Preferred Treatment Approach Research Articles

Preferred treatment approach to De Quervain Tenosynovitis in nursing women: conservative management or surgery?

We aimed to show the effectiveness of different treatment methods in the prevention of clinical symptoms and recurrence of De Quervain Tenosynovitis (DQT), which is often seen in nursing women. Three different treatment methods were used in 124 patients, all of whom were breastfeeding women who visited our clinic between 2017-2022 with a positive Finkelstein test and DQT. Group I comprised 56 patients who underwent surgical treatment under local anesthesia, Group II, 41 patients who received steroid injections as conservative treatment, and Group III, 27 patients who received wrist splints. The patient files of all groups were reviewed retrospectively, and the effects of the treatment methods on clinical symptoms and recurrence were investigated in patients who were followed up at the 2nd, 4th and 8th weeks. The recurrence rate of Group I patients, which were treated surgically, was significantly lower than that of Group II and III (p=0.0001). Among those who received conservative treatment, patients in Group II had significantly lower recurrence rates than those in Group III. At the 8th week of treatment, clinical symptoms had improved by 96.45%, 58.5%, and 7.4% in Groups I, II, and III, respectively. It is thought that the repetitive movements made during baby care and the edema that develops in breastfeeding women prepare the ground for DQT. Surgery is the most effective treatment method for the improvement of clinical symptoms and prevention of recurrence.

The Healthy Adult in Schema Therapy: Using the Octopus Metaphor

This conceptual paper presents the Healthy Adult mode in Schema Therapy using the octopus metaphor. As a relatively new form of integrative psychotherapy, Schema Therapy has in recent times become increasingly popular among psychotherapists, as a preferred transdiagnostic treatment approach. Schema Therapy, however, is not free from theoretical criticisms and practical challenges. The aim of this article is twofold. First, to offer clients a simple, pictorial, creative, powerful, and memorable metaphor that they can use to develop and strengthen their Healthy Adult mode as a positive psychological intervention to achieve their goals. Second, to present a parsimonious, creative, and flexible model, aligned with the integrative psychotherapy tradition, for psychotherapists to blend into their own style and practice. Drawing on relevant theoretical and empirical findings, and taking a scientist-practitioner stance, this article unpacks the therapeutic factors and mechanisms of change embedded in the use of metaphor, and how they can be integrated into Schema Therapy. The article elucidates the psychological linkages between theory and practice, and highlights the corresponding outcomes and benefits for clients. Thereby, it contributes to the multiple nuances and versions of Schema Therapy and integrative psychotherapy.

Prognostic Nutritional Index (PNI) and Neutrophil to Lymphocyte Ratio (NLR) as Predictors of Short-Term Survival in Patients with Advanced Malignant Biliary Obstruction Treated with Percutaneous Transhepatic Biliary Drainage

Effective biliary tree decompression plays a central role in the palliation of malignant biliary obstruction (MBO). When endoscopic drainage is unfeasible or unsuccessful, percutaneous transhepatic biliary drainage (PTBD) is the method of choice and preferred treatment approach in advanced hilar MBO. The prognostic nutritional index (PNI) reflects the patient's immunonutritional status, while the neutrophil to lymphocyte ratio (NLR) reflects the patient's inflammation status. The aim of the present study was to evaluate the prognostic value of preprocedural PNI and NLR on short-term survival in the advanced stage MBO population threatened with PTBD and to characterize the differences in immunonutritional and inflammatory status between 60-day survivors and non-survivors, as well as analyze other variables influencing short-term survival. This single-center retrospective study was conducted on patients undergoing palliative PTBD caused by MBO as a definitive therapeutic treatment between March 2020 and February 2022. After the procedure, patients were followed until the end of August 2022. A total of 136 patients with malignant biliary obstruction were included in the study. Based on receiver operating characteristic (ROC) curve analysis, optimal cut off-values for NLR (3) and PNI (36.7) were determined. In univariate regression analysis, age, absolute neutrophil count, albumin level, NLR ≤ 3, and PNI ≥ 36.7 were significant predictors of 60-day survival. Level of obstruction and PNI ≥ 36.7 were statistically significant independent predictors of 60-day survival in a multivariate regression model. Using PNI ≥ 36.7 as a significant coefficient from the multivariate regression model with the addition of NLR ≤ 3 from univariate analysis, a 60-day survival score was developed. PNI and NLR are easy to calculate from routine blood analysis, which is regularly conducted for cancer patients. As such, they represent easily available, highly reproducible, and inexpensive tests capable of expressing the severity of systemic inflammatory responses in patients with cancer. Our study highlights that preprocedural PNI and NLR values provide predictors of short-term survival in patients with MBO treated with palliative PTBD. In addition, the proposed 60-day survival score can contribute to better selection of future candidates for PTBD and recognition of high-risk patients with expected poor outcomes.

Economic Effects of Fixed-Dose Versus Loose-Dose Combination Therapy for Type 2 Diabetes Patients.

We examined the effects of fixe-dose combinations (FDCs) versus loose-dose combinations (LDCs) on costs from the payer and patient perspective and investigated potential channels contributing to differences in costs between the two modes of treatment. We investigated administrative data from 2017 to 2020 on diabetes patients in Germany. After using prospensity-score matching to remove dissimilarities between FDC and LDC patients, we compared changes in costs with a difference-in-differences approach. We analyzed pharmaceutical costs, inpatient and outpatient costs, other costs and total healthcare costs from the payer perspective, and co-payments from the patient perspective. The sample comprised 1117 FDC and 1272 LDC patients. Regression analysis revealed that FDC therapy significantly increased antidiabetic pharmaceutical spending in the first year by 5.5% (p<0.01), but decreased co-payments by 33% (p<0.01) in the first and 44% (p<0.01) in the second year. We also observed a trend towards higher outpatient spending in the first year. No significant differences were found with respect to inpatient or other costs. The increase in antidiabetic pharmaceutical spending did not contribute to a significant increase in total healthcare expenditure. We identified a shift of co-payments to the payer and higher adherence as possible mechanisms behind the increase in antidiabetic pharmaceutical spending. Although FDC therapy increased disease-specific pharmaceutical spending in the short term, this increase did not lead to differences in total healthcare costs from the payer perspective. From the patient perspective, FDC therapy may be the preferred treatment approach, because of significant saving in co-payments, which is likely attributable to the elimination of one co-payment and therefore a shift in costs to the payer.

First-Line Treatment of Waldenström’s Macroglobulinaemia: Considerations Based on the Dutch National Guideline

Waldenström macroglobulinemia (WM) is a rare B-cell Non-Hodgkin Lymphoma. There are only few prospective randomized clinical trials to guide treatment recommendations and there is no international consensus on a preferred first line treatment approach. In the recently revised Dutch guideline for WM, we describe recommendations for practice based as much as possible on the known data. Here, we summarize the considerations for first-line treatment based on these Dutch guidelines. Available evidence is summarized, including efficacy and toxicity data. Combinations of Rituximab with chemotherapy, proteasome inhibition or BTK-inhibition are all valid first line treatment options. The Dutch WM working group considers Dexamethasone/Rituximab/Cylofosfamide (DRC) a suitable first-line treatment for many WM patients, given the efficacy, the relatively mild toxicity profile and the extensive experience with this regimen. However, the long-term toxicities of DRC are unclear and need further clarification. Other regimens such as R-bendamustine, R-Bortezomib-dexamethason are also effective options, however with specific toxicities. BTK-inhibitors are not a preferred option in first line for most patients in the Dutch WM guidelines because of the need for longterm treatment and toxicities. Based on patient preferences research, future clinical trials should focus on effective fixed-duration regimens with non-cytotoxic therapies that have a favorable toxicity profile. Further development of (combinations with) BCL-2 inhibititors, novel proteasome inhibitors and BTK-inhibition could be interesting. In addition T-cell-directed treatments including bispecific antibodies as a monotherapy or combined with other novel agents deserve further study in WM.

Enhancing Radiation Therapy Plan Quality in a Multi-Site Randomized Clinical Trial with a Benchmark Credentialing Exercise: The VA STARPORT Experience

<h3>Purpose/Objective(s)</h3> VA STARPORT is a phase 2/3 trial comparing systemic therapy +/- PET-directed, metastasis directed radiation therapy (RT) for oligo recurrent prostate cancer enrolling at 16 sites. RT options include SBRT to metastases only or elective nodal RT with a simultaneous integrated boost (ENRT+SIB). We hypothesized that benchmark credentialing exercise results that were shared across study sites would enhance protocol understanding, increase compliance, and identify opportunities to improve the study protocol. <h3>Materials/Methods</h3> A hypothetical benchmark patient scenario was created including prior definitive prostate RT with recurrences in a right obturator node, right external iliac node, and right iliac bone. OARs, target structures, and prior RT dosimetry were created on an open-source CT dataset. The benchmark exercise included: Phase 1: Each site described their preferred protocol treatment approach (SBRT or ENRT+SIB) and RT details (dose, fractions, PTV margins, and method to address prior RT). Phase 2: Each site performed 2 standardized treatment planning exercises on the dataset (SBRT vs. ENRT+SIB). Compliance worksheets summarized and assessed dose metrics, target coverage, and conformality. Plan DICOM files, worksheets, and IMRT QA were submitted for central RT quality assurance (RTQA). Phase 3: SBRT and ENRT + SIB plans were scored by the study RTQA team using a numerical plan scoring system. Scorecards and lessons learned were discussed with local investigators and further communicated to all study sites. <h3>Results</h3> Site survey results (n=16) revealed 8 preferred ENRT+SIB. Only 4 ENRT+SIB prescriptions were per-protocol, and there was PTV margin non-compliance in an intended SBRT plan. Benchmark lessons learned are summarized in the Table. <h3>Conclusion</h3> A practical and useful benchmark exercise successfully assessed protocol compliance, revealed key lessons, and identified ways to improve the protocol's RT section and RTQA process. Teaching points and learned planning strategies were shared across study sites and have a potential to improve metastasis-directed RT planning for both trial and non-trial patients at each facility.

Patterns of Care after 68Ga-PSMA-PET in Patients with Radiorecurrent Localized Only Prostate Cancer

<h3>Purpose/Objective(s)</h3> Utilization of molecular imaging in men with recurrent prostate cancer after definitive treatment is rapidly increasing. However, randomized data to guide preferred treatment approaches after molecular imaging are lacking, particularly for men with radiorecurrent, localized-only disease. We sought to evaluate patterns of care in these men, in order to understand the referral patterns and care plans implemented as a result of molecular imaging. <h3>Materials/Methods</h3> From 2018-2020, 822 men were enrolled at a single institution on a prospective study (NCT03396874) assessing the diagnostic performance of ⁶⁸Ga-PSMA-11 PET (PSMA) in men with biochemical recurrence after initial definitive therapy. Among the 196 (24%) treated with upfront definitive radiation therapy (RT), 58 had an isolated local recurrence and form the cohort for the present analysis. We evaluated the patterns of care including specialty of ordering provider, patterns of consulted specialties after PSMA, and subsequent management. <h3>Results</h3> Fifty-eight men had PSMA positive radiorecurrent localized-only disease (n=58/196, 30%). PSMA for these men was most ordered by medical oncology (38%), urology (36%), and radiation oncology (24%). Median PSA at time of PSMA was 4.6 ng/mL. Median interval between initial RT and PSMA was 9 years. After PSMA, 101 consultations were completed, 40 urology (40%), 33 radiation oncology (32%), and 28 medical oncology (28%). Twenty-one percent of men saw all three specialties (n=12), 38% two (n=22), and 41% one (n=24). Thirty-nine men (67%) underwent prostate MRI, and 35 (60%) had a prostate biopsy. In total, 26 men (45%) underwent local therapy, which included salvage RT in 14 men (54%) [brachytherapy (n=9), SBRT (n=5)], cryotherapy/HIFU in 11 men (42%), and salvage prostatectomy for one (4%). Among the 28 patients (48%) not undergoing local therapy, 32% (n=9) were poor local therapy candidates due to poor GU/GI quality of life or prior focal therapy and received systemic therapy alone. Approximately one-third of patients underwent observation (n=19), driven frequently by patient preference rather than local therapy eligibility or age-related comorbidities (n=12/19). Patient management and treatment varied by the specialty ordering the PSMA and subsequent referral patterns. <h3>Conclusion</h3> Our data demonstrate significant heterogeneity in the management of patients with PSMA radiorecurrent localized-only prostate cancer. Treatment varied by ordering physician specialty and subsequent referral patterns after PSMA. As molecular imaging becomes more ubiquitous, our data demonstrate the need for multidisciplinary discussion as well as randomized trials in these patients to help guide the optimal treatment approach for this population.

LAPAROSCOPIC PERITONEAL EXCISION OF ENDOMETRIOSIS IMPROVES IN VITRO FERTILIZATION (IVF) LIVE BIRTH RATES IN WOMEN < 41 YEARS OF AGE WITH DIMINISHED OVARIAN RESERVE

In vitro fertilization (IVF) has become the preferred treatment approach for women with diminished ovarian reserve (DOR). Although there is a high prevalence of endometriosis in this population, data is lacking as it relates to the potential benefits of laparoscopy prior to IVF. The aim of this study is to determine whether laparoscopic peritoneal excision of endometriosis improves IVF live birth rates in women under 41 years of age with DOR.

S6K1 amplification confers innate resistance to CDK4/6 inhibitors through activating c-Myc pathway in patients with estrogen receptor-positive breast cancer

BackgroundCDK4/6 inhibitors combined with endocrine therapy has become the preferred treatment approach for patients with estrogen receptor-positive metastatic breast cancer. However, the predictive biomarkers and mechanisms of innate resistance to CDK4/6 inhibitors remain largely unknown. We sought to elucidate the molecular hallmarks and therapeutically actionable features of patients with resistance to CDK4/6 inhibitors.MethodsA total of 36 patients received palbociclib and endocrine therapy were included in this study as the discovery cohort. Next-generation sequencing of circulating tumour DNA in these patients was performed to evaluate somatic alterations associated with innate resistance to palbociclib. Then the candidate biomarker was validated in another independent cohort of 104 patients and publicly available datasets. The resistance was verified in parental MCF-7 and T47D cells, as well as their derivatives with small interfering RNA transfection and lentivirus infection. The relevant mechanism was examined by RNA sequencing, chromatin immunoprecipitation and luciferase assay. Patient-derived organoid and patient-derived xenografts studies were utilized to evaluated the antitumor activity of rational combinations.ResultsIn the discovery cohort, S6K1 amplification (3/35, 9%) was identified as an important reason for innate resistance to CDK4/6 inhibitors. In the independent cohort, S6K1 was overexpressed in 15/104 (14%) patients. In those who had received palbociclib treatment, patients with high-expressed S6K1 had significantly worse progression free survival than those with low S6K1 expression (hazard ratio = 3.0, P = 0.0072). Meta-analysis of public data revealed that patients with S6K1 amplification accounted for 12% of breast cancers. Breast cancer patients with high S6K1 expression had significantly worse relapse-free survival (hazard ratio = 1.31, P < 0.0001). In breast cancer cells, S6K1 overexpression, caused by gene amplification, was sufficient to promote resistance to palbociclib. Mechanistically, S6K1 overexpression increased the expression levels of G1/S transition-related proteins and the phosphorylation of Rb, mainly through the activation of c-Myc pathway. Notably, this resistance could be abrogated by the addition of mTOR inhibitor, which blocked the upstream of S6K1, in vitro and in vivo.ConclusionsS6K1 amplification is an important mechanism of innate resistance to palbociclib in breast cancers. Breast cancers with S6K1 amplification could be considered for combinations of CDK4/6 and S6K1 antagonists.

Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis

AimDefining universally accepted guidelines for the diagnosis and treatment of chronic exertional compartment syndrome (CECS) is hampered by the absence of high-quality scientific research. The aim of this Delphi study was to establish consensus on practical issues guiding diagnosis and treatment of CECS of the leg in civilian and military patient populations.MethodsAn international expert group was queried using the Delphi technique with a traditional three-round electronic consultation. Results of previous rounds were anonymously disclosed in the questionnaire of rounds 2 and 3, if relevant. Consensus was defined as > 70% positive or negative agreement for a question or statement.ResultsThe panel consisted of 27 civilian and military healthcare providers. Consensus was reached on five essential key characteristics of lower leg CECS. The panel achieved partial agreement regarding standardization of the diagnostic protocol, including muscle tissue pressure measurements. Consensus was reached on conservative and surgical treatment regimens. However, the experts did not attain consensus on their approach of postoperative rehabilitation and preferred treatment approach of recurrent or residual disease. A summary of best clinical practice for the diagnosis and management of CECS was formulated by experts working in civilian and military healthcare facilities.ConclusionThe Delphi panel reached consensus on key criteria for signs and symptoms of CECS and several aspects for conservative and surgical treatment. The panel did not agree on the role of ICP values in the diagnostic process, postoperative rehabilitation guidelines protocol, or the preferred treatment approach for recurrent or residual disease. These aspects serve as a first attempt to initiate simple guidelines for clinical practice.

Attitudes toward innovative mental health treatment approaches in Germany: E-mental health and home treatment.

E-mental health and home treatment are treatment approaches that have proven to be effective, but are only slowly implemented in the German health care system. This paper explores the attitudes toward these innovative treatment approaches. Data was collected in two large, non-clinical samples representative of the German population in spring 2020 (N = 2,503) and winter 2020/2021 (N = 2,519). Statistical associations between variables were examined using two-tailed tests. Binary and multinomial logistic regressions were performed to predict attitudes toward online-based treatment concepts and home treatment approaches. Only few (<20%) people preferred online-based treatment approaches, while a larger proportion (~50%) could imagine being treated at home. Overall, younger subjects were more open to online-therapy approaches, while people with lower education preferred more often a traditional therapy setting. Acceptance of online-therapy did not raise significantly during the first months of the COVID-19 pandemic. When different online-based treatment options were available, the probability of accepting home treatment significantly increased with increasing levels of therapeutic support. Further promotion of acceptance for online-therapy and home treatment seems to be necessary. In the future, more information on innovative treatment approaches should be actively provided.

Oncological and functional outcomes after testis-sparing surgery in patients with germ cell tumors: a systematic review of 285 cases

Introduction and objectivesIn several urogenital cancers, organ-preserving surgery represents the preferred treatment approach, but in patients with testicular germ cell tumors (tGCTs), radical orchiectomy represents the standard of care. This study aimed to summarize published case series assessing oncological and functional outcomes after testis-sparing surgery (TSS) in patients with tGCTs.Materials and methodsA systematic literature review and individual patient data meta-analysis were conducted of published cases with tGCT treated with TSS.ResultsOf 2,333 reports, we included 32 reports providing data on 285 patients, including 306 testicles treated with TSS. Adjacent germ cell neoplasia in situ (GCNIS) was described in 43%. Hypogonadism and infertility after TSS were diagnosed in 27% and 18%. In patients undergoing adjuvant testicular radiotherapy, hypogonadism was diagnosed in 40%. Patients treated with adjuvant testicular radiotherapy after TSS exhibited a significantly lower incidence of local recurrence (2% vs. 50%, p < 0.001). Distant metastases after TSS were observed in 2%.ConclusionThe current data questions the benefits of TSS in tGCT patients. If at all, TSS should only be offered to well-informed patients with a singular testicle, excellent compliance, a singular tumor less than 2 cm located at the lower pole of the testicle, and normal preoperative endocrine function. Unless patients plan to father a child within a short time frame, adjuvant testicular radiotherapy should be recommended after TSS. Radical orchiectomy remains the standard of care, but future studies may support the use of TSS in selected men.

Patient Preferences for Neoadjuvant Therapy in Pancreatic Ductal Adenocarcinoma.

Physicians are increasingly recommending neoadjuvant therapy (NT) before surgery for pancreatic ductal adenocarcinoma (PDAC). However, patient preferences for and opinions regarding NT are poorly understood. Survivors and caregivers from a national PDAC patient advocacy organization completed an online survey assessing preferences for NT versus surgery first (SF) and factors influencing their decision making. Among 54 participants, 74.1% had a personal history of PDAC. While most patients preferred SF for resectable disease, NT was the preferred treatment approach for borderline resectable, locally advanced, and resectable cancers with high carbohydrate antigen 19-9. The most important factor influencing patient decision making regarding NT was its impact on overall survival while the least important was published national guidelines. The most preferred rationale for NT was ability to downstage to surgical resection and early treatment of micrometastatic disease. Among a national cohort of PDAC survivors and caregivers, the majority preferred SF for resectable PDAC, whereas NT was preferred when the resectability of a tumor was in question. The impact of NT on quantity and quality of life, as well as the likelihood of achieving surgical resection, was most highly valued by participants.

Outcomes of neoadjuvant combination chemotherapy with and without targeted therapy in HER2-positive breast cancer: A real-world experience from tertiary care center in North India.

e12601 Background: Neoadjuvant chemotherapy (NACT) with HER2 blockade is preferred approach for treatment of early and locally advanced HER2 positive breast cancer. However, there is a lack of survival data with respect to pathological complete response (pCR) from India. Methods: We retrospectively evaluated 211 HER2 positive female breast cancer patients registered between years 2014 and 2021, who received three different NACT regimens (i) Anthracycline free TCH (n=116) [docetaxel (75mg/m2), carboplatin (AUC = 6) and trastuzumab (8mg/kg loading followed by 6mg/kg) with G-CSF q 21 days], (ii) EC-TH (n=52) [epirubicin (90 mg/m2) and cyclophosphamide (600 mg/m2) for 4 cycles followed by 4 cycles of docetaxel (85mg/m2)] and (iii) EC-T (n=43, without trastuzumab due to financial constraints). Primary end point was pCR. Secondary end points were disease free survival (DFS), Overall Survival (OS) and safety profile. Results: Median age was 45 years (24-71), 88 (41.7%) were postmenopausal and 104 (49.3%) were ER/PR positive. Twenty-two (10.4%) patients were stage II, 164 (77.7.%) were stage III and 25 (11.9%) were oligometastatic stage IV. Distribution of age, performance status, tumor size and nodal positivity were comparable across the study groups. Pathological CR in trastuzumab containing groups, was higher compared to non-trastuzumab containing group (35.8% vs 20%, p=0.045) and was similar between, TCH and EC-TH groups. Median follow-up was 32.9 months (5.7-108), 3-year DFS and OS were 54.8% and 92.1% respectively. Pathological CR rates and survival outcomes of the three groups are given in table 1. When stratified by pCR status, in the trastuzumab containing groups, achievement of pCR translated to improved DFS (log rank p=0.01). This survival advantage of pCR was not seen in non-trastuzumab containing group. The outcome of trastuzumab containing both regimens were similar. Grade 3/4 toxicities were recorded in 21.6% of TCH, 26.7% of EC-TH and in 25.2% of EC-T groups. Most common toxicities were anemia (16.3%), thrombocytopenia (14.2%) and vomiting (10.2%). Conclusions: Trastuzumab containing regimens impact pCR rates and in turn the survival outcomes among Indian women with HER2 positive breast cancer. Safety and efficacy of anthracycline free TCH regimen is comparable with EC-TH.[Table: see text]

Safety and Efficacy of Inpatient Diabetes Management with Non-insulin Agents: an Overview of International Practices.

Purpose of ReviewThe field of inpatient diabetes has advanced significantly over the last 20 years, leading to the development of personalized treatment approaches. However, outdated guidelines still recommend the use of basal-bolus insulin therapy as the preferred treatment approach, and against the use of non-insulin anti-hyperglycemic agents.Recent FindingsSeveral observational and prospective randomized controlled studies have demonstrated that oral anti-hyperglycemic agents are widely used in the hospital, including studies of DPP-4 agents and GLP-1 agonists.SummaryWith advances in the field of inpatient diabetes management, a paradigm shift has occurred, from an approach of recommending “basal-bolus regimens” for all patients to a more precision medicine option for hospitalized non-critically ill patients with type 2 diabetes.

Role of CDK4/6 inhibitors in patients with hormone receptor (HR)-positive, human epidermal receptor-2 negative (HER-2) metastatic breast cancer study protocol for a systematic review, network meta-analysis and cost-effectiveness analysis

IntroductionIt is currently unclear which cyclin-dependent kinase 4/6 (CDK4/6) inhibitor, combined with endocrine therapy, is the preferred treatment approach in patients with hormone receptor (HR)-positive, human epidermal receptor-2 (HER2) negative...

Cervical carotid occlusion in acute ischemic stroke: Should we give tPA?

Background: Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions.Methods: Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach.Results: Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality.Conclusion: Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.

Comparisons between lysis and lavage, intra-articular steroid injections, and three-point subsynovial steroid injections using operative single-cannula arthroscopy — A retrospective analysis

The aim of this study is to compare the effectiveness of intra-articular and three-point sub-synovial steroid injections.In this retrospective Cohort study an OSCA lysis and lavage, intra-articular and threepoint sub-synovial steroid injections were performed and the maximal interincisinal opening (MIO), pain using 10- point visual analog scale (VAS) and quality of life (QOL) were measured one week before the procedure and 1, 3, 6, 12 months, and 2 and 3years after surgery.Sixty-five patients suffering from internal derangement refractory to conservative treatment charts were reviewed. successfully lowered pain (p value = 0.0012), and improved mouth opening (p value = 0.023), and quality of life (QoL) (p value = 0.003) for up to 6 months after surgery. OSCA with intra-articular CS injections effectively lowered pain (p value = 0.0025), and improved mouth opening (p value = 0.03) and QoL (p value = 0.004) for 12 months. In comparison, OSCA with sub-synovial steroid injections was significantly effective in lowering pain (p value = 0.000002), improving mouth opening (p value = 0.000004), and QoL (p value p = 0.000006) for the duration of the 36-month follow-up period within the limitations of the study it seems that the OSCA technique with site-specific, sub-synovial CS injections should be the preferred treatment approach when the priority is long-term success concerning pain relief, increased mouth opening and improved quality of life in Wilkes II-IV patients.

Epidemiology of early esophageal adenocarcinoma.

Background/AimsEndoscopic resection has become the preferred treatment approach for select early esophageal adenocarcinoma (EAC); however, the epidemiology of early stage disease has not been well defined. MethodsSurveillance Epidemiology and End Results (SEER) data were analyzed to determine age-adjusted incidence rates among major epithelial carcinomas, including EAC, from 1973 to 2017. The percent change in incidence over time was compared according to tumor subtype. Early T-stage, node-negative EAC without metastasis was examined from 2004 to 2017 when precise T-stage data were available. ResultsThe percent change in annual incidence from 1973 to 2017 was 767% for EAC. Joinpoint analysis showed that the average annual percent change in EAC from 1973 to 2017 was 5.11% (95% confidence interval, 4.66%–5.56%). The annual percent change appeared to plateau between 2004 and 2017; however, early EAC decreased from 2010 to 2017, with an annual percent change of –5.78%. ConclusionsThere has been a 7-fold increase in the incidence of EAC, which was significantly greater than that of the other major epithelial malignancies examined. More recently, the incidence of early EAC has been decreasing. Approximately one in five patients has node negative, potentially resectable early stage disease.

Optimal surgical treatment for paratesticular leiomyosarcoma: retrospective analysis of 217 reported cases

BackgroundParatesticular leiomyosarcoma (LMS) is a rare tumor. Conventionally, tumor resection by high inguinal orchiectomy is performed as the preferred treatment approach for paratesticular sarcoma. On the other hand, testis-sparing surgery has recently attracted attention as a less-invasive treatment option for paratesticular sarcoma. However, the prognostic predictors and optimal treatment strategy for paratesticular LMS remain unclear because of its rarity. In this study, we systematically reviewed previously reported cases of paratesticular LMS to evaluate the prognostic factors and establish the optimal treatment strategy.MethodsA systematic search of Medline, Web of Science, Embase, and Google was performed to find articles describing localized paratesticular LMS published between 1971 and 2020 in English. The final cohort included 217 patients in 167 articles. The starting point of this study was the time of definitive surgical treatment, and the end point was the time of local recurrence (LR), distant metastasis (DM), and disease-specific mortality.ResultsPatients with cutaneous LMS had a slightly better LR-free survival, DM-free survival, and disease-specific survival than those with subcutaneous LMS (p = 0.745, p = 0.033, and p = 0.126, respectively). Patients with higher grade tumors had a significantly higher risk of DM and disease-specific mortality (Grade 3 vs Grade 1 p < 0.001, and Grade 3 vs Grade 1 p < 0.001, respectively). In addition, those with a microscopic positive margin had a significantly higher risk of LR and DM than those with a negative margin (p < 0.001, and p = 0.018, respectively). Patients who underwent simple tumorectomy had a slightly higher risk of LR than those who underwent high inguinal orchiectomy (p = 0.067). Subgroup analysis of cutaneous LMS demonstrated that the difference in LR between simple tumorectomy and high inguinal orchiectomy was limited (p = 0.212). On the other hand, subgroup analysis of subcutaneous LMS revealed a significant difference in LR (p = 0.039).ConclusionsOur study demonstrated that subcutaneous LMS and high-grade tumors are prognostic factors for paratesticular LMS. For subcutaneous LMS, tumorectomy with high inguinal orchiectomy should be the optimal treatment strategy to achieve a negative surgical margin.