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PubMed2001

Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers.

In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), secondary analyses revealed that Comb had a significant incremental effect over MedMgt (with a small effect size for this comparison) when categorical indicators of excellent response and when composite outcome measures were used. In addition, children with parent-defined comorbid anxiety disorders, particularly those with overlapping disruptive disorder comorbidities, showed preferential benefits to the Beh and Comb interventions. Parental attitudes and disciplinary practices appeared to mediate improved response to the Beh and Comb interventions.

Attention Deficit Disorder with Hyperactivity↗

PubMedDate not supplied

A fully automatic multimodality image registration algorithm.

OBJECTIVE: A fully automatic multimodality image registration algorithm is presented. The method is primarily designed for 3D registration of MR and PET images of the brain. However, it has also been successfully applied to CT-PET, MR-CT, and MR-SPECT registrations. MATERIALS AND METHODS: The head contour is detected on the MR image using a gradient threshold method. The head region in the MR image is then segmented into a set of connected components using the K-means clustering algorithm. When the two image sets are registered, the segmentation of the MR image indirectly generates a segmentation of the PET image. The best registration is taken to be the one that optimizes the segmentation induced on the PET image. In this article, the K-means minimum variance criterion is used as a cost function, and the optimization is performed using the method of coordinate descent. RESULTS: The algorithm was tested on 80 H2 15O PET and MR image pairs from 10 subjects. Qualitatively correct results were obtained in all cases. With use of external markers visible in both image modalities, the average registration error was estimated to be < 3 mm. CONCLUSION: The algorithm presented in this article requires no user interaction and can be applied to a wide range of registration problems. Quantitative and qualitative evaluations of the algorithm indicate a high degree of accuracy.

Algorithms↗

PubMed1980

Multimodal treatment of a case of obsessive-compulsive neurosis.

A severe incapacitating case of obsessive-compulsive neurosis was treated in hospital with an intense multimodal approach including individual, conjoint marital, and group psychotherapy, behavioral therapy, occupational and recreational therapy, milieu therapy, and medications. The separate treatments appeared to have a synergistic effect. The patient's symptoms decreased dramatically, and he resumed his normal occupational and family functions and responsibilities. At 2-year follow-up, the patient remained well.

Adult↗

PubMed1997

Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation.

BACKGROUND: Recently, invasive intensive care unit monitoring of cerebral oxygenation has become feasible. The purpose of this study was to investigate the effects of standard therapeutic interventions used in the treatment of intracranial hypertension on cerebral oxygenation and other physiologic parameters in comatose patients. METHODS: In the neurosurgical intensive care unit, Ptio2, and jugular bulb oxygen saturation (Sjvo2), arterial blood pressure, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were prospectively studied (0.1 Hz acquisition rate) with a multimodal monitoring system in 21 patients with severe traumatic brain injury during various treatment modalities: dopamine and mannitol infusion, head positioning, and induced arterial hypocapnia. RESULTS: For baseline CPP values below 40 mm Hg, dopamine infusion was more effective in decreasing ICP and improving Ptio2 and Sjvo2 than for initial CPP values above 60 mm Hg. Treatment with mannitol, although improving CPP and lowering ICP, did not affect Ptio2 and Sjvo2. CPP in this group, however, was always above 60 mm Hg. Forced hyperventilation to an end-tidal Pco2 of 21 mm Hg normalized ICP and CPP, but significantly reduced cerebral oxygenation. CONCLUSION: A CPP > 60 mm Hg emerges as the crucial factor guaranteeing sufficient brain oxygenation. Any intervention used to further elevate CPP does not improve cerebral oxygenation, to the contrary, forced hyperventilation even bears the risk of inducing brain ischemia.

Brain Chemistry↗

PubMed2000

Multimodality treatment of nongalenic arteriovenous malformations in pediatric patients.

OBJECTIVE: Previously reported series of arteriovenous malformations (AVMs) in pediatric patients have primarily used a single-modality treatment approach of either surgery, radiosurgery, or embolization, with significant treatment-related morbidity and mortality. At our institution, we have used a combined multidisciplinary team approach of all three treatment modalities, alone or in combination, to minimize complications and to maximize efficacy in the management of these lesions. METHODS: We retrospectively reviewed 40 consecutive pediatric patients with AVMs seen at our institution from 1991 to 1999. A multidisciplinary team planned the treatment for each AVM. The treatment modality consisted of the following approaches: surgery alone in 14 patients, a combination of endovascular embolization and surgery in 6 patients, radiosurgery alone in 11 patients, a combination of endovascular embolization and radiosurgery in 2 patients, and a combination of radiosurgery and surgery in 2 patients. Four patients are receiving ongoing multistaged treatment for reduction of the nidus size for eventual surgical resection or radiosurgical obliteration of large, complex lesions. In one patient, no treatment was recommended. RESULTS: The clinical outcomes for the overall series were 95.0% excellent or good (Glasgow Outcome Scale score 5 or 4), 2.5% fair (Glasgow Outcome Scale score 3), and 2.5% dead. Radiographic efficacy in the patients who have completed treatment was 92.9% complete obliteration of their AVMs and 7.1% incomplete obliteration. Of the 10 patients who had seizures, 9 are seizure-free. CONCLUSION: A combined multimodality approach of surgery, radiosurgery, and embolization in managing AVMs in pediatric patients can improve outcomes and minimize morbidity and mortality.

Adolescent↗

PubMed1998

Multimodality evaluation of pressure relief surfaces.

Multimodality evaluation of six different support surfaces was performed measuring interface pressure, transcutaneous oxygen tension, and blood flow in pressure ulcer-prone areas on healthy subjects. Interface pressure was measured with a flexible force-sensing resistor array. The interface pressure distribution patterns of 10 healthy male volunteers were measured in the supine and lateral positions using a pressure sensor (force sensing resistor) array. Transcutaneous oxygen (TcPO2) and laser Doppler flowmeter probes were placed over the sacrum, the right trochanter, and the right ischium. Data were recorded for 15 minutes each with the subject in the supine and lateral decubitus positions. Statistically significant differences (p < 0.05) between the various surfaces could be observed for blood flow and pressure measurements, especially in the lateral position over the trochanter and for the TcPO2 measurements in the supine position over the sacrum. We conclude that measuring interface pressure, transcutaneous oxygen tension, and blood flow allows a more thorough evaluation of the physiologic effects of special support surfaces than any single technique. Future studies on patients will assess algorithms for using these measurement techniques to predict the efficacy of various support surfaces in minimizing pressure ulceration.

Blood Gas Monitoring, Transcutaneous↗

PubMed2004

Multimodality imaging in partial epilepsies.

PURPOSE OF REVIEW: The rapid expansion of novel applications and the development of new techniques in structural and functional imaging modalities present a troubling challenge to keep up with and harness potential valuable information created in this critical field of epilepsy localization and non-invasive in-vivo research. RECENT FINDINGS: Recent advances in epilepsy imaging have centered on: (1) improving the localization of epileptogenic tissue beyond that of state-of-the-art structural magnetic resonance imaging; (2) monitoring the development and progression of epileptogenic pathology, particularly mesial temporal sclerosis; and (3) an investigation of the in-vivo structural and functional disturbances underlying and revealing mechanisms of partial epilepsy pathophysiology. SUMMARY: The main impact of the progress in epilepsy localization with multimodality imaging is to allow more effective presurgical evaluation and the selection of patients with intractable seizures. By combining serial imaging findings and genetic studies, the major questions surrounding the development and progression of mesial temporal sclerosis with regard to the cause and consequence of epilepsy will soon be answered. Long-standing questions concerning in-vivo metabolic and neurotransmitter disturbances associated with partial epilepsy, detected and depicted (but not understood) with magnetic resonance spectroscopy and positron emission tomography, are finally being addressed.

Brain Damage, Chronic↗

PubMed2006

Thermal and tactile sensory deficits and allodynia in a nerve-injured patient: a multimodal psychophysical and functional magnetic resonance imaging study.

OBJECTIVE: A case study was conducted to examine a patient with chronic neuropathic pain of the right foot following peripheral nerve injury and characterize associated sensory abnormalities. METHODS: Multimodal psychophysical examination of the patient's affected and nonaffected foot included thermal sensibility, dynamic touch, and directional sensibility. In addition, we used functional magnetic resonance imaging to study cortical representation of brush-evoked allodynia. RESULTS: Detailed psychophysical examination revealed substantial deficits in warm, cool, and tactile perception on the injured foot. These findings indicated severe dysfunction of perceptual processes mediated by A beta, A delta, and C fibers. Despite reduced tactile perception, light touch evoked a deep burning pain in the foot. Functional magnetic resonance imaging during brushing of the patient's injured foot showed that tactile allodynia led to activation of several cortical regions including secondary somatosensory cortex, anterior and posterior insular cortex, and anterior cingulate cortex. Brushing of the patient's nonaffected foot led to fewer activated regions. DISCUSSION: The profound sensory disturbances suggest a possible deafferentation type of tactile allodynia mediated by changes within the central nervous system, such as a disruption of normal tactile or thermal inhibition of nociception. The functional magnetic resonance imaging data suggest that tactile allodynia is represented in similar brain regions as experimental pain.

Adult↗

PubMed2003

Ischiogluteal bursitis: multimodality imaging findings.

Ischiogluteal bursitis is a rare, infrequently recognized condition. Two cases of ischiogluteal bursitis in an 80-year-old man and a 75-year-old woman are presented. Both patients presented with a painful buttock mass. Contrast-enhanced multiplanar reconstruction computed tomography scans revealed a lesion with peripheral enhancement inferior to the ischial tuberosity. Magnetic resonance imaging revealed a lesion with low or intermediate signal intensity on T1-weighted images. T2-weighted images revealed a lesion with high signal intensity. Postcontrast magnetic resonance imaging scans revealed peripheral enhancement of the lesion. The multimodality imaging findings of ischiogluteal bursitis have not been described previously. Ischiogluteal bursitis should be considered in the differential diagnosis of a buttock mass.

Aged↗

PubMed2006

Multimodal prophylaxis for THA with mechanical compression.

We used mechanical thromboembolism prophylaxis using intraoperative thigh-calf pneumatic compression and other measures in 1032 consecutive primary and revision total hip arthroplasties. No chemical prophylactic measures were used until after duplex ultrasonography was performed by experienced technologists before discharge. Asymptomatic proximal thrombi were treated with low molecular weight heparin and warfarin, whereas those patients with a negative scan or distal thrombi only were advised to take aspirin 325 mg twice a day for 6 weeks. Regional anesthesia was used in 95% of the arthroplasties. Using this protocol, the 30-day mortality was 0.3%. There was one autopsy-proven fatal pulmonary embolism (0.09%). One other patient died suddenly with cardiac arrest after abdominal pain and vomiting, but no autopsy was performed. Symptomatic pulmonary embolism occurred in seven patients (0.7%), four occurring early and three late. Only one of these seven patients had a positive duplex scan. Deep vein thrombosis occurred in 41 patients (3.9%) and 35 remained asymptomatic. We observed no association between type of surgery (primary or revision), age, gender or preoperative diagnosis and pulmonary embolism or deep vein thrombosis. The data confirm the efficacy of a multimodal protocol with thigh-calf mechanical prophylaxis for almost all patients undergoing primary or revision total hip arthroplasty.

Adult↗

PubMed2003

Multimodality monitoring of transcranial electric motor and somatosensory-evoked potentials during surgical correction of spinal deformity in patients with cerebral palsy and other neuromuscular disorders.

STUDY DESIGN: This prospective, descriptive study determined the reliability of transcranial electric motor and posterior tibial nerve somatosensory-evoked potentials in children with neuromuscular scoliosis. OBJECTIVE: To assess the applicability of transcranial electric motor and posterior tibial nerve somatosensory-evoked potentials during surgical correction of neuromuscular scoliosis, particularly with cerebral palsy-related deformity. SUMMARY OF BACKGROUND DATA: During corrective spinal surgery for neuromuscular scoliosis, intraoperative multimodality spinal cord monitoring is recommended. There exist conflicting, retrospective studies regarding the reliability of spinal cord monitoring in patients with neuromuscular scoliosis. METHODS: Transcranial electric motor potentials and posterior tibial nerve somatosensory-evoked potentials were monitored in all patients presenting for spinal fusion between 2000 and 2001. Anesthesia was standardized for all patients. RESULTS: There were 68 patients subdivided into two subject groups. Group I consisted of 39 patients with neuromuscular scoliosis associated with cerebral palsy, and Group II consisted of 29 children with neuromuscular scoliosis due to a disease process other than cerebral palsy. Five of the 68 patients had significant amplitude changes in 1 or both monitoring methods during surgery relative to baseline. Of these, one had permanent neurologic deficit despite standard intervention. Somatosensory-evoked potentials were monitored successfully in 82% of the cerebral palsy and 86% of the noncerebral palsy patients. Transcranial electric motor-evoked potentials, on the other hand, were monitorable in 63% of patients with mild or moderate degrees of cerebral palsy and 39% of those with severe involvement. Eighty-six percent of those with noncerebral palsy-related neuromuscular scoliosis had recordable motor-evoked potentials at baseline. CONCLUSION: Both transcranial electric motor and posterior tibial nerve somatosensory-evoked potentials can be monitored reliably in most patients with neuromuscular scoliosis. Those with severe cerebral palsy present the greatest challenge to successful neurophysiologic monitoring.

Adolescent↗

PubMed2005

Lasting remission following multimodal treatment in a patient with metastatic breast cancer.

We report on a lasting remission from multimodal treatment in a patient with hepatic metastasized breast cancer. After surgical removal of a singular hepatic metastasis, the patient underwent leukapheresis of peripheral blood mononuclear cell (PBMCs). For induction chemotherapy, the patient received 2 cycles of epirubicin and paclitaxel (ET). After 1 cycle of epirubicin and ifosfamide (EI), peripheral blood stem cells were harvested. After a final cycle of ET, the patient underwent high-dose chemotherapy (HDCT; thiotepa 600 mg/m/melphalan 180 mg/m) and autologous stem cell transplantation. Once reconstitution was achieved, PBMCs were reinfused followed by i.v. application of a trifunctional antibody (TrAb) with specificities anti-EpCAMxanti-CD3. TrAbs are able to simultaneously bind tumor cells, T cells, and additionally FcgammaR type I and III+accessory cells via their Fc region. Side-effects during treatment were hematotoxicity, mucositis and gastrointestinal toxicity. TrAb treatment resulted in intermittent fever, chills, elevated liver enzymes, systemic inflammatory response syndrome and pulmonary leakage. With a follow-up period of more than 8 years the patient is still in remission (96+months). This case suggests the feasibility and efficacy of combining surgery, standard and HDCT, and subsequent immunotherapy in metastatic breast cancer. Further investigation of this approach is indicated in a subgroup of patients with oligometastatic breast cancer.

Adult↗

PubMed2004

Children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment: impact on parental practices.

OBJECTIVE: To test the hypothesis that multimodal psychosocial intervention, which includes parent training, combined with methylphenidate significantly enhances the behavior of parents of children with attention-deficit/hyperactivity disorder (ADHD), compared with methylphenidate alone and compared with methylphenidate and nonspecific psychosocial treatment (attention control). METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate therapy were randomized for 2 years to receive either (1) methylphenidate treatment alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, academic assistance, and psychotherapy; or (3) methylphenidate plus attention control treatment. Parents rated their knowledge of parenting principles and negative and positive parenting behavior. Children rated their parents' behavior. RESULTS: Psychosocial treatment led to significantly better knowledge of parenting principles but did not enhance parenting practices, as rated by parents and children. Significant improvement in mothers' negative parenting occurred across all treatments and was maintained. CONCLUSIONS: In nonconduct-disordered, stimulant-treated children with ADHD, parent training does not improve self-rated parental behavior. The benefits of brief stimulant treatment for negative parental behavior are sustained with extended treatment.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment.

OBJECTIVE: To test the hypotheses that in children with attention-deficit/hyperactivity disorder (ADHD) (1) symptoms of ADHD, oppositional defiant disorder, and overall functioning are significantly improved by methylphenidate combined with intensive multimodal psychosocial treatment compared with methylphenidate alone and with methylphenidate plus attention control and (2) more children receiving combined treatment can be taken off methylphenidate. METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to (1) methylphenidate alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, psychotherapy, and academic assistance, or (3) methylphenidate plus attention psychosocial control treatment. Assessments included parent, teacher, and psychiatrist ratings, and observations in academic and gym classes. RESULTS: Combination treatment did not lead to superior functioning and did not facilitate methylphenidate discontinuation. Significant improvement occurred across all treatments and continued over 2 years. CONCLUSIONS: In stimulant-responsive children with ADHD, there is no support for adding ambitious long-term psychosocial intervention to improve ADHD and oppositional defiant disorder symptoms. Significant benefits from methylphenidate were stable over 2 years.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment.

OBJECTIVE: To test the hypothesis that intensive multimodal psychosocial intervention (that includes academic assistance and psychotherapy) combined with methylphenidate significantly enhances the academic performance and emotional status of children with attention-deficit/hyperactivity disorder (ADHD) compared with methylphenidate alone and with methylphenidate combined with nonspecific psychosocial treatment (attention control). METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to receive one of three treatments: (1) methylphenidate alone, (2) methylphenidate plus psychosocial treatment that included academic remediation, organizational skills training, and psychotherapy as well as parent training and counseling and social skills training, or (3) methylphenidate plus attention control treatment. Children's function was assessed through academic testing, parent ratings of homework problems, and self-ratings of depression and self-esteem. RESULTS: No advantage was found on any measure of academic performance or emotional status for the combination treatment over methylphenidate alone and over methylphenidate plus attention control. Significant improvement occurred across all treatments and was maintained over 2 years. CONCLUSIONS: In stimulant-responsive young children with ADHD without learning and conduct disorders, there is no support for academic assistance and psychotherapy to enhance academic achievement or emotional adjustment. Significant short-term improvements were maintained over 2 years.

Affect↗

PubMed2004

Multimodality therapy for thymic carcinoma (TCA): results of a 30-year single-institution experience.

SUMMARY: The aim of this study was to correlate the clinicopathologic features and therapeutic approaches with the outcome of patients with thymic carcinoma (TCA), an aggressive, uncommon malignancy of the anterior mediastinum. TCA is morphologically distinct from thymoma, a cytologically bland, often encapsulated, locally invasive, rarely metastatic tumor. The Roswell Park Cancer Institute tumor registry was used to identify patients with TCA or invasive thymic neoplasm of the epithelial type (TNET). Between 1971 and 2001, 22 patients had a pathologic diagnosis of TCA and/or TNET. The mean age at diagnosis was 53 years (range: 19-77), and the male/female ratio was 3:1 (16/6). Initial symptoms were respiratory in about half the patients (10/22). Complete surgical resection was done in five patients. Postoperative cisplatin-based chemotherapy and radiation was administered to seven patients. Pathologic examination showed low grade(n = 14), intermediate grade (n = 7), and high grade (n = 1) TCA. Capsular invasion was present in 83% of the specimens. As of June 2002, nine patients are alive and eight are disease free. The median survival is 44.7 months. Locally invasive disease precluded complete surgical resection in more than half of our cases. Incomplete surgical resection did not preclude long-term survival if multimodality platinum-based therapy was used.

Adult↗

PubMed2003

Long-term results of multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome.

PURPOSE: Chronic prostatitis/chronic pelvic pain syndrome is a prevalent and multifactorial condition. Many patients have the condition for years despite conventional therapies. We assess the outcomes of multimodal therapy in patients with long-standing chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: A total of 53 patients with chronic prostatitis treated at our clinic with a minimum followup of 6 months were assessed by the National Institutes of Health-Chronic Prostatitis Symptom Index and by a global assessment score. Treatments included antibiotics, prostatic massage, anti-inflammatory phytotherapy, alpha-blockers and neuromuscular agents. RESULTS: Mean age patient was 45 years and median symptom history was 3.5 years. Based on localizing cultures, and microscopy of urine and prostatic fluid 13% of the cases were category II, 41% were category IIIa and 46% were category IIIb. Mean followup from the last visit was 417 days (range 185 to 1,247). Mean changes +/- SE from the initial to the final score on the National Institutes of Health-Chronic Prostatitis Symptom Index were 10.4 +/- 3.3 to 5.9 +/- 4.4 for pain, 4.2 +/- 2.9 to 2.0 +/- 2.7 for urinary, 8.2 +/- 2.9 to 4.7 +/- 3.4 for quality of life and 22.7 +/- 6.6 to 13.2 +/- 9.5 for total score (p <0.0001). Based on a global subjective assessment 43 of the patients (80%) were better, 8 were the same and 3 were worse. At final assessment 39% of the patients were on no therapy, 22% were on an alpha-blocker, 37% were on quercetin, 13% were on neuromuscular agents and 9% were on antibiotics. CONCLUSIONS: An approach using stepwise therapy with antibiotics, anti-inflammatories and neuromuscular agents can be successful in the majority of patients with long-standing chronic prostatitis.

Adult↗

PubMed2004

Multimodal treatment of children with unresectable or recurrent desmoid tumors: an 11-year longitudinal observational study.

The primary goal of treatment for desmoid tumors is complete surgical resection to achieve negative margins. In adults with unresectable or recurrent lesions, treatment options include noncytotoxic and cytotoxic drugs, but little is known about nonsurgical treatment in children. Between 1992 and 2003 six children (four girls, two boys) with a median age of 2.5 years (range 11 months to 9 years) received multimodal adjuvant therapy for unresectable or recurrent desmoid tumors. Primary treatment consisted of noncytotoxic treatment with tamoxifen (1 mg/kg orally, twice daily) and diclofenac (2 mg/kg rectally, twice daily), whereas two children with life-threatening tumor progression in addition received treatment intensification with weekly vinblastine (6 mg/m intravenously) and methotrexate (30 mg/m intravenously). Of the four children with unresectable tumors, two achieved remarkable tumor shrinkage and two had stable disease, whereas two patients were disease-free for 3.7 and 2.6 years after nonradical resection. Median observation time was 3.1 years (range 1-11 years). Treatment was generally well tolerated; only one patient developed pubertal acceleration after a duration of tamoxifen treatment of 9.3 years. Because of the potential life-threatening situation, the management of children with unresectable or recurrent desmoid tumors requires a multidisciplinary approach. Nonaggressive therapy with tamoxifen and diclofenac may be the first treatment choice in these patients, but in patients with progressive disease, cytotoxic chemotherapy is indicated. Weekly administration of vinblastine and methotrexate seems to be safe and effective in these children.

Antineoplastic Combined Chemotherapy Protocols↗