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PubMed2004

Multimodal treatment of hepatocellular carcinoma (HCC).

Screening of patients at risk for hepatocellular carcinomas (HCC) and preventive virustatic therapy are the first steps in a multimodal treatment concept, because delayed detection leads to a poor prognosis with median survival of <10 months. Surgical resection of HCC is still the treatment of choice in patients with good residual liver function, however, recurrence-free 5-year survival after curative resection is low (33%). In patients with cirrhosis, only 25% of HCC are resectable, limited by low hepatic functional reserve. HCC in patients with non-cirrhotic livers are the domain of extended resections. In newer reports, transplantation in patients with cirrhosis is rated more positively when restricted to patients with solitary nodules <5 cm or up to 3 tumors <3 cm. A new option in HCC therapy are the local methods for tumor ablation, preferably radiofrequency ablation (RFA), especially in patients with limited liver function, non-resectable or multifocal tumors. A new horizon is opened combining these options and multimodal approaches with transarterial chemoembolisation (TACE). This trend to multimodal approaches promises a yet unknown improvement in the prognosis of patients with HCC. Controlled randomized studies comparing and validating the different methods and defining combined treatments according to liver function and tumor stage are eagerly awaited.

Antineoplastic Agents↗
PubMed2001

Multimodal online monitoring in middle cerebral artery territory stroke.

BACKGROUND AND PURPOSE: Patients with large middle cerebral artery infarction and elevated intracranial pressure (ICP) who are undergoing invasive intensive care therapy require technical monitoring. However, the effectiveness of the current gold standard, measurement of ICP, is limited. Furthermore, the effects of what is considered to be standard antiedema medical treatment are not fully understood. We studied whether multimodal monitoring can help to overcome this problem. METHODS: ICP, cerebral perfusion pressure (CPP), and partial brain tissue oxygen pressure (PbrO(2)) were continuously measured within the white matter of the frontal lobe unilaterally or bilaterally. We analyzed the effects of antiedema drugs and looked for pattern changes in the PbrO(2) before transtentorial herniation in patients in whom this could not be prevented. Furthermore, complications were registered. RESULTS: We performed 27 measurements in 21 patients. A total of 297 antiedema drug administrations were analyzed in 11 patients. Hyper-HAES and mannitol were most often associated with an increase in CPP and PbrO(2), whereas the use of thiopental and tromethamine led to negative or contrary effects, although ICP was decreased in every case. Pattern changes in the PbrO(2) curve could be observed between 6 to 18 hours before transtentorial herniation. No bleeding complication or infections were observed. CONCLUSIONS: Multimodal monitoring can be used to monitor antiedema drug effects. Our data suggest that with multimodal monitoring, pathophysiological changes could be predicted considerably in advance. ICP alone is of questionable use. Furthermore, this method might help to optimize the timing of invasive therapy in space-occupying infarction.

Brain Edema↗
PubMed2004

Multimodal treatment for ADHD among youths in three Medicaid subgroups: disabled, foster care, and low income.

OBJECTIVE: This study compared the use of treatments for attention-deficit hyperactivity disorder (ADHD) among three distinct subpopulations of Medicaid-insured youths who have very different mental health needs and patterns of service use: those with federally documented disability, those in foster care, and those in families with low income. METHODS: This one-year, cross-sectional study of community mental health services used administrative data. Individuals who were younger than 20 years, who were continuously enrolled in one Mid-Atlantic state Medicaid program, and who had two or more medical encounters associated with an ADHD diagnosis in 1998 were identified (N=1,296). Measures of the use of mental health services were the number of different classes of psychopharmacologic medications, the psychopharmacologic regimen, and the combined use of pharmacotherapy and psychotherapy treatments (multimodal treatment). RESULTS: Use of multiple psychopharmacologic agents was greater in the disabled and foster care groups compared with the low-income group. Significantly fewer mental health provider visits, but greater use of stimulant treatment only, were observed in the low-income group compared with the other groups. Youths in the disabled group were significantly more likely than youths in the low-income group, but not more likely than youths in the foster care group, to receive multimodal treatments. Children in foster care were significantly more likely than those in the other groups to use a substance abuse service. CONCLUSIONS: Among a cohort of Medicaid-enrolled youths with ADHD, co-existing psychiatric disorders and complex psychopharmacologic treatments were more common in the disabled and foster care groups than in the low-income group. Youths with disabilities were significantly more likely than youths in the low-income group to receive multimodal treatment.

Adolescent↗
PubMed1993

Aims and methodological problems in multimodal treatment studies.

The paper outlines the growing acceptance and use of multimodal treatment approaches to treat a variety of psychiatric disorders in childhood and adolescence. It then explores some of the problems of multimodal treatment studies. Problems in assessing outcome of efficacy of the interventions, particularly as they pertain to specific interventions and particular areas of functioning are discussed as well as the issues of appropriate control and comparison groups. The problems with regard to appropriate control and comparison groups are explored with respect to diagnosis and interventions. Finally, an ongoing multimodal treatment study of children with attention deficit hyperactive disorder is used to illustrate how some of the problems described can be solved.

Adolescent↗
PubMed1992

Ten-year outcome of patients with advanced epithelial ovarian carcinoma treated with cisplatin-based multimodality therapy.

PURPOSE: At the end of the 1970s it was thought that advanced epithelial ovarian cancer (EOC) could be cured by multimodality treatment using surgery, cisplatin-based combination chemotherapy, and radiotherapy (RT). Such multimodality treatment was used as standard therapy at our institution. Our long-term results are reviewed. PATIENTS AND METHODS: One hundred ninety-five previously untreated patients with stage III or IV EOC were treated between April 1979 and December 1982. All patients were to have debulking surgery, when feasible, followed by the administration of doxorubicin and cisplatin at 50 mg/m2 every 3 weeks until a total dose of doxorubicin of 450 mg/m2 had been reached. RT was used in addition in patients with disease remaining after the chemotherapy. Maintenance chemotherapy with oral cyclophosphamide and hexamethylmelamine (altretamine) was administered to patients who did not have a documented histologic complete remission. RESULTS: The 10-year overall and failure-free survivals were 4% and 8%, respectively. The median overall survival was 2 years. The achievement of a histologic complete response (n = 32) did not equate to cure because 20 (63%) of the patients eventually relapsed. Multivariate analysis identified residual disease of greater or less than 2 cm as the only independent prognostic factor. CONCLUSIONS: Our multimodality treatment program was noncurative for the majority of the patients. Innovative therapies are needed before we can hope to cure such disease.

Adult↗
PubMed1993

Stage III neuroblastoma over 1 year of age at diagnosis: improved survival with intensive multimodality therapy including multiple alkylating agents.

PURPOSE: A nonrandomized, single-arm trial was conducted to assess the efficacy of multimodality therapy including intensive chemotherapy with multiple alkylating agents in the treatment of children with Evans stage III neuroblastoma older than 1 year at diagnosis. PATIENTS AND METHODS: Twenty-five patients with a median age of 18 months at diagnosis were treated with multimodality therapy including surgery and chemotherapy using either nitrogen mustard (mechlorethamine), doxorubicin, cisplatin, dacarbazine (DTIC), vincristine, and cyclophosphamide (MADDOC) or cisplatin and cyclophosphamide induction followed by maintenance MADDOC (induction MADDOC) protocols. Sixteen of 25 patients also received radiotherapy to the tumor bed and primary lymph nodes. Event-free survival (EFS) was compared with that reported previously in the literature. N-myc amplification was evaluated prospectively and the Shimada classification was evaluated retrospectively as potential prognostic factors. RESULTS: We report a 72% EFS (95% confidence interval +/- 18%) with a median follow-up of 85 months. EFS was significantly worse for patients with tumors demonstrating N-myc amplification (P = .018). Patients classified as favorable according to the Shimada system experienced a significantly better EFS (P = .04), but unfavorable patients still maintained a 60% EFS. CONCLUSION: Intensive multimodality treatment including MADDOC and induction MADDOC chemotherapy provides a very good EFS for children older than 1 year who have stage III neuroblastoma. Children classified as favorable according to the Shimada system have a better prognosis. Patients whose tumors demonstrate N-myc amplification have a poor prognosis despite therapy.

Alkylating Agents↗
PubMed1998

High-dose multimodality therapy with autologous stem-cell support for stage IIIB breast carcinoma.

PURPOSE: Women with locally unresectable and inflammatory breast carcinoma (IBC) have an approximately 30% 5-year disease-free survival (DFS) rate with conventional multimodality therapy. A short but dose-intensive multimodality phase II trial was designed in an attempt to improve outcome in stage IIIB disease. Mastectomy was performed after high-dose therapy to evaluate pathologic response to treatment. METHODS: Women with newly diagnosed disease received four 2-week cycles of doxorubicin 90 mg/m2 with granulocyte colony-stimulating factor (G-CSF), followed by cyclophosphamide 6,000 mg/m2, thiotepa 500 mg/m2, and carboplatin 800 mg/m2 (CTCb) with marrow and peripheral-blood progenitor cell (PBPC) support. Local therapy consisted of mastectomy and radiotherapy. Tamoxifen (5 years) was begun if the patient was estrogen receptor-positive (ER+). RESULTS: Fifty women (46 stage IIIB [91% IBC], four stage IIIA) entered the study and 47 are assessable. Ten had mastectomy before any systemic therapy (seven with pathologic IBC, three with residual tumor after mastectomy). Eighty percent received full-dose doxorubicin with 60% on schedule. Clinical response rates to induction were 15% complete response (CR), 5% very good partial response (VGPR), 59% partial response (PR), and 21% minor response (MR)/stable disease (SD). Mastectomy after CTCb in 37 patients showed a 14% pathologic CR rate, 29% microscopic foci in breast and/or axilla, and 57% gross tumor. Fifteen (32%) patients have relapsed (median, 17 months post-CTCb). The 30-month DFS is estimated at 64%. For those in pathologic CR, with microscopic, or with gross disease remaining after CTCb, the 30-month DFS is estimated at 100%, 70%, and 38%, respectively. Those with zero, one to three, or > or = four positive nodes at axillary dissection had a median DFS of 31, 18, and 13 months, respectively. CONCLUSION: This short but dose-intensive multimodality approach for stage IIIB breast carcinoma is feasible with encouraging results to date.

Adult↗
PubMed2003

Multimodality treatment of giant intracranial arteriovenous malformations.

OBJECTIVE: Giant arteriovenous malformations (AVMs) (i.e., those greater than 6 cm at maximum diameter) are difficult to treat and often carry higher treatment morbidity and mortality rates than do smaller AVMs. In this study, we reviewed the treatment, angiographic results, and clinical outcomes in 53 patients with giant AVMs who were treated at Stanford between 1987 and 2001. METHODS: The patients selected included 20 males (38%) and 33 females (62%). Their presenting symptoms were hemorrhage (n = 20; 38%), seizures (n = 18; 34%), headaches (n = 8; 15%), and progressive neurological deficits (n = 7; 13%). One patient was in Spetzler-Martin Grade III, 9 were in Spetzler-Martin Grade IV, and 43 were in Spetzler-Martin Grade V. The mean AVM size was 6.8 cm (range, 6-15 cm). AVM venous drainage was superficial (n = 7), deep (n = 20), or both (n = 26). At presentation, 31 patients (58%) were graded in excellent neurological condition, 17 were graded good (32%), and 5 were graded poor (9%). RESULTS: The patients were treated with surgery (n = 27; 51%), embolization (n = 52; 98%), and/or radiosurgery (n = 47; 89%). Most patients received multimodality treatment with embolization followed by surgery (n = 5), embolization followed by radiosurgery (n = 23), or embolization, radiosurgery, and surgery (n = 23). Nineteen patients (36%) were completely cured of their giant AVMs, 90% obliteration was achieved in 4 patients (8%), less than 90% obliteration was achieved in 29 patients (55%) who had residual AVMs even after multimodality therapy, and 1 patient was lost to follow-up. Of the 33 patients who either completed treatment or were alive more than 3 years after undergoing their most recent radiosurgery, 19 patients (58%) were cured of their AVMs. The long-term treatment-related morbidity rate was 15%. The clinical results after mean follow-up of 37 months were 27 excellent (51%), 15 good (28%), 3 poor (6%), and 8 dead (15%). CONCLUSION: The results in this series of patients with giant AVMs, which represents the largest series reported to date, suggest that selected symptomatic patients with giant AVMs can be treated successfully with good outcomes and acceptable risk. Multimodality treatment is usually necessary to achieve AVM obliteration.

Adolescent↗
PubMed2002

Optimal design method of a low-loss broadband Y branch with a multimode waveguide section.

An optimal design method for a low broadband silica-on-silicon Y branc is considered. A multimode waveguide section, which was used earlier to reduce the excess loss, is designed optimally when the light distribution at the end of the multimode waveguide section is matched to the profile of the symmetric supermode for the structure of the two branching waveguides. An optimization method that combines the genetic algorithm and a gradient-based search method is used to obtain the optimal geometrical parameters for the multimode waveguide section as well as the widths for the input and branching waveguides.

Journal Article↗
PubMed2003

Micro-optical 1 x 4 fiber switch for multimode fibers with 600-microm core diameters.

The design, manufacture, and test of a 1 x 4 micro-optical fiber switch for multimode fibers with 600-microm core diameters are described. Microlens array telescopes allow for variable and fast beam deflection when the positions of the cylindrical microlens arrays relative to each another are altered by specially designed piezomechanical actuators. Standard achromats are used for collimation of light emitted by the input multimode fiber and for focusing of the deflected light onto a linear array of output multimode fibers. Design and assembly of micro-optical as well as of optomechanical components are discussed. Insertion loss and cross talk are measured, and the results are compared with those of numerical optical simulations. Measurements of switching time and long-term stability, as well as of thermal behavior, are also presented.

Journal Article↗
PubMed2004

Finite-element modal analysis of large-core multimode optical fibers.

Plastic optical fibers that are a typical large-core multimode optical fiber support a great number of modes compared with conventional silica-glass multimode optical fibers. So far the WKB method hasbeen used for most of the modal analyses of these fibers because of a great number of guided modes. We describe the accurate eigenmodal analysis of large-core multimode optical fibers with the finite-element method (FEM) and compute the propagation constants of all LP modes. In addition, the FEM has a strong advantage for arbitrary core profiles whereas the WKB method is not suitable fornonmonotonic profiles. To demonstrate the advantage, we apply the FEM to the fiber having sinusoidal fluctuations.

Journal Article↗
PubMed2004

Experimental study of bent multimode optical waveguides.

Bend losses of bent multimode waveguides have been experimentally studied. The results experimentally verify a simple analytical expression based on ray optics that can be used to determine bend losses in bent multimode waveguides. We have also shown that bend-induced losses in such multimode optical waveguides are wavelength independent.

Journal Article↗
PubMed2003

Mode-order converter in a multimode waveguide.

A novel device that converts the order of modes in an integrated-optic multimode waveguide was proposed and fabricated. The device consists of two mode splitters and tapered waveguides. Its operation at a wavelength of 1.55 microm was confirmed by observation of the output mode profiles. The cross talk measured by an indirect method was >10.2 dB. The excess loss with reference to a straight multimode waveguide was 1.5 dB, compared with the propagation loss of a straight multimode waveguide.

Journal Article↗
PubMed2004

Remote multiplexing of holograms with random patterns from multimode fiber bundles.

We propose the remote multiplexing of holograms with random patterns from a multimode fiber bundle used as the reference beams. The random pattern reference beam is characterized by the superposition and concatenation of propagation modes of multimode fiber and free space. For angle, shift, and wavelength remote multiplexing we compare two methods of laser coupling to the fiber bundle, i.e., direct coupling and lens coupling. A theoretical discussion that uses mode orthogonality is provided to describe multiplexing characteristics, and the theory is verified by experimental results. These remote-multiplexing methods can be applied to general multimode waveguide arrays for construction of compact and integrated optical systems in which multiplexing can be controlled remotely.

Journal Article↗
PubMed2004

Diffraction-limited polarized emission from a multimode ytterbium fiber amplifier after a nonlinear beam converter.

The multimode and depolarized output beam of a highly multimode diode-pumped Yb-doped fiber amplifier is converted to a diffraction-limited, linearly polarized beam by a self-referencing two-wave-mixing process in an infrared-sensitive photorefractive crystal (Rh:BaTiO3). As much as 11.6 W of single-mode output is achieved with a 78% multimode-to-single-mode photorefractive conversion efficiency.

Journal Article↗
PubMed2004

All propagation modes of large-core multimode optical fibers with an arbitrary core profile.

Plastic optical fibers are typical large-core multimode optical fibers. High-bandwidth graded-index plastic optical fibers, which support a great number of propagation modes compared with conventional silica-glass multimode optical fibers, were developed in the 1990s. However, because they support a great number of propagation modes, their modal analyses have been limited to the WKB analysis. We obtain all the propagation modes of a convex-index large-core multimode optical fiber by use of the finite-element method, which has a strong advantage for arbitrary core profiles.

Journal Article↗
PubMed2005

Fano resonances in prism-coupled multimode square micropillar resonators.

We report Fano resonances in a multimode square glass micropillar resonator; the resonances were obtained by using angle-resolved prism coupling. Our experiments reveal characteristically asymmetric line shapes of high-Q resonances and of detuned low-Q resonances in multimode reflection spectra. The asymmetric resonance line shapes evolve for an approximately pi phase within a 0.5 degree range of reflection angles. We model our observed asymmetric multimode resonances by the far-field interference between a light wave that is evanescently coupled with a high-Q mode orbit and a coherent light wave that is refractively coupled with a detuned low-Q mode orbit.

Journal Article↗
PubMed2006

Beam cleanup in a self-aligned gradient-index Brillouin cavity for high-power multimode fiber amplifiers.

We propose a beam cleanup setup to convert a multimode beam into a single-mode beam by use of the Brillouin effect in a multimode gradient-index (GI) fiber. Phase conjugation and beam cleanup regimes in highly multimode fibers are discussed, and the self-aligned GI fiber Brillouin cavity is presented. We report a preliminary conversion from an M2=6.5 beam into an M2=1.3 beam with 31% efficiency.

Journal Article↗