Treatment Philosophy Research Articles

Evolution of treatment mechanics and contemporary appliance design in orthodontics: A 40-year perspective.

Until the early 1970s, successful treatment with the Begg technique and the Tweed edgewise technique required tedious wire bending. The introduction of Andrews' straight wire appliance changed that, and it was one of the most significant contributions in the history of orthodontics. The straight wire appliance significantly reduced the amount of wire bending and also brought along other options in treatment mechanics. Retraction of the canines with elastic chains and ligature wires became more common. Sliding mechanics in place of closing loops became the method of space closure for a significant number of clinicians. Edgewise force levels were initially used to close spaces; however, it was soon observed that lighter forces were more effective with sliding mechanics. Along with these changes, it became apparent that compensation in the appliance was needed, depending on the type of malocclusion and particularly with varying extraction sequences. Various appliance designs were developed to accommodate changes in mechanics and force levels. These modifications improved tooth positions at the end of treatment as long as the brackets were properly placed. These major changes in appliances, force levels, and treatment mechanics can be traced back to the work of Dr Lawrence Andrews and the straight wire appliances.

How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient populations.

BackgroundWe recently developed a clinical decision support tool, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases. After making it publicly available on www.PATHFx.org, we attempted to externally validate it using independent, international data.MethodsWe collected data from patients treated at 13 Italian orthopaedic oncology referral centers between 2010 and 2013, then applied to PATHFx, which generated a probability of survival at three and 12-months for each patient. We assessed accuracy using the area under the receiver-operating characteristic curve (AUC), clinical utility using Decision Curve Analysis (DCA), and compared the Italian patient data to the training set (United States) and first external validation set (Scandinavia).ResultsThe Italian dataset contained 287 records with at least 12 months follow-up information. The AUCs for the three-month and 12-month estimates was 0.80 and 0.77, respectively. There were missing data, including the surgeon’s estimate of survival that was missing in the majority of records. Physiologically, Italian patients were similar to patients in the training and first validation sets. However notable differences were observed in the proportion of those surviving three and 12-months, suggesting differences in referral patterns and perhaps indications for surgery.ConclusionsPATHFx was successfully validated in an Italian dataset containing missing data. This study demonstrates its broad applicability to European patients, even in centers with differing treatment philosophies from those previously studied.

The Australian Treatment Outcome Study - implications for treatment philosophies, policy, political processes and practice.

The Australian Treatment Outcome Study - implications for treatment philosophies, policy, political processes and practice.

Surgical management of petroclival meningiomas: Factors affecting early post-operative outcome

Introduction. Petroclival meningiomas pose a major challenge to the treating neurosurgeon. The philosophy of treatment has changed over the decades from a nihilistic attitude to that of aggressive total excision to now a more tempered, maximal safe excision preventing morbidity followed by adjuvant treatment. Despite the advances in neurosurgery, surgical management of these tumours is still associated with sizable morbidity and mortality. Material and methods. This is a retrospective study of surgically managed petroclival meningiomas at our institute. Clinical status, radiological features and surgical outcome were analysed. Results. Between January 2003 and August 2013, we have operated on 30 patients. The most common presenting complaints were varying degrees of cranial nerve involvement and cerebellar dysfunction. Surgery was done using one of the skull base approaches with the retrosigmoid approach being used maximally (22 cases). Total or near-total excision was possible in 11 cases. There was a post-operative deterioration in cranial nerve functions in all patients and deterioration in Karnofsky Performance Score in seven patients at discharge. Three improved to independent status on follow-up. There was mortality in two cases. Overall 23 of the 30 patients (76.6%) had favourable outcomes. Conclusions. These are challenging tumours to treat and are associated with sizable morbidity and mortality. On statistical analysis, we found that if the tumour has a size of 3–5 cm and petroclival in location with no sphenoid extension and the lesion is homogenous on T2-weighted images, then there was a trend towards gross total resection and favourable outcome.

Communication Commentary: Obsessive-Compulsive and Related Disorders: From Compulsions to Communication: Forming a Therapeutic Alliance With Individuals Diagnosed With Obsessive-Compulsive Disorder

Communication Commentary: Obsessive-Compulsive and Related Disorders: From Compulsions to Communication: Forming a Therapeutic Alliance With Individuals Diagnosed With Obsessive-Compulsive Disorder

Practice Note: The Irish Drug Treatment Court

Although international countries seek to adopt the American drug court model, each country brings its own culture, philosophy of treatment, and drug use context that affects how each court is implemented. This article reviews the history and context of the Irish Drug Treatment Court. Differences from the American model are considered, such as an emphasis on harm reduction, provision of services predominantly to heroin users, the use of an adult education program as the main intervention, and a varying view of therapeutic jurisprudence. Process and outcome evaluation findings are presented, along with a final discussion related to drug court practice.

Do intensivists prognosticate patients differently from themselves or their loved ones?

There is a paucity of data about whether our treatment philosophy is different for our patients as compared with what we would have wanted for ourselves, or while acting as surrogate decision-makers for our loved ones.

Specific Injuries Management in the Postoperative of Congenital Heart Diseases (II): Univentricular Hearts

It is very important to understand that the univentricular heart surgery is just palliative, not being in anyway a definitive or curative surgery, but nowadays it’s the best initial treatment of this complex heart disease. The fundamental philosophy of treatment of every univentricular heart is to ensure the flow system and/or restrict the lung flow. Thus, initially a patient with univentricular heart who is undergoing surgery may need to ensure systemic flow (reconstruction of the aortic arch type Norwood), to restrict the lung flow (pulmonary banding) or to provide enough pulmonary flow (pulmonary-systemic fistulae). However, some heart diseases with univentricular physiology remain “balanced” autonomously, until the “second” stage of palliation is performed (cavo-pulmonary anastomosis type Glenn), but others require performance of pulmonary banding, if there’s no native lung protection and/or repair of the systemic circuit in a first stage, to reach next palliation steps in the best possible conditions.

Music Therapy and Chronic Mental Illness: Overcoming the Silent Symptoms

The National Institutes of Mental Health (National Institutes of Mental Health, n.d.) reports that about 4.1% of the adult U.S. population, or approximately 9.6 million adults, suffer from serious mental illness, at an estimated yearly cost of over $300 billion per year. These statistics are admittedly conservative, however, since sources for collecting data often do not include population groups likely to suffer from mental illness, such as the homeless or the incarcerated. The National Alliance on Mental Illness (NAMI) (NAMI, 2013) estimates that about 13.6 million Americans live with serious mental illness, and that about two-thirds of these people experience co-occurring mental health and substance abuse disorders. Considering these kinds of numbers and costs, it is not surprising that our healthcare system focuses its attention on the stabilization of active symptoms that are troublesome and/or injurious and cause difficulty in the community. Those who work with the seriously mentally ill, however, know that stabilization of primary symptoms is really only the beginning of being able to function well in daily life, and that return to the community as functioning and productive members requires far more treatment and support than the simple abatement of the symptoms that cause them to be problematic or harmful to self and others.Non-pharmaceutical treatment philosophies for individuals with chronic mental illness (CMI) tend to center on behavioral and/or cognitive behavioral approaches in both in-patient and community placements, presumably because these approaches are considered best practice (Glancy & Saini, 2005). These approaches tend to be those which are easily studied and objectively documented. Lack of rigorous testing of other treatment approaches, however, may suggest that these behaviorally based approaches can really only be considered the most studied, as opposed to best practice. Behavioral and cognitive-behavioral approaches to treatment can be quite effective for helping individuals with CMI learn to control some of their symptomatic behavior and develop more functional social skills, but may do little to identify and address the non-behavioral issues that tend to disrupt long-term stability.The impact of serious mental illness can touch every domain of an individual's life. It is not usual for relationships with family, friends, and other social support to be severely disrupted, and even severed completely, because of an individual's behavior during active episodes of symptoms like psychosis, mania, paranoia, and so forth. Dreams for the future can be erased, and the individual's identity as it was understood previous to mental illness can be destroyed. In some cases, individuals with CMI find themselves to be entwined in the legal system for criminal behavior committed while in a state of diminished mental capacity. Awareness of these losses as the individual regains some stability can be devastating and should be considered a major trauma. Individuals with CMI, who can have significant difficulty reintegrating as functional members of the community, may be repeatedly reminded of this trauma each time they encounter difficulties with illness management, interpersonal relationships, independent living, employment, and coping with the stressors of everyday life. They potentially deal with re-traumatization on a regular, and perhaps even daily, basis.Onset of numerous CMIs occurs in early adulthood, the time of life when individual identity is taking shape and the ability to exercise independence and pursue hopes and dreams is within reach. Serious mental illness can halt this development, and often shatters the possibility of return to the type of life imagined prior to illness onset. Individuals with CMI often experience a good deal of grief in relation to these losses. At the same time, symptomatology that is unresolved (e.g., negative symptoms) and the immobilization of emotions that sometimes occurs with pharmaceutical treatment make it difficult to actively work through and resolve feelings of grief. …

The role of neck dissection in squamous cell carcinoma of the head and neck.

Lymph node metastases in the neck are a major prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC). Assessment and treatment of lymph nodes in the neck are of utmost importance. Inappropriate management of lymph node metastases can result in regional failure. Radical neck dissection has been and is still considered the "gold standard" for the surgical management of lymph node metastases of HNSCC. However, the philosophy of treatment of the neck has evolved during the last decades. Surgeons progressively realized that extensive neck dissections were associated with a higher morbidity but not always with a better oncologic outcome than more limited procedures. Today, a comprehensive therapeutic approach of the neck is multidisciplinary, taking into account the patient's quality of life without jeopardizing cure and survival. A better understanding of the patterns of lymph node metastasis promoted the use of selective neck dissection in selected patients. Sentinel lymph node biopsy is a reliable diagnostic procedure for staging the neck in node-negative early oral cavity squamous cell carcinoma. With increasing use of chemoradiation in locally advanced HNSCC, paradigms are evolving. Currently, there are strong arguments supporting the position that neck dissection is no longer justified in patients without clinically residual disease in the neck.

Usefulness of Preoperative Orthopedics in Shaping Alveolar Ridges in 0-to-12-Month-Old Children with Unilateral Complete Cleft Lip and Palate. A Systematic Review

Background: Among the alternatives for early treatment of cleft lip and palate (LPC), preoperative orthopedics has been proposed for the alignment of alveolar ridges. Currently, there are two treatment philosophies regarding whether or not using preoperative orthopedics because there is still much controversy on its actual effects. Purpose: To determine the reported usefulness of preoperative orthopedics in molding alveolar ridges in 0-to-12-monthold children with unilateral complete LPC. Methods: A systematic review of the literature was carried out using the Medline, Elsevier, Cochrane, and EBSCO databases. Search descriptors were pre-surgical orthopedics, alveolar ridge, alveolar molding, and unilateral complete cleft lip and palate. After reading of titles, abstracts, and full articles, the quality and validity of studies were determined through the Consort, Strobe, and Quorum checklists. Data were classified by the level of evidence and grades of recommendation based on the Scottish Intercollegiate Guidelines Network guidelines. Results: From a total of 4738 titles we identified 88 articles that met the inclusion criteria. After analyzing the files, we only found three articles that provided adequate evidence on the topic of study. Conclusion: There is not enough scientific evidence to support the usefulness of preoperative orthopedics in shaping alveolar ridges. There are other influencing factors that should also be studied.KEYWORDSpreoperative orthopedics; alveolar ridge; alveolar molding; unilateral complete cleft lip andpalate

Redox therapy in neonatal sepsis: reasons, targets, strategy, and agents.

Neonatal sepsis is one of the most fulminating conditions in neonatal intensive care units. Antipathogen and supportive care are administered routinely, but do not deliver satisfactory results. In addition, the efforts to treat neonatal sepsis with anti-inflammatory agents have generally shown to be futile. The accumulating data imply that intracellular redox changes intertwined into neonatal sepsis redox cycle represent the main cause of dysfunction of mitochondria and cells in neonatal sepsis. Our aim here is to support the new philosophy in neonatal sepsis treatment, which involves the integration of mechanisms that are responsible for cellular dysfunction and organ failure, the recognition of the most important targets, and the selection of safe agents that can stop the neonatal sepsis redox cycle by hitting the hot spots. Redox-active agents that could be beneficial for neonatal sepsis treatment according to these criteria include lactoferrin, interleukin 10, zinc and selenium supplements, ibuprofen, edaravone, and pentoxifylline.

Innovation Attributes and Adoption Decisions: Perspectives from Leaders of a National Sample of Addiction Treatment Organizations

Drawing on diffusion theory to further knowledge about evidence-based practices (EBPs) in the treatment of substance use disorders (SUDs), this study describes the perceived importance of innovation attributes in adoption decisions within a national sample of SUD treatment organizations. Face-to-face interviews were conducted with leaders of 307 organizations. A typology differentiated organizations reporting: (1) adoption of a treatment innovation in the past year (“recent adoption”), (2) plans to adopt an innovation in the upcoming year (“planned adoption”), or (3) no actual or planned adoption (“non-adoption”). About 30.7% of organizations reported recent adoption, 20.5% indicated planned adoption, and 48.8% were non-adopters. Leaders of organizations reporting recent adoption (n=93) or planned adoption (n=62) rated the importance of innovation attributes, including relative advantage, compatibility, complexity, and observability, on these adoption decisions using a Likert scale that ranged from 0 to 5. Innovation attributes most strongly endorsed were consistency with the program’s treatment philosophy (mean=4.47, SD=1.03), improvement in the program’s reputation with referral sources (mean=4.00, SD=1.33), reputational improvement with clients and their families (mean=3.98, SD=1.31), and reductions in treatment dropout (mean=3.75, SD=1.54). Innovation characteristics reflecting organizational growth and implementation costs were less strongly endorsed. Adopters and planners were generally similar in their importance ratings. There were modest differences in importance ratings when pharmacological innovations were compared to psychosocial interventions. These findings are consistent with diffusion theory and suggest that efforts to link EBPs with client satisfaction and potential reputational benefits may enhance the diffusion of EBPs. Attention to these attributes when developing and evaluating SUD treatment interventions may enhance efforts to increase subsequent adoption.

Soul of an Agency: Psychodynamic Principles in Action in the World of Community Mental Health

ABSTRACTCommunity mental health has undergone a number of evolutions since Lyndon Johnson declared a War on Poverty and gave birth to the community mental health movement. This paper describes a philosophy of treatment involving long‐term psychotherapy to resistant and multiple problem families in disadvantaged communities. The agency's primary philosophy is described as a psychoanalytic frame that guides treatment from a secure attachment site (clinic) in the community. The interventions use home and community based therapists with supports from psychiatry, psychology, and therapeutic mentoring. The focus of all treatment is for high‐risk families to remain in the community and not burden corrections, courts, child welfare, or juvenile justice systems. Therapy forms the connection that can help families navigate schools, medical providers, courts, and social service systems. The agency forms the positive attachment site; clinicians come and go. The net effect is sustained connection to families that would have otherwise been broken apart by domestic violence, school crimes, addiction, gangs, poverty, homelessness, and community violence. Copyright © 2014 John Wiley & Sons, Ltd.

New trends in rectal cancer treatment

SUMMARY The treatment philosophy for rectal cancer has changed a lot during the last three decades. In the 1970s it was more or less a pure surgical business and rectal cancer was considered radiation resistant. Owing to the unacceptable high local recurrence rates, surgery was changed (the total mesorectal excision technique) during the 1980s and treatment was, in many countries, concentrated to lager units. Moreover, the addition of adjuvant radiotherapy was tested during the same period in several randomized trials and demonstrated that the local recurrence rate could be reduced by 50%, provided the radiation dose was high enough. Since then, treatment has changed very rapidly with several interesting approaches, such as timing and type of radiotherapy, the place of chemotherapy, surgery with modern technique including laparoscopy; natural orifice transendoscopic surgery or robotics; and the whole idea of ‘wait-and-watch’ program. All of these new aspects are covered and discussed in the view of the standard-of-care in 2014.

Evidence-based medicine: Craniosynostosis.

After studying this article, the participant should be able to: (1) Make the appropriate diagnosis for each of the single-sutural synostoses, based on the physical examination. (2) Explain the functional concerns associated with these synostoses and why surgical correction is indicated. (3) Distinguish between the different types of surgical corrections available, the timing for these various interventions, and in what ways these treatments achieve overall management objectives. (4) Identify the basic goals involved in caring for the syndromic synostoses. This article provides an overview of the diagnosis and management of infants with craniosynostosis. This review also incorporates some of the treatment philosophies followed at The Craniofacial Center in Dallas, but is not intended to be an exhaustive treatise on the subject. It is designed to serve as a reference point for further in-depth study by review of the reference articles presented. This information base is then used for self-assessment and benchmarking in parts of the Maintenance of Certification process of the American Board of Plastic Surgery.

Communication Commentary: Time in a Bottle: The Psychopharmacologist-Patient Relationship in “Split-Treatment” Models of Care

The doctor-patient relationship has been and remains the keystone of all medical care. It is the medium by which symptom data are gathered, diagnosesmade, thepatient is engaged in the enterprise of formulating a treatment plan, the issues of motivation and adherence are addressed, and nonjudgmental support is provided to enhance the work of healing (1). Medical communications researchers Roter and Hall (2) remarked that “talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved” (p. 8). They noted that we in the psychiatry field are “participating in a dramatic transformation of the identity of our profession. Clinical practice is moving toward psychopharmacological evaluation and treatment monitoring as the principal role for psychiatrists in direct service provision” (p. 13). Psychiatrists often work in teams with nonphysician therapists, casemanagers, andother specialists. This model can be very effective for individualizing care such that patients may receive appropriate multidisciplinary treatment from professionals with high levels of expertise in their areas of specialization. Access to psychiatric care is often limited. A collaborative care team or “split-treatment” model in which nonphysicians provide psychotherapy and/or other psychosocial interventions and physicians provide psychiatric assessment and psychopharmacological care allows greater psychiatric access for patients in need. In fact, Interian and colleagues

Management of acute and chronic vascular conditions of the hand

Management of acute and chronic vascular disorders of the hand in patients with vasospastic and vaso-occlusive disorders is a complex problem and requires a multidisciplinary approach. The ischemia-related pain, skin ulcerations, and ultimately the threat of digital gangrene require a concerted effort to improve perfusion using a combination of medications and surgery. The purpose of this work is to review our experience over the past 2 decades with this cohort of patients including the variability of the clinical presentation, a method of classification, and a practical treatment philosophy.

Executive Functioning and Social Pragmatic Communication Skills: Exploring the Threads in Our Social Fabric

The development of treatment plans and related strategies to help our students with social pragmatic challenges improve upon their social communicative competencies requires us to explore how Theory of Mind (ToM), Central Coherence (CC), and Executive Functioning (EF) are interwoven. In this article, we will deconstruct elements of social learning to explore how EFs play a critical role in face-to-face communication and how this information is not captured on any current standardized assessment currently available in our field. Addressing the need to teach our students to be stronger social observers or “detectives” in order to socially problem solve and the practice adapting their behaviors based on the situation and the people within it is key to teaching social EF. Treatment philosophy encouraging the use of systematic social communication frameworks, such as Carol Gray's Social Stories (Gray & Garand, 1993) and Social Thinking's Social Behavior Mapping (Winner, 2007b) is explored to assist our students' in their development of social and self-regulatory strategies.

Extraction and non extraction - an overview

Every orthodontists often appear to have conflicting treatment plans for the same patient. The reason is not that they see very different problems or have radically different philosophies of treatment, but rather that each doctor has a different line in the gray area between extractions and nonextraction. Two treatment plans that appear very different can both be based on a similar analysis of the patient's problem, but end up with very different treatments due to the black and white nature of the decision making process. It is important to understand that in borderline cases there are no correct or right answers. Both treatments performed by competent orthodontists would produce a good result, but neither is perfect. Each option would have pros and cons, and orthodontists and dentists could (and do) spend endless amounts of time debating which option is “right”.