Practical Approach For Treatment Research Articles

Warfarin overdose successfully treated using prophylactic vitamin K infusion without severe coagulopathy: A case report.

Warfarin, a vitamin K antagonist, is widely used for preventing and treating thromboembolic diseases. While guidelines exist for managing elevated prothrombin time-international normalized ratio (INR) in patients on warfarin, the treatment for warfarin overdose in these patients is yet to be standardized. A 41-year-old woman ingested 230 mg of warfarin with suicidal intent, along with other medications. Initially unconscious, her INR was 1.0, and laboratory results were normal. Prophylactic continuous menaquinone-4, vitamin K2, injections were administered before the INR increased. After stopping vitamin K2 72 h later, her INR rose to 1.8, but she recovered without severe coagulopathy or bleeding, despite a high initial warfarin concentration. This is the first case of warfarin overdose managed with prophylactic vitamin K2 injections before INR elevation, successfully preventing severe complications. Prophylactic vitamin K infusion may be a practical approach for warfarin overdose treatment in non-dependent patients.

Expanded Lateral Thoracic Flap and Torso Advancement Flap for the Treatment of Postburn Breast Deformity.

Deep burns to the upper abdomen that involve the submammary fold can lead to downward contracture and may cause significant asymmetry in a single breast, which can cause serious aesthetic and psychological problems, especially when they occur during childhood or before puberty. The objective of this study was to establish a practical treatment approach for postburn unilateral breast reconstruction after downward contracture. We conducted this retrospective review of patients with postburn unilateral breast deformity who underwent reconstruction using the expanded lateral thoracic flap and torso advancement flap from 2016 through 2021. We collected data on various characteristics, including patient information, surgical procedure details, number of expanders used, reconstruction effectiveness, and postoperative breast development. A total of 25 patients were included in the study, and all flaps survived. A total of seven complications related to the expander were recorded, including one hematoma, three port and tube issues, two cases of skin ischemia, and one instance of expander exposure. All complications were effectively managed through appropriate interventions. Breast position deviations were corrected, resulting in breast symmetry with the opposite side. The results of this study indicate that the expanded lateral thoracic flap and torso advancement flap procedure can effectively and safely restore the position of postburn breasts and promote symmetrical breast development. This procedure may be one of the options for reconstruction of postburn unilateral breast deformity.

A Montmorillonite-Based Pickering Nanoemulsion for the Integration of Photothermal Therapy and NIR-Responsive Drug Delivery.

Chemo/photothermal combination therapy is a promising and practical approach for cancer treatment which calls for certain nanovehicles to achieve the spatiotemporal co-occurrence of photothermal conversion and drug delivery. Herein, we developed a montmorillonite-based Pickering emulsion equipped with a near-infrared photothermal agent (indocyanine green, ICG) and anticarcinogen (paclitaxel, PTX). With both montmorillonite and ICG functioning as interfacial stabilizers, the Pickering emulsion showed good stability and nanoscale droplet size, which were favored for cellular applications. Due to the vast oil-water interface, where the majority of amphiphilic ICG was prone to distribute, the Pickering nanoemulsion could achieve a higher local concentration of ICG than the aqueous solution, therefore leading to a higher local photothermal performance under near-infrared irradiation. The Pickering nanoemulsion exhibited fast cell penetration, which promoted the photothermal therapeutic effect of ICG. Moreover, the inner phase of the Pickering nanoemulsion also facilitated the loading of PTX, further improving its killing efficacy against cancer cells under near-infrared irradiation, because the photothermal conversion of the Pickering nanoemulsion could not only cause heat damage by itself but also promote the loaded PTX to diffuse out and induce cell death. Therefore, this clay-based Pickering nanoemulsion as a nanovehicle could realize the synergy of chemo- and photothermal therapy.

Current and future advances in practice: SAPHO syndrome and chronic non-bacterial osteitis (CNO).

Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome is a rare, underdiagnosed disease with a wide clinical spectrum. Sterile bone inflammation, predominantly of the anterior chest, and skin manifestations (palmoplantar pustulosis, psoriasis vulgaris and acne) are the key features of SAPHO, which shares certain similarities with SpA. SAPHO is closely related to paediatric chronic non-bacterial osteitis (CNO), a spectrum of autoinflammatory bone diseases. The aetiology of SAPHO is considered multifactorial based on a complex interplay of genetic, immune and infectious factors. Despite the increasing awareness of SAPHO/CNO, diagnostic delay is common, as validated classification and diagnostic criteria are lacking. Treatment of SAPHO represents a challenge and includes anti-inflammatory drugs, antibiotics, bisphosphonates, synthetic conventional DMARDs and off-label use of anti-cytokine biologics and Janus kinase inhibitors. This review summarizes the current diagnostic and practical treatment approach to SAPHO/CNO and highlights the ongoing research endeavours concerning the definition and validation of diagnostic criteria, core domains and treatment.

High relative humidity environment alleviates hypoxia-induced pulmonary arterial hypertension in mice

The environment has long been considered a crucial factor influencing the onset and progression of pulmonary diseases. Environmental therapy is also a practical treatment approach for many conditions. While research has explored the effects of factors like air pressure and oxygen concentration on pulmonary arterial hypertension (PAH), the impact of air humidity on PAH has not been investigated. In this study, we examined the role of different air humidity levels in a mouse model of PAH by controlling relative humidity. We induced PAH in mice using 10 % hypoxia, which led to significant thickening of the pulmonary vasculature, elevated right ventricular systolic pressure, and an increased right ventricular hypertrophy index (RVHI). However, when exposed to an environment with 80–95 % relative humidity, there was a marked reduction in the extent of pulmonary vascular remodeling, decreased vascular thickening, and lower RVHI, effectively preserving right heart function. Notably, changes in the Bmpr2/Tgf-β signaling pathway were significant and may play a pivotal role in this protective effect. In summary, our findings indicate that high relative humidity confers a protective effect on hypoxia-induced PAH in mice, providing novel insights into potential treatments for PAH.

An ultrasensitive electrochemical/colorimetric dual-mode self-powered biosensing platform for lung cancer marker detection by multiple-signal amplification strategy

BackgroundIn recent years, miRNAs have emerged as potentially valuable tumor markers, and their sensitive and accurate detection is crucial for early screening and diagnosis of tumors. However, the analysis of miRNAs faces significant challenges due to their short sequence, susceptibility to degradation, high similarity, low expression level in cells, and stringent requirements for in vitro research environments. Therefore, the development of sensitive and efficient new methods for the detection of tumor markers is crucial for the early intervention of related tumors. ResultsAn ultrasensitive electrochemical/colorimetric dual-mode self-powered biosensor platform is established to detect microRNA-21 (miR-21) via a multi-signal amplification strategy. Gold nanoparticles (AuNPs) and VS4 nanosheets self-assembled 3D nanorods (VS4-Ns-Nrs) are prepared for constructing a superior performance enzyme biofuel cell (EBFC). The double-signal amplification strategy of Y-shaped DNA nanostructure and catalytic hairpin assembly (CHA) is adopted to further improve enhance the strength and specificity of the output signal. In addition, a capacitor is matched with EBFC to generate an instantaneous current that is amplified several times, and the output detection signal is improved once more. At the same time, electrochemical and colorimetric methods are used for dual-mode strategy to achieve the accuracy of detection. The linear range of detection is from 0.001 pg/mL to 1000 pg/mL, with a relatively low limit of detection (LOD) of 0.16 fg/mL (S/N = 3). SignificanceThe established method enables accurate and sensitive detection of markers in patients with lung cancer, providing technical support and data reference for precise identification. It is anticipated to offer a sensitive and practical new technology and approach for early diagnosis, clinical treatment, and drug screening of cancer and other related major diseases.

A practical approach for anabolic treatment of bone fragility with romosozumab.

Romosozumab, a fully humanized anti-sclerostin-antibody, is a bone-builder stimulating osteoblasts and inhibiting osteoclast by activation of the canonical Wnt-beta catenin signaling. This unique mechanism of action has the potential to address unmet needs in osteoporosis management. The multifaceted practical clinical issues related to romosozumab are discussed, especially focusing on the rationale of employing a sclerostin inhibitor to target bone fragility as first line or second line treatment in post-menopausal osteoporosis and in males at increased risk of fractures. Four randomized clinical trials with several post-hoc analyses and more than ten observational studies have consistently demonstrated that romosozumab is effective in rapidly increasing bone mineral density (BMD) and decreasing risk of vertebral, non-vertebral and hip fractures in post-menopausal women at very-high risk of fractures. In male osteoporosis, only data on BMD are available. Noteworthy, romosozumab was shown to be more effective and rapid than teriparatide in improving BMD, bone structure and strength at the hip, especially in women already treated with anti-resorptive drugs. Interestingly, even if romosozumab displays best results in treatment-naïve patients, its favourable effects on BMD were observed even in women previously treated with teriparatide or denosumab, although to a lesser extent. Based on the available evidence, romosozumab could be proposed as ideal drug in several clinical settings, such as non-fractured post-menopausal women at very-high risk of fractures, patients with recent hip fracture, patients non responder to bisphosphonates and short-term denosumab therapy.

The Significance of Key Proteins in the RAS Signaling Pathway: Implications for Cancer and Therapeutic Targets

The RAS signaling pathway is a crucial cell transduction pathway central to transmitting signals from outside the cell to the cell nucleus and influencing fundamental biological mechanisms like cell growth, division, and specialization. This signaling pathway has recently received much attention in scientific research because of its involvement in various diseases, especially carcinogenesis. Our study identified the significance of crucial proteins in the RAS signaling cascade in cancer development and progression. We found that proteins such as PDGFRB, PDGFB, IGF1, HRAS, HGF, FGF10, and ABL1 are involved in various types of cancer and could serve as potential therapeutic targets. Misregulation of these proteins may result in unregulated cell proliferation and contribute to cancer development and maintenance. The study also emphasizes the importance of oncogenes in cancer development, with RAS being identified as a pivotal oncogene. In addition, the findings indicate several proteins, including PDGFRA, NRAS, HRAS, CSF1R, KIT, MET, ABL1, FGFR2, FGFR3, and KRAS, function as oncogenes and are related to different forms of cancer and diseases. Targeted therapies for these proteins are being investigated in various cancer types, including gastrointestinal stromal tumors, chronic myelogenous leukemia, and bladder cancer. Moreover, we identified NF1 as a critical tumor suppressor gene essential in regulating cellular proliferation. Mutations in the NF1 gene lead to neurofibromatosis category 1. This paper emphasizes the significance of crucial proteins implicated in the RAS signaling pathway in cancer growth and advancement. Understanding the complexity of these proteins and their dysregulation could offer essential insights into the progression of practical treatment approaches that enhance and refine cancer therapies. These findings provide promising avenues for further research and advances in cancer treatment and give us hope for better outcomes in the fight against this challenging disease.

Rucaparib monotherapy in the heavily pre-treated metastatic castrate-resistant prostate cancer setting: practical considerations and alternate treatment approaches

Rucaparib monotherapy in the heavily pre-treated metastatic castrate-resistant prostate cancer setting: practical considerations and alternate treatment approaches

Hydroxylamine enhanced Fe3O4/H2O2 system for removing tartrazine

In recent years, dye wastewater caused serious effects on environmental ecology and human health. Thus, in the present study, hydroxylamine (HA) was used to improve the Fe3O4/H2O2 process for removing the typical dye pollutant (tartrazine). Only 2.8% tartrazine could be removed in Fe3O4/H2O2 system within 60 min at the reaction of 1 g/L Fe3O4, 1 mM H2O2, and pH 4 while 97.5% tartrazine could be removed within 20 min after adding 1 mM HA into the Fe3O4/H2O2 system. Compared with Fe3O4/H2O2 system, the removal rate for removing tartrazine in Fe3O4-HA/H2O2 system could enhance more than 100 times. Electron paramagnetic resonance tests (EPR), radical quenching experiments and quantitative determination demonstrated that •OH was the major reactive species for removing tartrazine in Fe3O4-HA/H2O2 system and •OH produced concentration in Fe3O4-HA/H2O2 system was also much higher than that in Fe3O4/H2O2 system. The key factors affecting tartrazine removal in Fe3O4-HA/H2O2 system were also conducted. The optimal HA dosage, Fe3O4 dosage, and H2O2 dosage was 1 mM, 1 g/L and 1 mM. The optimal initial pH in Fe3O4-HA/H2O2 system was 3, but compared with Fe3O4/H2O2 system, the tatrazine removal efficiency could significantly improve under any initial pH condition. Fe3O4-HA/H2O2 process had strong adaptability to inorganic ions and good applicability to different pollutants. Fe3O4-HA/H2O2 process also exhibited good recycle ability for tartrazine removal. Overall, Fe3O4-HA/H2O2 process is an effective and good practical applicability approach for dye wastewater treatment.

Effect of Shunthi dhanyaka sadhita jala and lifestyle modifications in the management of Prameha purvarupa (prediabetes): An observation

In prediabetes, the blood glucose levels are higher than normal but not enough to qualify as diabetes. The prevalence of prediabetes in India is 14%. Prevention of prediabetes would prevent life-threatening consequences. Prameha purvarupa (~prodromal symptoms of diabetes mellitus) in Ayurveda correlates clinically to the features of prediabetes. Prameha purvarupa is a Santarpanottha (~sedentary lifestyle related) and Meda pradoshaja vikara (~disorder of adipose tissue) that typically manifests in individuals who are Chankramana dveshi (~aversion to walking) and is brought on by vitiated Doshas (~regulatory functional factors of the body) and Dushyas (~which gets vitiated by aggravated Doshas). Elevation of blood glucose level in prediabetes may be considered retention of Ama (~metabolic toxins) in the body. A 38-year-old prediabetic female, unable to lose weight after several attempts, was managed for three months with Shunthi dhanyaka sadhita jala (~water processed with dry ginger, and coriander). In addition, she was also suggested Chankramana (~brisk walking) during the early hours of the day and Swabhavika nidra (~regular and natural sleep). Improvement in glycosylated hemoglobin, and disappearance of Prameha purvarupa such as Karapada tala daha (~burning sensation of palms and soles), Madhura asyata (~sweet taste in mouth), and weight loss after three months of management. The case report depicts the effectiveness of a simple, practical, and affordable Ayurvedic treatment approach in the management of prediabetic conditions.

Effectiveness of telerehabilitation intervention to improve pain and physical function in people with patellofemoral pain syndrome: study protocol for a randomized controlled trial

BackgroundPatellofemoral pain syndrome (PFPS) is a common musculoskeletal condition in young and active adults. Exercise therapy is an essential part of rehabilitation in people with PFPS (PwPFPS). Telerehabilitation is an innovative treatment approach that has been used in several musculoskeletal conditions. This study aims to investigate the non-inferiority of telerehabilitation through a smartphone application, the Vito App, compared to face-to-face physical therapy on reducing pain and improving physical function, quality of life, and psychological factors.MethodsThis randomized controlled trial will include 60 PwPFPS. to a control group (face-to-face physical therapy) or an experimental group (telerehabilitation). The intervention for both groups consists of stretching, strengthening, balance, and functional exercises for 6 weeks and three sessions per week. The primary outcomes are pain intensity by visual analog scale (VAS), physical function by the Kujala questionnaire and functional tests including the bilateral squat, anteromedial lunge, and step down, and quality of life by the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire quality of life subscale. Secondary outcomes are psychological factors such as anxiety and depression assessed with the Hospital Anxiety and Depression Scale (HADS) questionnaire, kinesiophobia assessed with the Tampa scale, and pain catastrophizing assessed with the Pain Catastrophizing Scale (PCS). Assessments will be held in 3 phases: pre-test (before the intervention), post-test (after the 6 weeks of intervention), and follow-up (1 month after the end of the intervention).DiscussionWe expect that both the control group and experimental group will show similar improvements in clinical and psychological outcome measures. If our hypothesis becomes true, PwPFPS can use telerehabilitation as a practical treatment approach. Telerehabilitation can also enhance accessibility to rehabilitation services for active adults and for people living in remote and rural areas.Trial registrationIranian Registry of Clinical Trials (IRCT) IRCT20201112049361N1. Registered on 29 October 2022.

Outcomes of Venoplasty with Stent Implantation in Patients with Chronic Venous Symptoms following Deep Vein Thrombosis in the Iliofemoral Segment

Background and Objectives Deep vein thrombosis (DVT) is a common vascular condition that affects 1 to 3 per 1,000 people annually. Proximal thrombosis (including iliac veins) poses a higher risk for postthrombotic syndrome (PTS). Therefore, the present study investigated the outcomes of venoplasty with stent placement in patients with chronic venous symptoms following DVT in the iliofemoral segment. Subjects and Methods This cross-sectional study included patients with an age range of 20 to 70 years who presented with chronic symptoms of iliofemoral obstructive venous lesion following DVT. They received local anesthesia with lidocaine, and if necessary, by venous sedation under lower extremity venography using catheter with popliteal vein surgery on the same side and placement of a sheet. Pre-intervention and six-month post-intervention data on relevant variables were collected, documented, and subjected to analysis. Results Of the 24 patients participating in the study, 70.8% were male and 29.2% were female with a mean age of 51.42 ± 8.27 years. There was a significant difference in pain and wound condition before and 6 months after the intervention (P <0.001). After the intervention, 58.3% of the patients were in painless condition, and the frequency of patients without wounds increased from 12.5% to 66.7%. Edema changes were not significant (P = 0.29) Conclusion Stent placement for patients experiencing chronic venous symptoms secondary to iliofemoral DVT demonstrates efficacy in pain reduction and wound healing, establishing itself as a practical and user-friendly treatment approach.

CAR T-cell therapy and the onco-nephrologist.

Cell therapy, specifically the revolutionary chimeric antigen receptor (CAR) T-cell therapy, has transformed the landscape of oncology, making substantial strides in practical treatment approaches. Today, established guidelines for diseases such as lymphomas, myelomas, and leukemias actively advocate the utilization of these once-unconventional therapies. The practical impact of these therapies is underscored by their unparalleled efficacy, reshaping the way we approach and implement treatments in the realm of oncology. However, CAR T-cell therapy, with its performance in anti-tumor aggression through cellular action and inflammatory response, also comes with various adverse events, one of which is kidney injury. Therefore, the management of these side effects is extremely important. The integration of knowledge between oncologists and specialized nephrologists has led to the emergence of a new sub-area of expertise for onco-nephrologists specializing in managing kidney complications from immune effector therapies.

Heart Failure Registries in Asia – What Have We Learned?

Heart Failure (HF) is one of the leading problems in cardiology practice today. Acute decompensated heart failure (ADHF) is a significant cause of mortality and morbidity worldwide, and this is more relevant in the Asian subcontinent with a high population burden. Various regional registries in Asia have given us valuable insight into the aetiology and outcomes in this context. Though there are regional differences, it is clear from the review carried out in this paper that HF affects a much younger population. The comorbidities like diabetes and hypertension are high. Chronic kidney disease and atrial fibrillation are higher compared to the Western cohort. Heart failure with preserved ejection fraction is less often seen. The in-hospital mortality ranges from 2.8% to 8.4%. The one-year mortality is higher, and re-hospitalization is very high. Though in many Asian countries, guideline-directed medical therapy is initiated in hospitals, adherence is low. This is the challenge, and the way forward is only a practical team-based heart failure treatment approach. In the modern-day world of digital technology, the onus is on us to develop an integrated system of care in HF. This is by using available resources and opening up HF clinics. This review compares the strengths and limitations of various heart failure registries conducted in Asia and also gives a direction to plan effective strategies for improving heart failure care.

Optimal strategies of oncolytic virus-bortezomib therapy via the apoptotic, necroptotic, and oncolysis signaling network.

Bortezomib and oncolytic virotherapy are two emerging targeted cancer therapies. Bortezomib, a proteasome inhibitor, disrupts protein degradation in cells, leading to the accumulation of unfolded proteins that induce apoptosis. On the other hand, virotherapy uses genetically modified oncolytic viruses (OVs) to infect cancer cells, trigger cell lysis, and activate anti-tumor response. Despite progress in cancer treatment, identifying administration protocols for therapeutic agents remains a significant concern, aiming to strike a balance between efficacy, minimizing toxicity, and administrative costs. In this work, optimal control theory was employed to design a cost-effective and efficient co-administration protocols for bortezomib and OVs that could significantly diminish the population of cancer cells via the cell death program with the NF$ \kappa $B-BAX-RIP1 signaling network. Both linear and quadratic control strategies were explored to obtain practical treatment approaches by adapting necroptosis protocols to efficient cell death programs. Our findings demonstrated that a combination therapy commencing with the administration of OVs followed by bortezomib infusions yields an effective tumor-killing outcome. These results could provide valuable guidance for the development of clinical administration protocols in cancer treatment.

Investigation of DNA Hybridization on Nano-Structured Plasmonic Surfaces for Identifying Nasopharyngeal Viruses.

Recently, studies have revealed that human herpesvirus 4 (HHV-4), also known as the Epstein-Barr virus, might be associated with the severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Compared to SARS-CoV-2 infection alone, patients coinfected with SARS-CoV-2 and HHV-4 had higher risks of fever, inflammation, and even death, thus, confirming that HHV-4/SARS-CoV-2 coinfection in patients could benefit from clinical investigation. Although several intelligent devices can simultaneously discern multiple genes related to SARS-CoV-2, most operate via label-based detection, which restricts them from directly measuring the product. In this study, we developed a device that can replicate and detect SARS-CoV-2 and HHV-4 DNA. This device can conduct a duplex polymerase chain reaction (PCR) in a microfluidic channel and detect replicates in a non-labeled manner through a plasmonic-based sensor. Compared to traditional instruments, this device can reduce the required PCR time by 55% while yielding a similar amount of amplicon. Moreover, our device's limit of detection (LOD) reached 100 fg/mL, while prior non-labeled sensors for SARS-CoV-2 detection were in the range of ng/mL to pg/mL. Furthermore, the device can detect desired genes by extracting cells artificially infected with HHV-4/SARS-CoV-2. We expect that this device will be able to help verify HHV-4/SARS-CoV-2 coinfected patients and assist in the evaluation of practical treatment approaches.

Chemical properties and inhibitory activities of tyrosinase, α‐glucosidase, and urease from chloroform extract of Curcuma aromatica Salisb. rhizomes

Abstract"Nghệ trắng" has the scientific name of Curcuma aromatica Salisb., belongs to the Ginger family (Zingiberaceae), and its rhizomes are used to prevent aging, anti‐inflammatory, and improve skin. From the chloroform extract of C. aromatica, six known compounds, including (‐)‐hannokinol (1), (3R,5R)‐3,5‐diacetoxy‐1,7‐bis(4‐hydroxyphenyl)heptane (2), naringenin (3), 2‐(4‐(hydroxymethyl)phenyl)propan‐2‐ol (4), 5‐hydroxymethylfurfural (5), and bisacurone (6), were isolated. Structures of all compounds were elucidated by analyzing NMR data together with comparing them to references. All isolated compounds were found for the first time in the C. aromatia rhizomes grown in Vietnam. The results of bioactivity evaluation showed that naringenin (3) has an effect against tyrosinase and α‐glucosidase with the IC50 values of 96.4 and 248.2 μM, respectively. (‐)‐Hannokinol (1) is a moderate bioactivity ingredient capable to inhibiting α‐glucosidase and urease with the IC50 value of 216.4 and 244.4 μM, respectively. Consequently, these results suggest that chloroform extract of C. aromatica may be a practical therapeutic approach for diabetes, melanogenesis, and stomach ulcer treatment.

1008 Excessive daytime sleepiness in myotonic dystrophy treated with modafinil

Abstract Introduction Physiology of excessive daytime sleepiness (EDS) in myotonic dystrophy type 1 (DM1) remains incompletely understood and best practice treatment approaches are unclear. Report of case(s) We present a 73-year-old man with atrial fibrillation, implantable cardioverter defibrillator for inducible ventricular tachycardia, hypertension, and severe obstructive sleep apnea (OSA) was referred after a recent diagnosis of myotonic dystrophy type 1 (DM1) for EDS. He presented with foot pain, balance issues, and falls. A subdural hemorrhage from a fall prompted thorough evaluation including electromyography. This showed length-dependent polyneuropathy type pattern with features of subacute and chronic denervation change and myotonic discharges in right vastus medialis and bilateral tibialis anterior and gastrocnemius muscles. Myotonic Syndrome Advanced Evaluation revealed with a repeat expansion mutation in DMPK gene (85 and 13 CTG repeats). He was previously diagnosed severe OSA with an AHI of 64 and titrated onto bilevel. He recalled no improvement in symptoms with bilevel. He noted sleeping 10-12 hours per night and feeling rested. However, he takes multiple times per day for hours at a time. When actively working on tasks he feels alert and focused. Epworth sleepiness scale (ESS) was 12. Polysomnogram on bilevel followed by MSLT demonstrated control of OSA and mean sleep onset latency of 8 minutes and 5 sleep onset REM periods. With relatively little impairment and a desire for intermittent improved wakefulness, he was started on modafinil 200mg daily as needed. He reported a robust response to modafinil without the need for additional naps or cardiac complications thus far. Repeat ESS only improved to 10. Conclusion This case highlights the need for a precision medicine approach as subpopulations exist even within the specific diagnosis excessive daytime sleepiness in myotonic dystrophy. People with DM1 have been similarly reported with little improvement in ESS but dramatic subjective improvement in symptoms with modafinil. A Cochrane Review and a European Medicines Agency recommendations on modafinil are not supportive of its use in DM1 despite a subpopulation with a clear response. Interestingly, clinical measures do not seem to predict response to modafinil, suggesting unmeasured and, potentially, varied pathologies of excessive daytime sleepiness in DM1. Support (if any)

An evidence-based stepwise approach to orthopedic treatment

Treatment protocols help organize data for accurate diagnosis and treatment planning. The aim was to develop a logical series of steps predicated on the latest credible body of evidence. The steps were developed for Class II patients with hyperdivergent growth patterns. The steps include establishing 1) the patient's problem list to determine the treatment objectives; 2) the theoretical basis modifying growth; 3) the etiology of the problem 4) the growth mechanisms that produce normal growth, and 5) a practical and realistic treatment approach. Departing from traditional assessments by reverse engineering the problem, potential gaps in the application of knowledge to practice may be recognized and addressed.