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When the board never seems to have enough time for planning and critical decision making, a board retreat may be the answer. This article describes one hospital's experience and offers advice on the planning of a successful board retreat.
Interferon (IFN) results in normalization of the serum alanine aminotransferase (ALT), loss of detectable serum hepatitis C virus (HCV) RNA, and histologic improvement in approximately 40% of patients. However, regardless of the duration of initial therapy, most patients relapse within the first few months after the drug is stopped and only a small proportion have a sustained response. Retreatment of IFN relapsers with the combination of IFN and oral ribavirin for 6 months results in end-of-treatment loss of detectable HCV RNA and normalization of the ALT level in over 80% of patients. Nearly half achieve a sustained viral-negative response. Histologic improvement occurs in nearly two thirds of patients retreated with combination therapy and is most pronounced in those who lose serum HCV-RNA.
In many cases, unsuccessful endodontic treatment is followed by apicoectomy. Endodontic retreatment, however, could be an appropriate alternative for apicoectomy more frequently. In this paper indications, specific problems and treatment methods are presented for endodontic retreatment, apicoectomy and intentional replantation.
PURPOSE: To report a successful case management of a retinal tear post-Laser in situ Keratomileusis (LASIK) and retreatment. RESULTS: A patient with the history of ocular trauma underwent LASIK procedure for myopic astigmatism. Three months post-LASIK, she received additional excimer laser treatment for a symptomatic persistent central island. One month later; the patient experienced a flap tear at the edge of a prior chorioretinal scar. Retinal tear repair was successfully accomplished by indirect application of photocoagulation laser without damage to the corneal flap. CONCLUSIONS: To date, no definitive causal relationship has been established between retinal tear(s) and corneal refractive surgery. This report describes a retinal tear and repair, post-LASIK retreatment. The use of the indirect binocular argon laser alleviates the need to compress the LASIK flap and minimizes the potential for creating flap folds and striae, especially in the early post operative period. Clinicians should be on alert to consider this possible complication, post-LASIK and excimer laser; especially within a population whose clinical findings place them at greater risk.
Because of the anatomical proximity, infection of posterior upper teeth can spread into the maxillary sinus. When confronted with a large persistent periapical lesion on a posterior maxillary root-treated tooth, the practitioner should question the quality of the previous endodontic treatment, evaluate the impact of the potential causes of failure and consider, in the majority of cases, the conservative non-surgical retreatment instead of extraction or periapical surgery of the dental element. This paper reports two cases of healing of extensive periapical bone destruction and of the co-existing sinus pathology of odontogenic origin after non-surgical endodontic retreatment of previously root-treated upper molars. Misconceptions concerning the role of epithelium in the periapical lesion are discussed. Also, emphasis is put on the need of precise radiological diagnosis, pre-operatively as well as post-operatively to ascertain healing and to avoid unnecessary delay in the appropriate management of these patients.
OBJECTIVE: To investigate the effects of laser in situ keratomileusis (LASIK) on the corneal endothelium, retina and optic nerve for correcting residual myopia caused by undercorrection or regression. METHODS: The pre- and post-operative values of central corneal endothelium and electrophysiological functions of retina and optic nerve were analyzed respectively in 23 eyes of 18 patients who received LASIK retreatment. The endothelium checked by contact specular microscopy was analyzed for central cell density (CCD), coefficient of cell variation in size and hexagonality preoperatively and 1, 4, 12 weeks after the operation. The amplitude and latency of P(100) in standard pattern visual evoked potentials (P-VEPs), that of a, b waves of different reactions in flash electroretinograms (F-ERGs) and also the total amplitude of oscillatory potentials (OPs) were evaluated preoperatively and 2, 12 weeks after the operation. RESULTS: The mean CCD decreased significantly (3.94%) one week after the operation (P < 0.01). The change was negatively correlated with the thickness of residual untreated posterior cornea (r = -0.719, P < 0.01) and not significantly correlated with the amount of laser pulse (r = 0.371, P > 0.05). There was no significant difference between preoperative and either 4 or 12 week postoperative CCD (P > 0.05). No significant differences in mean coefficient variation and hexagonality were found between preoperative and postoperative values in the follow up (P > 0.05). Examination of electrophysiological function showed that the amplitude of P(100) increased and the latency of P(100) decreased 2 and 12 weeks postoperatively. The significant changes were only at spatial frequency 34' in the P-VEPs test (P < 0.05). In F-ERGs test, there was no significant change in amplitude, latency of a, b waves or total amplitude of OPs between pre-operative and either 2 or 12 week post-operative values (P > 0.05). CONCLUSIONS: Retreatment after LASIK may cause a reversible reduction of CCD with no morphological changes in a short period (1 week) after the operation. It was not absolutely safe for corneal endothelium when the thickness of residual untreated basal cornea approaches to 200 micro m. These results show that the operation seems not to cause functional impairment in the retina and optic nerve. And it also can improve the quality of vision for some degrees.
A study of rifabutin in the retreatment of patients with chronic pulmonary tuberculosis whose strains of tubercle bacilli were resistant to all three of the drugs isoniazid, streptomycin, and rifampicin, and usually to others as well, was undertaken in 22 Chinese patients in Hong Kong. They were arranged in 11 pairs such that the resistance pattern of the strains for both patients was the same or closely similar. One of each pair was allocated at random to receive rifabutin (B) daily and the other rifampicin (R) daily. The two members of each pair were also prescribed the same or similar companion drugs, selected on the basis of the results of susceptibility tests and of the history of previous antituberculosis chemotherapy. The bacteriological results showed no evidence of a sustained benefit in any patient. A temporary response was seen on sputum smear examination in 14 patients (7B, 7R), of whom 10 (5B, 5R) had a period of smear-negativity, and on sputum culture examination in 10 patients (5B, 5R), of whom 3 (2B, 1R) had a period of culture-negativity. The duration of response was longer for the B patient in 5 pairs and for the R patient in 5. Two patients (both B) had rifabutin-susceptible strains on admission to the study; their temporary responses were among the best and were associated with the emergence of rifabutin resistance, suggesting that rifabutin may have contributed to their response. A total of 17 patients, including 7 not in the paired comparison, were subsequently retreated with ofloxacin; 10 showed a response, disease becoming and remaining quiescent in 3.(ABSTRACT TRUNCATED AT 250 WORDS)
This article describes postimplant follow-up and retreatment of a 66-year-old patient with an esthetically compromising fixed maxillary tissue-integrated prosthesis and a mobile mandibular overdenture stabilized by precision attachments with a gold clip bar cemented to the transmucosal posts of a bone plate staple implant. Following successful completion of prosthodontic treatment, the patient returned with a fracture of the left transmucosal pin in the mandibular bone plate staple implant that was retreated with Brånemark implants and a fixed prosthesis.
Exudative age-related macular degeneration (ARMD) is benefiting at present from new therapeutic approaches. Randomized clinical trials have demonstrated the efficacy of photodynamic therapy (PDT) in stabilizing visual acuity at 3 years. The basis of PDT consists in activating a photosensitizer with an adapted laser wavelength. Functional results are obtained on the basis of a strict classification of type of the new vessels responsible for exudative ARMD, based on fluorescein angiography. Thus, subfoveal lesions, in the form of either predominantly classic (visible new vessels>50%) or occult choroidal neovascularization (CNV), are the only indication for this therapy. Classic juxtafoveal CNV, where laser photocoagulation thermal burns may extend into the foveola, may be an extension of the indication of PDT. The follow-up after PDT is based on fluorescein angiography findings. The extension and persistence of leakage from the CNV remains an indication for retreatment. Ongoing studies are evaluating a number of features in order to define the responder group and possibly simplify the retreatment indications.
PURPOSE: To evaluate the outcome of wavefront-guided ablations for the correction of residual myopia and astigmatism after standard laser in situ keratomileusis (LASIK). METHODS: Twenty nine eyes of 26 patients who underwent wavefront-guided LASIK retreatment with Alcon CustomCornea (Alcon Laboratories Inc, Fort Worth, Tex) were evaluated. Complete ophthalmologic examination, corneal topography, and wavefront measurements were performed. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, and wavefront analysis were evaluated preoperatively, 1 week, 3 months, and 6 months after surgery. Wavefront measurements were assessed using the LADARWave device. Statistical analysis was performed using the McNemar test and percentages of success. RESULTS: One week postoperatively, UCVA was > or =20/40 in 100% of eyes (> or =20/20 in 31%) and BSCVA was > or =20/40 in 100% (> or =20/20 in 73%). Wavefront analysis showed a decrease in total aberrations, high order aberrations, defocus, coma, spherical aberration, and other terms of higher order aberrations at 1-week follow-up. Three months postoperatively, UCVA was > or =20/40 in 100% of eyes (> or =20/20 in 38%) and BSCVA was > or =20/40 in 100% (> or =20/20 in 81%). Six months postoperatively, UCVA was > or =20/40 in 100% of eyes (> or =20/20 in 60%) and BSCVA was > or =20/40 in 100% (> or =20/20 in 90%). Wavefront analysis showed decrease in total aberration, high order aberration, defocus, coma, and spherical aberration. CONCLUSION: Wavefront-guided LASIK retreatment in post-LASIK eyes represents a good option for laser vision correction. All eyes showed reduction in pre-existing total aberrations. Some high order aberration components decreased in this initial series. Further follow-up is necessary to assess the initial predictability of wavefront-guided LASIK upgrade.
SETTING: Public ambulatory centers in northern Lima, Peru. OBJECTIVE: To compare two retreatment strategies in Category I failures. DESIGN: Retrospective cohort study of Category I failures enrolled between February 1997 and October 2001. Strategy A was a nationwide approach, applying a Category II regimen; if that regimen failed, a standardized regimen including second-line drugs was used. Strategy B was a pilot protocol designed to diagnose and treat multidrug-resistant tuberculosis (MDR-TB); this strategy included drug susceptibility testing (DST) and eliminated the Category II regimen. RESULTS: Of 125 patients that Category I failed to cure, 73 entered Strategy A and 52 entered Strategy B. Almost 90% of those with DST results had MDR-TB. Strategy B was three times more likely than Strategy A to cure patients (79% vs. 38%, RR = 2.9, 95% CI 1.7-5.1) and five times more likely to cure patients than the Category II regimen alone (79% vs. 15%, RR 5.2, 95% CI 3.0-9.2). Strategy B also significantly reduced delays to MDR-TB diagnosis and to the initiation of MDR-TB therapy. CONCLUSIONS: Under program conditions, a retreatment strategy based on DST and eliminating the Category II regimen can improve clinical outcomes among Category I treatment failures found to have active, infectious MDR-TB.
The National Rural Health Mission (NRHM), launched by the present government as part of its honouring the Common Minimum Programme (CMP) commitment, had its content shaped by an active process of dialogue between many stakeholders. This article traces the contours of the discussions on three key concerns of civil society that influenced their contributions to the shaping of the National Rural Health Mission agenda. These three concerns were promotion of targeted sterilisation, a retreat of the state from its commitments to the health sector and that the NRHM agenda would lead to privatisation of public health facilities. Whereas fears on targeted sterilisation and retreat of the state may be unrealistic, there is a thrust to increased involvement of the private sector, which needs to be understood in its entirety. There is need for continued engagement byequity concerned public health professionals and health activists at all levels of implementation and not merely community monitoring to influence and shape the National Rural Health Mission in a pro-poor direction.
We reviewed the records of 24 patients with rheumatoid arthritis who underwent 25 retreatments with gold salt injections given at a frequency greater than the usual monthly maintenance. Subject to the limitations of retrospective review, it was judged that every patient had improved on retreatment (5 fair, 19 good, 1 excellent), and there was only 1 instance of toxicity necessitating cessation of chrysotherapy. Repeat courses of gold salt injections of increased frequency appears to be a safe and effective therapeutic option for patients with rheumatoid arthritis who relapse after initial successful treatment.
The informality of an educational retreat can break down traditional barriers to learning and self-knowledge. A retreat can encourage autonomy, teamwork and reflection
To evaluate the effect of a second cycle of alpha-IFN treatment on patients who have not responded to a first cycle or responded and relapsed, 37 patients, 25 men and 12 women, mean age 41 yr, were retreated with alpha-interferon (IFN). Seven patients responded to the first cycle of treatment, and 30 did not. Five patients who had not responded to the second cycle received a third one. All patients received twice the dose of the first cycle unless they experienced side effects during the first cycle. Thus, nine patients received 9 mU/w, nine received 15 mU/w, and 19 received 30 mU/w for 6 months. Complete response was defined as nondetectable hepatic hepatitis C virus (HCV)-RNA at the end of therapy; sustained response was defined as normal ALT levels with negative serum HCV-RNA at > 6 months after cessation of therapy. Of the 30 nonresponders to the first cycle, eight responded to the second, but only four (13%) had a sustained response. Six of the seven responders to the first cycle responded to the second cycle, but only three had a sustained response (3/7, 43%) (p = NS). Although 33 and 21% (p = NS) of those who were treated with 15 mU/w and 30 mU/w, respectively, showed a sustained response, none of those treated with 9 mU/w had a sustained response (p = NS). Although age or sex of the patients studied had no effect on the response rate, liver histology was an important factor because only noncirrhotics showed a long term response (47 vs 0%; p < 0.02). There was no difference in response rate between patients with chronic active hepatitis and chronic persistent hepatitis. In conclusion, noncirrhotic patients who have not responded or responded and relapsed to a 6-month course of alpha-INF (3-5 mU three times per week) should try a second course at a dose of 15 mU/w. Retreatment may induce complete and long lasting response in 13% of the initial nonresponders and 43% of the initial responders. A second course of alpha-IFN in nonresponding cirrhotics appears ineffective in clearing the virus at the doses used.
PURPOSE: The purpose of this study was to examine the pattern of relapse and the treatment of relapse with either surgery or repeat immunotherapy in patients with metastatic melanoma or renal cell carcinoma who had previously responded to interleukin-2-based therapy. PATIENTS AND METHODS: Over a 10-year period 1051 patients with metastatic melanoma or renal cell carcinoma were treated with interleukin-2-based immunotherapy at a single institution. One hundred fifty-nine patients who relapsed after an initial partial response or complete response to interleukin-2-based immunotherapy formed the study population for this retrospective review. Medical records, physical examination forms, and relevant radiographs were reviewed to determine response, relapse site(s), and response to treatment for relapse. RESULTS: Relapse after an initial response to interleukin-2-based therapy occurred in 84 (80%) of 105 patients with metastatic melanoma and in 75 (70%) of 107 patients with metastatic renal cell carcinoma. Relapse after an initial partial response involved 71 (97%) of 73 patients with metastatic melanoma and 55 (86%) of 64 patients with metastatic renal cell carcinoma. The initial site(s) of relapse after a partial response involved a new site(s), old site(s), or both old and new sites with relatively even distribution. Relapse after an initial complete response occurred in 13 (41%) of 32 patients with metastatic melanoma and in 20 (47%) of 43 completely responding patients with metastatic renal cell carcinoma. Surprisingly, the initial site of relapse after a complete response involved only new sites of disease in 70% of patients. Retreatment of relapses with the same interleukin-2-based therapy originally used was effective in only one (2%) of 54 selected patients, but a different interleukin-2-based therapy in 35 patients resulted in five responders (a 14% secondary response rate). Most re-responders, however, responded to treatment with tumor-infiltrating lymphocytes and interleukin-2, and only one of 20 patients responded to retreatment with interleukin-2 alone. Surgical metastasectomy with therapeutic intent in 25 selected melanoma patients and in 31 selected renal cell cancer patients resulted in a 2-year progression-free survival of 18% in patients with metastatic melanoma and 37% in patients with metastatic renal cell carcinoma. DISCUSSION: In patients with metastatic melanoma or renal cell carcinoma, tumor relapse was common after a partial response to an interleukin-2-based therapy and included previously identified sites of disease in most patients. Relapse after a complete response was less frequent and involved only new sites in a majority of patients. In selected patients who relapsed, repeat treatment with the same interleukin-2-based therapy that provided the initial response was rarely effective. However, with a different interleukin-2-based therapy, usually using tumor-infiltrating lymphocytes, repeat treatment induced secondary responses in some patients. In addition, salvage metastasectomy resulted in durable progression-free survival in selected patients.
Peripheral vasodilation is considered an important factor in the pathophysiology of the hepatorenal syndrome (HRS). Therefore, the aim of this study was to evaluate the therapeutic potential of the vasoconstrictor ornipressin plus dopamine in the treatment of the most severe form of HRS, namely HRS type 1. Seven cirrhotic patients (creatinine clearance 15 +/- 1 mL/min, UNaV 7 +/- 2 mmol/24 h) with HRS type 1 were included in the study after normalization of central venous pressure with intravenous albumin and low-dose dopamine had failed to prevent further deterioration of renal function. Ornipressin was given continuously (intravenous 6 IU/h) in combination with dopamine (2-3 microgram/kg/min) until creatinine clearance had increased to above 40 mL/min or adverse events prevented further treatment. HRS was reverted in 4 of 7 patients after 5 to 27 days (creatinine clearance 51 +/- 4 mL/min, UNaV 47 +/- 11 mmol/24 h) of treatment. Withdrawal was necessary in 1 patient after 15 days because of intestinal ischemia. Treatment failure was observed in 2 of 7 patients (creatinine clearance 19 +/- 10 mL/min, UNaV 8 +/- 3 mmol/24 h). Two of 4 responders had recidivant HRS 2 and 8 months after initial therapy, respectively. HRS in 1 of these patients was reverted with 18 days of ornipressin retreatment. The other patient had to be withdrawn from ornipressin after 2 hours because of ventricular tachyarrhythmia. Altogether, 3 of 7 patients survived HRS type 1, 1 after successful ornipressin therapy and liver transplantation, 1 with 2 successful courses of ornipressin, and 1 with liver transplantation after ornipressin treatment had failed. Thus, ornipressin plus dopamine can be a useful therapeutic option in patients with HRS type 1, especially as bridge to liver transplantation.
Twenty-four patients with chronic hepatitis B virus (HBV), antibody to hepatitis B e antigen (anti-HBe), HBV DNA positivity, and alanine transaminase (ALT) elevation who failed previous interferon alfa (IFN-alpha) therapy were included in a pilot study of combination therapy with ribavirin and IFN-alpha. The patients received daily oral ribavirin (1,000-1,200 mg according to body weight) plus 5 million units (MU) IFN-alpha2b three times a week for 12 months and were followed-up for 12 months. The median viremia level decreased significantly at the end of treatment (1.2 x 10(3) copies/mL) and follow-up (4.0 x 10(2) copies/mL) compared with the baseline (3.0 x 10(6) copies/mL; P <.05). After 12 months, 8 of 24 (33%) patients had cleared HBV DNA and 12 (50%) had normal ALT levels. At the end of the study virological and biochemical response was 50% and 21%, respectively. Thus, virological and biochemical response sustained in 5 of 24 (21%) patients retreated with ribavirin and IFN-alpha; none of them lost hepatitis B surface antigen (HBsAg). Liver histology improved in 2 of 4 sustained responders but in none of the 12 nonresponders with paired biopsies (P =.05). The response was independent of dose and duration of previous treatment, viral load, or the distribution of HBV precore wild-type/mutant variants. However, sustained responders had significantly higher necroinflammation (P =.036) and fibrosis (P =.007) scores. IFN-alpha-related side effects were mild and reversible on discontinuation. In 4 (17%) patients who suffered nausea and diarrhea the ribavirin dosage was reduced by 50% after 1 month of therapy and finally discontinued in all of them. No patient had liver disease decompensation. In summary, combination therapy with ribavirin and IFN-alpha may be efficacious to treat viremic anti-HBe-positive patients with chronic hepatitis B who have failed previous IFN therapy.