Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the pathophysiologic bases for nerve injury and how they apply to patient evaluation and management. 2. Recognize the wide variety of injury patterns and associated patient complaints and physical findings associated with peripheral nerve pathology. 3. Evaluate and recommend further tests to aid in defining the diagnosis. 4. Specify treatment options and potential risks and benefits. SUMMARY: Peripheral nerve disorders comprise a gamut of problems, ranging from entrapment neuropathy to direct open traumatic injury and closed brachial plexus injury. The pathophysiology of injury defines the patient's symptoms, examination findings, and treatment options and is critical to accurate diagnosis and treatment. The goals of treatment include management of the often associated pain and improvement of sensory and motor function. Understanding peripheral nerve anatomy is critical to adopting novel nerve transfer procedures, which may provide superior options for a variety of injury patterns.     

Neurofeedback for Autistic Spectrum Disorder: A Review of the Literature

There is a need for effective interventions to address the core symptoms and problems associated with autistic spectrum disorder (ASD). Behavior therapy improves communication and behavioral functioning. Additional treatment options include psychopharmacological and biomedical interventions. Although these approaches help children with autistic problems, they may be associated with side effects, risks or require ongoing or long-term treatment. Neurofeedback is a noninvasive approach shown to enhance neuroregulation and metabolic function in ASD. We present a review of the literature on the application of Neurofeedback to the multiple problems associated with ASD. Directions for future research are discussed.     

Cystic fibrosis: A look into the future of prenatal screening and therapy

Despite recent guidelines suggesting prenatal screening for carriers of cystic fibrosis (CF) mutations, many physicians do not offer patients this service or even counseling. Some argue that the risks of miscarriage associated with prenatal diagnostic techniques outweigh the benefit of added insight, but with the advent of newer, noninvasive techniques, risks of miscarriage may be significantly lowered. Prenatal diagnosis provides parents the time to prepare for raising a child with CF, and soon, could provide treatment options in utero that could improve quality of life. Here, we describe two of the most promising gene therapy approaches: lentivirus and adenoassociated virus (AAV)‐mediated gene transduction. Thus, prenatal detection and treatment is in a most crucial stage for care of patients with CF. Birth Defects Research (Part C) 105:73–80, 2015. © 2015 Wiley Periodicals, Inc.     

Quality of life issues in relation to the aromatase inhibitor

Maturing data from aromatase inhibitor (AI) trials reveal benefits to many women who might otherwise have relapsed and died from breast cancer. In advanced disease the case for the use of AIs is well established but in the adjuvant and chemoprevention settings some worries about long-term safety remain. Large numbers of women may already be cured by surgery, chemotherapy and radiotherapy making further adjuvant treatment unnecessary. In chemoprevention the ratio of risks to putative benefits remains very unclear, so results from major trials are needed to clarify. When making decisions about treatment women need information about: the available options, likely therapeutic gains, predicted side-effects and convenience of treatment. Adherence is then dependent on the actual burden experienced and impact on QoL. Healthcare professionals often underestimate non-life-threatening but QoL-threatening side-effects, making treatments appear more favorable and acceptable during discussion about therapeutic options. It was hoped that AIs would enhance efficacy without producing unacceptable side-effects that diminish QoL and reduce adherence. Recently published results from the QoL sub-protocols of ATAC, IES and MA-17, looking at anastrozole, exemestane and letrozole, respectively, provide useful indications about the QoL associated with AIs. More information gained from longer-term patient follow-up and preference studies are needed to help clinicians making treatment recommendations and to assist development of ameliorative interventions needed to accompany the most efficacious therapies.     

Aetiology and therapeutics of burning mouth syndrome: an update

doi: 10.1111/j.1741‐2358.2010.00384.x Aetiology and therapeutics of burning mouth syndrome: an update Objective: To provide a review on the aetiology and therapeutic options for the management of patients with burning mouth syndrome (BMS). Background: BMS is a chronic disorder that frequently affects women and is characterised by burning symptoms of the oral mucosa without clinical signs. This syndrome has a complex and multifactorial characteristics, but its aetiology remains unknown and this makes it difficult with regard to the treatment and management of such patients. Despite not being accompanied by evident organic changes and not presenting risks to health, BMS can significantly reduce the quality of life for patients. Methods and materials: The article reviews the literature regarding aetiologic factors, clinical implications and treatment of BMS. Conclusion: The involvement of neurological, emotional and hormonal alterations is proposed in BMS aetiology. However the mechanisms of its development are complex and not completely understood. Tricyclic antidepressants, benzodiazepines and antipsychotic drugs are the most accepted options in treatment and show variable results. The correct diagnosis of BMS and the exclusion of possible local or systemic factors that can be associated with the symptoms are fundamental. It is also important to evaluate the quality of life for these patients to recognise the potential impact of this condition on their lives.     

Targeting epigenetic modifications as a potential therapeutic option for diabetic retinopathy

Diabetic retinopathy (DR) is the leading cause of visual impairment in adults of working age (20–65 years) in developed countries. The metabolic memory phenomena (persistent effect of a glycemic insult even after retrieved) associated with it has increased the risk of developing the complication even after the termination of the glycemic insult. Hence, the need for finding early diagnosis and treatment options has been of great concern. Epigenetic modifications which generally occur during the beginning stages of the disease are responsible for the metabolic memory effect. Therefore, the therapy based on the reversal of the associated epigenetic mechanism can bring new insight in the area of early diagnosis and treatment mechanism. This review discusses the diabetic retinopathy, its pathogenesis, current treatment options, need of finding novel treatment options, and different epigenetic alterations associated with DR. However, the main focus is emphasized on various epigenetic modifications particularly DNA methylation which are responsible for the initiation and progression of diabetic retinopathy and the use of different epigenetic inhibitors as a novel therapeutic option for DR.     

STEM CELL TREATMENTS IN CHINA: RETHINKING THE PATIENT ROLE IN THE GLOBAL BIO‐ECONOMY

The paper looks in detail at patients that were treated at one of the most discussed companies operating in the field of untried stem cell treatments, Beike Biotech of Shenzhen, China. Our data show that patients who had been treated at Beike Biotech view themselves as proactively pursuing treatment choices that are not available in their home countries. These patients typically come from a broad variety of countries: China, the United Kingdom, the United States, South Africa and Australia. Among the patients we interviewed there seemed to be both an awareness of the general risks involved in such experimental treatments and a readiness to accept those risks weighed against the possible benefits. We interpret this evidence as possibly reflecting the emergence of risk‐taking patients as ‘consumers’ of medical options as well as the drive of patients to seek treatment options in the global arena, rather than being hindered by the ethical and regulatory constraints of their home countries. Further, we found that these patients tend to operate in more or less stable networks and groups in which they interact and cooperate closely and develop opinions and assessments of available treatment options for their ailments. These patients also perform a multiple role as patients, research subjects, and research funders because they are required to pay their way into treatment and research activities. This new social dynamics of patienthood has important implications for the ethical governance of stem cell treatments.     

Out-of-field organ doses and associated risk of cancer development following radiation therapy with photons

Innovations in cancer treatment have contributed to the improved survival rate of these patients. Radiotherapy is one of the main options for cancer management nowadays. High doses of ionizing radiation are usually delivered to the tumor site with high energy photon beams. However, the therapeutic radiation exposure may lead to second cancer induction. Moreover, the introduction of intensity-modulated radiation therapy over the last decades has increased the radiation dose to out-of-field organs compared to that from conventional irradiation. The increased organ doses might result in elevated probabilities for developing secondary malignancies to critical organs outside the treatment volume. The organ-specific dosimetry is considered necessary for the theoretical second cancer risk assessment and the proper analysis of data derived from epidemiological reports. This study reviews the methods employed for the measurement and calculation of out-of-field organ doses from exposure to photons and/or neutrons. The strengths and weaknesses of these dosimetric approaches are described in detail. This is followed by a review of the epidemiological data associated with out-of-field cancer risks. Previously published theoretical cancer risk estimates for adult and pediatric patients undergoing radiotherapy with conventional and advanced techniques are presented. The methodology for the theoretical prediction of the probability of carcinogenesis to out-of-field sites and the limitations of this approach are discussed. The article also focuses on the factors affecting the magnitude of the probability for developing radiotherapy-induced malignancies. The restriction of out-of-field doses and risks through the use of different types of shielding equipment is presented.     

Canine prostatic disease: a review of anatomy, pathology, diagnosis, and treatment

Disease conditions affecting the canine prostate gland are encountered frequently in small animal practice. The most common conditions affecting the canine prostate include benign prostatic hyperplasia, prostatitis, prostatic cysts, and prostatic neoplasia. Clinical signs associated with each of these conditions often overlap; therefore, it is important to reach a definitive diagnosis prior to initiating treatment. This paper reviews the diseases associated with the prostate gland of the dog, their diagnosis, as well as current treatment options for management of these conditions. Emphasis is placed on proper diagnostic sampling of the prostate gland, its fluid, and interpretation of findings, as well as emerging medical options for treatment of canine prostatic disease.     

Treatment of amphibians infected with chytrid fungus: learning from failed trials with itraconazole, antimicrobial peptides, bacteria, and heat therapy

Amphibian conservation goals depend on effective disease-treatment protocols. Desirable protocols are species, life stage, and context specific, but currently few treatment options exist for amphibians infected with the chytrid fungus Batrachochytrium dendrobatidis (Bd). Treatment options, at present, include antifungal drugs and heat therapy, but risks of toxicity and side-effects make these options untenable in some cases. Here, we report on the comparison of several novel treatments with a more generally accepted antifungal treatment in experimental scientific trials to treat Bd-infected frogs including Alytes obstetricans tadpoles and metamorphs, Bufo bufo and Limnodynastes peronii metamorphs, and Lithobates pipiens and Rana muscosa adults. The experimental treatments included commercial antifungal products (itraconazole, mandipropamid, steriplantN, and PIP Pond Plus), antimicrobial skin peptides from the Bd-resistant Pelophylax esculentus, microbial treatments (Pedobacter cryoconitis), and heat therapy (35°C for 24 h). None of the new experimental treatments were considered successful in terms of improving survival; however, these results may advance future research by indicating the limits and potential of the various protocols. Caution in the use of itraconazole is warranted because of observed toxicity in metamorphic and adult frogs, even at low concentrations. Results suggest that rather than focusing on a single cure-all, diverse lines of research may provide multiple options for treating Bd infection in amphibians. Learning from 'failed treatments' is essential for the timely achievement of conservation goals and one of the primary aims for a publicly accessible treatment database under development.     

Bioethics for clinicians: 2. Disclosure.

In the context of patient consent, "disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The clinician''s goal is to disclose information that a reasonable person in the patient''s position would need in order to make an informed decision. Therefore, clinicians may need to consider how the proposed treatment (and other options) might affect the patient''s employment, finances, family life and other personal concerns. Clinicians may also need to be sensitive to cultural and religious beliefs that can affect disclosure.     

Selecting Treatment for Distal Ureteral Calculi: Shock Wave Lithotripsy versus Ureteroscopy

Shock wave lithotripsy (SWL) and ureteroscopy (URS) are both effective treatments for removal of distal ureteral calculi, associated with high success rates and limited morbidity. The American Urological Association Ureteral Stones Clinical Guidelines Panel has found both to be acceptable treatment options for patients, based on the stone-free results, morbidity, and retreatment rates for each respective therapy. However, costs and patient satisfaction or preference were not addressed, and the report was based on data derived from older endoscopic and lithotripsy technology. Each of these treatment options has valid advantages and disadvantages. Both modalities are reasonable treatment options for the majority of patients with distal ureteral calculi. Whereas SWL is less invasive, the high, immediate success rate with minimal morbidity and decreased cost makes URS a very valid competitor. The results of treating patients with larger stones favor URS.     

Minimally Invasive Therapy for Prostate Cancer: Use of Nomograms to Counsel Patients about the Choice and Probable Outcome of Therapy

Despite dramatic and recently accelerated advances in the reduction of morbidity linked to radical prostatectomies, significant short- and long-term morbidity is still associated with this surgical procedure. Currently both surgical and nonsurgical minimally invasive options are available for men with clinically localized prostate cancer, including laparoscopic and robotic radical prostatectomy, brachytherapy, and cryosurgical ablation of the prostate, with others, such as high intensity focused ultrasound, under investigation. In continued efforts to improve patient outcomes and to tailor treatment options to individual patient circumstances, nomograms have been developed and are increasingly being used by physicians and patients, alike, to guide therapeutic choices at each stage of disease. This tool predicts the possibility of successful treatment for the patient based on factors such as prostate-specific antigen levels, clinical stage of disease, and biopsy results. The current and future development, design, availability, and use of nomograms is described along with the historic and newer minimally invasive treatment options for prostate cancer.     

Foraging decisions in risk-uniform landscapes

Behaviour is shaped by evolution as to maximise fitness by balancing gains and risks. Models on decision making in biology, psychology or economy have investigated choices among options which differ in gain and/or risk. Meanwhile, there are decision contexts with uniform risk distributions where options are not differing in risk while the overall risk level may be high. Adequate predictions for the emerging investment patterns in risk uniformity are missing. Here we use foraging behaviour as a model for decision making. While foraging, animals often titrate food and safety from predation and prefer safer foraging options over riskier ones. Risk uniformity can occur when habitat structures are uniform, when predators are omnipresent or when predators are ideal-free distributed in relation to prey availability. However, models and empirical investigations on optimal foraging have mainly investigated choices among options with different predation risks. Based on the existing models on local decision making in risk-heterogeneity we test predictions extrapolated to a landscape level with uniform risk distribution. We compare among landscapes with different risk levels. If the uniform risk is low, local decisions on the marginal value of an option should lead to an equal distribution of foraging effort. If the uniform risk is high, foraging should be concentrated on few options, due to a landscape-wide reduction of the value of missed opportunity costs of activities other than foraging. We provide experimental support for these predictions using foraging small mammals in artificial, risk uniform landscapes. In high risk uniform landscapes animals invested their foraging time in fewer options and accepted lower total returns, compared to their behaviour in low risk-uniform landscapes. The observed trade off between gain and risk, demonstrated here for food reduction and safety increase, may possibly apply also to other contexts of economic decision making.     

Recent advances in refractive surgery

Refractive errors are some of the most common ophthalmic abnormalities world-wide and are associated with significant morbidity. Tremendous advances in treating refractive errors have occurred over the past 20 years. The arrival of the excimer laser has allowed a level of accuracy in modifying the cornea that was unattainable before. Although refractive surgery is generally safe and effective, it does carry some risks. Careful patient selection, meticulous surgical technique and frequent follow-up can avoid most complications. The experience of a surgical team can also affect the outcome and the incidence of complications. The future should bring continued improvement in outcomes, fewer complications and exciting new options for treating refractive errors.     

Treatment options for stress urinary incontinence

Treatment options for stress urinary incontinence (SUI) in women are designed to prevent the involuntary loss of urine from the urethra during increases in intraabdominal pressure that occur during physical activity, coughing, or sneezing. Effective nonsurgical therapies include behavioral therapy (eg, bladder training, fluid and dietary modification) and drug therapy. Surgical therapy for this condition has existed for well over 100 years. Currently, approximately 200 different surgical procedures have been described. Because of the physiologic risks inherent in surgical procedures, the cost of hospitalization, and the loss of productivity during convalescence, surgeons continue to modify their techniques to improve efficacy, safety, and cost-effectiveness, and to minimize invasiveness. No single procedure or intervention is optimal for all patients. Having a variety of treatment options offers the possibility of tailoring therapy to the desires and needs of the individual patient. The key to an optimal therapeutic outcome is an accurate diagnosis combined with the selection of an appropriate intervention that is acceptable to the patient after balancing multiple factors.     

Common crossroads in diabetes management

The prevalence and impact of type 2 diabetes are reaching epidemic proportions in the United States. Data suggest that effective management can reduce the risk for both microvascular and macrovascular complications of diabetes. In treating patients with diabetes, physicians must be prepared not only to tailor the initial treatment to the individual and his or her disease severity but also to advance treatment as necessary and in step with disease progression. The majority of patients with diabetes are not at goal for glycated hemoglobin A1C, fasting plasma glucose, or postprandial plasma glucose levels. Although lifestyle changes based on improved diet and exercise practices are basic elements of therapy at every stage, pharmacologic therapy is usually necessary to achieve and maintain glycemic control. Oral antidiabetic agents may be effective early in the disease but, eventually, they are unable to compensate as the disease progresses. For patients unable to achieve glycemic control on 2 oral agents, current guidelines strongly urge clinicians to consider the initiation of insulin as opposed to adding a third oral agent. Recent research suggests that earlier initiation of insulin is more physiologic and may be more effective in preventing complications of diabetes. Newer, longer-lasting insulin analogs and the use of simplified treatment plans may overcome psychological resistance to insulin on the part of physicians and patients. This article summarizes the risks associated with uncontrolled fasting and postprandial hyperglycemia, briefly reviews the various treatment options currently available for type 2 diabetes, presents case vignettes to illustrate crossroads encountered when advancing treatment, and offers guidance to the osteopathic physician on the selection of appropriate treatments for the management of type 2 diabetes.