Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD.

We have created an evidence-based guide for clinicians to the relative utility of nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD). This article uses the term evidence-based in the sense applied by the Oxford Center for Evidenced-Based Medicine to help readers understand the degree to which nonpharmacologic treatments are supported by the scientific literature. This article also reviews the magnitude of the treatment effect expressed as the standardized mean difference effect size (also known as Cohen D). It then describes a meta-algorithm to describe how to integrate pharmacologic and nonpharmacologic treatments for ADHD.

Atualização terapêutica no tratamento dos craniofaringiomas / Therapeutic update on the treatment of craniopharyngiomas

O craniofaringioma é uma neoplasia de natureza benigna, pouco frequente, responsável por 1 por cento a 3 por cento de todos os tumores intracranianos, sendo a mais frequente neoplasia intracraniana não neuroepitelial na criança. Geralmente o tumor é restrito à região selar e ao III ventrículo, mas, em decorrência da infiltração e frequente aderência ao sistema nervoso central, apresenta comportamento clínico muitas vezes desfavorável, sendo classificado pela Organização Mundial de Saúde (OMS) como grau I, caracterizado como tumor de baixo ou incerto potencial de malignização. As sequelas endocrinológicas ganham destaque devido ao importante impacto na qualidade de vida dos pacientes, na maioria das vezes crianças. O hipopituitarismo e a obesidade hipotalâmica são complicações frequentes, sendo o tratamento desse tumor um grande desafio para endocrinologistas e neurocirurgiões. A combinação da cirurgia, radioterapia e aplicação de drogas e radioisótopos intratumorais tem como objetivo maximizar as chances de cura e tentar minimizar as sequelas pós-operatórias, mas, mesmo assim, a recidiva ainda é frequente. A escolha da modalidade de tratamento mais adequado para os craniofaringiomas é uma decisão difícil e que deve sempre ser individualizada para cada paciente. Com o objetivo de explorar as múltiplas opções terapêuticas para o craniofaringioma, foi realizada revisão na literatura com ênfase nas possibilidades terapêuticas e complicações inerentes ao tratamento dessa patologia.

Craniopharyngioma is an uncommon benign neoplasm, accounting for 1 percent-3 percent of all intracranial tumors, and the most common non-neuroepithelial intracranial neoplasm in childhood. Usually, the tumor is confined to the sellar region and the third ventricle, but due to frequent infiltration and adherence to the central nervous system, it often has an unfavorable clinical behavior. Therefore, it is classified by the World Health Organization (WHO) as a tumor of low or uncertain malignant potential. Endocrine after effects, mainly hypothalamic hypopituitarism, obesity and diabetes insipidus are highlighted due to their important impact on the quality of life of patients, mostly children. Optimal treatment of this tumor is a major challenge for neurosurgeons and endocrinologists. The combination of surgery, radiation, and application of radioisotopes and intratumoral drugs, aims at maximizing the chances of cure with minimal complications. Yet, recurrence is still frequent. Choosing the best treatment modality for craniopharyngiomas is a difficult decision, and it should always be specific for each case. In order to explore the multiple therapeutic options for craniopharyngiomas, we reviewed the literature with emphasis on the therapeutic possibilities and complications inherent to the treatment of this disease.

[Assessment of functioning in patients with head and neck cancer based on the international classification of functioning, disability and health (ICF)]. / Beurteilung von Funktionsfähigkeit bei Patienten mit Kopf-Hals-Tumoren, auf Basis der Internationalen Klassifikation für Funktionsfähigkeit, Behinderung und Gesundheit (ICF).

The article approaches with the question how preservation of function after treatment of head and neck cancer (HNC) can be defined and measured across treatment approaches. On the basis of the "International Classification of Functioning, Disability and Health (ICF)" a series of efforts are summarized how all relevant aspects of the interdisciplinary team can be integrated into a common concept.Different efforts on the development, validation and implementation of ICF Core Sets for head and neck cancer (ICF-HNC) are discussed. The ICF-HNC covers organ-based problems with food ingestion, breathing, and speech, as well as psychosocial difficulties.Relationships between the ICF-HNC and well-established outcome measures are illustrated. This enables the user to integrate different aspects of functional outcome into a consolidated approach towards preservation/rehabilitation of functioning after HNC - applicable for a variety of treatment-approaches and health-professions.

Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions.

BACKGROUND: Interventions for preventing falls in older people often involve several components, multidisciplinary teams, and implementation in a variety of settings. We have developed a classification system (taxonomy) to describe interventions used to prevent falls in older people, with the aim of improving the design and reporting of clinical trials of fall-prevention interventions, and synthesis of evidence from these trials. METHODS: Thirty three international experts in falls prevention and health services research participated in a series of meetings to develop consensus. Robust techniques were used including literature reviews, expert presentations, and structured consensus workshops moderated by experienced facilitators. The taxonomy was refined using an international test panel of five health care practitioners. We assessed the chance corrected agreement of the final version by comparing taxonomy completion for 10 randomly selected published papers describing a variety of fall-prevention interventions. RESULTS: The taxonomy consists of four domains, summarized as the "Approach", "Base", "Components" and "Descriptors" of an intervention. Sub-domains include; where participants are identified; the theoretical approach of the intervention; clinical targeting criteria; details on assessments; descriptions of the nature and intensity of interventions. Chance corrected agreement of the final version of the taxonomy was good to excellent for all items. Further independent evaluation of the taxonomy is required. CONCLUSIONS: The taxonomy is a useful instrument for characterizing a broad range of interventions used in falls prevention. Investigators are encouraged to use the taxonomy to report their interventions.

Electrochemotherapy for treatment of skin and soft tissue tumours. Update and definition of its role in multimodal therapy.

Electrochemotherapy (ECT) is a therapeutical procedure based on the induction of cell membrane electroporation, by cell exposure to electric fields lasting a few microseconds, combined with the local or systemic administration of cytotoxic drugs, with an intracellular target and high intrinsic efficacy, but poor cell membrane permeability. ECT is an effective local therapy for any histological tumour that has been used clinically since 2005 and is currently in use in 83 centres all over Europe. In the literature, ECT as a local oncological treatment shows an objective response between 70 and 90% in mucocutaneous primary and metastatic lesions, is cost effective and has few local and systemic side effects. In this manuscript, we present an overview of the European experience in ECT, as well as our own experience in a specialised Spanish oncological centre and in a basic oncological unit in Nicaragua. The purpose is to reflect on the role that this procedure could have in the treatment of skin and mucosal cancer as part of a multidisciplinary approach.

Electrochemotherapy for treatment of skin and soft tissue tumours. Update and definition of its role in multimodal therapy

Electrochemotherapy (ECT) is a therapeutical procedure based on the induction of cell membrane electroporation, by cell exposure to electric fields lasting a few microseconds, combined with the local or systemic administration of cytotoxic drugs, with an intracellular target and high intrinsic efficacy, but poor cell membrane permeability. ECT is an effective local therapy for any histological tumour that has been used clinically since 2005 and is currently in use in 83 centres all over Europe. In the literature, ECT as a local oncological treatment shows an objective response between 70 and 90% in mucocutaneous primary and metastatic lesions, is cost effective and has few local and systemic side effects. In this manuscript, we present an overview of the European experience in ECT, as well as our own experience in a specialised Spanish oncological centre and in a basic oncological unit in Nicaragua. The purpose is to reflect on the role that this procedure could have in the treatment of skin and mucosal cancer as part of a multidisciplinary approach (AU)

[Therapeutic update on the treatment of craniopharyngiomas]. / Atualização terapêutica no tratamento dos craniofaringiomas.

Craniopharyngioma is an uncommon benign neoplasm, accounting for 1%-3% of all intracranial tumors, and the most common non-neuroepithelial intracranial neoplasm in childhood. Usually, the tumor is confined to the sellar region and the third ventricle, but due to frequent infiltration and adherence to the central nervous system, it often has an unfavorable clinical behavior. Therefore, it is classified by the World Health Organization (WHO) as a tumor of low or uncertain malignant potential. Endocrine after effects, mainly hypothalamic hypopituitarism, obesity and diabetes insipidus are highlighted due to their important impact on the quality of life of patients, mostly children. Optimal treatment of this tumor is a major challenge for neurosurgeons and endocrinologists. The combination of surgery, radiation, and application of radioisotopes and intratumoral drugs, aims at maximizing the chances of cure with minimal complications. Yet, recurrence is still frequent. Choosing the best treatment modality for craniopharyngiomas is a difficult decision, and it should always be specific for each case. In order to explore the multiple therapeutic options for craniopharyngiomas, we reviewed the literature with emphasis on the therapeutic possibilities and complications inherent to the treatment of this disease.

Classifying breast cancer surgery: a novel, complexity-based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients.

BACKGROUND: One of the basic prerequisites for generating evidence-based data is the availability of classification systems. Attempts to date to classify breast cancer operations have focussed on specific problems, e.g. the avoidance of secondary corrective surgery for surgical defects, rather than taking a generic approach. METHODS: Starting from an existing, simpler empirical scheme based on the complexity of breast surgical procedures, which was used in-house primarily in operative report-writing, a novel classification of ablative and breast-conserving procedures initially needed to be developed and elaborated systematically. To obtain proof of principle, a prospectively planned analysis of patient records for all major breast cancer-related operations performed at our breast centre in 2005 and 2006 was conducted using the new classification. Data were analysed using basic descriptive statistics such as frequency tables. RESULTS: A novel two-type, six-tier classification system comprising 12 main categories, 13 subcategories and 39 sub-subcategories of oncological, oncoplastic and reconstructive breast cancer-related surgery was successfully developed. Our system permitted unequivocal classification, without exception, of all 1225 procedures performed in 1166 breast cancer patients in 2005 and 2006. CONCLUSION: Breast cancer-related surgical procedures can be generically classified according to their surgical complexity. Analysis of all major procedures performed at our breast centre during the study period provides proof of principle for this novel classification system. We envisage various applications for this classification, including uses in randomised clinical trials, guideline development, specialist surgical training, continuing professional development as well as quality of care and public health research.

Terapia manual y terapia combinada en el abordaje de puntos gatillo: revisión bibliográfica / Manual therapy and combined therapy in the trigger point approach: a review of the bibliography

Un punto gatillo miofascial es una zona en un músculo esquelético relacionada con un nódulo palpable hipersensible, localizado en una banda tensa. La prevalencia de los puntos gatillo en la población asintomática es del 50%. Para su resolución se utilizan diferentes técnicas de tratamiento, aisladas o combinadas, sin que quede claro cuál es la más efectiva. El objetivo de este trabajo es determinar si el tratamiento mediante terapia combinada (ultrasonido más corriente de baja o media frecuencia) es más efectivo que los tratamientos manuales habitualmente utilizados para la resolución de puntos gatillo. Para ello, se realizó una búsqueda en las bases de datos Cochrane, PEDro y PubMed; se hallaron 24 artículos relacionados con el objetivo. Analizando los resultados, las técnicas manuales que parecen presentar un mayor efecto en el tratamiento de puntos gatillo son la liberación por presión y aerosol frío relacionado con estiramiento. No se hallaron resultados concluyentes en cuanto a terapia combinada. Todo ello nos indica la necesidad de profundizar en la investigación acerca del tratamiento de los puntos gatillo y la efectividad de las diferentes técnicas estudiadas(AU)

Myofascial trigger points are hyperirritable spots located in a taut band of skeletal muscle. Prevalence of this disease in the asymptomatic population is approximately 50%. Several modalities of treatment are used to inactivate trigger points, however, there is no evidence to show which is the most effective. The aim of this paper is to find out the effectiveness of combined therapy (ultrasound plus low or medium frequency current) compared to manual therapy to inactivate trigger points. A bibliographic research was done among the Cochrane, PEDro and PubMed databases, 24 papers related to the objective of the study being found. The results show that the manual techniques that present the most effect in the treatment of trigger points are ischemic compression and spray and stretch technique. No results were found on the combined therapy. This indicates the need to further investigate combined therapy and manual therapy in the treatment of myofascial trigger points and the different techniques studied in this paper(AU)

Nomogram ranking as new objective evaluation method in various treatment strategies for patients with prostate cancer with various clinicopathologic backgrounds.

OBJECTIVES: To propose a "nomogram ranking" that gives an objective assessment of any treatment strategy from various institutions. It is difficult to objectively compare treatment outcomes for patients with prostate cancer among institutions because of the large differences in the clinicopathologic backgrounds and treatment strategies. METHODS: From January 2001 to September 2005, 71 consecutive patients with locally advanced prostate cancer were treated with external beam radiotherapy (EBRT) and subsequent high-dose rate brachytherapy combined with long-term hormonal therapy. The 5-year prostate-specific antigen relapse-free survival (PFS) rates were calculated by Kaplan-Meier analysis for all patients and also for subdivided patients according to prostate-specific antigen range or Gleason score. Also, the 5-year PFS rates were estimated by Kattan nomogram, assuming that all 71 patients were treated with 72 Gy of EBRT or EBRT plus neoadjuvant hormonal therapy. The estimated PFS rates were ranked in order from worse to better outcomes (nomogram ranking). The 5-year PFS rates estimated by Kaplan-Meier analysis assessed the position within the nomogram ranking. RESULTS: The 5-year PFS rate estimated by Kaplan-Meier analysis for all 71 patients was 82.4%. The median 5-year PFS rate estimated by Kattan nomogram was 66%, assuming that all patients were treated with EBRT and neoadjuvant hormonal therapy. The actual 5-year PFS rate estimated by Kaplan-Meier analysis ranked 56 of 71 patients assumed to be treated with neoadjuvant hormonal therapy and EBRT. Subdivided analyses revealed that our treatment strategy might be advantageous for patients with a Gleason score of 7 or less, regardless of the prostate-specific antigen level. CONCLUSIONS: The nomogram ranking might be an objective and reliable assessment method of various treatment strategies for patients with prostate cancer.

Classifying the intensity of pediatric cancer treatment protocols: the intensity of treatment rating scale 2.0 (ITR-2).

BACKGROUND: To develop and validate a method of classifying the intensity of pediatric oncology treatments using four operationally defined categories of treatment intensity. PROCEDURE: An earlier version of a rating scale, the intensity of treatment rating (ITR), was revised and validated in two phases. In the Scale Construction phase, three criterion raters revised the ITR items based on consensus and item agreement data from pediatric oncologist raters (N = 15). In the Scale Validation phase, the new ITR-2 items were validated using a second set of pediatric oncologists external to our institution (N = 12). In addition, a third group of raters (N = 16), was employed to assess inter-rater reliabilities for 12 patients at varying levels of treatment intensities. RESULTS: Agreement between criterion ratings and the median of external raters for all 34 items on the ITR-2 was very high (r = 0.95, range 0.71-0.91). When the ITR-2 was used to rate 12 patient examples, the inter-rater agreement among pediatric oncologists was also very high (median agreement between criterion-rater pairs: r = 0.87; overall relatedness among 16 raters: r(ICC) = 0.83). CONCLUSIONS: The revised ITR Scale 2.0 (ITR-2) is a valid and reliable scale for classifying the intensity of pediatric oncology treatments.

[Choroidal metastases of malignancies. Review of treatment methods with special regard to application of radiotherapy]. / Przerzuty nowotworowe do naczyniówki galki ocznej. Przeglad metod leczenia ze szczególnym uwzglednieniem radioterapii.

Choroidal metastases are developed in 4 - 12% of patients with solid malignancies. Typical symptoms are loss of visual acuity or visual field, photophobia and floaters. In therapy of choroidal metastases are used following methods: surgery, laser photocoagulation, radiotherapy, and systemic treatment (anti-neoplastic chemotherapy or hormonotherapy). At choice of method of treatment it is taking not only features associate with choroidal metastases (as size, shape, number of changes and localization) but also: performance status of patient and the presence of metastases in any sites. The purpose of this paper is the review of treatment methods of choroidal metastases with special regard to application of radiotherapy. Radiotherapy is a conservative method of treatment, and it is used as brachytherapy or external beam irradiation (teleradiotherapy). Brachytherapy is recommended in case of single change, with base diameter below 18 mm. The positive results are observed in 90% cases. Teleradiotherapy is used in metastatic tumours which size exceed possibility successfully using of brachytherapy, and in case of multiple foci of choroidal changes, and metastases bilaterally localized. 70 - 89% patients developed regression of choroidal metastases after external beam irradiation. The preservation of bulbus oculi is observed in 98% patients. Presented paper showed application of methods of brachytherapy used in Ophthalmological Department of Jagiellonian University, and technique of teleradiotherapy used in Radiotherapy Department of Oncology Centre in Krakow, which are used in treatment of choroidal metastases.

Tratamiento oncológico de los tumores cerebrales de los niños

No disponible

[Development of a guideline for rehabilitation of patients with low back pain-- phase 2: analysis of data of the classification of therapeutic procedures]. / Leitlinienentwicklung in der Rehabilitation bei Rückenschmerzpatienten--Phase 2: Ergebnisse einer Analyse von KTL-Daten.

Initiated by the Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte), the project is aimed at developing an evidence-based guideline for rehabilitation of patients with low back pain (LBP). Guideline development will be based on a systematic review of the literature, an analysis of the treatment procedures currently employed in rehabilitation, inclusion of the patients' perspectives as well as consultation of experts' panels of clinically experienced physicians and therapists. Formulation of the guideline will then be carried out in a structured consensus building process. This article is focused on analysing the present situation with regard to the treatments received by patients insured by the BfA, using data from routine documentation according to the Classification of Therapeutic Procedures (KTL, Klassifikation Therapeutischer Leistungen). The analysis is intended to provide indications of a basic need to implement a common guideline as well as, simultaneously, to explore possible deficits in present treatment practices, hence to define priorities requiring special attention in the framework of guideline development. As a result of a systematic literature review, the KTL-defined therapeutic procedures that had emerged as relevant in the rehabilitation of LBP patients were aggregated into so-called therapeutic modules which then formed the basis of the analysis. In all, more than 46,000 KTL-data of 2438 patients with a diagnosis of "low back pain" (M54.5 ICD-10) were included. In the rehab centres investigated, rehabilitation of patients with LBP follows a multidimensional, multiprofessional therapeutic strategy. More than 90 % of all patients receive treatments from the modules "medical training therapy", "health education", "physiotherapy", and "physical therapy". Treatments provided to a majority of the patients are massage (78 %), electrotherapy (67 %) as well as psychotherapy (68 %). Women more frequently than men receive therapies belonging to the "psychological treatments" and "occupational therapies" modules; younger patients receive more of the "training therapies", and more often. When treatments are compared across centres, a large variability in the therapeutic procedures provided becomes apparent. This high degree of variability suggests that development and implementation of a common clinical practice guideline for rehabilitation of patients with chronic low back pain should receive priority attention.

Tratamento combinado do transtorno de panico: farmacologico e psicoterapico / Combined pharmacological and psycotherapic treatment in panic disorder

O tratamento combinado para o transtorno de panico tem sido considerado o mais eficaz por unir as vantagens do tratamento farmacologico, que suprime os ataques de panico rapidamente, e do tratamento cognitivo-comportamental que promove gradualmente a aquisicao de repertorios eficazes de enfrentamento a ansiedade e ao panico...