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Experimental argon laser photocoagulation. III. Relative dangers of immediate vs delayed retreatment.

Monkey retinas were studied histopathologically to assess the relative effects of immediate versus delayed repetitive photocoagulation with the argon laser. Immediate retreatment adds relatively little damage to that created in the retinal nerve fiber layer by the initial photocoagulation. Delayed retreatment increases destruction of all retinal layers, including the nerve fiber layer, and also increases the chance of inducing hemorrhage. When argon laser retreatment of a retinal locus is necessary, it is much safer to do so immediately (within a few hours) rather than after days or weeks.

Animals↗

Resident, faculty, and residency program development. An integrated approach through annual retreats.

Retreats during residency training have evolved as an escape from the daily routine. Recognizing that the retreat format could also be used as a foundation for program design and personal development, we have designed annual retreats for each of the 3 years of pediatric residency training. The sessions vary in length and agenda, but serve as the basis for an ongoing effort fostering growth and maturation of the department and its component participants. The effectiveness of the program (and the morale of the residents) is greatly influenced by this program.

Chicago↗

Advance toward S phase and retreat toward deeper "G0" states in resting 3Y1 cells with environmental changes.

To elucidate conditions which affect the lag time for resting cells to enter S phase after serum stimulation, we used a wild-type 3Y1 rat fibroblast line and four temperature-sensitive mutants of 3Y1 (3Y1tsD123, 3Y1tsF121, 3Y1tsG125, and 3Y1tsH203). Among these five lines, in only tsG125 cells was there an obviously prolonged lag time with increase in time in resting state at 33.8 degrees C. The resting wild-type 3Y1 cells, preexposed to 39.8 degrees C, also showed a prolongation of lag time. The prolongation in tsG125 had a certain limit. Preexposure to 39.8 degrees C before serum stimulation accelerated such prolongation in tsG125 to its limit, but did not change the limit, per se. Resting tsG125 cells stimulated by serum at 39.8 degrees C, did not enter S phase, yet they did advance toward S phase. When they were kept at 39.8 degrees C, they retreated toward a deeper resting state ("G0") with time. These retreats correlated with the decrease in stimulating activity in the culture media. About 20% of the resting tsG125 cells stimulated by serum at 39.8 degrees C were committed to enter S phase, when the extent of commitment was examined at 33.8 degrees C. Most of the tsG125 cells committed at 33.8 degrees C did not enter S phase, when the extent of commitment was examined at 39.8 degrees C. More cells were committed after stimulation at 33.8 degrees C than at 39.8 degrees C, when the test was done at 33.8 degrees C. We suggest that resting cells may be reversibly changed within range of resting states, in either direction, that is, advance toward S phase or retreat toward deeper "G0." These changes may be determined by alterations in the balance between synthesis and decay of the preparedness for the initiation of DNA synthesis caused by cellular response to environmental changes (e.g., medium activity, temperature, etc.). The ts defect in tsG125 may affect the cell cycle progression, both before and after commitment by serum.

Animals↗

Recurrent ovarian carcinoma: retreatment utilizing combination chemotherapy including cis-diamminedichloroplatinum in patients previously responding to this agent.

Eleven women with advanced ovarian cancer treated postoperatively with combination chemotherapy (cytoxan, hexamethylmelamine, Adriamycin, and cis-platinum) had disease-free intervals of 5 to 46 months (mean: 22 months) and subsequently developed recurrent carcinoma. Each patient was then retreated with combination chemotherapy which included cis-platinum. There was a 72% response rate to retreatment (36% complete, 36% partial). These overall and complete remission rates are comparable to those of platinum-based combination chemotherapy in patients without prior treatment. Those patients who responded to retreatment had a significantly longer mean survival rate than those who did not.

Adult↗

Evaluation of image-guided helical tomotherapy for the retreatment of spinal metastasis.

INTRODUCTION: Patients with vertebral metastasis that receive radiation therapy are typically treated to the spinal cord tolerance dose. As such, it is difficult to successfully deliver a second course of radiation therapy for patients with overlapping treatment volumes. In this study, an image-guided helical tomotherapy system was evaluated for the retreatment of previously irradiated vertebral metastasis. METHODS AND MATERIALS: Helical tomotherapy dose gradients and maximum cord doses were measured in a cylindrical phantom for geometric test cases with separations between the planning target volume (PTV) and the spinal cord organ at risk (OAR) of 2 mm, 4 mm, 6 mm, 8 mm, and 10 mm. Megavoltage computed tomography (CT) images were examined for their ability to localize spinal anatomy for positioning purposes by repeat imaging of the cervical spine in an anthropomorphic phantom. In addition to the phantom studies, 8 patients with cord compressions that had received previous radiation therapy were retreated to a mean dose of 28 Gy using conventional fractionation. RESULTS AND DISCUSSION: Megavoltage CT images were capable of positioning an anthropomorphic phantom to within +/-1.2 mm (2sigma) superior-inferiorly and within +/-0.6 mm (2sigma) anterior-posteriorly and laterally. Dose gradients of 10% per mm were measured in phantom while PTV uniformity indices of less than 11% were maintained. The calculated maximum cord dose was 25% of the prescribed dose for a 10-mm PTV-to-OAR separation and 71% of the prescribed dose for a PTV-to-OAR separation of 2 mm. Eight patients total have been treated without radiation-induced myelopathy or any other adverse effects from treatment. CONCLUSIONS: A technique has been evaluated for the retreatment of vertebral metastasis using image-guided helical tomotherapy. Phantom and patient studies indicated that a tomotherapy system is capable of delivering dose gradients of 10% per mm and positioning the patient within 1.2 mm without the use of special stereotactic immobilization.

Adult↗

CustomCornea wavefront retreatment after conventional laser in situ keratomileusis.

PURPOSE: To evaluate the safety and efficacy of performing laser in situ keratomileusis (LASIK) retreatment using the Alcon CustomCornea system in patients who had prior myopic LASIK using conventional (nonwavefront) software. SETTING: Private practice ophthalmology clinic, St. Paul, Minnesota, USA. METHODS: In this prospective interventional trial, consecutive patients having CustomCornea retreatment following conventional LASIK were evaluated. Main outcome measures were uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), refractive error, and higher-order aberrations (HOAs). RESULTS: Fourteen eyes of 10 patients were evaluated, with a mean follow-up of 5.3 months (range 6.2 to 15.4 months). Mean UCVA improved from 20/50 (logMAR) to 20/26 (P<.001). Mean spherical equivalent changed from -1.45 diopters (D) to +0.52 (P<.00001). Total aberrations, HOAs, defocus, and spherical aberration improved significantly. No eye lost a line of BCVA; 4 eyes (28.6%) gained 1 line, and 1 eye (7.1%) gained 2 lines. Ten eyes (71.4%) were within 0.5 D of emmetropia. Four eyes were overcorrected by 1.00 to 2.00 D. Risk factors for overcorrection included increased HOAs, higher spherical aberration, and not using the surgeon's offset at the time of surgery. CONCLUSIONS: Wavefront retreatment following conventional LASIK is safe and effective. Care must be taken when treating patients with higher amounts of total aberration, especially spherical aberration. Refractive results are closer to emmetropia when the surgeon's offset is used.

Adult↗

Flap tearing during lift-flap laser in situ keratomileusis retreatment.

A flap tear occurred during laser in situ keratomileusis (LASIK) retreatment using a flap-lifting technique in 1 eye of 2 patients 4 to 5 months after the primary procedure. In the first case, the tear occurred in a decentered, standard thickness flap (168 mum) in a location close to the corneal limbus and limbal vessels. In the second case, the tear occurred in a well-centered thin flap (116 mum) that involved a peripheral corneal pannus. The false track was identified early, and central extension of the tear was averted. After the flap was successfully dissected, retreatment was performed without further complications. This report suggests that flaps with margins near the limbus or a corneal pannus may be prone to an earlier and stronger healing process at the edge that may lead to a flap tear during LASIK retreatment. This may be of increasing importance because of the trend toward larger flap diameters.

Adult↗

Extracorporeal shock wave lithotripsy retreatment ("stir-up") promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy.

A prospective randomized study was performed to compare the results of piezoelectric extracorporeal shock wave lithotripsy (ESWL) retreatment versus surveillance only in 50 patients with persistent caliceal stone fragments after primary ESWL for renal calculi. After a 3-month followup significant decreases in residual debris were observed in the retreated group, while changes in the control group were negligible. Considering the low morbidity of outpatient ESWL with a pain-free, second generation lithotriptor, ESWL retreatment of completely fragmented but persistent stone debris appears to be justified to render the kidney stone-free.

Adult↗

Endodontic retreatment: a rational approach to root canal reinstrumentation.

During nonsurgical endodontic retreatment, endodontic instruments are forced apically to remove the root canal filling material and regain canal patency. Undiscriminating burrowing down the canal in the apical direction may be fruitless and harmful. To avoid complications, the dentin overhanging the canal orifice must be removed and an unobstructed access established to the root filling material, so as to facilitate its removal. Reinstrumentation of the filled canal must take into consideration the nature of the filling material and the physical properties of endodontic instruments, as well as the dynamic aspects of canal preparation. This article discusses the mechanical considerations pertaining to root canal retreatment and outlines a step by step rationale approach to retreatment.

Dental Cavity Preparation↗

Survey of endodontic retreatment methods used to remove intraradicular posts.

A survey was conducted to determine the frequency and popularity of contemporary methods used in endodontic retreatment to remove intraradicular posts. Opinions and rationales were also sought for the choice of surgical management instead of nonsurgical retreatment. A questionnaire was sent to 571 active Diplomates of the American Board of Endodontics with 324 members responding (56.7%). Hand instruments, such as hemostats or special forceps, were the most commonly used, often in conjunction with ultrasonic or sonic vibration to loosen the post or break down the cement interface. A wide range of rationales was identified for the use of surgical retreatment methods, with failure to remove the post after reasonable nonsurgical efforts being the most often cited.

Dental Instruments↗

Endodontic retreatment in small and large curved canals.

This study used a special jig system, photography, and a sonic digitizer to evaluate the change in canal size and location after retreatment in 20 teeth with small or large curved canals (greater than 23 degrees). During initial instrumentation, small canals enlarged twice as much as large canals in the coronal and middle areas. During retreatment, small and large canals showed 30 to 85% enlargement compared with that of the initial instrumentation. There was a trend, primarily during retreatment, for small canals to deviate more than large canals away from the original canal location.

Dental Pulp Cavity↗

Endodontic retreatment in large and small straight canals.

The change in original canal size and location after canal preparation and after reinstrumentation using a step-back technique was studied in small and large canals with less than 20-degree curvature. Teeth were mounted in jigs and then sectioned. The jig permitted the sectioned teeth to be repositioned exactly. Slides were made of the canal in the coronal, middle, and apical at the following intervals: before instrumentation, after instrumentation, and after reinstrumentation. The increase in canal area and the direction of movement was measured. The data were analyzed by ANOVA and Duncan's multiple range test. The results showed: (a) All canal areas increased after retreatment. The retreated apical canal increased in area significantly more (25.4%) than middle (4.0%) or coronal (3.0%) regardless of whether the canal was large or small. (b) The retreated canals tended to move in the same direction they moved after first instrumentation.

Analysis of Variance↗

A statistical analysis of surgical and nonsurgical endodontic retreatment cases.

A total of 1300 endodontic patient charts were analyzed for factors that may have contributed to the failure of the original treatment or the success of the retreatment. Of those surveyed, 667 had recall information of 6 months or more and were used to consider success rates. The remaining cases were analyzed for other information. The findings were tabulated and analyzed by computer for significant relationships. The overall success rate for retreatment was 65.6% with an additional category of "uncertain" of 18.3%. Surgical treatment was necessary to retreat 53.5% of the cases.

Adolescent↗

Photorefractive keratectomy retreatments for regression. One-year follow-up.

PURPOSE: Ninety eyes were retreated to correct myopic regression, with or without corneal haze, after primary photorefractive keratectomy (PRK); astigmatism ranging from -0.50 to -3 diopters (D) was present in 43 eyes. RESULTS: The sphere (mean +/- standard deviation) was -2.82 +/- 1.74 D before repeat surgery. At 6 months, the mean was +0.30 D; at 1 year, it was -0.17 D. Patients were divided into two groups: group 1 included 56 eyes with little or no haze (< or = 1). The mean sphere value for this group was -2.13 D before retreatment; at 1 year, it was -0.20 +/- 0.76 D. At 6 months, 84% of sphere values were within +/- 1 D of the intended correction, with a mean haze value of less than 0.5, similar to that before repeat surgery; there was a mean gain of 0.25 Snellen line of best-corrected visual acuity. Astigmatism equal or greater than -0.5 D was present in 34 eyes (mean, -1.17 +/- 0.55 D). At 6 months, astigmatism was reduced to -0.45 +/- 0.48 D. The second group included 34 eyes with corneal haze greater than 1 (mean, 2.7). The mean sphere value was -3.95 D before photorefractive keratectomy and -0.12 +/- 1.48 D 1 year after treatment. Fifty percent of the mean sphere values were within +/- 1 D at 6 months, with a mean haze value of 1. The gain in mean best-corrected visual acuity was 1.3 Snellen lines. The mean astigmatism in nine eyes was -1.75 +/- 0.75 D before photorefractive keratectomy and -0.72 +/- 0.78 D 6 months after treatment. CONCLUSION: There is a significant difference in the outcome predictability between the two groups. A second photorefractive keratectomy can be done 6 months after the primary treatment in patients with regression with or without trace haze. This group has a High predictability in achieving a good correction, with a low complication rate. When haze is present, retreatments are less predictable with 40% of patients overcorrected. Generally, however, these eyes have a statistically significant decrease in haze (Student's t test; P < 0.01) and an improvement in best-corrected visual acuity.

Cornea↗

Retreatment after photorefractive keratectomy for low myopia.

OBJECTIVE: The purpose of the study was to evaluate the results of retreatment for low myopia after primary photorefractive keratectomy (PRK). DESIGN: A prospective study. PARTICIPANTS: A total of 48 eyes of 37 patients from 566 eyes of 331 patients originally treated for myopia of up to -6 diopters (D) were studied. INTERVENTION: Photorefractive keratectomy by the Coherent Schwind Keratom II excimer laser was performed. MAIN OUTCOME MEASURES: The parameters evaluated were visual acuity, refraction, and corneal clarity. RESULTS: Of the 566 eyes with myopia up to -6 D, 48 eyes (8.5%) required retreatment. The sphere (mean +/- standard deviation) was -0.88 +/- 1.24 D before second surgery. At 6 months, the mean was -0.04 +/- 0.91; at 1 year, it was -0.33 +/- 0.75 D. At 6 months, 75% of sphere value was within +/- 1 D. The preoperative uncorrected visual acuity (UCVA) was 20/200 or worse in 12.8% of eyes and 20/40 or better in 40.4% of eyes. Six months after reoperation, 20/60 UCVA was obtained in 17.4% of eyes. All others (82.6%) had UCVA of 20/40 or better, 26.1% better than 20/20. The proportion of eyes with best spectacle-corrected visual acuity better than 20/20 decreased from 60.0% to 47.1% 6 months after reoperation. Six months after reoperation, haze 1 was present in 42.9% and haze 2 in 4.7% of eyes, and in no eye was haze worse. CONCLUSION: Retreatment after PRK for low myopia can significantly increase UCVA and decrease residual refractive error without significant complications.

Adult↗

[Monitoring the patient after treatment: angiographic aspects of recurrence and indications for retreatment].

OBJECTIVES: Dynamic phototherapy with intravenous injection of Verteporfin (Visudyne) is a relatively recent therapeutic concept based on a photochemical reaction. Its statistically significant efficacy has been demonstrated in treating choroidal newvessels and age-related macular degeneration. This occlusion is often temporary, thus requiring repeated treatments in persistent cases and/or recurrences. Angiographic monitoring of the patient, over the short or medium term and then later over the long term, will identify these cases. METHODS: The indications for retreatment are based on very close follow-up with fluorescein angiographic results, and the persistence or reappearance of leakage should be analyzed and clearly distinguished from staining phenomena. Leakage is an essential element and the main diagnostic criterion of recurrence. Associated criteria could be envisaged based on follow-up angiographic examinations at different stages of progression: early, at 4 or 6 weeks (often a good indicator of progression), or at 3 months, currently indispensable. RESULTS: With a relatively stable lesion with no progression or extension, the angiographic examination will make it possible to decide whether a treatment is needed: either retreatment if there is leakage or no treatment if the lesion is fibrous. To assist in therapeutic decisions, a number of arguments must be gathered based on fluorescein angiography but also on indocyanine green angiography (ICG), which will analyze neovascularization, and optical coherence tomography (OCT) examination, which will bring out the presence or absence of fluid at the lesion, as well as functional signs of visual acuity. In difficult cases, the angiographic examination will determine the source of the major decreases in acuity that can be caused by hemorrhages, breaks (which are not necessarily absolute contraindications for retreatment), or acute choroidal ischemia. CONCLUSIONS: Fluorescein and IGC angiographic follow-up and OCT examinations will screen and analyze persistence or reperfusion of choroidal neovessels as well as the extension or reappearance of lesions and, on the other hand, the presence or absence of fibrotic staining phenomena and scarring. The changes in central visual acuity and different functional signs are indicators of patient management and therapeutic indications.

Angiography↗

Strategy for retreatment of therapeutic failure of eradication of Helicobacter pylori infection.

BACKGROUND AND AIM: A proton pump inhibitor (PPI)-based triple therapy consisting of a PPI, amoxicillin (A) and clarithromycin (C) or metronidazole (M) provides an eradication rate ranging from 80 to 90%. However, there have been few controlled studies with regard to the most effective regimen to re-treat patients after failure of the first-line therapy. Accordingly, we retrospectively reviewed our experiences and compared regimens with different combinations of antimicrobials to determine the optimal retreatment regimen. METHODS: Out of 133 patients who had received second-line therapy after failure of first-line PPI/AC therapy, we selected, for review, patients who took the prescribed drugs for first-line therapy equal to, or more than 80%. As a result, data on 114 patients (83 males and 31 females; mean age 49.1 +/- 13.0 years; peptic ulcer n = 89; non-ulcer dyspepsia, n = 25) were eligible for evaluation. They had either repeated the PPI/AC regimen (n = 34; 5-14 days), or had been administered the PPI/AM regimen (n = 80; 10 days). The cure rates of the two regimens were compared. RESULTS: The eradication rates for second-line therapy with the PPI/AC regimen versus the PPI/AM regimen were 52.9% (95% CI, 35-70) versus 81.3% (95% CI, 71-89) by intention-to-treat analysis (P < 0.01), and 62.1% (95% CI, 42-79) versus 91.4% (95% CI, 81-97) by per-protocol analysis (P < 0.01). CONCLUSION: The eradication rate for the PPI/AM retreatment regimen was significantly higher than for the repeated PPI/AC regimen, suggesting that a 10-day PPI/AM regimen can be recommended as a retreatment regimen for patients who had first-line eradication therapy by PPI/AC regimens.

2-Pyridinylmethylsulfinylbenzimidazoles↗

Retreatment Tolerance of Normal Tissues.

The experimental data for reirradiation of various normal tissues are reviewed. Retreatment tolerance is discussed in relation to the interval between treatments and the initial treatment dose delivered. To facilitate a comparison between tissues with different radiosensitivities, both initial and retreatment doses are described in terms of percent extrapolated tolerance dose, using linear-quadratic fraction concepts. The data indicate that rapidly dividing tissues, such as skin and intestine, recover rapidly and can be reirradiated to almost full tolerance within 1 to 3 months. Some slowly dividing tissues, eg, lung and spinal cord, are capable of a more limited long-term recovery and can be reirradiated with partial tolerance doses. For these tissues, reirradiation tolerance increases with time between treatments and is inversely related to the initial dose. In other tissues, eg, bladder, the reirradiation tolerance is independent of retreatment interval suggesting permanent residual injury. In the kidney, reirradiation tolerance actually decreases with time, indicative of further progression of subclinical damage from the first treatment.

Journal Article↗