Previous Treatment Protocols Research Articles

Evidence of resistance to ivermectin in the gastrointestinal nematodes of horses from Mexican southeast.

Gastrointestinal nematodes (GIN) are a major impediment to breeding and exploitation of horses. Traditional control of GIN has generated resistance to main anthelmintics, including ivermectin. An analysis of five ranches with a history of IVM use was done to determine the efficacy and resistance of GIN to IVM treatment in horses from the Mexican southeast. Predesigned questionnaires were applied to collect information on previous treatment protocols. The fecal egg count reduction test (FECRT) was applied to determine resistance. Before IVM application, a McMaster test was used to diagnose GIN infection in horses, and feces cultures were done to identify L3 larvae for Strongylida eggs. Pre-treatment samples showed that 72.7% (80/110) of horses were GIN positive, with cyathostomins being the most frequent (91.8%), followed by Oxyuris equi (7.0%), Parascaris equorum (1.0%), and Strongylus vulgaris (0.2%). Based on the results, the horses at each ranch were divided in control (CG) and experimental (EG) groups with similar eggs per gram of feces (EPG). The EG (40/80) was dewormed with IVM (0.2mg/kg orally) and the CG (40/80) remained untreated. After 14days, EPG were measured, and feces cultures were done again to identify L3 larvae. After treatment of EG, 40% (16/40) of horses were positive, the most frequently identified GIN were cyathostomins (98.6%), followed by P. equorum (1.0%) and S. vulgaris (0.2%). Three of the five ranches were classified as resistant, according to the FECRT, with a percentage of reduction from 53 to 68%, all of which used IVM ≥4 times annually. This is the first evidence of resistance in cyathostomins to IVM treatment in horses from the Mexican southeast, adding to the current problem of anthelmintic resistance in equine GIN.

Positive outcome of administering palonosetron and haloperidol combination in cyclic vomiting syndrome: a case report.

Background: Cyclic vomiting syndrome (CVS) is a rare disorder in which a patient suffers from recurrent episodes of nausea and vomiting. Onset usually occurs early in childhood, later it might progress into a chronic condition highly affecting on the quality of life. No solid treatment protocol is available to treat CVS. There are many cases in which no improvements are observed after years of trying different treatment regimens. Case Presentation: Here we report a 15-year-old female who was diagnosed as a patient of CVS at the age of 7. She was admitted to the medicine ward within 3 hours of onset in the last year. The patient possesses a history of a unique pattern of onset. She has been hit by the recurrence of the disorder almost once in 8-11 months, lasting for 10-14 days, manifesting as intense nausea, and vomiting once in every 20-40 minutes followed by irregular asymptomatic intervals. Various treatment regimens of unsatisfactory outcome were applied on this patient over the years. After analyzing her previous treatment protocols, we decided to try something new and aggressive, moving with palonosetron and haloperidol, a combination that was never applied on this patient. Conclusion: The outcome was ‘magical' according to the parents of the patient marked by declining of the symptom immediately and complete relief within the next 72 hours, the earliest ever after having onset for this particular patient's past history of encountering CVS.

Evaluating the Feasibility and Efficacy of A Novel CBTi/SMT Treatment Protocol for Cardiac Rehab Patients: A Non-Randomized Pilot Trial

ABSTRACT Introduction Cardiac patients and those with chronic medical conditions often suffer from comorbidities such as insomnia and mood disorders. Previous treatment protocols have focused on resolving symptoms of anxiety and depression in this population using Stress Management Training (SMT). However, these treatments have neglected the importance of sleep problems in these patients. This pilot trial sought to address this by examining the feasibility of a novel CBTi/SMT treatment protocol. Methods 42 participants attending a Cardiac Rehab (CR) exercise program registered in this 7-week non-randomized pilot trial. The primary objective of the pilot trial was to determine the feasibility of the protocol for retention and adherence rates. Secondarily, the authors sought to examine the potential efficacy of the program in terms of treating insomnia, depression, anxiety, emotion dysregulation, and arousal. Results 29 participants attended at least 1 class, with 21 participants completing the program. The average attendance for the program completers was 6 out of 7 classes (SD = 0.8) with four days of practice each week (SD = 1.6) for 33 minutes daily (SD = 16.8). Moreover, the number of participants meeting clinical threshold for insomnia, anxiety, and/or depression was significantly reduced at post-treatment and follow-up. Similarly, raw scores on the relevant scales were significantly reduced at both timepoints. Conclusion This pilot trial provided preliminary evidence for the feasibility and efficacy of targeting sleep improvement with a combined CBTi/SMT protocol. This provides the groundwork for future RCTs to establish the effectiveness of targeting insomnia in a range of medical populations.

"ConnectToBrain" : Synergy project for therapeutic closed-loop stimulation of brain network disorders

Therapeutic non-invasive transcranial brain stimulation with previous treatment protocols showed at best moderate effect sizes and large interindividual variability with asubstantial proportion of non-responders. A currently intensively discussed approach to address these problems is individualized closed-loop stimulation. ConnectToBrain is asynergy project funded by the European Research Council to develop noninvasive closed-loop therapeutic stimulation of network disorders of the human brain.It consists of three main pillars: (1)development of amultichannel transcranial magnetic stimulation (mTMS) coil array that covers nearly all of the cerebral cortex and enables highly precise electronic control of location, direction, intensity and timing of the induced electrical fields, (2)development of real-time analysis of activity and connectivity in brain networks using electroencephalography (EEG) for instantaneous spatial and temporal control of stimulation (brain state-dependent, closed-loop stimulation) and adaptive optimization of treatment effects by machine learning and (3)translation of these neurotechnological innovations into physiological and clinical studies.

How Successful is Switching from Bevacizumab or Ranibizumab to Aflibercept in Age-Related Macular Degeneration? A Systematic Overview

Emerging anti-vascular endothelial growth factor (anti-VEGF) therapies for neovascular age-related macular degeneration (nAMD) have revolutionised medical retina practice and the management and eventual outcome of nAMD. Recent research has focused on evaluating and comparing the efficacy of the two most widely employed anti-VEGF agents, bevacizumab and ranibizumab; however, a subgroup of patients with nAMD demonstrates a suboptimal response to standard therapy. We have therefore conducted a review of pertinent studies published until August 2018 which have documented the clinical efficacy when switching to a different anti-VEGF. Evidence on baseline disease characteristics, injection frequency and disease outcome has been obtained for patients treated with ranibizumab 0.5 mg and/or bevacizumab 1.25 mg and were switched to aflibercept 2 mg. Our review identified 45 studies investigating switching to aflibercept. Our review showed a clear anatomical benefit after the switch in terms of central retinal thickness and pigment epithelium detachment characteristics, whereas the functional outcomes were variable. Remarkable heterogeneity was documented among the relevant studies with regard to several factors including the baseline characteristics of the cohorts, the non-response definition and previous treatment protocols. Larger prospective trials with appropriate control arms are therefore required to elucidate the potential benefit when switching between anti-VEGF agents in refractory nAMD.

Bloodstream infections in acute myeloid leukemia patients treated according to the Finnish Leukemia Group AML-2003 protocol – a prospective nationwide study

Background: Infections greatly influence the outcome of acute myeloid leukemia (AML) patients receiving intensive treatment. The aim of this study was to establish the incidence, microbial etiology, risk factors and prognosis of bloodstream infections (BSIs) in patients with AML and compare the results with the previous treatment protocol (AML-92).Methods: Registery data were gathered prospectively from 357 patients aged 16–65 years recruited on the AML-2003 treatment protocol between November 2003 and November 2011 during different treatment cycles.Results: Blood culture data were available on 977 treatment episodes, in which there were 503 BSIs (51%). The overall incidence rate (IR) for BSIs (per 1000 hospital days) was 16.7. Twenty patients (5.6%) died due to an infection and 16 of them (80%) had a BSI. The most commonly detected microbes (polymicrobial episodes included) in blood cultures were coagulase-negative staphylococci (CoNS, 24.7%), viridans group streptococci (VGS, 19.1%), enterococci (13.9%) and Enterobacteriacae group (25.9%). The etiology of BSIs varied greatly from treatment cycle to cycle.Conclusions: Enterococcal BSIs have increased compared to our previous treatment protocol, and they represent significant pathogens in blood cultures. Infection-related mortality has decreased despite the increase in the IR of BSIs. Enterococci seem to be an increasingly prominent pathogen underlying BSIs in the AML patients, especially during induction therapy (20%).

Rapid progression of mixed neuroendocrine carcinoma-acinar adenocarcinoma of the prostate: A case report.

The current study presents the case of a 78-year-old male with mixed neuroendocrine (NE) carcinoma-acinar adenocarcinoma of the prostate. The patient received endocrine therapy (maximal androgen blockade) after the initial diagnosis resulting in a significant decrease in serum prostate-specific antigen (PSA) level. The patient underwent transurethral resection of the prostate after 6 months of androgen-deprivation therapy for extraordinarily salient difficulty in urination, and histopathology demonstrated mixed NE carcinoma-acinar adenocarcinoma once again. The NE prostate cancer progressed rapidly even though the serum PSA was controlled at a low level on account of the endocrine therapy. Previous treatment protocols were replaced by combined chemotherapy and endocrine therapy, and the patient responded well. The patient's serum PSA remained at a low level, however, urethral dilatation for acute urinary retention was required again 5 months later and the lower urinary tract symptoms became increasingly evident. The patient eventually died of cachexia.. These findings indicate that mixed NE carcinoma-acinar adenocarcinoma has a higher degree of malignancy and that endocrine therapy for prostate cancer has a propensity to facilitate progression of this tumor.

Thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An Evidence-based review.

The majority of aluminum phosphide (ALP) toxicity cases are suicidal attempts. Despite advances in critical care medicine, the mortality rate of ALP remains very high. Unfortunately, knowledge on the toxicokinetics of ALP is very low. An obsolete idea was proposed that inhibition of complex IV of cytochrome C oxidase is responsible for multiorgan dysfunction. However, based on human studies, this effect might be insignificant. Thus, a novel idea proposes that the main mechanism might be vascular wall integrity disruption. The low frequency of acute toxicity and unanswered questions about the toxicokinetics and toxicodynamics has led to leaden advances of novel treatments. The aim of this review was to evaluate problems regarding current treatment protocols and propose new ideas based on updated information. For this purpose, we reviewed all available articles on the management of ALP poisoning published to date. Considering failure of conventional therapies on maintaining systolic blood pressure, correcting acid-base disturbances, and support cardiac function, the previous treatment protocols have been overruled. However, repudiate of conventional treatments in this deadly condition is not without penalties for the health-care provider. The introduction of new therapies including refuse of gastric lavage with water-soluble compounds, administration of a high molecular weight colloidal solution for fluid resuscitation and termination using sodium bicarbonate, and vasoactive agents has been prospected to improve patient survival. This protocol is in early clinical evaluation; nevertheless, it appears to improve patient's survival; hence, future randomized trials should be performed to support their effectiveness.

The Effect of a New Type of Dressing for Chronic Venous Wounds

Aims: The aim of the current study was to assess the clinical efficacy of the FlaxAid dressing for the treatment of chronic venous wounds in a patient unresponsive to previous treatment protocols. Presentation of Case: A 50-year old male patient presented with recurrent venous ulcers of the lower extremities. All of the ulcers had lasted for 5 years and their size was increasing despite clinically relevant local therapy. FlaxAid dressing were applied to the wound area in three stages consisting of FlaxAid dressings wetted with: isotonic salt solution; oil emulsion; and seedcake extract. Discussion and Conclusion: After 12 weeks of therapy with the newly developed FlaxAid bandages, all of the patient’s ulcers had been cured. After 6 months of follow-up, the sites of the patient’s ulcers were found to still be in a healthy state. Case Study British Journal of Medicine & Medical Research, 4(12): 2463-2469, 2014 2464

Repair of submucous cleft palate with Furlow palatoplasty

ObjectiveSubmucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI. MethodsThis prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy. ResultsSignificant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory. ConclusionsFurlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

The Application of In Vivo Confocal Scanning Laser Microscopy in the Diagnosis and Evaluation of Treatment Responses in Mooren's Ulcer

To evaluate the extent of corneal inflammation and the response to treatment in patients with Mooren's ulcer, by in vivo confocal microscopy (IVCM). Twenty-two eyes of 15 patients with Mooren's ulcer were enrolled in this prospective study. All subjects underwent routine ophthalmic examinations, IVCM, and conjunctival histopathologic examination of specimens in patients undergoing conjunctival excision. Eyes with active ulcer were treated with topical corticosteroids and additional therapy, depending on the signs and symptoms. Eyes in remission continued to receive the previous treatment protocols. The relation between the severity of ulcer and inflammation status as assessed by IVCM was also studied. The endpoints were inflammatory cell density (ICD), counted by IVCM, and the extent of the limbal arc involved with ulcers. Ten eyes had active corneal ulcers, and 12 eyes had been in remission for the past year. The mean ICD of eyes with active ulcers before treatment was 2092.7 ± 1538.6 cells/mm(2) (range, 835.3-7832.7; 95% CI, 3232.5-952.9). Nine of the eyes improved at 8 weeks, with a decrease in ICD to 249.1 ± 109.0 cells/mm(2) (range, 100.3-595.3; 95% CI, 329.8-168.3). One eye had corneal perforation, and ICD immediately before perforation was 1677.6 ± 247.6 cells/mm(2). The mean ICD of 12 eyes in remission was 357.5 ± 266.8 cells/mm(2) (range, 12.7-1127.0; 95% CI, 555.2-159.8). The correlation of the ICD and the extent of limbal involvement with ulcers was strong (R(2) = 0.8119). ICD evaluated by IVCM is a useful and promising parameter for evaluation of the degree of inflammation in eyes with Mooren's ulcer and for assessment of response to treatment.

Penile Mondor's disease can be effectively treated with the use of an acetyl salicylic acid and pentoxifylline combination

Since penile Mondor's disease is a rare condition, different treatment choices are used. Herein we recommend a new treatment strategy with acetylsalicylic acid and pentoxifylline, which was tested in 14 patients with penile Mondor's disease. Materials and methods: Fourteen patients with the clinical presentation of penile Mondor's disease were included. Patients were given acetylsalicylic acid (ASA) 500 mg qid and pentoxifylline 600 mg bid for 14 days. Physical examinations were performed in all patients. In addition, ultrasonic examinations were done before the treatment and on days 7 and 14 of treatment to evaluate dorsal vein thrombosis. Results: Physical examinations revealed lesions parallel to the coronal sulcus in 9 patients and in the dorsal aspect of the proximal penis in 5 patients. All patients had painful induration of the penis. On day 7, hyperechoic structures were still observed in 8 patients and no thrombus was seen in 6 patients. Ultrasonographic measurements were repeated 14 days after treatment and a hyperechoic structure was observed in 4 patients. No side effects were encountered during the follow-up period. Conclusion: We think that the ASA and pentoxifylline protocol, which is also used for the treatment of thrombotic events in other parts of the body, helps to resolve penile Mondor's disease in a shorter time compared to previous treatment protocols. Further randomized controlled studies are needed for a definitive decision.

Surgical treatment of primary intramedullary spinal cord tumors in adult patients

Primary spinal cord intramedullary tumors are rare and present with insidious symptoms. Previous treatment protocols emphasized biopsy and radiation/chemotherapy but more aggressive protocols have emerged. To report our experience. Forty-eight patients were diagnosed with primary intramedullary tumors. The cervical cord was involved in 27% and thoracic in 42% of patients. Complete microsurgical removal was attempted whenever possible without added neurological morbidity. Complete resection was obtained in 33 (71%) patients. Neurological function remained stable or improved in 32 patients (66.7%). Ependymoma was the most frequent tumor (66.7%). Neurological outcome is superior in patients with subtle findings; aggressive microsurgical resection should be pursued with acceptable neurological outcomes.

EVALUATION OF ENDOTOXIN MODELS FOR THE STUDY OF SEPSIS

Many strategies have been proposed for the treatment of sepsis, and most of the proposed treatment modalities have failed in clinical trials. Many of the previous treatment protocols called for blocking the activity of a single, clearly defined mediator. The underlying hypothesis was that sepsis induced a specific mediator that then caused organ injury and death. This simple, linear reasoning was frequently based on cytokines that were defined using endotoxin models of sepsis. The endotoxin models were widely used to study the pathophysiology of sepsis and were felt to adequately reproduce the full spectrum of inflammatory changes observed in patients with sepsis. Based on mortality and hematologic changes, these assumptions appeared justified. As the models were examined more closely, and directly compared with focus of infection models that more accurately portray the changes in sepsis, it became apparent that the endotoxin models did not accurately mimic the patient with sepsis. In the endotoxin models, the explosive release of cytokines into the circulating blood volume was reproducibly found regardless of the species studied (human, primate, pig, rat, or mouse). This lead to a series of anticytokine sepsis trials, all of which failed. The cytokine response in focus of infection models, such as that induced by cecal ligation and puncture, was examined and found to be more similar to that observed in patients with sepsis. When cytokine inhibitor strategies were used in the cecal ligation and puncture model, they were also generally found to lack efficacy. Compounds that have been shown to be effective at reducing mortality in endotoxin models should be re-evaluated in more clinically relevant models of sepsis.

Inhibition of flexor tone

Purpose: The purpose of this study is to demonstrate a progressive use of neuromuscular electrical stimulation (NMES) by using a systematic approach to the reduction of spasticity. Spasticity can limit function in patients after a cerebral vascular accident (CVA). Flexor synergistic patterns present with variable tone and frequently respond well to electrotherapy. Previous treatment protocols use the approach of stimulating spastic musculature to fatigue or antagonistic musculature to strengthen and facilitate (Currier, 1983). This protocol utilizes an electromesh glove after 30 minutes of antagonistic muscle facilitation to stimulate intrinsic muscle contraction, allowing facilitation of digital extension and abduction, therefore reducing tone and allowing static progressive splinting to minimize tone. Method: Three patients presented after left-sided flexor synergistic tone at approximately 60 degrees of wrist flexion with digital composite flexion, elbow at 40 degrees of flexion without volitional control. NMES was used to stimulate the antagonistic muscle groups consisting of extensor carpi radialis longus and brevis (ECRL/B), extensor digitorum communis (EDC), and triceps. Channel 1 was applied to the triceps to facilitate elbow extension for increased reach envelope for improved functional use of the hand and ease for splinting. Channel 2 was applied to the wrist extensors to facilitate wrist position and digital extension for appropriate pre-contact grasp formation. This configuration was applied for 30 minutes using an alternating ramped burst program with an asymmetrical waveform for same musculature. Channel 2 started after channel 1 had completed the cycle. Channel 1 gradually increased intensity for 0.5 seconds, and then held a set intensity for 5.0 seconds and then decreased intensity over 0.5 seconds. Channel one is then off for 6.0 seconds. As channel intensity is decreasing, channel 2 started increasing intensity, via the same pattern. The negative electrode was placed over motor point with cycle rates used to produce tetany at 25–50 pps (the minimum rate that produced a good tetanized contraction dependent on tone) (Kahn 1987). An electromesh glove was fitted with repositioning of proximal electrodes utilizing channel 2, after stimulation of the antagonistic musculature permitted positioning of the wrist in neutral. The electromesh glove was worn for an additional 30 minutes. A static progressive splint with a wrist hinge hand portion was fabricated over the electromesh glove. The splint is to be worn after application of the above NMES protocol permits wrist at neutral or into extension. Observation: The patients presented with the wrists at neutral after a progression of NMES to triceps and ECRL/B and EDC. Reduction of hand intrinsic musculature tightness was achieved after use of the electromesh glove along with reduction of extrinsic flexor synergistic tone. Reduction of tone allowed ease of static progressive splinting with a hinged wrist splint. Conclusion: Flexor spasticity can be a hindrance to personal hygiene and impedes functional activity. This method of using NMES and electromesh glove to initiate elbow extension, wrist extension, and digital extension with abduction promotes interference to the flexor synergistic pattern of the upper extremity, eliciting motor contraction of previously inactive extensor musculature.

The treatment of multidrug-resistant tuberculosis in Turkey.

We evaluated the results of treatment in 158 consecutive patients with multidrug-resistant tuberculosis who were treated at our center in Istanbul. A total of 21 female patients and 137 male patients (age range, 15 to 68 years) received treatment for multidrug-resistant tuberculosis between March 1992 and October 1999. The patients had previously received a mean of 5.7 antituberculosis drugs and were infected with organisms that were resistant to a mean of 4.4 drugs. All patients were infected with organisms that were resistant to both isoniazid and rifampicin. The regimens we used were selected on the basis of previous treatment protocols and the results of susceptibility tests. All patients received at least three drugs thought to be active; the treatment was continued for at least 18 months after the conversion to a negative culture and for at least 24 months in the absence of first-line drugs. The mean number of drugs given during the study was 5.5 (range, 3 to 9). Surgical resection was performed in 36 patients. Adverse effects led to discontinuation of one or more drugs in 62 patients (39 percent). Cultures became negative in 150 patients (95 percent) after a mean of 1.9 months (range, 1 to 9). The overall success rate of treatment was 77 percent, with cures in 78 patients (49 percent) and probable cures in 43 (27 percent). Treatment failed in 13 patients (8 percent). Seven patients died (4 percent). Seventeen patients (11 percent) did not complete the treatment regimen. The patients with unsuccessful outcomes were older than those with successful outcomes (mean age, 42 years vs. 36 years; P=0.008), had received a larger number of drugs previously (median, six vs. five; P=0.048), were more likely to have been treated previously with ofloxacin (57 percent vs. 30 percent, P=0.004), and were less likely to have received ofloxacin as part of the study protocol (65 percent vs. 84 percent, P=0.018). Thirty-eight percent of the patients with unsuccessful outcomes were infected with organisms that were resistant to more than five drugs. In a step-down logistic-regression analysis, a successful outcome was independently associated with a younger age (P=0.013) and the absence of previous treatment with ofloxacin (P=0.005). Most patients with multidrug-resistant tuberculosis can be cured with the use of appropriate, intensive treatment regimens.

A retrospective review of gemcitabine use in advanced epithelial ovarian cancer

Background. In North America, epithelial ovarian cancer (EOC) is the fifth most common cause of cancer death among women. Many drugs are used in the treatment of EOC, with gemcitabine showing recent promise. The objective of this study was to determine whether gemcitabine is a beneficial treatment option for patients with EOC. Methods. The charts of 20 heavily pretreated women (median: four previous treatment protocols, range: 1-6) with a histological diagnosis of EOC were retrospectively reviewed to determine response. Eligible patients were treated with gemcitabine at a starting dose of 800 mg/m2 as an intravenous infusion on days 1, 8, and 15 of each 28-day cycle. The patients had a median age of 56 years (range 37-81). Results. Response to treatment was assessed both clinically and serologically (CA-125 tumor marker was monitored). Of the 20 enrollees, 17 were evaluable clinically and 16 were evaluable serologically (2 were not evaluable by either technique). There were two (12%) patients with a clinical partial response, six (35%) patients with clinical stable disease, nine (53%) patients with clinical progressive disease, and three patients that were not evaluable clinically. There were four (25%) patients with sero-logical partial response, six (38%) patients with stable serological disease, six (38%) patients with serological progressive disease, and four patients that were not evaluable serologically. Physician-reported toxicity included fatigue; however, this information was recorded inconsistently. Conclusion. Gemcitabine showed modest activity in heavily pretreated EOC with a 12% clinical partial response rate and a 25% serological partial response rate. No serious toxicities were encountered.