decision making in MO and SG resulting in a higher rate of patients deemed (borderline) resectable. Furthermore, following training MO and SG opted less often for preoperative CTx.

Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future

In rectal cancer treatment, both the local primary and the regional and systemic tumour cell deposits must be taken care of in order to improve survival. The three main treatments, surgery, radiotherapy, and chemotherapy, each with their own advantages and limitations, must then be combined to improve results. Several large randomized trials have shown that combinations of the modalities have markedly reduced the loco-regional recurrences, but have not yet had any major influence on overall survival. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals), is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, treatment of rectal cancer is administered to populations of individuals, based upon clinical factors and imaging, and can presently not be further individualized. There is an urgent need to develop response predictors.

AOS7 Role of cryotherapy in multidisciplinary management of endobronchial metastases

Background Metastases to the bronchial tree from extrapulmonary malignancies can cause significant symptoms that preclude systemic treatment of the primary disease. The aim in this study was to assess the role of cryotherapy as part of a multidisciplinary treatment in patients with endobronchial metastases. Methods Between 1995 and 2011, 35 patients (23 men; age range 22–80 years) with endobronchial metastases (11 colorectal, 11 renal, 4 oesophageal, 9 other) received endobronchial cryotherapy under general anaesthetic via a rigid and fiberoptic bronchoscope (temperature 70 °C; exposure to probe 240 s, number of freezing cycles 1–4, number of procedures 1–5) as part of the multidisciplinary treatment for the primary tumour. The main presenting symptom was dyspnoea in 14, stridor in 9, haemoptysis in 7, and cough in 5 patients. Findings There were no peri-operative or in-patient deaths. Endobronchial cryotherapy was undertaken as a day-case procedure in more than 80% of cases. Survival from starting cryotherapy was from 10 days to 4 years and 8 months, with a median of 34 weeks. Twenty-two patients reported a significant improvement in their main presenting symptom. In half the patients, endoluminal patency was increased by 50% or more after cryotherapy. Improvement allowed the majority of the patients to continue systemic treatment of their primary tumour. Interpretation Endolumenal cryotherapy is a safe and effective treatment modality in patients with symptoms secondary to endobronchial metastases. Cryotherapy gives rapid resolution of symptoms and can be undertaken as a day-case procedure in most patients. It improves the patient’s condition, permitting systemic treatment of the primary tumour. The authors declared no conflicts of interest.

562 OUTCOMES IN PATIENTS WITH VIABLE CANCER AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease I1 Apr 2010562 OUTCOMES IN PATIENTS WITH VIABLE CANCER AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION Shilajit Kundu, Brett Carver, Nicholas Karanikolas, George Bosl, Robert Motzer, Dean Bajorin, Darren Feldman, and Joel Sheinfeld Shilajit KunduShilajit Kundu More articles by this author , Brett CarverBrett Carver More articles by this author , Nicholas KaranikolasNicholas Karanikolas More articles by this author , George BoslGeorge Bosl More articles by this author , Robert MotzerRobert Motzer More articles by this author , Dean BajorinDean Bajorin More articles by this author , Darren FeldmanDarren Feldman More articles by this author , and Joel SheinfeldJoel Sheinfeld More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.808AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Risk stratification for patients with advanced disease, completeness of surgery, and improved chemotherapy regimens have resulted in a decrease in the incidence of viable germ cell tumor in resected retroperitoneal specimens. We report on the incidence and clinical outcomes of patients treated with post-chemotherapy lymph node dissection that had residual viable GCT in the retroperitoneum. METHODS From 1989 to 2009, 985 patients with advanced NSGCT were treated with induction and/or salvage chemotherapy followed by PC-RPLND. Following institutional review board approval, complete clinical and pathologic data were obtained from our prospective surgical database. Ninety patients were found to have viable GCT at RPLND. Clinical and pathologic features of patients with viable cancer are reported. Categorical variables were compared using the chi-square or Fisher's exact test. Logistic regression was used to assess factors that were associated with the presence of viable cancer. Survival analysis was performed using the Kaplan-Meier method, and comparisons were made using the log-rank test. RESULTS Viable cancer was more prevalent in patients with increasing clinical stage, IGCCCG risk category, pre-chemotherapy mass size, pre-surgery mass size, elevated AFP, elevated HCG, and patients that received 2nd/3rd line vs. induction chemotherapy. Actuarial 5-year relapse free survival (RFS) was 62% (95% CI 49, 72). RFS was not significantly different between patients that received induction chemotherapy vs. 2nd/3rd line chemotherapy. Adjuvant chemotherapy significantly improved RFS rates in patients that received induction chemotherapy, but not in patients that received 2nd/3rd line chemotherapy prior to PC-RPLND. Actuarial 5-year disease specific survival (DSS) was 71% (95%CI 58,80). Disease specific survival was significantly worse in patients that received 2nd/3rd line chemotherapy (p=0.05). CONCLUSIONS Following chemotherapy a significant number of patients with viable cancer are cured after surgery even in the setting of salvage chemotherapy. Surgery remains an integral component in the multidisciplinary treatment of patients with advanced GCTs. Cure can be achieved in 78% of patients after induction chemo and 58% of patients after salvage chemotherapy at 5 years. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e220-e221 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shilajit Kundu More articles by this author Brett Carver More articles by this author Nicholas Karanikolas More articles by this author George Bosl More articles by this author Robert Motzer More articles by this author Dean Bajorin More articles by this author Darren Feldman More articles by this author Joel Sheinfeld More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The value of physical performance tests for predicting therapy outcome in patients with subacute low back pain: a prospective cohort study

Considering the enormous costs of intensive multidisciplinary treatment, predictive tests for therapy outcome are needed to evaluate patients' performance potential and increase cost effectiveness. Somatic parameters are commonly used to evaluate health status and serve as an additional means of forecasting the prognosis, yet little is known of their validity. In this study, we investigated the prognostic value of somatic parameters regarding the outcome of multidisciplinary treatment in patients with subacute low back pain. The study was designed as a prospective cohort study of 162 patients. Somatic parameters were assessed with three physical performance tests (Villiger test, Oesch test, Biering-Sørensen test) before treatment (T0), after 3 weeks' inpatient therapy (T1) and at 6-month follow-up (T2). Psychometric characteristics of subjective pain perception (VAS), a pain disability index (PDI) and a physical capability index (FFbH-R) were recorded. Correlation coefficients between the physical performance test scores and psychometric characteristics were calculated. To predict therapy outcome, discriminant analyses were performed. A control group (n = 30) was evaluated at similar time points without receiving any therapy. Our results demonstrate good discrimination between patients and controls by means of the investigated performance tests and exhibit a significant negative correlation with the psychometric data. Lower outcome values at study entry correlated with higher pain intensity and disability after multidisciplinary treatment. However, the statistical magnitude of correlation was relatively low and further discriminant analysis did not reveal any predictive value. Consequently the physical performance tests do not have a prognostic value regarding therapy outcome.

Orthopedic surgery implications of breast cancer

Breast cancer is the most common malignancy and the second leading cause of death in women. The metastatic involvement of bone denotes disease progression and decreased survival. Controversy exists regarding the exact pathophysiologic mechanism of metastasis and the different pathways that determine an osteoblastic versus osteoclastic bone compromise. Several breakthrough advances in imaging techniques aid in the detection, staging and follow-up of bone metastases. Although usually responsive to hormonal therapy and pharmacologic interventions, skeletal metastases often require some type of surgical intervention. Orthopedic surgeons should establish an active role in the multidisciplinary treatment of patients with breast cancer.

Multidisciplinary treatment of patients with hepatocellular carcinoma

Hepatocellular carcinoma is one of the most common malignancies in the world. When it is diagnosed, patients can choose from among several potentially curative treatments, such as surgical resection, transplantation, ablation therapy and transcatheter arterial chemoembolization. This review will give an overview of the present management of hepatocellular carcinoma. Liver transplantation is considered the best curative option, achieving a high rate of complete response, especially in patients with small hepatocellular carcinoma and good residual liver function. However, a shortage of donor livers restricts the availability of transplantation. In addition, only a minority of patients with hepatocellular carcinoma can be treated surgically, owing to impaired hepatic reserve, multiple intrahepatic lesions, extrahepatic lesions and the inability to obtain an optimal tumor-free margin. Therefore, for most patients, other types of interventions (transcatheter arterial chemoembolization, percutaneous ethanol injection and radiofrequency ablation) have been developed. Among them, two local ablative modalities, percutaneous ethanol injection and percutaneous radiofrequency ablation, have been accepted as the only potentially curative nonsurgical treatments for hepatocellular carcinoma. Radiofrequency ablation may become a standard nonsurgical treatment option for patients with early hepatocellular carcinoma.

New Indication for Reduction Surgery in Patients with Advanced Hepatocellular Carcinoma with Major Vascular Involvement

The prognosis of advanced hepatocellular carcinoma (HCC) remains poor, particularly in patients with tumor thrombi (TT) in the major vessels. From July 1992 to October 2004, 161 patients diagnosed as having advanced HCC with major vascular involvement were seen consecutively at our hospital. Among these patients, 32 (20%) underwent surgical resection [16 complete resection (CR), 16 reductive resection (RR)]. Eighteen patients (11%) received radiotherapy (RT), 73 (45%) underwent transcatheter arterial chemoembolization (TACE) or transcatheter arterial infusion chemotherapy (TAI), 8 (5%) with distant metastases received systemic chemotherapy, and 30 (19%) received palliative therapy. Excluding the CR group, the patients in the RR group had a higher 1-year survival rate than the other treatment groups. However, there was no significant difference in the overall survival rates of the RR, RT, and TACE/TAI groups. When we evaluated prognostic factors to clarify the indications for RR in the multidisciplinary treatment of patients with advanced HCC with TT, prothrombin activity (PA) was identified as a significant independent preoperative factor for overall survival in the RR group. The survival rate in patients with PA of < or = 78% was significantly lower than that of patients with PA of > 78% (P = 0.0004). The median survival time of patients with serum PA of > 78% who underwent RR was 13.9 months and that of patients who underwent CR was 9.1 months, with no survival difference between the groups. In advanced HCC with major vascular involvement, patients who had RR with PA of greater 78% achieved a similar survival to those who had CR. The surgeon should still proceed with RR in those patients with serum PA of > 78% if CR does not seem feasible on preoperative evaluation.

Biology and therapeutic advances for pediatric osteosarcoma.

Osteosarcoma is the most common malignant bone tumor in children and adolescents. Survival for these patients was poor with the use of surgery and/or radiotherapy. The introduction of multi-agent chemotherapy dramatically improved the outcome for these patients and the majority of modern series report 3-year disease-free survival of 60%-70%. This paper describes current strategies for treating patients with osteosarcoma as well as review of the clinical features, radiologic and diagnostic work-up, and pathology. The authors review the state of the art management for patients with osteosarcoma in North America and Europe including the use of limb-salvage procedures and reconstruction as well as discuss the etiologic and biologic factors associated with tumor development. Therapy-related sequelae and future directions in the biology and therapy for these patients are also discussed.

Timectomía en la miastenia gravis

To analyze outcome after thymectomy in patients with myasthenia gravis (MG). Thirty-five patients with MG underwent surgery in our service between June 1987 and June 1998. Ten had associated thymomas. Preoperative Osserman classification showed 2 at level I, 20 at level IIA, 11 at level IIB and 2 at level III. Extended thymectomy through a medial sternotomy was performed in all. Postoperative complications developed in three patients (1 medullary aplasia, 1 postoperative reintubation, 1 myasthenic crisis). Mean follow-up was 89 months, with 22.8% achieving complete remission and 97.1% reporting improvements. The results were similar in the 10 patients with thymomas (20% full remission and 90% showing improvement). By DeFilippi classification, 22.8% were in class 1, 22.8% in class 2, 51.4% in class 3 and 2.8% in class 4. By Osserman classification, 9 were in the same category before and after surgery, 12 had improved one level, 10 had improved 2 levels, 3 had improved 3 levels and 1 patient had improved 4 levels. Thymectomy is an appropriate therapeutic procedure in the multidisciplinary treatment of patients with MG and it is the approach of choice for patients with associated thymomas. The intra- and post-operative complication rate is low and the rate of clinical improvement is high.

The use of bupropion in the treatment of restlessness after a traumatic brain injury

The occurrence of restlessness after a traumatic brain injury (TBI) is common. Severe restlessness can be a barrier in the multidisciplinary treatment of patients with TBI. The following case describes a patient with restlessness after a head-on motor vehicle accident. The patient was tachycardic, diaphoretic, demonstrating decerebrate posturing and a Rancho Los Amigos Stage II?III. Significant left lower leg restlessness was severe enough to cause bruising and ulceration. A multidisciplinary look was taken at the effects of using different neurotransmitter modulators in the treatment of restlessness after a TBI. Current biology treatment options include the use of medications that either modulate dopamine or noradrenaline alone. Bupropion effects both the dopaminergic and noradrenergic pathways. In the following case, the patient's restlessness was resistant to almost every medication employed. The only medication that proved to be effective in significantly reducing the patient's restlessness was bupropion. The evidence for the use of bupropion in the treatment of restlessness after a TBI has never been discussed previously, aside from anecdotal accounts. It is hoped that this case will prove insight into another treatment option for patients who have severe restlessness.

Stage-oriented nursing care rates in neurologic rehabilitation

The aim of this pilot study done in a neurological rehabilitation center for children and adolescents was to increase the transparency of costs in relation to work and to gain differentiated daily rates according to the kind and amount of nursing and multidisciplinary treatment of patients in different phases (B, C, D) of neurorehabilitation. Presented and discussed are methods and instruments for performance registration and connecting them to costs. As the study shows quite different daily rates are necessary to assure adequate treatment for young patients in different phases--early to late--of neurological rehabilitation.

Long-term postoperative survival of a gastric cancer patient with numerous para-aortic lymph node metastases.

A56-year-old man with advanced gastric cancer was referred to our hospital. Preoperative abdominal computed tomography revealed numerous enlarged lymph nodes, including the lymph nodes of the paraaortic region. The patient underwent total gastralectomy, splenectomy, left-adrenalectomy and resection of the body and tail of the pancreas by Appleby's method, along with paraaortic lymph node dissection. Microscopic examination revealed that the tumor was a solid type, poorly differentiated adenocarcinoma, which displayed invasion of the serosal surface. There were apparently many lymph node metastases. We identified 31 cancer-positive paraaortic nodes, while the total number of lymph node metastases was 81. It was not possible to administer sufficient postoperative adjuvant chemotherapy, as the patient experienced postoperative complications, including pancreatic fistula and watery diarrhea. Despite the lack of sufficient chemotherapy, the patient has subsequently remained disease-free for 9 years and 3 months, and continues to visit our hospital as an outpatient. In conclusion, we wish to emphasize the need for a critical application of paraaortic lymph node dissection as one modality of multidisciplinary treatment in patients with advanced gastric cancer in whom paraaortic lymph node metastasis is strongly suspected preoperatively.

Multidisciplinary treatment of patients with gender dysphoria

Patients with gender dysphoria are best treated by a multidisciplinary team. Such a team consists of a nucleus of specialists who sees the patient frequently and a peripheral group that sees patients incidentally. The tasks of each team member are described, and the value of the multidisciplinary cooperation is highlighted. Gender dysphoria patients are better treated with a team approach than with treatment by individual specialists who are working independently of one another.

Transcatheter Arterial Embolization of Vesical Artery in the Treatment of Invasive Bladder Cancer

Transcatheter arterial embolization was performed in a total of 70 patients with invasive bladder cancer from October 1980 to December 1987. It was performed as a part of multidisciplinary treatment in patients with invasive bladder cancer. Microencapsulated mitomycin C, gelatin sponge and lipiodol (iodized oil) were used as the embolic material. As a result, reduction of tumor size was noted in 56.7%, but there was no embolic materials-related significant difference. Stage reduction was noted in 72.7% of patients where pathological stages were confirmed by operation. Hemostatic effects were noted in 76.5%. The symptoms of side effects included fever, leukocytosis, urinary frequency and pain, but none of them was severe. The results of the present study indicate that embolization of the vesical artery is useful in the treatment of bladder cancer.