Recommended Treatment Strategy Research Articles

Lifestyle Weight-Loss Intervention Outcomes in Overweight and Obese Adults with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

The majority of people with type 2 diabetes are overweight or obese, and weight loss is a recommended treatment strategy. A systematic review and meta-analysis was undertaken to answer the following primary question: In overweight or obese adults with type 2 diabetes, what are the outcomes on hemoglobin A1c (HbA1c) from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? Secondary questions are: What are the lipid (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides) and blood pressure (systolic and diastolic) outcomes from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? And, what are the weight and metabolic outcomes from differing amounts of macronutrients in weight-loss interventions? Inclusion criteria included randomized clinical trial implementing weight-loss interventions in overweight or obese adults with type 2 diabetes, minimum 12-month study duration, a 70% completion rate, and an HbA1c value reported at 12 months. Eleven trials (eight compared two weight-loss interventions and three compared a weight-loss intervention group with a usual care/control group) with 6,754 participants met study criteria. At 12 months, 17 study groups (8 categories of weight-loss intervention) reported weight loss <5% of initial weight (−3.2 kg [95% CI: −5.9, −0.6]). A meta-analysis of the weight-loss interventions reported nonsignificant beneficial effects on HbA1c, lipids, or blood pressure. Two study groups reported a weight loss of ≥5%: a Mediterranean-style diet implemented in newly diagnosed adults with type 2 diabetes and an intensive lifestyle intervention implemented in the Look AHEAD (Action for Health in Diabetes) trial. Both included regular physical activity and frequent contact with health professionals and reported significant beneficial effects on HbA1c, lipids, and blood pressure. Five trials (10 study groups) compared weight-loss interventions of differing amounts of macronutrients and reported nonsignificant differences in weight loss, HbA1c, lipids, and blood pressure. The majority of lifestyle weight-loss interventions in overweight or obese adults with type 2 diabetes resulted in weight loss <5% and did not result in beneficial metabolic outcomes. A weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals. Weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control. Nutrition therapy for individuals with type 2 diabetes should encourage a healthful eating pattern, a reduced energy intake, regular physical activity, education, and support as primary treatment strategies.

How should immunomodulators be optimized when used as combination therapy with anti-tumor necrosis factor agents in the management of inflammatory bowel disease?

In the last 15 years the management of inflammatory bowel disease has evolved greatly, largely through the increased use of immunomodulators and, especially, anti-tumor necrosis factor (anti-TNF) biologic agents. Within this time period, confidence in the use of anti-TNFs has increased, whilst, especially in recent years, the efficacy and safety of thiopurines has been questioned. Yet despite recent concerns regarding the risk: benefit profile of thiopurines, combination therapy with an immunomodulator and an anti-TNF has emerged as the recommended treatment strategy for the majority of patients with moderate-severe disease, especially those who are recently diagnosed. Concurrently, therapeutic drug monitoring has emerged as a means of optimizing the dosage of both immunomodulators and anti-TNFs. However the recommended therapeutic target levels for both drug classes were largely derived from studies of monotherapy with either agent, or studies underpowered to analyze outcomes in combination therapy patients. It has been assumed that these target levels are applicable to patients on combination therapy also, however there are few data to support this. Similarly, the timing and duration of treatment with immunomodulators when used in combination therapy remains unknown. Recent attention, including post hoc analyses of the pivotal registration trials, has focused on the optimization of anti-TNF agents, when used as either monotherapy or combination therapy. This review will instead focus on how best to optimize immunomodulators when used in combination therapy, including an evaluation of recent data addressing unanswered questions regarding the optimal timing, dosage and duration of immunomodulator therapy in combination therapy patients.

The Role of Glutamatergic Dysfunction in Treatment-Resistant Obsessive-Compulsive Disorder: Treatment of an Adolescent Case with N-Acetylcysteine Augmentation

[Author Affiliation]Kemal Utku Yazici. 1 Department of Child and Adolescent Psychiatry, Firat University Faculty of Medicine, Elazig, Turkey.Ipek Percinel. 2 Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye, Turkey.Address correspondence to: Kemal Utku Yazici, Department of Child and Adolescent Psychiatry, Firat University Faculty of Medicine, Elazig 23023, Turkey, E-mail: dr.kemal.utku@outlook.comTo The Editor:Obsessive compulsive disorder (OCD) is a common, chronic, and treatment resistant neuropsychiatric disorder that frequently begins during childhood and adolescence (Jenike 2004; Heyman et al. 2006). The recommended treatment strategy for OCD in children and adolescents includes cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), either individually or combined. However, treatment with SSRIs in addition to clomipramine and typical/atypical antipsychotic agents is recommended for cases that do not respond to normal OCD treatment (American Academy of Child and Adolescent Psychiatry 2012; Arumugham and Reddy 2013). Despite these various treatment approaches, the desired reduction in symptom severity is not always achieved, and, therefore, other treatment options must be considered (Abudy et al. 2011; Arumugham and Reddy 2013).N-acetylcysteine (NAC) is an antioxidant molecule that modulates glutamate (glu) transmission in the brain (Berk et al. 2013). Recent reports have indicated the importance of glutamatergic dysfunction in OCD pathophysiology and the influence of glutamatergic agents in OCD (Chakrabarty et al. 2005; Pittenger et al. 2011; Kariuki-Nyuthe et al. 2014), which has led to the increased use of NAC for the treatment of OCD (Lafleur et al. 2006; Afshar et al. 2012; Van Ameringen et al. 2013). Herein, we discuss the use of NAC to treat a 15-year-old girl with treatment-resistant OCD.Case ReportA 15-year-old female patient was brought to our clinic by her mother, who indicated that the girl had the following complaints: Fear of becoming ill, anxiety about becoming infected from touching strangers, frequent hand washing, staying in the bathroom for extended periods, checking and rechecking homework and school bags before going to school, and returning to check the door just after leaving the house. Based on the history reported by her and her mother, the patient's obsessive tendencies began ∼3 years ago, and she was diagnosed with OCD at that time by another child psychiatrist in a different center. First, she underwent CBT for 1 month, but had no reduction in her complaints. Therefore, in addition to the CBT, she was started on sertraline therapy, which was increased until the dose reached 150 mg/day. However, she reported that her obsessive thoughts and behaviors continued without any decrease, and over the next 2 years, she was treated with fluoxetine (40 mg/day), citalopram (60 mg/day), fluvoxamine (200 mg/day), clomipramine (150 mg/day), risperidone (3 mg/day) and aripiprazole (15 mg/day) for at least 16 weeks, either individually or combined. After a period of time, she refused to visit the doctor because she was not benefiting from the medication. She reported a minor reduction in her complaints while using citalopram alone, and, therefore, made her own decision to use only citalopram. However, she decided to seek medical treatment at our clinic as a result of family pressure, additional complaints of moodiness and unhappiness, and continued obsessive thoughts and behaviors, which were still severe. She had been using 60 mg/day of citalopram for ∼ 4 months when she came to our clinic. Her history had no indications of any mental or motor development problems. Her family history revealed that her aunt had received treatment for 10 years for OCD. Our psychological assessment revealed that the patient had contamination and pathological doubt obsessions, and checking/rechecking and frequent hand washing compulsions, but no depressive symptoms. …

Incorporating carbon storage into the optimal management of forest insect pests: a case study of the southern pine beetle (Dendroctonus frontalis Zimmerman) in the New Jersey Pinelands.

Forest insect pest disturbance is increasing in certain areas of North America as many insect species, such as the southern pine beetle, expand their range due to a warming climate. Because insect pests are beginning to occupy forests that are managed for multiple uses and have not been managed for pests before, it is becoming increasingly important to determine how forests should be managed for pests when non-timber ecosystem services are considered in addition to traditional costs and revenues. One example of a service that is increasingly considered in forest management and that may affect forest pest management is carbon sequestration. This manuscript seeks to understand whether the incorporation of forest carbon sequestration into cost-benefit analysis of different forest pest management strategies affects the financially optimal strategy. We examine this question through a case study of the southern pine beetle (SPB) in a new area of SPB expansion, the New Jersey Pinelands National Reserve (NJPR). We utilize a forest ecology and economics model and include field data from the NJPR as well as outbreak probability statistics from previous years. We find under the majority of scenarios, incorporating forest carbon sequestration shifts the financially optimal SPB management strategy from preventative thinning toward no management or reactionary management in forest stands in New Jersey. These results contradict the current recommended treatment strategy for SPB and signify that the inclusion of multiple ecosystem services into a cost-benefit analysis may drastically alter which pest management strategy is economically optimal.

Therapy of AIDS-Related Cryptococcal Meningitis

Cryptococcal meningitis is a common and severe opportunistic infection in advanced HIV, with the highest burden of disease in resource-poor settings in sub-Saharan Africa. It is invariably fatal if left untreated, and carries a high mortality even with treatment. High fungal burden, raised intracranial pressure, and reduced level of consciousness at presentation are associated with poorer outcomes. The recommended treatment strategy consists of a two-week induction phase, then eight weeks of consolidation therapy, followed by long-term maintenance therapy until restoration of immune function by antiretroviral therapy (ART) for HIV. Induction treatment should consist of a rapidly fungicidal drug. Amphotericin B has demonstrated superiority to fluconazole both in terms of fungicidal activity and mortality outcomes. A combination of amphotericin B at 1 mg/kg/day plus flucytosine 100 mg/kg/day has been associated with a reduction in mortality as compared to amphotericin B alone. This regimen should be used where available, with fluconazole as an acceptable alternative second agent if flucytosine is unavailable. In resource-limited settings where both amphotericin B and flucytosine are often unavailable, fluconazole monotherapy is still often used. In this setting, high-dose fluconazole at 1,200 mg/day should be used as induction therapy, although fungal clearance with this regimen is inferior to amphotericin B-based therapy. Consolidation and maintenance therapy with fluconazole is recommended. Aggressive management of raised intracranial pressure by repeated therapeutic lumbar puncture is an essential adjunct to antifungal chemotherapy. Surgical intervention, such as ventriculoperitoneal shunting for refractory raised intracranial pressure, is rarely required. In patients who are not already on ART, this should be commenced no earlier than four weeks after starting induction treatment for cryptococcal meningitis, as earlier initiation of ART may be associated with immune reconstitution inflammatory syndrome (IRIS). There are ongoing efforts to evaluate fluconazole and flucytosine combination therapy as an alternative induction regimen, as well as shorter courses of amphotericin B, in resource-poor settings with limited access to antifungal agents.

Management of hemophilia in Korea: the past, present, and future.

Management of hemophilia in Korea: the past, present, and future.

Comparing cost-effectiveness of standardised tuberculosis treatments given varying drug resistance

There is a growing need to identify appropriate standardised treatment strategies that will adequately treat various forms of drug-resistant tuberculosis (TB) and prevent multidrug-resistant (MDR)-TB. A Markov model estimated treatment-related acquired MDR-TB, mortality, disability-adjusted life years and costs in settings with different prevalence of isoniazid monoresistant TB and MDR-TB. We compared four treatment strategies: 1) the standard World Health Organization recommended treatment strategy; 2) adding ethambutol throughout the 6-month treatment of new cases; 3) using a strengthened standardised retreatment regimen; and 4) using standardised MDR treatment for failures of initial treatment. Treatment-related outcomes were derived from the published literature, and costs from direct surveys. A strengthened retreatment regimen, which could achieve lower failure, relapse and acquired MDR rates in isoniazid monoresistant cases, was predicted to be the most cost-effective strategy in all modelled settings. Empirical MDR treatment of failures of initial treatment was the most costly strategy but resulted in the fewest deaths. Adding ethambutol throughout initial treatment would be most effective in preventing acquired MDR, but would lead to excess cases of blindness. A high priority should be given to improving the standardised retreatment regimen, as this is predicted to produce greater benefits than other recently recommended strategies.

Issue Highlights

Issue Highlights

New methods in diagnosis and therapy Stroke following transcatheter aortic valve implantation. Is neuroprotection justified?

Degenerative aortic stenosis (AS) is the most frequent type of valvular heart disease. In patients with symptomatic AS surgical aortic valve replacement (SAVR) is a recommended treatment strategy. Due to a high risk of perioperative mortality, up to 30% of patients with AS are considered not suitable for SAVR. In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery. In the two randomized trials published so far and numerous registries, stroke and transient ischemic attack still remain serious periprocedural complications after TAVI. Because the majority of these episodes are driven by microembolization during the procedure, different neuroprotection devices were developed and clinically tested. Embrella and SMT are deflector devices, using a microporous membrane mounted on a nitinol frame, designed to cover the ostia of the brachiocephalic trunk and the left carotid artery. The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery. Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR. However, to date the efficacy of the neuroprotection systems has not been assessed in randomized trials. Before we know the results of such trials, the use of the devices should be limited to patients at high risk of neurological complications, such as patients with previous stroke, massive calcification on aortic leaflets, annulus and porcelain aorta.

Cardiac resynchronization therapy (CRT): Clinical trials, guidelines, and target populations

Over the last 10 years, several large, well-designed clinical trials have firmly established the role of cardiac resynchronization therapy (CRT) as a recommended treatment strategy for moderate-to-severe heart failure (HF). A review of the relevant results from the MUSTIC, MIRACLE, CONAK-CD, and MIRACLE ICD trials reveals that in patients with New York Heart Association (NYHA) class III-IV HF, CRT produces consistent improvements in quality of life, functional status, and exercise capacity while also providing strong evidence for reverse remodeling and diminished functional mitral regurgitation, resulting in reductions in both HF hospitalizations and all-cause morbidity and mortality. In patients with earlier NYHA class I-II HF, the benefit of CRT has been more controversial. The principal ongoing challenges addressed in this article include the substantial 30% of patients who receive a CRT device but fail to respond, the wide variations in how to define "response" vs "nonresponse," and how to identify patients who will benefit from CRT, especially narrow QRS (<120 ms), those with right bundle branch block, and those with mild-to-moderate (NYHA class I-II) HF. An important result of this uncertainty is the lack of a good sense of the optimal rate of CRT implantation, making consideration of the data reviewed in this article crucial for identifying important gaps of knowledge and mechanisms of action that need to be studied in the near future.

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

Asymptomatic severe mitral valve (MV) regurgitation with preserved left ventricular function is a challenging clinical entity as data on the recommended treatment strategy for these patients are scarce and conflicting. For asymptomatic patients, no randomised trial has been performed for objectivising the best treatment strategy. The Dutch AMR (Asymptomatic Mitral Regurgitation) trial is a multicenter, prospective, randomised trial comparing early MV repair versus watchful waiting in asymptomatic patients with severe organic MV regurgitation. A total of 250 asymptomatic patients (18-70years) with preserved left ventricular function will be included. Intervention will be either watchful waiting or MV surgery. Follow-up will be 5years. Primary outcome measures are all-cause mortality and a composite endpoint of cardiovascular mortality, congestive heart failure, and hospitalisation for non-fatal cardiovascular and cerebrovascular events. Secondary outcome measures are total costs, cost-effectiveness, quality of life, echocardiographic and cardiac magnetic resonance parameters, exercise tests, asymptomatic atrial fibrillation and brain natriuretic peptide levels. Additionally, the complication rate in the surgery group and rate of surgery in the watchful waiting group will be determined. The Dutch AMR trial will be the first multicenter randomised trial on this topic. We anticipate that the results of this study are highly needed to elucidate the best treatment strategy and that this may prove to be an international landmark study.

Prognostic Implications of Intraoperative Radiotherapy for Unresectable Pancreatic Cancer

Background/Aims: To assess the prognostic effect of intraoperative radiotherapy (IORT) in unresectable pancreatic cancer. Methods: We reviewed 198 patients with unresectable pancreatic cancer, which was found during experimental laparotomy. Liver metastasis was observed in 70 patients, peritoneal metastasis in 44, liver and peritoneal metastasis in 23 and locally advanced tumor in 61. Treatment consisted of IORT with or without postoperative chemotherapy. Overall survival (OS) and prognostic factors were evaluated for each pattern of disease spread. Results: IORT was performed in 120 patients, and chemotherapy was administered in 80. Sixty patients did not receive either treatment. OS in the untreated group was significantly inferior to that for IORT alone and IORT plus gemcitabine (GEM)-based chemotherapy. IORTand GEM-based chemotherapy were identified as independent prognostic factors [hazard ratio (HR) = 0.51, p < 0.001; HR = 0.43, p < 0.001]. IORT was an independent prognostic determinant for patients with peritoneal metastasis (HR = 0.24, p = 0.011) but not for those with liver metastasis (HR = 0.78, p = 0.381). Conclusion: IORT followed by GEM-based chemotherapy is the recommended treatment strategy in unresectable pancreatic cancer.

Long-term comparison of balloon angioplasty with provisional stenting versus routine stenting in patients with non-ST-elevation acute coronary syndrome.

Background. In patients with unstable angina or non-ST-elevation acute coronary syndrome (NSTE-ACS) who are eligible for PCI, routine stenting is the recommended treatment strategy, based on the opinion of experts. Provisional stenting may provide a viable alternative by retaining the early benefits of stenting without its potential late hazards.Method. Patients with NSTE-ACS were randomised to provisional or routine stenting after coronary angiography. Patients were followed for up to ten years. The occurrence of major adverse cardiac events (MACE) was recorded.Results. 237 consecutive patients with NSTE-ACS were randomly assigned to routine stenting (n=116) or provisional stenting (n=121). No difference in the incidence of MACE at 30 days was observed. At six months, angiographic restenosis was lower in the routine stenting group (41 vs. 20%, p=0.02), paralleled by more MACE in the provisional stenting group at one year (40.5 vs. 27.6%, p=0.036). At complete follow-up the difference in MACE was not significant (61.2 vs. 50%, p=0.084) because of relatively more target lesion revascularisations in the routine stent group. There was no difference in the incidence of very late stent thrombosis (1.7 vs. 3.4%, p=0.439). The only independent predictor of MACE was beta-blocker use (RR 0.62 [0.431; 0.892] p=0.010).Conclusion. In selective patients with NSTE-ACS, routine stenting was more beneficial than provisional stenting for a period of up to five years, driven by a reduction in repeat revascularisation procedures. After this period, the benefit was no longer significant. Beta-blocker use was the only independent predictor of MACE throughout the complete follow-up period. (Neth Heart J 2010;18:307-13.).

Clinical Outcome Following Conservative vs Revascularization Therapy in Patients With Stable Coronary Artery Disease and Borderline Fractional Flow Reserve Measurements

Fractional flow reserve (FFR) measurements in the so-called gray-zone range of > or = 0.75 and < or =0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24+/-16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment.

Neoadjuvante und adjuvante Therapie bei Rektumkarzinom in der Praxis. Wieviele Patienten gelangen tatsächlich in multimodale Therapiekonzepte? Eine Analyse des Tumorzentrums Schwerin

For rectal cancer in UICC stage II or III, a neoadjuvant chemoradiotherapy or short-course radiotherapy is established to reduce the incidence of local relapses. It has been documented that the neoadjuvant therapy is superior to the adjuvant therapy. In spite of the formulation of therapeutic principles in guidelines, they are not consistently applied. The actual rate of application and the reasons for a change from the recommended treatment strategy have been investigated. The data of the tumour centre West Mecklenburg were analysed. Data concerning the type and stage of rectal cancer, multimodal treatment (surgery with or without neoadjuvant therapy or adjuvant therapy) and treatment according to the level of medical care of hospitals were recorded from 2000 to 2008. In addition, in our clinic prospectively collected data of patients with rectal cancer (September 2006 until December 2008) were used to find out the reasons for the denial of neoadjuvant therapy. During the observation period we detected 348 patients with rectal cancer in UICC stage II or III in the area of the tumour centre West Mecklenburg. 16 % of these patients were treated pre-operatively. An increase in the preoperative multimodal treatment from 3 % to 39 % was observed. Hospitals with higher provisions of medical care applied the multimodal treatment 4-fold more frequently during this period of time. 55 patients of our own clinic were found to be of UICC stage II or III. 6 patients were emergency cases. The carcinoma was found in the lower or middle third of the rectum in 38 of our patients. The endosonographical examination could not adequately show the tumour or was falsely negative in 16 of these patients. A neoadjuvant treatment was started for 58 % of the patients. Overall, 76 of patients with rectal carcinoma were treated adjuvant or neoadjuvant, 62 of them with a complete treatment scheme. The application of neoadjuvant treatment for rectal carcinoma in UICC stage II or III in West Mecklenburg was unexpectedly low during the observation period. However, an increase in treatment frequency was detected. During the same period of time the number of patients treated in hospitals of basic and standard medical care decreased by half. This is the reason for the regional increase of neoadjuvant treatment. 47 % of the patients of our clinic received neoadjuvant chemoradiotherapy or a short-course radiotherapy. Including the adjuvant treatment, 76 % of all patients were treated multimodally. An increase in neoadjuvant treatment can only be achieved by shifting patients to centres with an appropriate diagnostic facility and a regular tumour board for rectal cancer.

Primary paraspinal hydatid cyst: a case report

Hydatid disease is a parasitic infection generally occurring in specific geographical areas. Exclusive involvement of the muscles is extremely uncommon, because implantation at this site would require passage through the filters of the liver and lung. En bloc resection without inducing rupture and spreading the daughter cyst is recommended treatment strategy and accepted to be curative for intramuscular hydatid cyst. We report a case of primary hydatid cyst of the erector spinae muscle.

Abstract 2667: Aspiration Coronary Thrombectomy for Acute Myocardial Infarction Improves Myocardial Salvage Index. Single Center Randomized Study

Primary percutaneus intervention (pPCI) is a recommended treatment strategy for acute myocardial infarction with ST segment elevation (STEMI). Adjunctive thrombectomy may add clinical benefits. The aim of our study was to compare the efficacy of aspiration thrombectomy versus standard pPCI for STEMI. The primary endpoint was salvage index assessed by sestamibi SPECT perfusion imaging. Single centre randomized study on aspiration thrombectomy in acute STEMI. 135 patients (88 males, mean age 64,3±12,4 yrs) with first acute STEMI were enrolled between Nov 2004 and Dec 2007. Inclusion criteria were: first anterior or inferior STEMI within 12 hours from pain onset with culprit lesion in left anterior descending (LAD) or right coronary artery (RCA) and TIMI flow ≤ 2. Patients were randomly assigned to thrombectomy with Rescue or Diver device followed by stent implantation (65) vs. standard pPCI with stenting (70 pts). 5 patients initially randomised to thrombectomy were finally treated with standard pPCI. Two SPECT examinations were performed: before and 5– 8 days after reperfusion therapy. Five patients died 3–7 days after the procedure, and in 3 pts second SPECT could not be performed because of patients’ severe condition. Thus two SPECT examinations were performed in 127 patients (63 treated with thrombectomy and 64 in control group). These 127 subject were the basis of the intention to treat analyses. There were 41 pts with anterior STEMI and 86 pts with inferior STEMI. Both treatment groups were similar regarding baseline demographic and clinical variables. Based on the SPECT perfusion imaging results, the final infarct size was assessed and myocardial salvage index (proportion of the myocardium at risk salvaged by reperfusion) was calculated. Baseline myocardium at risk area was 35,0%±2,8% in thrombectomy group vs 35,8%±10,9% in control patients. (p=NS). Myocardial salvage index was larger in patients treated with aspiration thrombectomy (0,33±0,27 vs. 0,20 ± 0,21 p = 0,004). Moreover, final infarct size was significantly smaller in patients treated with thrombectomy: 23,9% ± 13,1 % vs.28,3 % ±9,6% p = 0,005. Our results show that coronary thrombectomy is beneficial as an adjunctive therapy to pPCI in STEMI.

Primary paraspinal hydatid cyst treated with puncture, aspiration, injection and re-aspiration (PAIR) technique: a case report

Hydatid disease is a parasitic tapeworm infection that usually involves liver and lungs. Primary skeletal muscle hydatid cyst without liver and lung involvement is rare. En bloc resection without inducing rupture and spreading the daughter cyst is recommended treatment strategy and accepted to be curative for intramuscular hydatid cyst. We report a case of primary hydatid cyst of the erector spinae muscle which was treated successfully with ultrasonography guided puncture, aspiration, injection of 95% ethanol and re-aspiration (PAIR) technique.

Treatment of eosinophilic esophagitis: Drugs, diet, or dilation?

A number of recent studies have demonstrated that a variety of treatments effectively improve symptoms and histology in the majority of patients with eosinophilic esophagitis. Therapeutic options include pharmacologic treatments, such as oral and topical corticosteroids and leukotriene-receptor antagonists. In children, the high response rates to dietary modification and elimination suggest that certain foods may serve as environmental triggers for the eosinophilic infiltration. Because many adults present with strictures, endoscopic esophageal dilation is another management modality. Despite these treatment options, several controversies exist in the recommended treatment strategy. Whether the goal of therapy is resolution of symptoms, tissue eosinophilia, or both remains uncertain owing to the paucity of data on the natural history of the condition. Furthermore, important differences in the clinical presentations of eosinophilic esophagitis in children and adults point toward the possible need for different treatment approaches in the two patient populations.

Treatment paradigms on hepatitis B e antigen-negative chronic hepatitis B patients

The primary goal of treatment in hepatitis B e antigen (HBeAg)-negative patients with chronic hepatitis B (CHB) is potent and durable suppression of hepatitis B virus (HBV) replication. It results in biochemical and histological remission of CHB and is the prerequisite for the prevention of cirrhosis, its life-threatening complications and hepatocellular carcinoma. Responses that are durable after the cessation of treatment are referred to as sustained virological responses, whereas those persisting under therapy are referred to as treatment-maintained virological responses. Treatment paradigms of sustained virological response in HBeAg-negative CHB are practically restricted to conventional IFN-α and pegylated interferons (peg-IFNs), and are limited only to patients with compensated liver disease. Long-lasting maintained virological responses without HBV resistance in HBeAg-negative CHB are achievable by all approved nucleos(t)ide analogues (lamivudine, adefovir and entecavir) in highly variable rates, depending on their potency, rapidity of virological response and genetic barrier to resistance. The maintenance of response under 5 years of adefovir treatment represents the most effective treatment paradigm for HBeAg-negative CHB, whereas such long-term data with entecavir and tenofovir monotherapy may become available in the near future. In patients with lamivudine-resistant HBV mutants, the recommended treatment strategy is to add adefovir at the same time as continuing treatment with lamivudine. There are no treatment paradigms as yet of combination therapy from the very outset with two nucleoside analogues for use in treatment-naive patients.