Multimodal Treatment Approach Research Articles

Infant malignant ectomesenchymoma masquerading as inguinal hernia in two patients

Infant malignant ectomesenchymoma masquerading as inguinal hernia in two patients

Proposal for a Novel Grading System for Rhino-Maxillary Mucormycosis Based on the Analysis of 30 Cases

We analyzed the data of 30 randomly selected individuals, who had visited a maxillofacial radiology centre in a span of 30 days. The aim was to find a correlation of mucormycosis with various predisposing factors and the clinical progression of the disease in order to develop a system that helps the professionals and the people to detect the condition early and minimize the morbidity and mortality. We graded the patients based on their symptoms, clinical features, and CBCT findings into Grade 1 - mild cases. Grade 2 - moderate cases. Grade 3 - severe cases. Successful management of mucormycosis is based on early detection, multimodal treatment approach, including reversal or discontinuation of underlying predisposing factor, early administration of active antifungal agents at the optimal dose, complete removal of all infected tissues and the use of various adjunctive therapies.

The contemporary role of metastasectomy in the management of metastatic RCC

Metastasectomy was initially described in the 1970s as a therapeutic strategy for patients with metastatic renal cell carcinoma. Since that time, systemic therapy options have grown exponentially, most recently with the introduction of immunotherapy. We aimed to review the contemporary literature regarding the role of metastasectomy in the era of targeted therapy and immunotherapy. Historically, metastasectomy has benefited patients with small volume, single-organ metastases, with favorable outcomes amongst younger, healthier patients with metastases to specific sites. The interplay between the employment of metastasectomy and systemic therapy has been limited to small, retrospective series with significant patient selection bias. More recently, investigators have conducted randomized controlled trials exploring the use of targeted therapies in the adjuvant setting after metastasectomy. Initial randomized data suggested no benefit in using sorafenib in this setting, and a subsequent study demonstrated possible harm in using pazopanib after metastasectomy. However, the role of other novel systemic therapies, including immunotherapy, nor the timing of use, have been meaningfully explored. Metastasectomy appears to be a valuable therapeutic option in the properly selected patient, requiring a multi-disciplinary management strategy and, pending future trials, a multimodal treatment approach.

ADHD—What is Behavioral Therapy?

Patient Education| 2021 ADHD—What is Behavioral Therapy? Connected Content Translation: TDAH—¿Qué es la terapia conductual? Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation ADHD—What is Behavioral Therapy? . Pediatric Patient Education 2021; 10.1542/ppe_document162 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All AAP SitesAll PublicationsPediatric Patient Education Search Advanced Search There are specific ways you can help your child with attention deficit/hyperactivity disorder (ADHD) succeed. Read on for information from the American Academy of Pediatrics about behavioral therapy for a child with ADHD. Most experts recommend using both behavioral therapy and medication to treat ADHD depending on the age of the child. This is known as a multimodal treatment approach. There are many forms of behavioral therapy, but all have a common goal—to change the child’s physical and social environments to help him improve his attention and activity. Behavioral therapy has 3 basic principles. Set specific, doable goals. Set clear and reasonable goals for your child, such as staying focused on homework for a certain amount of time or sharing toys with friends. Provide rewards and consequences. Give your child a specified reward (positive reinforcement) every time he... © 2020 American Academy of Pediatrics. All rights reserved. You do not currently have access to this content.

Techniques and strategies for regional anesthesia in acute burn care-a narrative review.

Burn injuries and their treatments result in severe pain. Unlike traumatic injuries that are characterized by a discrete episode of pain followed by recovery, burn-injured patients endure pain for a prolonged period that lasts through wound closure (e.g. background pain, procedural pain, breakthrough pain, neuropathic pain and itch). Regional anesthesia, including peripheral nerve blocks and neuraxial/epidural anesthesia, offers significant benefits to a multimodal approach in pain treatment. A ‘regional-first’ approach to pain management can be incorporated into the workflow of burn centers through engaging regional anesthesiologists and pain medicine practitioners in the care of burn patients. A detailed understanding of peripheral nerve anatomy frames the burn clinician’s perspective when considering a peripheral nerve block/catheter. The infra/supraclavicular nerve block provides excellent coverage for the upper extremity, while the trunk can be covered with a variety of blocks including erector spinae plane and quadratus lumborum plane blocks. The lower extremity is targeted with fascia iliaca plane and sciatic nerve blocks for both donor and recipient sites. Burn centers that adopt regional anesthesia should be aware of potential complications and contraindications to prevent adverse events, including management of local anesthetic toxicity and epidural infections. Management of anticoagulation around regional anesthesia placement is crucial to prevent hematoma and nerve damage. Ultimately, regional anesthesia can facilitate a better patient experience and allow for early therapy and mobility goals that are hallmarks of burn care and rehabilitation.

Immunotherapy: The future of cancer treatment.

Head and neck squamous cell carcinomas (HNSCCs) are one of the most common cancers worldwide. A large number of patients are diagnosed with locally advanced disease and require multimodal treatment approaches. Standard treatment modalities ranging from surgery to chemotherapy and radiation are yielding mixed results. To overcome this hurdle, newer innovative approaches are required to reduce the morbidity and mortality of the patients. In the last few decades, immunotherapy has become an important part of treating some types of cancer. The immune system plays a key role in the development, establishment and progression of HNSCC. A greater understanding of the dysregulation and evasion of the immune system in the evolution and progression of HNSCC provides the basis for improved therapies and outcomes for patients. Newer types of immune treatments are now being studied, and they will impact how we treat cancer in the future. This article provides a brief overview of the current immunotherapeutic strategies for cancer with emphasis on HNSCC.

HGG-21. GERMLINE MUTATIONS IN MSH2 GENE IN PEDIATRIC PATIENTS WITH CONGENITAL AND SPORADIC GLIOBLASTOMA

INTRODUCTIONGlioblastoma (GBM) remains one of the biggest therapeutic challenges in neuro-oncology. In spite of multimodal treatment approaches the prognosis of GBM is extremely poor, median survival is estimated about 12–16 months. Although GBM is one of the most common and malignant primary brain tumors, pediatric glioblastoma, including congenital is a very rare tumor, with an incidence of about 1.1–3.4 per million live births. Moreover, the mode of presentation, behavior, response to therapy and molecular background of pediatric glioblastomas differs from adult type of GBM. Until now, about ten patients with congenital glioblastoma have been described and in none of them germline markers were examined. Here we report two patients with GBM, one with congenital tumor with germline mutations in MSH2 gene.METHODSTargeted Next-Generation Sequencing (NGS) of the probands DNA extracted from leucocytes was performed using the TruSight One sequencing panel on an Illumina HiSeq 1500. Applied gene panel investigated the coding sequence and splice sites of 4813 genes associated with known disease phenotypes. The NGS data were analyzed using an in-house procedure. Identified variants were validated by Sanger sequencing.RESULTSNGS analysis of patients constitutional DNA revealed know, pathogenic variants c.940C>T and c.942 + 3A>T in MSH2 gene (NM_000251.3) associated with MMR-dependent hereditary cancer syndromes.CONCLUSIONMolecular analysis are heavily needed for better understanding of pediatric GBM etiology and new treatment modality implementation. Identification of this oncogenic driver may provide insight into the pathogenesis of GBM, including congenital cases. Funded by National Science Centre, Poland (2016/23/B/NZ2/03064 and 2016/21/B/NZ2/01785).

Clinical application of photobiomodulation therapy in a zoological setting

Photobiomodulation therapy (PBMT) uses wavelengths of light that have biostimulatory effects on target tissues. This results in three primary therapeutic effects: anti-inflammatory, analgesia and the regeneration of damaged tissues. The application of PBMT is non-invasive, painless and is often used as an adjunctive therapy to multimodal treatment approaches in zoological settings. Individual treatment plans are required; plans must consider species variability in patient size, skin thickness, coat colour and the depth of the target tissue. Treatment can often be achieved through positive reinforcement training and in a minimally invasive way to ensure the welfare of the patient. The medical benefits of PBMT in zoo animals are poorly described in the literature and confounding factors make it challenging to prove treatment efficacy.

Predicting survival in anaplastic astrocytoma patients in a single-center cohort of 108 patients

BackgroundCurrent guidelines for the treatment of anaplastic astrocytoma (AA) recommend maximal safe resection followed by radiotherapy and chemotherapy. Despite this multimodal treatment approach, patients have a limited life expectancy. In the present study, we identified variables associated with overall survival (OS) and constructed a model score to predict the OS of patients with AA at the time of their primary diagnosis.MethodsWe retrospectively evaluated 108 patients with newly diagnosed AA. The patient and tumor characteristics were analyzed for their impact on OS. Variables significantly associated with OS on multivariable analysis were included in our score. The final algorithm was based on the 36-month survival rates corresponding to each characteristic.ResultsOn univariate analysis, age, Karnofsky performance status, isocitrate dehydrogenase status, and extent of resection were significantly associated with OS. On multivariable analysis all four variables remained significant and were consequently incorporated in the score. The total score ranges from 20 to 33 points. We designated three prognostic groups: A (20–25), B (26–29), and C (30–33 points) with 36-month OS rates of 23%, 71%, and 100%, respectively. The OS rate at 5 years was 8% in group A, 61% in group B and 88% in group C.ConclusionsOur model score predicts the OS of patients newly diagnosed with AA and distinguishes patients with a poor survival prognosis from those with a greater life expectancy. Independent and prospective validation is needed. The upcoming changes of the WHO classification of brain tumors as well as the practice changing results from the CATNON trial will most likely require adaption of the score.

Robotic or laparoscopic surgery for rectal cancer - which is the best answer? A comprehensive review of oncological outcomes

Treatment of rectal cancer is ever evolving with the introduction of newer surgical technologies and multimodal treatment approach. The literature evaluating the various surgical treatment options with regards to operative and nonoperative outcomes is abundant. This is a comprehensive review focused on oncological outcomes of rectal cancer resection performed robotically or laparoscopically. Based on the current literature available, there is no significant difference in total mesorectal excision completeness, lymph node harvest, positive circumferential resection margin, or proximal resection margin between robotic and laparoscopic approaches for rectal resection. Selection of surgical approach should not be based on pathological outcomes as they are equivalent.

Disentangling the therapeutic tactics in GBM: From bench to bedside and beyond.

Glioblastoma multiforme (GBM) is one of the most common and malignant form of adult brain tumor with a high mortality rate and dismal prognosis. The present standard treatment comprising surgical resection followed by radiation and chemotherapy using temozolomide can broaden patient's survival to some extent. However, the advantages are not palliative due to the development of resistance to the drug and tumor recurrence following the multimodal treatment approaches due to both intra- and intertumoral heterogeneity of GBM. One of the major contributors to temozolomide resistance is O6 -methylguanine-DNA methyltransferase. Furthermore, deficiency of mismatch repair, base excision repair, and cytoprotective autophagy adds to temozolomide obstruction. Rising proof additionally showed that a small population of cells displaying certain stem cell markers, known as glioma stem cells, adds on to the resistance and tumor progression. Collectively, these findings necessitate the discovery of novel therapeutic avenues for treating glioblastoma. As of late, after understanding the pathophysiology and biology of GBM, some novel therapeutic discoveries, such as drug repurposing, targeted molecules, immunotherapies, antimitotic therapies, and microRNAs, have been developed as new potential treatments for glioblastoma. To help illustrate, "what are the mechanisms of resistance to temozolomide" and "what kind of alternative therapeutics can be suggested" with this fatal disease, a detailed history of these has been discussed in this review article, all with a hope to develop an effective treatment strategy for GBM.

CTIM-06. DENDRITIC CELL VACCINE STUDY FOR RECURRENT, HIGH-GRADE GLIOMA: TISSUE-BASED RNA SEQUENCING AND SERUM CYTOKINE LEVELS AS POTENTIAL BIOMARKERS

Abstract BACKGROUND Glioblastoma is the most common primary malignant brain tumor. Despite multimodality treatment approach, median progression-free survival (PFS) is only 8 months, median overall-survival (OS) 14 months and 5-year survival rate of under 10%. Dendritic cells (DCs) are the professional antigen presenting cells of the immune system. The rationale for sensitizing dendritic cells to a pool of non-selected tumor antigens is based on the marked heterogeneity present within glioblastoma tumor cells. METHODS Phase 1/feasibility study of DC vaccine for recurrent high-grade glioma was conducted. Pooled, non-selected tumor antigens collected via tumor cell lysate were used for DC sensitization. RNA sequencing analysis was performed on all tumor samples. Cytokine levels in serum were detected using a Luminex cytokine panel. RESULTS A total of 20 patients were enrolled onto this study (median age 58yrs, range: 39–74, 65% male). Pathology showed WHO grade IV glioblastoma in 14 (70%) and grade III anaplastic astrocytoma in 6 (30%) patients. IDH wild type in 19 (95%) patients. Treatment emergent adverse events (all grades, regardless of attribution) occurred in more than 15% of the patients (20% fatigue, 15% dizziness, 15% headache, none leading to treatment discontinuation). There were five grade 3–4 and none grade 5 events. One grade 4 event (seizure) probable related to investigational treatment leading to treatment discontinuation. Four grade 3 events (dysphasia, possible related; intracranial hemorrhage unrelated; muscle weakness, unlikely related and hematoma, unrelated). Median PFS was 3.8 months. Median OS was 11 months. RNA sequencing in tumor samples and correlation with cytokine levels in serum is currently been analyzed. CONCLUSION Tumor lysate pulsed DC vaccination demonstrates acceptable safety and tolerability in high-grade glioma patients. Evaluations of integrating molecular profiling RNA sequencing information and cytokine levels to identify potential subset of patients with significant clinical benefit will be provided.

Cytoreductive surgery and HIPEC in colorectal cancer—did we get hold of the wrong end of the stick?

SummaryCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are a multimodal treatment approach combining surgical interventions of varying extent with administration of heated cytostatic drugs flushed through the abdominal cavity. Hitherto, this treatment has been popular for peritoneal metastasis (PM), e.g. from colorectal cancer (CRC). Recent randomized controlled trials (RCT) question the benefit of HIPEC in its present form for CRC treatment and raise fundamental issues, eliciting discussions and expert statements regarding HIPEC relevance and interpretation of these results. Unfortunately, such discussions have to remain uninformed, due to the lacking publication of crucial peer reviewed RCT results. Novel basic research aware of HIPEC futility suggests there may be systematic limitations. Innovative modelling approaches for HIPEC may shed light on the reasons for therapeutic failure of frequently used drugs and may lead the way to select better alternatives and/or more rational approaches for the design of HIPEC procedures (e.g. regarding exposure time or temperature). Available evidence strongly supports the notion that CRS is the mainstay for the treatment effects observed in PM from CRC. Unfortunately, HIPEC has become a surrogate for surgical expertise in the field and optimal surgery may therefore outweigh the potentially harmful effects of HIPEC treatment, particularly in lieu of modern systemic chemotherapies. The current situation which frequently is assumed to be deadlocked should be regarded as a challenge to investigate HIPEC with well-designed prospective clinical trials, potentially even constituting an opportunity for introducing innovative trial designs that solve the multifaceted issues of a very heterogeneous treatment approach.

Association of Planning Target Volume with Patient Outcome in Inoperable Stage III NSCLC Treated with Chemoradiotherapy: A Comprehensive Single-Center Analysis.

Simple SummaryNon-small cell lung cancer (NSCLC) in stage III is often inoperable and highly heterogeneous. The primary gross tumor volume is prognostically relevant in several types of cancer, including oral carcinoma, B-cell lymphoma, and sarcoma. The planning target volume (PTV), including the primary tumor and involved lymph node stations, can vary widely, and its prognostic value for stage III is unclear. We aimed to evaluate the impact of the PTV for overall survival (OS), progression-free survival, and loco-regional control in 122 consecutive patients treated with definitive chemoradiotherapy (CRT). Median follow-up for the entire cohort was 41.2 (range: 4–108) months; median overall survival (OS) reached 20.9 (95% CI: 14.5–27.3) months. In a multivariate analysis including age, gender, total radiation dose, and histology, PTV ≥ 700 ccm was found to be an independent prognostic factor for OS (hazard ratio (HR): 1.705, 95% confidence interval (CI): 1.071–2.714, p = 0.025). In conclusion, non-operable stage III NSCLC patients with PTV ≥ 700 ccm showed significantly detrimental outcomes after conventionally fractionated CRT. PTV should be considered as a stratification factor in multimodal clinical trials for inoperable stage III NSCLC.Inoperable stage III non-small cell lung cancer (NSCLC) represents a highly heterogeneous patient cohort. Multimodal treatment approaches including radiotherapy have been the new standard of care, with promising outcomes. The planning target volume (PTV), including the primary tumor, involved lymph node stations and safety margins, can vary widely. In order to evaluate the impact of the PTV for overall survival (OS), progression-free survival (PFS) and loco-regional control, we analyzed retrospective and prospective data of 122 consecutive patients with inoperable stage III NSCLC treated with CRT. The majority of patients (93%) received a total dose ≥ 60 Gy and 92% of all patients were treated with concurrent or sequential chemotherapy. Median follow-up for the entire cohort was 41.2 (range: 3.7–108.4) months; median overall survival (OS) reached 20.9 (95% CI: 14.5–27.3) months. PTVs from 500 to 800 ccm were evaluated for their association with survival in a univariate analysis. In a multivariate analysis including age, gender, total radiation dose and histology, PTV ≥ 700 ccm remained a significant prognosticator of OS (HR: 1.705, 95% CI: 1.071–2.714, p = 0.025). After propensity score matching (PSM) analysis with exact matching for Union internationale contre le cancer (UICC) TNM Classification (7th ed.)T- and N-stage, patients with PTV < 700 ccm reached a median PFS and OS of 11.6 (95% CI: 7.3–15.9) and 34.5 (95% CI: 25.6–43.4) months vs. 6.2 (95% CI: 3.1–9.3) (p = 0.057) and 12.7 (95% CI: 8.5–16.9) (p < 0.001) months in patients with PTV ≥ 700 ccm, respectively. Inoperable stage III NSCLC patients with PTV ≥ 700 ccm had significantly detrimental outcomes after conventionally fractionated CRT. PTV should be considered as a stratification factor in multimodal clinical trials for inoperable stage III NSCLC.

Longitudinal Outcomes of a Multimodal Treatment Approach Including Mandibular Distraction Osteogenesis and Continuous Positive Airway Pressure for Pierre Robin Sequence

Longitudinal Outcomes of a Multimodal Treatment Approach Including Mandibular Distraction Osteogenesis and Continuous Positive Airway Pressure for Pierre Robin Sequence

Treating acne scars in 2020: Use of lasers

AbstractBackgroundAcne scarring is an unfortunate complication of acne vulgaris. Acne scars occur in nearly 49% of people that suffer from acne and has shown psychosocial effects such as poor self‐esteem, social isolation, low confidence, in addition to a significant depression risk factor and suicide. Multimodal treatment approaches can improve efficacy and treatment considerations should be based on individualized patients. Utilizing lasers in treating acne scars as well as acne scars in ethnic skin are reviewed. Energy‐based devices include fractional (ablative and nonablative) for moderate to severe acne in addition to novel device systems.MethodsA literature review of treating acne scars with lasers including pulse dye laser, fractional (ablative and nonablative), picosecond, and novel devices.ResultsUse of lasers in treating acne scars is an effective approach and multimodal device options for acne scarring are presented in the review.ConclusionAcne‐scarring laser treatment modalities and evidence‐based treatments should be promoted for each individual patient. Updated laser treatments for acne scarring are covered, in addition to ethnic skin, along with a discussion and selection on laser treatment modalities.

Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment.

Fibromyalgia is characterized by chronic widespread pain, fatigue, sleep disturbances and functional symptoms. The etiopathogenesis, diagnostic criteria and classification criteria of fibromyalgia are still debated and, consequently, so are the strategies for treating this condition. Fibromyalgia is the third most frequent musculoskeletal condition, and its prevalence increases with age. However, although diagnosis has improved with the evolution of more accurate diagnostic criteria, a considerable proportion of physicians still fail to recognize the syndrome. Many factors contribute to the development of fibromyalgia in a unique manner: genetic predisposition, personal experiences, emotional-cognitive factors, the mind-body relationship and a biopsychological ability to cope with stress. The multiple components of the pathogenesis and maintenance of the condition necessitate a multi-modal treatment approach. Individually tailored treatment is an important consideration, with the increasing recognition that different fibromyalgia subgroups exist with different clinical characteristics. Consequently, although an evidence-based approach to fibromyalgia management is always desirable, the approach of physicians is inevitably empirical, and must have the aim of creating a strong alliance with the patient and formulating shared, realistic treatment goals.

Les critères de qualité de la chirurgie carcinologique: Quality criteria for lung cancer surgery

AbstractFor a patient with an early-stage non-small cell lung cancer (NSCLC) surgical resection remains the treatment of choice on the condition that a complete resection is obtained. As clinical staging may be quite different from pathological staging, peroperative evaluation of the primary tumour and locoregional lymph nodes is required to decide on the extent of resection and determine the ultimate prognosis of the patient. A systematic nodal dissection is necessary to obtain a precise nodal evaluation and accurate pathological staging. The simplest indicator of what constitutes an adequate intraoperative lymph node evaluation is adherence to the International Association for the Study of Lung Cancer (IASLC) guidelines, which specify the removal/examination of at least 3 intrapulmonary and 3 mediastinal lymph node stations, including subcarinal station 7 in all cases.The fundamental oncological principles of lung cancer treatment should guide our surgical interventions, either in daily practice or clinical research, especially in the era of the advent of alternative ablative therapies or multimodal treatment approaches with or without surgery. Quality assessment involves the surgeon and the pathologist equally. The most relevant information is completeness of resection [R0], which is the more reliable surrogate of long-term survival. Currently, most resections would be classified as uncertain or R[un] due to the inappropriateness of intraoperative lymph node evaluation.© 2020 SPLF. Published by Elsevier Masson SAS. All rights reserved.

7.5 AUTISM SPECTRUM DISORDER AND PSYCHOSIS: A CHALLENGING INTERSECTION FOR CLINICIAN, PATIENT, AND CAREGIVERS

Although individuals with autism spectrum disorder (ASD) develop psychotic symptoms at 3 times the rate of the general population, it remains an underrecognized and poorly understood phenomena. For some individuals with ASD, emerging psychotic symptoms can progress into a major thought disorder, such as schizophrenia or bipolar disorder, which are associated with significant morbidity and chronicity. Thus, signs of psychosis in ASD should prompt clinical attention and, when appropriate, early intervention. The objectives of this session are to: 1) identify the etiology and common presentations of psychosis in ASD; 2) discuss the differential diagnosis and assessment of psychosis in ASD including potential epiphenomena and diagnostic overshadowing; 3) review multimodal treatment approaches to psychosis in ASD; and 4) integrate and apply this material through several longitudinal clinical cases of psychosis in ASD.

Gliomas, germ cell tumors, and craniopharyngioma.

This report summarizes the current multimodality treatment approaches for children with low- and high-grade gliomas, germinoma, and nongerminomatous germ cell tumors, and craniopharyngiomas used in the Children's Oncology Group (COG) and the International Society of Pediatric Oncology (SIOP). Treatment recommendations are provided in the context of historical approaches regarding the roles of surgery, radiation, and chemotherapy. Future research strategies for these tumors in both COG and SIOP are also discussed.