Traditional Treatment Options Research Articles

Management of Immune Thrombocytopenic Purpura in Children

The treatment of immune thrombocytopenic purpura (ITP) in children is controversial, requiring individualized assessment of the patient and consideration of treatment options. If the platelet count is >10 000/μL and the patient is asymptomatic, a 'watch and wait' strategy is appropriate since most children with ITP will recover completely without pharmacotherapy. If therapy is indicated because of bleeding or a platelet count <10 000/μL, then treatment with glucocorticoids, intravenous immunoglobulin (IVIg), or anti-D are possible initial choices. Glucocorticoid treatment is the least expensive and is our usual first choice of therapy. Its use assumes that the blood counts and blood film have been evaluated to ensure the absence of evidence of alternative diagnoses, such as thrombotic thrombocytopenic purpura or incipient acute leukemia. IVIg is expensive and often causes severe headache, nausea and vomiting, and requires hospitalization at our institution. Anti-D therapy is also expensive and can only be used in patients who are Rhesus D positive. These therapies, even if only transiently effective, can be repeated if necessary. Children usually recover from newly diagnosed ITP, with or without multiple courses of medical therapy. If the disease becomes 'persistent' with severe thrombocytopenia and/or bleeding, and is no longer responsive to the three first-line therapies, the next approach includes the use of thrombopoietin receptor agonists or rituximab. When the disease persists for more than 1 year, it is considered chronic, and, if symptomatic, it may become necessary to consider third-line therapies, including splenectomy, alternative immunosuppressive agents, or combination or investigative chemoimmunotherapy. This review considers the indications, mechanism of action, and effectiveness of the traditional and novel treatment options for patients with ITP.

New anticoagulants in the prevention and treatment of venous thromboembolism

Clinical data on the risk factors, incidence, consequences and current treatment options of venous thromboembolism are reviewed. Current guidelines advise anticoagulant treatment for a few weeks or months in immobilized patients treated in hospital, and after major surgery. The initial treatment is based on heparin, followed by vitamin K antagonist treatment. Recently a number of new, partially orally administered medications have undergone clinical investigations and based on the results three of them were also registered for the prevention and treatment of venous thromboembolism. Direct thrombin inhibitors, direct and indirect Factor Xa inhibitors exhibited proven non-inferiority or superiority compared with traditional treatment options. The superior efficacy or non-inferiority was not accompanied with an increase in the bleeding risk. Results of the most important clinical trials are reviewed. Based on these results, prevention and treatment of venous thromboembolism will change substantially in the near future.

Continuous intra-arterial infusion of nimodipine at the onset of resistant vasospasm in aneurysmal subarachnoidal haemorrhage. Technical report

<title/>Cerebral vasospasm complicating the aneurysmal subarachnoid haemorrhage is a well known medical entity. The delayed ischemic neurological deficits (DINDs) as a result of vasospasm, remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options either medical or interventional, fail to reverse the vasospasm, continuous intra-arterial infusion of nimodipine through catheters direct in the spastic arteries, presents a promising treatment modality. We treated in our clinic four patients with severe aneurysmal subarachnoid haemorrhage and refractory vasospasms with continuous nimodipine infusion via catheters in both internal carotid arteries and discussed the efficacy of the method presenting an illustrative case and discussing the effect based on doppler examinations.

Percutaneous Instrumentation of Pathologic Vertebral Fractures

Vertebral metastatic disease leading to pathologic compression fractures is becoming increasingly common as patients with cancer are surviving for longer. Pathologic compression fractures severely limit quality of life; pain is nearly universal, and neurologic deficits are also common. Traditional treatment options have been limited to non-operative modalities, cement augmentation, or large circumferential decompressive procedures. Percutaneous spinal fixation provides another less invasive option, and can be used as a stand-alone procedure or in conjunction with open or minimally invasive decompression. This procedure may improve the quality of life of patients who would be deemed poor surgical candidates due to short life expectancy or medical comorbidities precluding major surgery.

How Patients With Schizophrenia Use the Internet: Qualitative Study

Background The Internet is an important source of health information for people with psychiatric conditions. Little is known about the way patients with schizophrenia use the Internet when it comes to issues related to their illness. Data on their specific needs, difficulties, and the consequences related to Internet use are lacking.Objective Our objective was to investigate the nature and subjective consequences of health-related Internet use among patients with schizophrenia.Methods In all, 26 individual semistructured interviews were conducted and analyzed qualitatively in groups of 4 until theoretical saturation was achieved.Results Study results suggest that the Internet is an influential source of illness-related information for patients with schizophrenia. Many aspects of their behavior around the Internet resemble those of individuals not afflicted by mental illness. Importantly, problems specific to patients with schizophrenia were stimulus overflow, an inability to deal with the abundance of information, difficulties with concentration, lack of energy, paranoid ideas, symptom provocation, and the need to distance themselves from illness-related topics as part of the recovery process. Internet information was subjectively perceived as having the potential to significantly change patients’ attitudes toward medication and their relationships with doctors.Conclusions These findings provide insight into how individuals with schizophrenia handle illness-related Internet information. The data could contribute to the continuous development of Internet-based interventions and offer novel approaches to optimizing traditional treatment options.

Treating Obesity in the Family Practice Setting

The health risks of obesity include the development of comorbid conditions and increased overall mortality. Obesity increases health-related costs for both patients and the healthcare system and significantly affects workforce productivity through increased absenteeism and higher health and insurance payments for employers. Discrimination against obese individuals exists in the workplace and in various social contexts. Obesity is a chronic condition with complex, multiple causes involving physiologic, genetic, and behavioral components, all of which must be addressed for successful treatment. Traditional treatment options include diet, exercise, and behavior modification, but recently, pharmacotherapy has been incorporated as an effective and safe adjunct for long-term treatment of obesity. Additionally, bariatric surgery is an option for selected morbidly obese individuals. Weight losses of only 5% to 10% of initial body weight confer proven clinical benefits. Such modest weight losses can be achieved and maintained within a supportive environment provided in a primary care practice.

Conservation Surgery for Early Laryngeal Carcinoma

Background: Squamous cell carcinoma is the commonest malignant tumour of the larynx. The traditional treatment options have included radiotherapy and total laryngectomy. Due to the pivotal role of the larynx in respiration, speech and deglutition, conservative approaches to the management of malignant lesions were suggested. These organ-preserving policies aim at preserving most of the laryngeal functions without compromising the oncological outcomes. Such approaches include organ-preserving radio/chemotherapy protocols, endoscopic laser surgery, photodynamic therapy and open conservative surgery. Each of these has their indications, advantages and disadvantages. The modern trend towards organ preservation protocols and endoscopic laser techniques seems to have supplanted open conservative surgery. However, these techniques still have an important role in the management of laryngeal malignancies. Methods: This is retrospective study on 216 patients followed for a minimum of 2 years and a maximum of 16. All patients underwent partial surgery as first-line treatment: 135 underwent partial vertical laryngectomy, 76 underwent supraglottic hemilaryngectomy and 5 underwent supracricoid subtotal laryngectomy. Results: Our overall disease-free survival was 92.1%, which compares favourably with most series. Total laryngectomy was performed in 11 patients (in 10 as salvage and in 1 for intractable aspiration) resulting in a laryngeal preservation rate of 94.4%. The decanulation rate was 95% (11 patients in the three types of surgery). There were no major morbidities or surgery-related mortalities. The most significant complication was aspiration (18.9% of patients), but it could be managed conservatively in all but one case. Conclusion: In this era of organ preservation policies, open conservative surgery offers a viable option with comparable functional and oncological results. It should be considered when logistic, economical or patient factors make other protocols impractical.

A retrospective cohort study of the impact of biologic therapy initiation on medical resource use and costs in patients with moderate to severe psoriasis

Biologic therapy has become established as an important treatment option in patients with severe psoriasis, but is significantly more expensive in terms of drug costs than traditional treatment options. Relatively little is known about the total healthcare cost of treating severe psoriasis in daily clinical practice and what the budgetary impacts of such high-cost drugs are when compared with standard systemic therapy. To describe the impact of biologic therapy introduction on the use of medical resources, costs and where available, outcomes in patients with moderate to severe psoriasis. Data were extracted from case notes of a sequential patient cohort with psoriasis attending a tertiary referral severe psoriasis service and initiated on biologics (adalimumab, efalizumab, etanercept or infliximab) for treatment of their psoriasis. Data on hospital resource use (inpatient, outpatient, day ward, accident and emergency visits and phototherapy sessions) and drug usage (systemic nonbiologic and biologic psoriasis therapies and supportive drugs) were collected for 12 months prior to, and at least 6 months following initiation of biologic therapy. Outcome was measured using the Psoriasis Area and Severity Index (PASI). Differences in resource use and associated costs and outcomes, between 12 months before and after initiation of biologic therapy, were tested using Wilcoxon paired sign tests for continuous data and the McNemar test for categorical data. Confidence intervals (CI) around treatment costs were constructed using a 5000-sample bootstrap analysis. The primary analysis population comprised 76 patients completing 12 months of biologic therapy: 71% males; mean age at time of study 47·3 years (range 23-74); mean duration of psoriasis 24·7 years (range 5·3-45·5). Significant reductions (P < 0·05) in the year following initiation of biologic therapy were observed for all hospital resource use categories, with mean annual costs reduced by £1682 (95% CI -3182 to -182·2; P = 0·05). Mean annual drug costs increased by £9456 (95% CI 8732-10,182; P < 0·001). Mean PASI fell by 8·9 points from 18·7 to 9·8 (95% CI -10·8 to -7·1; P < 0·001). Total healthcare costs associated with treatment of severe psoriasis with biologic therapy are significantly greater than with traditional systemic therapy. However, some of these are offset by substantial reductions in the number and length of hospital admissions and use of photo- and systemic therapy, and result in significantly improved patient outcome (as inferred by improvement in PASI).

A visceral pseudoaneurysm: management by EUS-guided thrombin injection

Visceral pseudoaneurysm is a rare but well-described complication of pancreatitis1,2 caused by the autodigestive function of pancreatic enzymes.3 The splenic, gastroduodenal, pancreaticoduodenal, and hepatic arteries are most commonly affected.2,4 Pseudoaneurysms require active management because of the high complication and mortality rates associated with rupture.2,5 Traditional treatment options include aneurysm exclusion, surgical excision or ligation, revascularization, and endovascular techniques such as angiographic embolization.

Managing Patients With Advanced and Metastatic Breast Cancer

Breast cancer is one of the most common cancers in women, and although the prognosis is good for patients with early-stage, localized disease, it is relatively poor for patients with metastatic breast cancer. Treatment options become progressively limited with advancing lines of therapy, primarily because of the development of tumor drug resistance. Nurses have a crucial role in managing patients with breast cancer; therefore, awareness of the clinical efficacy and side-effect profiles of traditional and newer treatment options is of great importance. The taxanes (docetaxel and paclitaxel) are well known for their efficacy in patients with breast cancer. The epothilones, a newer class of microtubule-targeting agents, also are proving beneficial. The most clinically advanced epothilone, ixabepilone, has been approved for the treatment of locally advanced or metastatic disease. Although taxanes and epothilones are similar mechanistically, the epothilones have unique structural, binding, and preclinical properties in terms of microtubule stabilization. Importantly, ixabepilone retains clinical efficacy in patients with metastatic breast cancer who show resistance to taxanes and anthracyclines.

Malformaciones venosas orofaciales de bajo flujo: esclerosis endoluminal con láser de diodo

Background Vascular anomalies are common processes that involve the head and neck region in more than 50% of the cases. Traditional treatment options such as surgery and chemical sclerosis have given way to modern less-invasive techniques, including Nd:YAG laser treatment. On the other hand, 980 nm laser diode has been successfully used for the endovenous sclerosis of varicose veins. Our proposal is the usage of diode laser (λ = 980 nm) to induce the sclerosis of low-flow venous malformations by intralesional photocoagulation, given this laser's ability to deliver the beam via a fiber optic cable. Objective To report our results in the treatment of orofacial low-flow venous malformations (LFVM) with diode laser endovenous sclerosis (DLES). Material and methods : The clinical records from 84 patients presenting with orofacial LFVM treated with DLES were collected. The technique used and short-term postoperative results were revised. Results After a follow-up period of at least 12 months after one or two DLES sessions, healing was observed in 95.24% of the cases. Only 4 cases showed relapse. Conclusions The DLES technique is a new therapeutic option for the treatment of orofacial LFVM, is minimally-invasive, allows an outpatient setting and achieves excellent functional and esthetic results avoiding more aggressive procedures.

Targeted molecular therapies in thyroid carcinoma

Thyroid cancer incidence has significantly increased in the last three decades and many patients seek medical attention for its treatment every year. Among follicular cell-derived tumors, the majority are differentiated thyroid carcinomas (DTC), whose prognosis is very good with only 15% of the cases presenting disease persistence or recurrence after initial treatment. Medullary thyroid carcinoma has a worse prognosis, especially in patients with diffused cancers at the time of initial surgery. Traditional treatment options for persistent or recurrent disease include additional surgery, radioiodine treatment and TSH-suppression in DTC patients; external beam radiotherapy, and cytotoxic chemotherapy, often have low efficacy and many patients with advanced disease ultimately die. In the last two decades many of the molecular events involved in cancer formation have been uncovered. This knowledge has prompted the development of novel therapeutic strategies mainly based on the inhibition of key molecular mediators of the tumorigenic process. In particular the class of small-molecule tyrosine kinase inhibitors was enriched by many compounds that have reached clinical trials and in some cases have had approval for clinical use in specific cancers. Many of these compounds entered clinical trials also for locally advanced or metastatic thyroid carcinomas showing very promising results.

Retaining central venous catheters in paediatric parenteral nutrition

This article aims to discuss problems with central venous catheters (CVCs) and offer strategies to assist in preventing their replacement. The article focuses on the most frequent complications of infection and obstruction. Traditional treatment options are presented and endoluminal brushing is introduced as an innovative treatment for retaining CVCs. The expert opinion that follows focuses on CVCs that are used for parenteral nutrition in paediatrics, but the evidence described can also be applied to larger adult catheters.

Immunotherapy as a Strategy for Treatment of Leishmaniasis: a Review of the Literature

Leishmaniasis occurs as a spectrum of clinical syndromes divided into cutaneous, mucocutaneous and visceral forms. The epidemiology and clinical features are highly variable owing to the interplay of many factors ranging from parasite species and strains, vectors, host genetics and environment. Currently, there is no effective licensed vaccine for use in humans against leishmaniasis. Most traditional and low-cost treatment options, particularly in poor and endemic areas, are toxic with many adverse reactions and they require a long course of administration. The use of more effective, less toxic drugs is limited because total treatment cost is very high (expensive) and there are fears of development of drug resistance. Recent studies indicate that certain strategies aimed at modulating the host immune response (collectively called immunotherapy) could result in prophylactic and/or therapeutic cure of leishmaniasis under both laboratory and field conditions. In this review, we focus on treatment of leishmaniasis with a particular emphasis on immunotherapy/immunochemotherapy as an alternative to conventional drug treatment.

Mothers’ Life-Worlds in a Developing Context when a Child has Special Needs

This South African study investigates the lived experiences of a group of isiZulu mothers of children diagnosed with multiple disabilities. Data collection from regular focus group discussions proceeded with the assistance of a translator skilled in working in isiZulu and English. The phenomenological approach employed revealed the mothers’ philosophical acceptance of their child’s disability. Issues of concern to the women that emerged include the effects of the child’s disability on their lives, the treatment options for their children, and their perceptions of the causes of the disability. The women reflect on both traditional and Western treatment options and articulate the constraints they experience as caregivers, with limited childcare facilities preventing them from finding employment, difficulties in accessing social service grants exacerbating their position, and various levels of family and community support experienced. The study underlines the need for more adequate service provision for children with special needs and their families, and for intervention programmes to be informed by an understanding of the contexts and ways of making meaning of those whose needs they are intended to serve.

Efficacy of Debridement Alone Versus Debridement Combined with Topical Antifungal Nail Lacquer for the Treatment of Pedal Onychomycosis: A Randomized, Controlled Trial

Pedal onychomycosis is a common malady caused by dermatophytes, saprophytes, and yeasts. Traditional treatment options for this condition include toenail debridement, and pharmacological therapies that range from the application of topical agents to the oral administration of antifungal medications. In this study, 55 patients (289 toenails) were randomly allocated to either nail debridement (27 [49.09%] patients) or debridement plus application of topical antifungal nail lacquer (28 [50.91%] patients). The primary outcome was mycological cure, and secondary outcomes included foot-related quality of life, and a number of clinically important toenail characteristics. After a median follow-up of 10.5 months (range, 3.25-14.25) months), patients in the antifungal nail lacquer group improved statistically significantly more than did those in the debridement alone group, and displayed a 76.74% rate of mycological cure. None of the patients in the debridement-only group experienced mycological cure. Variables that statistically significantly decreased the likelihood of cure included yeast on culture, pedal hyperhidrosis, cigarette smoking, involvement of the lunula, and involvement of >50% of the transverse width of the nail. Variables statistically significantly associated with an increased likelihood of cure included intervention before 6 months' duration, treatment at a large, urban practice, black race, and loss of protective sensation. 1.

Ventricular Assist Devices: History, Patient Selection, and Timing of Therapy

Timing of therapy and selection of patients in the use of ventricular assist devices (VADs) can be difficult. In general, consideration for VAD implantation is appropriate in patients with endstage heart failure who are failing optimal medical therapy and in whom no alternative traditional surgical treatment options are available. However, identifying when a particular patient has reached this point is not always straightforward. There are a broad range of medical and surgical therapies for patients with overt heart failure, and this armamentarium is constantly expanding. The risks, benefits, and expected outcomes with VAD therapy have also undergone dramatic changes over the last decade. Advances in technology have led to a proliferation of newer generation devices that are smaller, lighter, easier to implant, and more reliable than previous generation devices. This, in turn, has led to a markedly improved risk-benefit ratio, with increased durability and reduced morbidity. The indications for the implantation of ventricular assist devices have also evolved over the last several years, and specific patient presentations and goals of therapy have led to specific indications. Device therapy has traditionally been classified as bridge to recovery, bridge to transplantation, and destination therapy. However, such designations may not be well defined at the time of implantation, and recovery and response following initiation of VAD support may allow patients to change from one classification to another. The current data regarding indications and timing of device implantation are reviewed.

A prognostic gene expression index in ovarian cancer—validation across different independent data sets

Ovarian carcinoma has the highest mortality rate among gynaecological malignancies. In this project, we investigated the hypothesis that molecular markers are able to predict outcome of ovarian cancer independently of classical clinical predictors, and that these molecular markers can be validated using independent data sets. We applied a semi-supervised method for prediction of patient survival. Microarrays from a cohort of 80 ovarian carcinomas (TOC cohort) were used for the development of a predictive model, which was then evaluated in an entirely independent cohort of 118 carcinomas (Duke cohort). A 300-gene ovarian prognostic index (OPI) was generated and validated in a leave-one-out approach in the TOC cohort (Kaplan-Meier analysis, p = 0.0087). In a second validation step, the prognostic power of the OPI was confirmed in an independent data set (Duke cohort, p = 0.0063). In multivariate analysis, the OPI was independent of the post-operative residual tumour, the main clinico-pathological prognostic parameter with an adjusted hazard ratio of 6.4 (TOC cohort, CI 1.8-23.5, p = 0.0049) and 1.9 (Duke cohort, CI 1.2-3.0, p = 0.0068). We constructed a combined score of molecular data (OPI) and clinical parameters (residual tumour), which was able to define patient groups with highly significant differences in survival. The integrated analysis of gene expression data as well as residual tumour can be used for optimized assessment of the prognosis of platinum-taxol-treated ovarian cancer. As traditional treatment options are limited, this analysis may be able to optimize clinical management and to identify those patients who would be candidates for new therapeutic strategies.

New method of temporary rehabilitation after traumatic tooth loss in a juvenile patient: a case report

We report a 12-year-old female patient who had experienced traumatic loss of one of her permanent central incisors. In the course of interdisciplinary treatment, the gap in the front teeth was filled with a prosthetic plastic tooth fastened to an orthodontic palatal implant by means of a wire extension (stainless steel 1.2 mm; laser-welded). A palatal implant is a temporary orthodontic anchorage device which, in contrast to a conventional single tooth implant, is not inserted in the toothless alveolar bone but in the palatal region to permit unhindered maxillary growth. The advantages of this treatment compared with traditional treatment options are that it permits secure fixation, adjustment to vertical growth and good hygiene. Besides, it is an economical treatment modality, can be used as anchorage in conjunction with orthodontic treatment and provides good comfort, esthetics and phonetics.

Traditional healers and epilepsy treatment on the Kenyan coast

Traditional healers and epilepsy treatment on the Kenyan coast