Treatment algorithm for moderate to severe ulcerative colitis.

The care for a patient with ulcerative colitis (UC) remains challenging despite the fact that morbidity and mortality rates have been considerably reduced during the last 30 years. The traditional management with intravenous corticosteroids was modified by the introduction of ciclosporin and infliximab. In this review, we focus on the treatment of patients with moderate to severe UC. Four typical clinical scenarios are defined and discussed in detail. The treatment recommendations are based on current literature, published guidelines and reviews, and were discussed at a consensus meeting of Swiss experts in the field. Comprehensive treatment algorithms were developed, aimed for daily clinical practice.

Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p < 0.01). The patients in the new algorithm group were older (41 +/- 1 vs. 46.3 +/- 16.7 years, p=0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p= 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.

Treatment algorithm for moderate to severe ulcerative colitis

The care for a patient with ulcerative colitis (UC) remains challenging despite the fact that morbidity and mortality rates have been considerably reduced during the last 30 years. The traditional management with intravenous corticosteroids was modified by the introduction of ciclosporin and infliximab. In this review, we focus on the treatment of patients with moderate to severe UC. Four typical clinical scenarios are defined and discussed in detail. The treatment recommendations are based on current literature, published guidelines and reviews, and were discussed at a consensus meeting of Swiss experts in the field. Comprehensive treatment algorithms were developed, aimed for daily clinical practice.

The place of DPP-4 inhibitors in the treatment algorithm of diabetes type 2 : a systematic review of cost-effectiveness studies

Tese de mestrado, Epidemiologia, Universidade de Lisboa, Faculdade de Medicina, 2015

Three-year results of visual outcome with disease activity-guided ranibizumab algorithm for the treatment of exudative age-related macular degeneration

PURPOSE To evaluate 3-year follow-up treatment outcomes with ranibizumab (Lucentis(®)) 0.5 mg administered either monthly or quarterly on a pro re nata (PRN) basis according to a disease activity-guided monitoring and treatment algorithm. METHODS A total of 316 treatment-naive eyes of 316 patients with exudative age-related macular degeneration met the criteria for inclusion in this retrospective, interventional case series. Patients were treated with ranibizumab 0.5 mg according to a disease activity-guided algorithm with monthly monitoring. Optical coherence tomography and fluorescein angiography were routinely used to assess disease activity: active lesions were treated with a series of three monthly injections, whereas inactive lesions were treated with quarterly injections. RESULTS Mean Early Treatment Diabetic Retinopathy Study best-corrected visual acuity improved from 52 letters at baseline to 59 letters at 12 months, achieved with a mean of 7.1 injections, 61 letters at 24 months with a mean of 5.0 injections administered in the second year and 60 letters at 36 months with a mean number of 5.2 injections. CONCLUSIONS Monthly visits and a morphology-driven PRN regimen with 3 injections in case of recurrence plus quarterly injections in case of inactive CNV resulted in an average VA gain of 7-9 letters that could be maintained over 3 years.

[Acute lower gastrointestinal bleeding--an evidence-based algorithm for diagnosis and treatment]

Novel means to locate and treat lower gastrointestinal bleeding (lGB) allow to reduce the rate of required surgical interventions and help to limit the extend of resection. The risk stratification of patients with lGB is the primary step of our recommended treatment algorithm. Accordingly, risk stratifying instruments, which are only partly validated up to now, are gaining significance in lGB. Whereas, gastro-duodenoscopy and colonoscopy prior to angiography or scintigraphy are established diagnostic tools, capsule enteroscopy offers a novel approach to hemodynamic stable patients with lGB that are difficult to localize. With its every increasing sensitivity, Angio-Computer Tomography is likely to replace scintigraphy and diagnostic angiography in the very near future. In addition, recent advances in superselective microembolisation have been shown to have the potential rendering surgical interventions in a majority of patients with acute lGB unnecessary. The extend of required surgical resection is largely dependent on the success to localize the bleeding source of prior diagnostics. Only if the source is identified, a limited segmental resection should be performed. Should surgery be required, we suggest to maintain the effort to localize the bleeding, either by prior laparoscopy and/or by intraoperative entero-colonoscopy. Eventually, if the source of bleeding remains unclear total colectomy with ileorectal anastomosis represents the procedure of choice in patients with acute lGB.

Review of the efficacy and safety of cryoablation for the treatment of small renal masses

Purpose: Small renal masses are increasingly being discovered incidentally on imaging for another reason. The standard of care of these masses involves excision by open or laparoscopic techniques. Recently, ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, have taken a more prominent role in the treatment algorithm of these masses. We evaluate the effectiveness and safety of cryoablation to treat renal tumours. Methods: A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: the Cochrane Library, PUBMED, EMBASE and LILACS. Results: There was no clinical trial identified in the literature. Thus, we described the results from 23 case series and retrospective studies with a reasonable sample size (number of reported patients in each study ≥30), with a total of 2104 analyzed tumours from 2038 patients. There was wide variability in the outcomes reported, but success rates were generally good. Follow-up was generally short, but some series reported outcomes at 5 years. The most common complications reported were hemorrhage (some of the patients requiring transfusion), perinephric hematoma and urine leaks. Conclusion: Cryoablation presents a feasible treatment for patients with small renal masses. Only short-term data are available and, as such, meaningful conclusions regarding long-term cancer control cannot be made. More rigorous studies are needed. © 2013 Canadian Urological Association.

Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm

Successful treatment of prosthetic hip joint infection (PI) means elimination of infection and restored hip function. However, functional outcome is rarely studied. We analyzed the outcome of the strict use of a treatment algorithm for PI.

Pathomorphology and treatment of femoroacetabular impingement

Femoroacetabular impingement is recognized as a major cause of hip pain and early hip joint osteoarthritis in young adults. The dynamic conflict between the femoral neck and the acetabular rim has been shown to result in labral tears, cartilage lesions, and early osteoarthritis. To be successful, the treatment strategy should address the underlying pathomorphology at the femoral neck, the acetabulum, or both. An overview of the various pathomorphologies leading to femoroacetabular impingement and a treatment algorithm intended to preserve the native hip joint should be helpful to the orthopaedic surgeon treating patients with this condition.

Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany – Austria – Switzerland)

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Treatment approach in patients with hyperbilirubinemia secondary to liver metastases in gastrointestinal malignancies: a case series and review of literature

BACKGROUND: Treatment of patients with severe liver dysfunction including hyperbilirubinemia secondary to liver metastases of gastrointestinal (GI) cancer is challenging. Regimen of oxaliplatin and fluoropyrimidine (FP)/folinic acid (FA) ± a monoclonal antibody (moAb), represents a feasible option considering the pharmacokinetics. Clinical data on the respective dosage and tolerability are limited and no recommendations are available. METHODS: Consecutive patients with severe hyperbilirubinemia [>2 × upper limit of the normal range (ULN) and >2.4 mg/dl] due to liver metastases of GI cancer without options for drainage receiving oxaliplatin, FP/FA ± moAb were analyzed. To collect further data a review of the literature was performed. RESULTS: A total of 12 patients were identified between 2011 and 2015. At treatment start, median bilirubin level was 6.1 mg/dl (>5 × ULN, range 2.7-13.6). The majority of patients (n = 11) received dose-reduced regimen with oxaliplatin (60-76%) and FP/FA (0-77%), rapidly escalating to full dose regimen. During treatment, bilirubin levels dropped more than 50% within 8 weeks or normalized within 12 weeks in 6 patients (responders). Median overall survival was 5.75 months (range 1.0-16.0 months) but was significantly prolonged in responders compared to nonresponders [9.7 and 3.0 months, p = 0.026 (two-sided test); 95% confidence interval (CI): 1.10-10.22]. In addition, case reports or series comprising a further 26 patients could be identified. Based on the obtained data a treatment algorithm was developed. CONCLUSION: Treatment with oxaliplatin, FP/FA ± moAb is feasible and may derive relevant benefits in patients with severe liver dysfunction caused by GI cancer liver metastases without further options of drainage.

Development and Testing of An Automatic Lung IMRT Planning Algorithm

Knowledge-based radiation treatment is an emerging concept in radiotherapy. It

mainly refers to the technique that can guide or automate treatment planning in

clinic by learning from prior knowledge. Dierent models are developed to realize

it, one of which is proposed by Yuan et al. at Duke for lung IMRT planning. This

model can automatically determine both beam conguration and optimization ob-

jectives with non-coplanar beams based on patient-specic anatomical information.

Although plans automatically generated by this model demonstrate equivalent or

better dosimetric quality compared to clinical approved plans, its validity and gener-

ality are limited due to the empirical assignment to a coecient called angle spread

constraint dened in the beam eciency index used for beam ranking. To eliminate

these limitations, a systematic study on this coecient is needed to acquire evidences

for its optimal value.

To achieve this purpose, eleven lung cancer patients with complex tumor shape

with non-coplanar beams adopted in clinical approved plans were retrospectively

studied in the frame of the automatic lung IMRT treatment algorithm. The primary

and boost plans used in three patients were treated as dierent cases due to the

dierent target size and shape. A total of 14 lung cases, thus, were re-planned using

the knowledge-based automatic lung IMRT planning algorithm by varying angle

spread constraint from 0 to 1 with increment of 0.2. A modied beam angle eciency

index used for navigate the beam selection was adopted. Great eorts were made to assure the quality of plans associated to every angle spread constraint as good

as possible. Important dosimetric parameters for PTV and OARs, quantitatively

re

ecting the plan quality, were extracted from the DVHs and analyzed as a function

of angle spread constraint for each case. Comparisons of these parameters between

clinical plans and model-based plans were evaluated by two-sampled Students t-tests,

and regression analysis on a composite index built on the percentage errors between

dosimetric parameters in the model-based plans and those in the clinical plans as a

function of angle spread constraint was performed.

Results show that model-based plans generally have equivalent or better quality

than clinical approved plans, qualitatively and quantitatively. All dosimetric param-

eters except those for lungs in the automatically generated plans are statistically

better or comparable to those in the clinical plans. On average, more than 15% re-

duction on conformity index and homogeneity index for PTV and V40, V60 for heart

while an 8% and 3% increase on V5, V20 for lungs, respectively, are observed. The

intra-plan comparison among model-based plans demonstrates that plan quality does

not change much with angle spread constraint larger than 0.4. Further examination

on the variation curve of the composite index as a function of angle spread constraint

shows that 0.6 is the optimal value that can result in statistically the best achievable

plans.