Subjective Patient Improvement Research Articles

Ankle Arthroplasty Alternatives with Allograft and External Fixation: Preliminary Clinical Outcome

Tibiotalar joint reconstruction for the treatment of osteoarthritic and post-traumatic arthritic joint remains controversial and unsatisfactory. While the current literature recommends joint arthrodesis as a gold standard, current developments in allograft technology may aid in the repair of articular damage; avoid any metallic implant wear, failure, and revision; and preserve normal musculoskeletal biomechanics. The purpose of this retrospective study was to report the early clinical outcomes of ankle arthroplasty with allograft and with the application of a monolateral external fixation in the treatment of ankle arthritis. Eighteen patients (18 ankles, n = 18) with end-stage ankle arthritis, underwent surgical intervention. The mean preoperative AOFAS score was 32.0 +/- 1.1 (30-33) while the postop was 87.33 +/- 7.6 (81-97) (P = .000). There were no complications associated with the allograft material. There were also no complications with the external fixator. The early clinical outcome results provided an optimistic view of this procedure as another alternative treatment for the arthritic ankle, with subjective patient improvement and satisfaction, as well as a statistically significant and functionally increased range of motion and joint space and objective improvements. Allograft implantation with external fixation for the arthritic tibiotalar joint provided encouraging preliminary results and patient satisfaction mirroring current outcomes from shoulder and animal studies. 4.

Changes in health over time in patients with symptoms allegedly caused by their dental restorative materials

There was a subjective improvement in patients who had changed materials in all their restorations, but those with complex complaints became subjectively worse.

Chiropractic care in asthma and allergy

To provide a brief overview of the current state of evidence for chiropractic care, specifically in the management of asthma and to a lesser extent allergy. A search of MEDLINE for English-language articles published between January 1966 and July 2002 was conducted using the keywords asthma, allergy, manual therapy, physical therapy techniques, chiropractic, physical therapy (specialty), physiotherapy, massage, and massage therapy. A hand search of the primary chiropractic and osteopathic literature on the treatment of asthma was performed, and proceedings from a recent research symposium on spinal manipulation were included. Clinical controlled studies and systematic reviews on spinal manipulative therapy (SMT) and asthma were selected. There were no primary clinical trials on SMT and allergy found. Many of the claims of chiropractic success in asthma have been primarily based on anecdotal evidence or uncontrolled case studies. Three recently reported randomized controlled studies showed benefit in subjective measures, such as quality of life, symptoms, and bronchodilator use; however, the differences were not statistically significant between controls and treated groups. There were no significant changes in any objective lung function measures. The clinical issues emanating from these trials are discussed. There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy. Based on reported subjective improvement in patients receiving chiropractic care, certain clinical circumstances may warrant a therapeutic trial in patients with asthma. Further properly designed, collaborative research is needed to determine if there is a role for chiropractic SMT in the care of asthma or allergy.

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in the short term.

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a quality-of-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P<0.001 and P<0.001, respectively). The mean QOL score improved from 62 to 77 (P<0.01). Significant improvements were also demonstrated in the mean resting pressure (P<0.01), peak amplitude of squeeze (P<0.01), and the duration of squeeze pressure (P<0.05). The deferred 15-minute evacuation time also significantly increased (P<0.001). This study reported significant short-term improvement in fecal incontinence with electromyographic biofeedback therapy using validated subjective and objective scoring systems. Similarly, this treatment also significantly improved anorectal manometric findings. Our data confirm the role of biofeedback therapy in the multimodality approach to patients with fecal incontinence.

Techniques for radiofrequency ablation of head and neck tumors.

To describe the various techniques that have been developed for application of radiofrequency ablation in the palliative treatment of recurrent and advanced head and neck malignant tumors. Case series with a follow-up of 3 to 18 months. Faculty practice, research protocol, tertiary care academic medical center. Fifteen treatments were administered over a 3-year period to 12 patients with advanced and/or recurrent tumors. Eleven tumors were squamous cell carcinomas of the oral cavity, oropharynx, and maxillary sinus, and 1 tumor was a medullary thyroid carcinoma. Three of the 12 patients were treated on 2 separate occasions. Patients were selected as a referred sample and sent specifically for treatment with radiofrequency ablation because they were not candidates for the standard curative options of radiation or surgery. No patient refused enrollment, nor were any patients withdrawn because of adverse events. Radiofrequency ablation is a method of localized hyperthermia resulting in tissue necrosis. Ninety to 150 W of energy is applied, achieving intratumoral temperatures of 60 to 110 degrees C for 5 to 15 minutes per ablation. Techniques have been developed to apply radiofrequency ablation under direct vision, endoscopically, percutaneously, and with ultrasound and computed tomographic guidance. The radiofrequency ablation probe was accurately placed and treatment administered on 15 occasions. No perioperative deaths occurred. One patient suffered a stroke. Subjective patient improvement was reported with regard to pain (n=9), appearance (n=3), and function (n=4).

BIOPRO resurfacing endoprosthesis versus periarticular osteotomy for hallux rigidus: short-term follow-up and analysis

Forty-four patients (47 feet) were enrolled in a prospective hallux rigidus study. A subjective evaluation, physical examination, and radiographic analysis were performed preoperatively and at a 1-year follow-up. Twenty patients (20 feet) underwent a periarticular osteotomy, with 16 patients (16 feet) returning. Seven patients (9 feet) underwent a BIOPRO resurfacing endoprosthesis, with all patients returning. The subjective evaluation was based on a modified American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal 100-Point scale. The physical examination included first metatarsophalangeal joint range of motion. Radiographic analysis included the metatarsal protrusion distance, transverse plane angulation of the second digit, lateral talo-first metatarsal angle, sagittal plane relationship of the first and second metatarsals, and hallux equinus angle. Statistically significant differences between preoperative and postoperative values were found for the periarticular osteotomy group for the metatarsal protrusion distance ( P = .000), transverse plane angulation of the second digit ( P = .000), and lateral talo-first metatarsal angle ( P = .015). No other statistically significant differences between the pre-operative and post-operative values for either procedure group were found to exist. For this specific patient population the short-term results of surgical intervention for hallux rigidus, whether through a periarticular osteotomy or resurfacing endoprosthesis, provided subjective patient improvement and satisfaction, as well as, minimal increase in first metatarsophalangeal joint range of motion.

Nesiritide improves urine output in severely ill pediatric patients awaiting heart transplantation without severe hypotension

Background: Nesiritide (synthetic B-Natriuretic Peptide) has been shown to improve symptoms and hospitalization in adult patients with severe heart failure via a variety of mechanisms including enhanced diuresis. The major side effect precluding use is hypotension. This medication has not been evaluated in pediatric patients. The objective of this study is to review the use of nesiritide in a severely ill group of pediatric patients.Methods: This study reviews 10 uses of nesiritide in seven pediatric patients (ages 20 35 months old all but one less than 18 months old) who were awaiting cardiac transplantation due to severe congenital heart disease (6) or dilated cardiomyopathy (1). All patients were classified as Status IA on multiple inotrope infusions and diuretics. The study evaluated the effects of nesiritide on blood pressure and urine output values from the day prior to infusion to the final day of the infusion. All values are presented as mean S.D. with Student’s t-testing for statistical significance. Results: Nesiritide was infused for a 10.6 4.1 days at doses of 0.005 to 0.02mcg/kg/min. In one use, the infusionwas discontinued due to concern of hypotension (no significant change from the day prior to infusion on retrospective review). This patient’s infusion was resumed in 2 days. Infusions were continued until subjective patient improvement or cardiac transplant. Urine output (ml/kg/hr) improved by 24% (p 0.05) from preto duringnesiritide (pre 2.6 1.3 vs. during 3.6 1.6). Total urine output (ml) improved by 22% (p 0.05). The figure shows urine output changes with each infusion. There were no changes (p NS) in daily highest and lowest systolic blood pressure related to nesiritide infusion (pre high SBP 102 14 mmHg vs. post high 101 10; pre low SBP 78 11 vs. post low 74 10). Five of the seven patients received cardiac transplantation while two others clinically improved enough to discontinue nesiritide. No other adverse effects of nesiritide were noted. Conclusion: Nesiritide improves urine output without significant hypotension or other adverse effects in severely ill pediatric patients.

Urodynamic results of sacral neuromodulation correlate with subjective improvement in patients with an overactive bladder.

Standard urodynamic investigations showed no correlation between the efficacy of sacral neuromodulation (SNS) and urodynamic data. Ambulant urodynamic investigations (ACM) are presented as more sensitive and reliable in detecting and quantifying bladder overactivity. In this study we looked at the correlation and results of ambulant urodynamic data and the clinical effects of SNS. Data of patients with bladder overactivity, who underwent an ACM before and during SNS were investigated. Blind analyses of the ACM were performed and the detrusor activity index (DAI) was calculated as the degree of bladder overactivity of the detrusor. The ACM parameters, before and during SNS, were analyzed and correlated to the clinical effect of SNS. In 22 of the 34 patients a DAI before and during stimulation could be calculated because of quality aspects. In all other patients, the other ambulatory urodynamic parameters could be analyzed and a significant reduction was found in bladder overactivity. A significant correlation (p = 0.03) was found in DAI reduction of the ACM before and during SNS as compared to the clinical improvement in overactive bladder symptoms. The objective and subjective results show a decrease in bladder overactivity during SNS. During SNS bladder instabilities are still present, which is in accordance with the published literature. The reduction of the DAI during SNS as compared to before SNS correlates significantly to the clinical effect of SNS.

Combination gemcitabine and cisplatin chemotherapy for metastatic or recurrent nasopharyngeal carcinoma: report of a phase II study

BackgroundTo evaluate the efficacy and toxicity of combination gemcitabine plus cisplatin (GC) chemotherapy in metastatic or recurrent nasopharyngeal carcinoma (NPC). Patients and methodsForty-four patients of Chinese ethnicity with metastatic or recurrent NPC received ambulatory GC chemotherapy every 28 days (gemcitabine 1000 mg/m2 days 1, 8 and 15; cisplatin 50 mg/m2 days 1 and 8). There were 40 male and four female patients with a mean age of 47.4 years. More than half (54.5%) of the patients had received either prior platinum-based chemotherapy and/or radiotherapy to target lesions. ResultsThere were nine complete responses and 23 partial responses in the 44 patients, achieving an overallresponse rate of 73% (78% for the 41 assessable patients). The mean duration of response was 5.3 months. Improved subjective symptom-control scores were found in 78% of patients with pre-existing symptoms, while 64% of patients experienced improved general well-being scores. Toxicity was mainly hematological: grade III/IV anemia, granulocytopenia and thrombocytopenia were found in 11, 37 and 16% of cycles, respectively. With a median follow-up of 17.2 months, 62% survived 1 year while 36% were alive and progression free. ConclusionsGemcitabine plus cisplatin chemotherapy offers a satisfactory overall response rate, subjective patient improvement and safety profile for metastatic and recurrent NPC.

A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: Short-term follow-up and analysis

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus between February 1998 and April 1999. Thirty-eight patients (41 feet) returned at 1 year for follow-up evaluation. Each foot was graded according to a four-stage hybrid radiographic grading system. At 1-year follow-up, 10 patients were classified as grade I, 17 as grade II, 12 as grade III, and 2 as grade IV. Subjective evaluation was based on a modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. A pre- and postoperative objective physical examination and radiographic analysis were performed. Statistically significant differences between preoperative and postoperative values were found to exist for each portion of the subjective evaluation (p = .000); nonweightbearing dorsiflexion (p = .001); simulated weightbearing dorsiflexion (p = .003); metatarsal protrusion distance and angle of deviation of the second metatarsophalangeal joint (p = .000); and talar-first metatarsal angle (p = .015). For this specific patient population, the short-term results of surgical intervention for hallux rigidus provided subjective patient improvement and satisfaction, as well as a statistically significant but functionally minimal increase in first metatarsophalangeal joint dorsal range of motion. Additionally, in the 19 patients who underwent a periarticular decompression osteotomy, the intended correlation of plantar transposition of the capital fragment and offsetting the longitudinal shortening of the first metatarsal did not exist.

Urodynamic results of sacral neuromodulation and subjective improvement in patients with an overactive bladder

Urodynamic results of sacral neuromodulation and subjective improvement in patients with an overactive bladder

Medroxyprogesterone acetate and cancer cachexia: interleukin-6 involvement.

Cancer cachexia is a significant problem facing both patients and physicians. Many interventions have been tried in an attempt to remedy undernutrition in cancer patients. However, there is no convincing evidence that enteral/parenteral nutrition or the use of anabolic steroids is of any benefit in patients with cachexia. A recent prospective study revealed that oral medroxyprogesterone acetate (MPA) treatment reduces serum levels of interleukin (IL)-6, an important mediator of cancer cachexia, in patients with metastatic breast carcinoma regardless of response to the therapy. A decrease in serum IL-6 levels was well associated with subjective improvement in patients with metastatic breast carcinoma. Furthermore, clinically attainable concentrations of MPA can inhibit the growth of some human pancreatic carcinoma cells by inducing apoptosis in association with the phosphorylation of bcl-2. These results suggest that this agent may contribute to improved quality of life in patients with various cancers.

Double blind, randomised, placebo controlled, crossover, multicentre study to determine the efficacy of a 0.1% (w/v) sodium hyaluronate solution (Fermavisc) in the treatment of dry eye syndrome

BACKGROUND/AIMSHyaluronan (sodium hyaluronate) has been shown to confer objective and subjective improvement in patients with dry eye syndrome. This study compared the efficacy and safety of a 0.1% solution of...

Radiofrequency volumetric tissue reduction for treatment of turbinate hypertrophy: A pilot study

Objectives: Ideal treatment for nasal obstruction caused by turbinate hypertrophy remains in question. Medical therapy is often ineffective. Surgical procedures have associated morbidity including pain, bleeding, crusting, adhesion, infection, and dryness. Radiofrequency has recently been shown to be safe and effective in volumetric tissue reduction of the tongue in the animal model and of the palate in human beings. We prospectively evaluate the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) for the treatment of nasal obstruction caused by inferior turbinate hypertrophy. Methods: Twenty-two consecutive patients with nasal obstruction and associated inferior turbinate hypertrophy refractory to medical therapy were evaluated for RFVTR. The study design limited the region of treatment to the anterior third of the inferior turbinate. The procedures were performed in an ambulatory facility with patients under local anesthesia. Clinical examinations, patient questionnaires, and visual analog scales were used to assess treatment outcomes. Results: No adverse effects were encountered, including bleeding, crusting, dryness, infection, adhesion, or a worsening of obstruction. Mild edema was noted in all patients but was of short duration (24 to 48 hours). Posttreatment discomfort was well controlled with acetaminophen. Eight weeks after treatment, nasal breathing improved in 21 of 22 patients, with a 58.5% reduction in severity and a 56.5% decrease in the frequency of nasal obstruction. Conclusion: The results of this study demonstrate that RFVTR of the hypertrophic inferior turbinate is associated with minimal adverse effects. Furthermore, this new treatment modality achieves subjective improvement in patients with symptoms of nasal obstruction. However, because of the small sample size and short follow-up, future investigations are needed to fully evaluate the use of RFVTR in the treatment of nasal obstruction caused by turbinate hypertrophy. (Otolaryngol Head Neck Surg 1998;119:569-73.)

Dyspnea Response Following Bilateral Thoracoscopic Staple Lung Volume Reduction Surgery

Lung volume reduction surgery (LVRS) has shown promise for treating patients with severe emphysema in recent clinical trials. However, response following surgery is difficult to assess due to frequent discrepancies between subjective and objective outcomes. We evaluated the relationship between improvement in dyspnea and pulmonary function response in 145 consecutive patients with inhomogeneous emphysema enrolled in a bilateral thoracoscopic lung volume reduction protocol in order to assess predictors of improved dyspnea outcome and correlation of subjective and objective improvement measures. Baseline complete pulmonary function testing, spirometry, gas exchange, plethysmography, gas dilution lung volumes, along with resting dyspnea index determinations were performed preoperatively, and repeated short term (mean, 33 days; n=129) and long term (>6 months; mean, 276 days; n=84) following surgery. Improvement in FEV1 percent predicted was significantly associated with improvement in dyspnea scores, though considerable variability exists (r=0.04, p<0.01, short term; r=0.4, p=0.1, long term). In this preselected patient group, those with the extreme degrees of hyperinflation may have less improvement in dyspnea following LVRS than those with milder preoperative hyperinflation. Greater improvement in dyspnea short term and long term was seen in patients with lower presenting residual volume/total lung capacity ratios (r=0.4, p=0.02, short term; r=0.4, p<0.05, long term). Bilateral thoracoscopic staple LVRS results in significant objective and subjective improvement in patients with severe emphysema and hyperinflation. There was considerable variability between improvement in dyspnea and improvement in spirometry, and preoperative predictors of response may differ between these outcome variables. Further studies are needed to define the long-term implications of these findings.

Endoscopic Stenting and Sphincterotomy of the Minor Papilla in Symptomatic Pancreas Divisum: Results and Complications

Pancreas divisum has been postulated as a cause of acute pancreatitis and a chronic pain syndrome in a small subgroup of patients and can be treated with endoscopic dorsal pancreatic duct stent placement and minor papilla sphincterotomy. Twenty patients (9 with at least one attack of idiopathic pancreatitis, and 11 with severe pancreatic-type pain) were treated endoscopically. Dorsal duct stents were placed in 19 patients with subsequent needle knife sphincterotomy of the minor papilla over the stent. Clinical response was judged by comparison of symptoms (using a 0-to-l0 scale and the patient's overall assessment). The symptom score improved from 9.3 to 5.1 in the pancreatitis group and from 9.3 to 5.7 in the pain group. A good clinical response was observed in 3 of 7 patients in the pancreatitis group and in 6 of 11 in the pain group at a mean follow-up of 22 months. Complications of sphincterotomy were limited to pancreatitis in 6 patients (29%), 5 mild and 1 moderate according to published criteria. No patient required more than 4 days hospitalization. Two of 39 stents migrated into the pancreas, and another stent fractured and remained lodged in the pancreas. Eight of 9 patients evaluated demonstrated new morphologic duct changes on follow-up pancreatograms. Endoscopic stenting and sphincterotomy of the minor papilla are feasible and may be effective in some patients with pancreas divisum but carries a significant complication rate. The subjective improvement in patients with chronic pain warrants further controlled study.

Behavioral Techniques in the Treatment of Patients with Multiple Personality Disorder

AbstractReferences in the psychiatric literature to treatments other than psychodynamic psychotherapy and hypnosis for patients with multiple personality disorder (MPD) are scarce. Although behavioral techniques are used by MPD authorities, their use is not widely acknowledged. The following three cases suggest that after extensive attempts with traditional modes of therapy, the institution of behavioral techniques led to both objective and subjective improvement in patients' symptoms. The reality-oriented limits that were placed on the behavior of these patients were respected across alter personalities and continued to be effective at follow-up. These findings suggest that behavioral techniques may be potent in treating patients with this disorder.

A Controlled Study of Dimethyl Sulfoxide in Interstitial Cystitis

To evaluate the effectiveness of dimethyl sulfoxide in the treatment of patients with biopsies suggestive of interstitial cystitis, 33 patients underwent a controlled crossover trial. Patients were allocated randomly to receive 50 per cent dimethyl sulfoxide or placebo (saline). The medication was administered intravesically every 2 weeks for 2 sessions of 4 treatments each. Response was assessed urodynamically and symptomatically.Thirty women and 3 men (mean age 48 years and mean duration of symptoms 5.5 years) were entered into the study. No significant side effects to dimethyl sulfoxide were noted. When assessed subjectively, 53 per cent of dimethyl sulfoxide treated patients were markedly improved compared to 18 per cent of the placebo treated patients. Of the dimethyl sulfoxide group 93 per cent had objective improvement versus 35 per cent of the placebo group. Thus, dimethyl sulfoxide proved to be superior to placebo in the objective and subjective improvement of patients with interstitial cystitis.

The Role of Theophylline in the Treatment of Dyspnea in COPD

Dyspnea is influenced by both physiologic and psychologic factors. Breathlessness is common in patients with chronic obstructive pulmonary disease (COPD) and often is the reason that the individual patient seeks medical attention. In order to evaluate the different clinical studies involving the use of theophylline in COPD patients, it is important to consider the three distinct approaches for measuring dyspnea--psychophysical testing, clinical methods, and ratings during exercise. Four randomized, double-blind, placebo-theophylline trials from one to four weeks in duration have evaluated the impact of theophylline on lung function and breathlessness. In these studies, the overall improvement in forced expiratory volume in one second was quite consistent for theophylline compared with placebo therapy. When appropriate clinical methods for measuring dyspnea were used, theophylline showed a positive reduction in breathlessness. These reports suggest that theophylline provides modest objective and subjective improvement in patients with symptomatic chronic air flow obstruction.

Effect of fusaric acid (a dopamine beta-hydroxylase inhibitor) on phaeochromocytoma.

Fusaric acid, an inhibitor of dopamine beta-hydroxylase, which converts dopamine to noradrenaline, lowered the blood pressure and induced a subjective improvement in patients with phaeochromocytoma. These effects may be due either to an impairment of catecholamine biosynthesis or to a direct action on the blood vessels. The use of this drug in the treatment of patients with inoperable malignant phaeochromocytoma or neuroblastoma may improve symptoms and prolong survival.