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PubMed2005

Multimodal strategy for managing meningiomas in the elderly.

BACKGROUND: The incidence of brain tumors in elderly patients is increasing. It has become possible to treat meningiomas in the elderly by several modalities. We developed a successful multimodal strategy to treat these patients. METHODS: We registered 35 patients with meningiomas. Symptomatic meningiomas were treated surgically at the time of diagnosis (n=19). Of the 16 asymptomatic meningiomas, 5 were removed at the time of diagnosis. The other asymptomatic meningiomas (n=11) were treated conservatively and when the tumors increased in size, surgical treatment was considered. "Operated" patients with residual or recurrent tumors underwent radiosurgery with a gamma knife. FINDINGS: Surgical mortality and morbidity were 4% and 16%, respectively. Of the 25 "operated" patients, 21 (84.0%) had a good Karnofsky scale (> or =80%) at discharge. In all but two of the 11 patients with asymptomatic, conservatively treated meningiomas, the tumors did not increase during the follow-up period. Gamma knife radiosurgery, performed to treat 3 residual and 1 recurrent tumor, resulted in very good tumor control and none of the tumors increased after gamma knife surgery. CONCLUSIONS: Meningiomas in elderly patients require a multimodal approach. Our strategy, which includes surgery, radiosurgery, and conservative treatment, resulted in good tumor control and made it possible for patients to pursue their activities of daily life.

Age Factors↗
PubMed1998

Multimodal cerebral monitoring in comatose head-injured patients.

Monitoring of comatose patients in the neurosurgical intensive care unit (NICU) is constantly extended by the development of new methods for monitoring of cerebral function, metabolism and oxygenation. To simplify the interpretation of the rising number of parameters, and to avoid data overflow, a multimodal cerebral monitoring (MCM) system has been developed for the acquisition, display, on-line analysis and recording of physiological parameters from multiple bedside data sources. This article describes the technical details and the design of this computerized data acquisition system for variable applications in clinical patient monitoring and research. A Windows (Microsoft Corporation, Redmont, Washington) platform was equipped with an analog/digital converter board. Software for multimodal cerebral monitoring was developed using LabVIEW for Windows (National Instruments, Austin, Texas), a graphical programming system. Two software modules were created: One for the automatic acquisition of data, display of time dependent trend graphs, processing of on-line histograms, special functions for research, and storage of data in compatible format. The other module serves as an off-line monitor to display recorded data in various modalities. The MCM system has been used in 30 comatose patients with severe head injury. Mean time of MCM is 5.3 days (+/- 2.8 days), resulting in a total running time of the system of about 3800 hrs. Hardware and software proved to run stable and safe. The MCM system has become a valuable tool for monitoring of comatose patients. The simultaneous display of trend graphs of various monitoring parameters and the online processing of histograms improved the survey of the patient's condition in the ICU. Recorded data were analysed offline and contribute to a consecutively increasing data bank.

Brain Injuries↗
PubMed2004

Dyslexia: the possible benefit of multimodal integration of fMRI- and EEG-data.

Biological research about dyslexia has been conducted using various neuroimaging methods like functional Magnetic Resonance Imaging (fMRI) or Electroencephalography (EEG). Since language functions are characterized by both distributed network activities and speed of processing within milliseconds, high temporal as well as high spatial resolution of activation profiles are of interest: "where" can dyslexia specific activations be detected and "when" do language processes start to diverge between dyslexics and controls? Due to the network character of language processing, fMRI-constrained distributed source models based on EEG-data were computed for multimodal data integration. First single-case results show that this method could be a promising approach for the understanding of a repeatedly described experimental finding for dyslexia like that of an overactivation in inferior frontal language areas. Multimodal data analysis for the subjects presented here could probably demonstrate that inferior frontal overactivations are the consequence of a phonological deficit and could represent ongoing articulation processes used to solve phonologically challenging tasks.

Adolescent↗
PubMed2005

Multimodal percutaneous intervention for critical venous occlusive disease.

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease, who exhibit severe symptomatology. This study examined the results of multimodal percutaneous therapy for the treatment of complex critical venous thrombotic and occlusive disease. Twenty-five patients presented with critical venous thromboses or occlusions (11 with debilitating unilateral lower extremity edema causing ambulatory impairment, 2 with debilitating bilateral lower extremity edema, 3 with phlegmasia cerulea dolens, 2 with venous claudication, 2 with superior vena cava (SVS) syndrome with respiratory compromise, 4 with debilitating upper extremity edema, and 1 with renal insufficiency). Therapeutic modalities including thrombolysis, mechanical thrombectomy, percutaneous venoplasty and stent placement, temporary inferior vena cava filtration, and ultrasound guidance were used in all cases in conjunction with long-term systemic anticoagulation. The venous access site was determined by the anatomic location of the lesion and included popliteal, femoral, brachial, and lesser saphenous. Patients were followed with clinical exam and duplex surveillance. Resolution of symptoms was achieved in 18 of 25 patients (72%) and partial resolution occurred in 4 of 25 (16%). Failure of treatment identified as both lack of clinical response and evidence of continued venous thrombosis occurred 3 of 25 patients (12%). Restoration of arterial pulses and limb salvage was achieved in the three patients with phlegmasia cerulea dolens and acute limb-threatening ischemia. Both patients with SVC syndrome experienced resolution of respiratory compromise and facial edema. The mean length of follow-up was 11 +/- 2.7 months. Complications included transfusion requirement (2), hematuria (2), retroperitoneal hematoma (1), and cellulitis (1). Acute critical venous thrombotic and occlusive disease is responsive to multimodal percutaneous treatment. The relief of pain and resolution of acutely life and limb-threatening conditions in this most severely symptomatic subset of patients represents the immediate goal of treatment.

Algorithms↗
PubMed2005

Recent advances in multimodal treatment for gastric cancer: a review.

The prognosis after surgical treatment of gastric cancer remains poor. This review aims to clarify the indication for multimodal treatment of gastric cancer. A systematic literature research and evaluation of clinical data presented at important international cancer meetings were undertaken. Recently published results of large randomized phase III trials underscore the potential value of neoadjuvant chemotherapy or adjuvant chemoradiotherapy in gastric cancer. However, data from randomized controlled trials are still scarce, and it remains uncertain which subgroups of patients should routinely undergo multimodal treatment. In view of the side effects of pre- and foremost postoperative therapies, a more distinct definition of prognostic and predictive markers is warranted. Neoadjuvant chemotherapy is a rising option in locally advanced gastric cancer. Adjuvant chemoradiation has been shown to be beneficial in gastric cancer patients who have undergone suboptimal surgical resection. The benefits of adjuvant chemotherapy alone seem to be very small.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Evolutionary computation and multimodal search: a good combination to tackle molecular diversity in the field of peptide design.

The awesome degree of structural diversity accessible in peptide design has created a demand for computational resources that can evaluate a multitude of candidate structures. In our specific case, we translate the peptide design problem to an optimization problem, and use evolutionary computation (EC) in tandem with docking to carry out a combinatorial search. However, the use of EC in huge search spaces with different optima may pose certain drawbacks. For example, EC is prone to focus a search in the first good region found. This is a problem not only because of the undesirable and automatic rejection of potentially good search space regions, but also because the found solution may be extremely difficult to synthesize chemically or may even be a false docking positive. In order to avoid rejecting potentially good solutions and to maximize the molecular diversity of the search, we have implemented evolutionary multimodal search techniques, as well as the molecular diversity metric needed by the multimodal algorithms to measure differences between various regions of the search space.

Algorithms↗
PubMed1992

Multimodal therapy of small cell lung cancer in TNM stages I through IIIa.

Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.

Adult↗
PubMed1994

Aggressive multimodality therapy for malignant pleural mesothelioma.

Nineteen patients with clinical stage I malignant pleural mesothelioma were treated with aggressive multimodality therapy. Nine patients underwent pleurectomy and decortication followed by immediate intrapleural chemotherapy with cisplatin and mitomycin C. Ten patients required pleuropneumonectomy followed within 1 week to 2 weeks by intrapleural administration of cisplatin (100 mg). Four to 8 weeks after operation, 15 patients underwent postoperative adjuvant cisplatin-based systemic chemotherapy. There were three postoperative complications (16%) requiring reoperation and one postoperative death (5%). Intrapleural chemotherapy was well tolerated with no complications. Systemic chemotherapy was poorly tolerated, and there was one chemotherapy-related death. Sixteen patients (84%) experienced good to excellent palliation. Three patients are currently alive with no evidence of recurrent disease at 10, 35, and 43 months. The median overall survival was 13 months and the median disease-free survival, 11 months. Overall and disease-free 3-year survivals were 17% and 22%, respectively. Patients with epithelial malignant pleural mesothelioma had significantly better overall survival (p = 0.037) and disease-free survival (p = 0.02) than patients with sarcomatous or biphasic malignant pleural mesothelioma. We conclude that despite major toxicity, in select patients with clinical stage I malignant pleural mesothelioma, aggressive multimodality therapy offers effective palliation and occasional long-term disease-free survival.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1977

A computer program for fitting multimodal probability density functions.

A FORTRAN IV program is described, which may be run interactively with tutorial assistance or in batch and which allows a user to selectively fit any of seven probability density functions (p.d.f.'s) or a combination of the p.d.f.'s to a unimodal or multimodal histogram of empirical data. A "best-fit", uni- or multimodal p.d.f., which may be obtained by a method of nonlinear least squares or a generated p.d.f. may be displayed on a Tektronix 4010 terminal as a continuous curve against the background of a bar, square wave, symbol or point-plot histogram. The following, supportive statistical information is also displayed: (1) Kolmogorov-Smirnov probability of goodness of fit, (2) mean square error, (3) correlation coefficient, and (4) parameter estimates. The resident driver program and six overlayable segments have been implemented on a Digital Equipment Corporation LAB-11 minicomputer (PDP-11/20).

Computers↗
PubMed1986

Multimodal liquid chromatography columns for the separation of proteins in either the anion-exchange or hydrophobic-interaction mode.

Several high-performance stationary phases suitable for protein chromatography were synthesized. Columns packed with these materials could be operated independently in either the anion-exchange or hydrophobic-interaction mode. Two approaches were used to prepare these materials. In the first method, a polyamine was adsorbed on the surface of macroporous silica and then crosslinked with a multifunctional oxirane. The hydrophobicity of the crosslinking agent and the extent of interconnection were used to modulate the electrostatic and solvophobic interactions. The second approach also utilized a crosslinked polyamine stationary phase; however, the forces of interaction were attenuated through controlled acylation of surface amines with a small anhydride molecule. The resolving ability of these columns, functioning in either mode, was comparable to commercial high-performance liquid chromatographic columns, designed to operate by a single retention mechanism. Column selectivity for proteins was completely different in each mode. Protein fractions collected from a multimodal column, operated in the anion-exchange mode, could be further purified by rechromatographing them on the same column in the hydrophobic-interaction mode. Utility of the multimodal column was demonstrated with the fractionation of several cytochromes and ferredoxins from the cyanobacterium Microcystis aeruginosa.

Chemical Phenomena↗
PubMed1994

Image analysis and synthesis of multimodal images in medicine.

Radiologic and clinical practice can be enhanced by improved access to multimodal image information. Analysis, visualization, method characteristic image processing and image synthesis is needed not only for the interpretation of the images but also for performing effective consultations with clinical colleagues and computer supported therapy planning and control strategies. A method is presented which enables the fast display, three-dimensional visualization and the modality oriented analysis of multimodal image information. Based on a unique image format, modality specific procedures and two- or three-dimensional processing tools of image analysis produce the input data for therapy planning programs. The easy use of this multimedia visualization tool enables radiologists and clinicians to deal with their image data. The description of methods and procedures, as well as typical examples of radiologic practice will demonstrate the efficiency of the presented system.

Algorithms↗
PubMed1982

Multimodality treatment of patients with advanced ovarian carcinoma.

A multimodality treatment program has been applied to ovarian carcinoma at the Johns Hopkins Hospital since August 1975. Forty-nine patients were subdivided into 23 patients with maximally resected Stage III micrometastatic, and 26 patients with significant retained disease, 20 with Stage III macrometastatic and 6 with Stage IV. After initial pilot studies, those patients with minimally retained disease entered a randomized prospective study. Antiovarian antiserum was used in one arm of the study; in both study arms colloidal P-32, delayed split whole abdominal irradiation, and maintenance melphalan were used. For the 23 patients with micrometastatic disease the cumulative survival and survival without evidence of disease at four years is 78 and 34% respectively. Twenty-six patients with macrometastatic disease were treated with or without intraperitoneal antiserum and multiagent chemotherapy; their cumulative one year survival is 50%. The lack of significant toxicity of intraperitoneal antiovarian antiserum and the results of multimodality therapy indicate the feasibility of this therapeutic approach to further improve ovarian cancer therapy.

Adenocarcinoma, Mucinous↗
PubMed1989

Multimodal treatment for inflammatory breast cancer.

This is a retrospective study of 61 patients with clinically diagnosed breast cancer (IBC) treated with multimodality therapy between September 1977 and September 1985. All patients were scheduled to receive three courses of doxorubicin-based chemotherapy followed by mastectomy, further chemotherapy, and postoperative irradiation. Ten patients (16%) obtained a complete response, defined as either resolution of the clinical signs of inflammatory breast cancer (IBC) (4 patients) or no evidence of tumor in the mastectomy specimen (6 patients). Twenty-seven patients (45%) obtained a partial response, defined as a greater than 50% reduction in the clinical signs of inflammatory breast cancer. No response occurred in 24 patients (39%). Immediate mastectomy was done in 56 patients. Five patients whose disease was not resectable received preoperative irradiation. Nine patients at high risk for locoregional failure received postoperative irradiation immediately after mastectomy and before additional chemotherapy. Postoperative irradiation was given to the chest wall and peripheral lymphatics using standard or accelerated fractionation to a maximum dose of 60 Gy. Forty-six patients completed planned treatment including chemotherapy, surgery, and radiotherapy without failure. The minimum follow-up was 36 months. The 5-year actuarial disease-free survival was 70% for the complete response group, and 35% for the partial response group. All patients with no response failed by 34 months. The actuarial 5-year disease-free survival rate for the entire group was 27%. The 5-year actuarial locoregional control was 89% in the complete response group, 68% in the partial response group, 33% in the no response group, and 58% for all patients. Most failures were on the chest wall within the irradiated volume. Chest wall failures were more frequent in those who did not achieve brisk erythema or moist desquamation after postoperative irradiation. We conclude that multimodal treatment of patients with inflammatory breast cancer results in a low incidence of failure if complete response is obtained following initial chemotherapy. The locoregional control rate and actuarial 5-year disease-free survival for the entire group were not improved when mastectomy was done. Surgery should be done in those patients who respond adequately to chemotherapy, so that late sequelae of high-dose breast irradiation can be eliminated. Higher doses of postoperative irradiation may be required to improve local control in those patients with the poorest response to initial chemotherapy.

Adult↗
PubMed1996

Recurrences of rectal cancers: results of a multimodal approach with intraoperative radiation therapy. French Group of IORT. Intraoperative Radiation Therapy.

PURPOSE: Prognosis of recurrent rectal cancer remains poor, mainly because of the difficulties of achieving a satisfactory local control. Intraoperative radiation therapy (IORT) allows for the delivery of a complementary single dose to the tumor residues or to the tumor bed and could be useful jn a multimodal treatment. In an attempt to evaluate this interest, a retrospective analysis of patients treated with IORT in six French hospitals has been performed. METHODS AND MATERIALS: Data have been collected in 73 patients (41 men), with a mean age of 62 years, treated with IORT. Initial rectal tumors were large (mean diameter: 45 mm), partially or totally fixed to the contiguous structures in 39%, and with nodal involvement in 50% of the cases. Initial surgery had been a sphincter-sparing surgery in 67%; external radiation therapy had been delivered in 52%, and a chemotherapy had been given in 10% of the patients. Recurrences were isolated (without metastases) in 86%, and were posterior or posterolateral in 55% of the cases. Surgery allowed for a complete macroscopical resection in 57%, a partial resection with gross residual disease in 29%, and no resection in 14% of the recurrences. Intraoperative radiation therapy was delivered in a dose of 10 to 25 Gy (mean 18.5) through localizators of a mean diameter of 75 mm (60 to 110). External radiation therapy, either preoperative or postoperatively was given to 30 patients without prior radiation therapy. Ten patients received additional chemotherapy with 5-fluorouracil. RESULTS: Four postoperative deaths occurred. Postoperative morbidity occurred in 16 patients and some complications were probably related to the IORT procedure. Four long-term complications were observed. Overall actuarial survival occurred in 72.4% of the patients at 1 year, in 44.6% at 2 years, and in 30.6% at 3 years. Twenty-one local failures have been observed. Actuarial local control occurred in 71.3% of the patients at 1 year, 47.7% at 2 years, and 31.3% at 3 years. CONCLUSION: Intraoperative radiation therapy is a complementary treatment for recurrences of rectal cancer. It provides encouraging results, particularly in some selected situations, when patients have not previously been treated with external radiation therapy. Further studies of multimodal treatments are necessary.

Adult↗
PubMed1993

Data fusion in medical imaging: merging multimodal and multipatient images, identification of structures and 3D display aspects.

Data fusion in medical imaging can be seen into two ways (i) multisensors fusion of anatomical and functional information and (ii) interpatient data fusion by means of warping models. These two aspects set the methodological framework necessary to perform anatomical modelling especially when concerning the modelling of brain structures. The major relevance of the work presented here concerns the interpretation of multimodal 3D neuro-anatomical data bases. Three types of data fusion problems are considered in this paper. The first one concerns the problem of data combination which includes multimodal registration (multisensor fusion applied to CT, MRI, DSA, PET, SPECT, or MEG). In particular, the problem of warping patient data to an anatomical atlas is reviewed and a solution is proposed. The second problem of data fusion addressed in this paper is the identification of anatomical structures by means of image analysis methods. Two techniques have been developed. The first one deals with the analysis of image geometrical features to end up with the determination of a fuzzy mask to label the structure of interest. The second technique consists of labelling major cerebral structures by means of statistical image features associated with relaxation techniques. Finally, the paper presents a review of up to date 3D display techniques with a special emphasis on volume rendering and 3D display of combined data.

Algorithms↗
PubMed1990

Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program.

A sample of 200 patients who had been treated for alcoholism in a multimodal inpatient program that used aversion therapy as a treatment component was selected for outcome evaluation. One hundred sixty (80%) were located. A minimum of 13 months had elapsed since treatment (mean 20.5 months) collateral reports were used to verify self-reports in 36% of the cases. Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment (range 13 to 25 months, mean 20.5 months), and "current abstinence" (last 6 months). The abstinence rate for the first 12 months was 71.3%; for the total period since treatment, the rate was 65% (mean 20.5 months); the current abstinence rate was 78.1%. The data was also viewed from other perspectives. The findings of this study suggest that a multimodal alcoholism treatment program utilizing aversion conditioning is at least as acceptable to patients as counseling centered programs and can be expected to yield favorable abstinence rates.

Adult↗
PubMed2006

The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty.

This study evaluated the effect of a new multimodal perioperative anesthetic and pain management strategy for primary total hip (THA) and total knee arthroplasty (TKA). Two cohorts of 50 consecutive THA and 50 TKA patients from before and after initiation of the new protocol were compared. The protocol involved scheduled oral narcotics, cyclooxygenase-2 inhibitors, no intrathecal narcotics, femoral nerve catheters for TKAs, and local anesthetic wound infiltration. Use of patient-controlled analgesia was discouraged. Physical therapy was attempted on the day of surgery. The demographic data, surgical procedure, and implants were similar. There were statistically significant improvements after the protocol regarding rest-pain scores post-operative day (POD) 1 and 2, total narcotic consumption, distance walked POD 1 and 2, and length of stay. There were no significant differences in complications. Implementation of this new multimodal perioperative protocol combined with early mobilization for TKA and THA patients has shortened length of stay, improved pain control, and accomplished therapy goals sooner with less narcotic consumption.

Anesthesia, Epidural↗
PubMed2006

The neurocognitive bases of human multimodal food perception: consciousness.

This review explores how we become aware of the (integrated) flavor of food. In recent years, progress has been made understanding the neural correlates of consciousness. Experimental and computational data have been largely based on the visual system. Contemporary neurobiological frameworks of consciousness are reviewed, concluding that neural reverberation among forward- and back-projecting neural ensembles across brain areas is a common theme. In an attempt to extrapolate these concepts to the oral-sensory and olfactory systems involved with multimodal flavor perception, the integration of the sensory information of which into a flavor gestalt has been reviewed elsewhere (Verhagen, J.V., Engelen, L., 2006. The neurocognitive bases of human multimodal food perception: Sensory integration. Neurosci. Biobehav. Rev. 30(5): 613_650), I reconceptualize the flavor-sensory system by integrating it into a larger neural system termed the Homeostatic Interoceptive System (HIS). This system consists of an oral (taste, oral touch, etc.) and non-oral part (non oral-thermosensation, pain, etc.) which are anatomically and functionally highly similar. Consistent with this new concept and with a large volume of experimental data, I propose that awareness of intraoral food is related to the concomitant reverberant self-sustained activation of a coalition of neuronal subsets in agranular insula and orbitofrontal cortex (affect, hedonics) and agranular insula and perirhinal cortex (food identity), as well as the amygdala (affect and identity) in humans. I further discuss the functional anatomy in relation essential nodes. These formulations are by necessity to some extent speculative.

Brain↗