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PubMed2000

Pilot study of organ preservation multimodality therapy for locally advanced resectable oropharyngeal carcinoma.

The purpose of this study was to determine the early efficacy and toxicity of a new multimodality organ-preservation regimen for locally advanced, resectable oropharyngeal squamous cell carcinoma (SCC). Patients with T3-4N0-3M0 or T2N2-3M0 oropharyngeal SCC were eligible for this Phase II study. Patients needed the physiologic reserve for surgery and technically resectable tumors. Induction carboplatin (area under the curve = 6) and paclitaxel (200 mg/m2) x 2 cycles (q21 days) were given. Objective responders received definitive radiotherapy (XRT), 70 Gy/7 weeks with concurrent weekly paclitaxel. Initially, the dose of paclitaxel was 50 mg/m2/week; because of mucosal toxicity it was reduced to 30 mg/m2/week. Patients with N2-3 disease received post-XRT neck dissection and 2 more cycles of "adjuvant" chemotherapy. In the first 22 patients, the neutropenic fever rate was 27%. Although there has been no grade IV-V toxicity from induction therapy, grade II-III toxicity resulted in an unacceptable delay in starting XRT in 14% of patients. The response rate to induction chemotherapy was 91%. Grade III mucositis occurred in all patients during concurrent chemoradiotherapy. One patient died of pneumonia during concurrent chemoradiotherapy after receiving 26 Gy and 3 doses of paclitaxel 50 mg/m2. No dose-limiting toxicity occurred in 15 patients treated with concurrent paclitaxel 30 mg/m2/week. Actuarial overall survival at 18 months is 82%; local-regional control is 86%. To date, distant metastases have not developed in any patients. This regimen has intense but acceptable acute toxicity. The maximum tolerated dosage of weekly paclitaxel during standard continuous-course XRT is confirmed to be 30 mg/m2/week. The treatment efficacy of this regimen (response rate and short-term local-regional and distant control) is encouraging. Accrual continues to obtain long-term toxicity, efficacy, and quality-of-life data.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2003

A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery.

We compared pain intensity, analgesic consumption, patient satisfaction, and length of stay in 114 patients undergoing gastric bypass surgery under general anesthesia. Patients were randomized to incisional local anesthetic infiltration plus postoperative patient-controlled analgesia (Group A), epidural anesthesia and analgesia (Group B), or postoperative patient-controlled analgesia (Group C). All received perioperative nonsteroidal antiinflammatory drugs. Age, sex, body mass index, length of stay, and patient satisfaction were equivalent in all groups. Pain at time 0 and 36 h was the smallest in Group B, greater in Group A, and greatest in Group C. Pain scores in a subset of Group A were lower at all times than in Groups B and C, but this difference was significant only at 0, 12, and 36 h. In responders, infiltration analgesia as part of a multimodal regimen offers a simple, safe, and inexpensive alternative to epidural pain control.

Adolescent↗
PubMed2002

Propofol and sevoflurane in subanesthetic concentrations act preferentially on the spinal cord: evidence from multimodal electrophysiological assessment.

BACKGROUND: Animal experiments in recent years have shown that attenuation of motor responses by general anesthetics is mediated at least partly by spinal mechanisms. Less is known about the relative potency of anesthetic drugs in suppressing cortical and spinal electrophysiological responses in vivo in humans, particularly those, but not only those, connected with motor responses. Therefore, we studied the effects of sevoflurane and propofol in humans using multimodal electrophysiological assessment. METHODS: We studied nine healthy volunteers in two sessions during steady state sedation with 0.5, 1.0, and 1.5 microg/l (targeted plasma concentration) propofol or 0.2 and 0.4 vol% (end-tidal) sevoflurane. Following a 15-min equilibration period, motor responses to transcranial magnetic stimulation and peripheral (H-reflex, F-wave) stimulation were recorded, while electroencephalography and auditory evoked responses were recorded in parallel. RESULTS: At concentrations corresponding to two thirds of C(50 awake), motor responses to transcranial magnetic stimulation were reduced by approximately 50%, H-reflex amplitude was reduced by 22%, F-wave amplitude was reduced by 40%, and F-wave persistence was reduced by 25%. No significant differences between sevoflurane and propofol were found. At this concentration, the Bispectral Index was reduced by 7%, and the middle-latency auditory evoked responses were attenuated only mildly (N(b) latency increased by 11%, amplitude P(a)N(b) did not change). In contrast, the postauricular reflex was suppressed by 77%. CONCLUSIONS: The large effect of both anesthetics on all spinal motor responses, compared with the small effect on electroencephalography and middle-latency auditory evoked responses, assuming that they represent cortical modulation, may suggest that the suppression of motor responses to transcranial magnetic stimulation is largely due to submesencephalic effects.

Adult↗
PubMed1985

The role of splenectomy in multimodality treatment of thrombotic thrombocytopenic purpura.

Current treatment modalities for thrombotic thrombocytopenic purpura (TTP) include plasmapheresis (PP), splenectomy, steroids, dextran, other antiplatelet agents, and vinca alkaloids. Prior to the development of PP and use of multimodality treatment for TTP, mortality rates exceeded 50%. This report reviews 11 patients treated for TTP, demonstrates the successful use of splenectomy as salvage therapy, and defines our indications for splenectomy in the treatment of this disorder. Ten of 11 patients were initially treated with PP; three responded completely and one died of fulminant disease. Six patients had a transient partial response to plasmapheresis and were subsequently treated with splenectomy, steroids, and dextran-70. Initial plasmapheresis resulted in improvement in laboratory values and clinical status in those patients requiring splenectomy. Durable remission (6-48 months) was achieved in 91% of patients with minimal morbidity.

Adult↗
PubMed1987

Patterns of failure following surgical resection of colorectal cancer liver metastases. Rationale for a multimodal approach.

A total of 45 patients, after surgical resection of colorectal liver cancer metastases, were retrospectively analyzed to define areas of failure, to identify some possible prognostic factors (site of primary, stage, site, number of metastases, preoperative carcinoembryonic antigen, differentiation of the primary, type of surgery), and to seek a new rationale for a multimodal approach. The median postoperative follow-up was 18 months (range: 4-45 months). Survival rate was calculated by the actuarial method, and statistical significance was tested by the Mantel-Haenszel test. Twenty-eight patients had a relapse. These recurrences were hepatic in 11 patients, extrahepatic (intra- and extra-abdominal) in 12 patients, and intra- and extrahepatic in five patients: The stage (classification of the Istituto Nazionale Tumori of Milan) was the most important parameter related to the overall recurrence rate (47% in stage I, 62% in stage II, and 81% in stage III) and to the overall and disease-free survival. Stage was significantly related to hepatic relapse but not to extrahepatic relapse. In stage I the failure rate of 18 months was similar in hepatic and extrahepatic relapses (one third to one fourth of the patients); in stages II and III the hepatic failure rate was always higher than the extrahepatic rate. These data indicate that surgery alone is an inadequate form of therapy in cases of colorectal cancer metastases of the liver, and an adjuvant therapy, including alternate regimens of intraperitoneal and systemic chemotherapy, should be considered.

Actuarial Analysis↗
PubMed1995

Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients.

OBJECTIVE: The objective of this study was to evaluate long-term enteral nutrition support in postoperative cancer patients. BACKGROUND: Multimodality therapy for surgical patients with upper gastrointestinal malignancies may improve survival, but often results in substantial malnutrition, immunosuppression, and morbidity. The benefits of combined inpatient and outpatient enteral feeding with standard diets or diets supplemented with arginine, RNA + omega-3 fatty acids are unclear. METHODS: Sixty adult patients with esophageal (22), gastric (16), and pancreatic (22) lesions were stratified by disease site and percent usual weight and randomized to receive supplemental or standard diet via jejunostomy beginning on the first postoperative day (goal = 25 kcal/kg/day) until hospital discharge. Patients also were randomized to receive (n = 37) or not receive (n = 23) enteral jejunostomy feedings (1000 kcal/day overnight) for the 12- to 16-week recovery and radiation/chemotherapy periods. Plasma and peripheral white blood cells were obtained for fatty acid levels and PGE2 production measurements. RESULTS: Mean plasma and cellular omega 3/omega 6 fatty acid levels (percent composition) increased significantly (p < 0.05) in the arginine + omega-3 fatty acid group by postoperative day 7 (0.30 vs. 0.13) and (0.29 vs. 0.14) and continued to increase over time. Mean PGE2 production decreased significantly (p < 0.05) from 2760 to 1600 ng/10(6) cells/mL at day 7 in the arginine + omega-3 fatty acid group, whereas no significant change over time was noted in the standard group. Infectious/wound complications occurred in 10% of the supplemented group compared with 43% of the standard group (p < 0.05); mean length of hospital stay was 16 vs. 22 (p < 0.05) days, respectively. Of the patients who received postoperative chemoradiation therapy, only 1 (6%) of the 18 patients randomized to receive tube feeding did not continue, whereas 8 (61%) of the 13 patients not randomized to tube feedings required crossover to jejunostomy nutritional support. CONCLUSIONS: Supplemental enteral feeding significantly increased plasma and peripheral white blood cell omega 3/omega 6 ratios and significantly decreased PGE2 production and postoperative infectious/wound complications compared with standard enteral feeding. For outpatients receiving adjuvant therapy, those initially randomized to oral feedings alone required rehospitalization more frequently, and 61% crossed over to supplemental enteral feedings.

Aged↗
PubMed1996

Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma. Results in 120 consecutive patients.

OBJECTIVE: The authors examine the feasibility and efficacy of trimodality therapy in the treatment of malignant pleural mesothelioma and identify prognostic factors. BACKGROUND: Mesothelioma is a rare, uniformly fatal disease that has increased in incidence in recent decades. Single and bimodality therapies do not improve survival. METHODS: From 1980 to 1995, 120 patients underwent treatment for pathologically confirmed malignant mesothelioma at Brigham and Women's Hospital and Dana-Farber Cancer Institute (Boston, MA). Initial patient evaluation was performed by a multimodality team. Patients meeting selection criteria and with resectable disease identified by computed tomography scan or magnetic resonance imaging underwent extrapleural pneumonectomy followed by combination chemotherapy and radiotherapy. RESULTS: The cohort included 27 women and 93 men with a mean age of 56 years. Operative mortality rate was 5.0%, with a major morbidity rate of 22%. Overall survival rates were 45% at 2 years and 22% at 5 years. Two and 5-year survival rates were 65% and 27%, respectively, for patients with epithelial cell type, and 20% and 0%, respectively, for patients with sarcomatous or mixed histology tumors. Nodal involvement was a significant negative prognostic factor. Patients who were node negative with epithelial histology had 2- and 5-year survival rates of 74% and 39%, respectively. Involvement of margins at time of resection did not affect survival, except in the case of full-thickness, transdiaphragmatic invasion. Classification on the basis of a revised staging system stratified median survivals, which were 22, 17, and 11 months for stages I, II, and III, respectively (p = 0.04). CONCLUSIONS: Extrapleural pneumonectomy with adjuvant therapy is appropriate treatment for selected patients with malignant mesothelioma selected using a revised staging system.

Combined Modality Therapy↗
PubMed1999

A multimodal support group with Hispanic traumatic brain injury survivors.

OBJECTIVES: (a) To design and pilot a culturally sensitive and neuropsychologically informed support group addressing barriers to emotional, social, and vocational adjustment among high-level functioning Hispanic/Latino TBI survivors. (b) To determine efficacy through outcome measures. INTERVENTION: Ten-week multimodal, culturally sensitive support group focusing on TBI sequelae education, relaxation techniques, coping skills development, behavioral goal setting and monitoring, and family participation. PARTICIPANTS: Six Spanish-speaking high-level functioning TBI survivors aged 20-42. SETTING: Outpatient neuropsychological assessment and treatment center. OUTCOME MEASURES: Beck Hopelessness Scale; Purpose in Life Test; Perceived Self-Regulatory Ability Inventory. RESULTS: Participants' sense of personal destiny and feelings of hopelessness improved, as evidenced by objective measures and self-report. A telephone interview a year later indicated that gains had been maintained, and most participants were vocationally active. CONCLUSIONS: Results underscore the importance of considering linguistic and ethnic factors in developing support groups.

Adaptation, Psychological↗
PubMedDate not supplied

Multimodal neuroimaging approaches to disorders of consciousness.

Advances in neuroimaging techniques hold significant promise for improving understanding of disorders of consciousness arising from severe brain injuries. We review neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS. Multimodal neuroimaging studies using positron emission tomography techniques, functional magnetic resonance imaging, and quantitative electroencephalography and magnetoencephalography quantify variations of residual cerebral activity across these patient populations. The results suggest models to distinguish the pathophysiologic basis of VS and MCS. Less clear are potential brain mechanisms underlying late recovery of communication in rare MCS patients. Diffusion tensor magnetic resonance imaging studies and recent experimental findings suggest that structural remodeling of the brain following severe injury may play a role in late functional recoveries. More generally, relatively long time courses of recovery following severe brain injury emphasize the need to develop markers for identifying patients who may harbor potential for further meaningful recovery. Introduction of neuroimaging into the clinical evaluation process will require developing frameworks for longitudinal assessments of cerebral function. Although limited in number, available studies already provide important insights into underlying brain mechanisms that may help guide development of such assessment strategies.

Arousal↗
PubMed1997

Neurophysiological evaluation with multimodality evoked potentials in craniostenosis and craniofacial stenosis.

Multimodality evoked potentials (somatosensory and acoustic) have been recorded before surgery in children selected for surgical treatment for different kinds of craniostenosis and craniofacial stenosis. Evoked potentials were found to be deranged on at least one recording in 50% of cases, suggesting a significant incidence of neurophysiological alterations in these patients. No correlation was found between evoked potentials' derangements and clinical status, radiological findings, or different kinds of craniostenosis; moreover, a significant correlation was found between neurophysiological alterations and the age of the children. These preliminary data might define the possible role of neurophysiological tests in the presurgical evaluation of craniostenosis and craniofacial stenosis.

Aging↗
PubMed1989

Pitfalls in multimodality imaging in a patient undergoing evaluation for bone marrow transplantation.

Autologous bone marrow transplantation is being offered with increasing frequency as a therapeutic alternative to patients who have failed conventional chemotherapy. Presently, these patients are being evaluated with a variety of imaging modalities, including planar radiographs, nuclear bone and bone marrow scans, and CT and magnetic resonance imaging. A case is presented here that demonstrates potential pitfalls encountered in this multimodality approach. Correlation of imaging findings with patients history and clinical findings is essential for optimal interpretation of functional imaging modalities.

Adult↗
PubMed2001

Multimodal imaging quantitation of the lesion size in osteonecrosis of the femoral head.

Early diagnosis of osteonecrosis of the femoral head is important for initiating early treatment, which is associated with a more favorable outcome for patients. Confusion in evaluating the severity of the disease, and the clinical outcome after treatment partially is attributed to the use of various staging systems that are based on qualitative rather than quantitative criteria. At the authors' institution, 45 patients (77 hips) with osteonecrosis of the femoral head were evaluated using a multimodal imaging approach that included conventional radiography, bone scintigraphy, and magnetic resonance imaging. A computerized image analysis program that allowed quantification of the lesion size on radiographs and magnetic resonance images was used. Measurements of the extent of involvement on radiographs and selected serial magnetic resonance images were compared in 33 hips (42.9%) before collapse versus 44 hips (57.1%) after collapse. The size of the necrotic lesion varied significantly according to the specific stage of disease. Quantification of the lesion during the course of the disease provided a record of the progression of osteonecrosis, despite a spurious stability in staging. In general, conventional radiography closely approximated measurements of the lesion size obtained by magnetic resonance imaging. Bone scintigraphy and magnetic resonance imaging were well suited for detection of osteonecrosis at an early stage. Finally, precise quantification of the lesion size was an optimal preoperative means for evaluating the extent of involvement of the femoral head in the early and advanced stages of osteonecrosis.

Adolescent↗
PubMed1987

A multimodality projection console for the radiology conference room.

A multimodality projection console for the radiology conference room is described. The configuration of the TV camera, view boxes, switches, and adjacent lectern allows better transmission and easier manipulation of images during consultation and lecture sessions with the faculty, and house officers.

Education, Medical↗
PubMed1993

Effectiveness of a multimodal day treatment program for children with disruptive behavior problems.

OBJECTIVE: Children with disruptive behavior disorders are often also dysfunctional in academics, social skills, and self-esteem. The efficacy of multimodal day treatment in addressing these deficits was evaluated. METHOD: Thirty children, assigned to day treatment or a waiting list, were compared on measures of behavior, self-perception, academics, peer relations, and family functioning. RESULTS: Multivariate analyses of covariance showed that the treatment group improved significantly more on measures of behavior and self-perception. Six-month follow-up findings indicate that treated children had improved over time on all measures except academics. CONCLUSIONS: This study demonstrates that compared with a waiting list control group, day treatment produces greater gains, and that these gains are maintained at 6 months' follow-up. It also shows the need for a treatment that combines multiple modalities in dealing with children with disruptive behavior disorders.

Achievement↗
PubMed1994

A multimodal approach to functional dysphagia.

Functional dysphagia in children has historically been treated using a cognitive behavioral approach. The case of a 7-year-old boy treated using a successful multimodal approach, including behavioral, family, and play therapy with alprazolam augmentation, is reported. The patient showed minimal response to early interventions but rapidly improved with the prescription of alprazolam before meals.

Alprazolam↗
PubMed1995

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale.

OBJECTIVE: The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA. METHOD: A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA. RESULTS: Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)? CONCLUSIONS: The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Adolescent↗
PubMed1997

Outcome of multimodal day treatment for children with severe behavior problems: a five-year follow-up.

OBJECTIVE: To evaluate the long-term outcome of a multimodal day treatment program for children with severe behavior problems and to identify factors that may predict a positive outcome. METHOD: Thirty-three children who completed a day treatment program were assessed using a prospective, single-cohort design tested at intake, discharge, and 5-year follow-up. The child's functioning was assessed using the Revised Child Behavior Profile (RCBP), Hare Self-Esteem Scale, Depression Self-Rating Scale, Hopelessness Scale for Children, Index of Peer Relations, and a 5-point ordinal scale for scholastic reintegration. RESULTS: Repeated-measures analyses of variance showed that improvement was maintained on all measures between intake and 5-year follow-up. A stepwise multiple regression showed that 92% of the adjusted variance in the behavioral functioning of the children at 5-year follow-up, as assessed by the RCBP, was explained by parental cooperation, initial RCBP total and externalizing scores, and history of problem pregnancy. CONCLUSIONS: Children who were admitted to a day treatment setting appear to function well globally, even 5 years after discharge. Parental cooperation was the most important variable in predicting positive outcome.

Adolescent↗
PubMed2001

Multimodal treatment of ADHD in the MTA: an alternative outcome analysis.

OBJECTIVE: To conduct a post hoc investigation of the utility of a single composite measure of treatment outcome for the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) at 14 months postbaseline. BACKGROUND: Examination of multiple measures one at a time in the main MTA intent-to-treat outcome analyses failed to detect a statistically significant advantage of combined treatment (Comb) over medication management (MedMgt). A measure that increases power and precision using a single outcome score may be a useful alternative to multiple outcome measures. METHOD: Factor analysis of baseline scores yielded two "source factors" (parent and teacher) and one "instrument factor" (parent-child interactions). A composite score was created from the average of standardized parent and teacher measures. RESULTS: The composite was internally consistent (alpha = .83), reliable (test-retest over 3 months = 0.86), and correlated 0.61 with clinician global judgments. In an intent-to-treat analysis, Comb was statistically significantly better than all other treatments, with effect sizes ranging from small (0.28) versus MedMgt, to moderately large (0.70) versus a community comparison group. CONCLUSIONS: A composite of ADHD variables may be an important tool in future treatment trials with ADHD and may avoid some of the statistical limitations of multiple measures.

Analysis of Variance↗