Iontophoresis: an alternative in the treatment of dental caries?

Celiac sprue (CS) is frequently complicated by malignancy, most commonly small intestinal lymphoma. Our study was performed in an area with a high prevalence of CS to define the clinical features, response to treatment, and outcome of this tumor. Of a total of 31 lymphomas complicating CS identified, 30 case records and 24 tumor specimens were reviewed. Overall 1-year survival was 9 of 29 (31%) and 5-year survival 3 of 27 (11%). Seven previously diagnosed celiac patients developed lymphoma; length on gluten-free diet ranged from 12 to 252 months (median 44 months). In this group, presentation was nonspecific, diagnosis difficult, and survival poor (lymphoma diagnosed in life in four of seven, mean survival 2.25 months). Twenty-three patients had CS and lymphoma diagnosed during the same illness. In this group, 14 of 23 presented with a surgical emergency and were treated with tumor resection and chemotherapy. Nine are disease-free and alive or died of another cause after 10-196 months (mean 74 follow-up). Celiac-associated lymphoma is a frequent, difficult to diagnose, and commonly fatal complication of CS. An aggressive diagnostic approach, including laparoscopy, is recommended. Long-term survival can be expected in a significant number of these patients and in our series was almost exclusively confined to those treated with chemotherapy.     

Social dominance and Darwinian fitness in laboratory mice: an alternative test

An 8 week old infant with severe heart failure from type 1 truncus arteriosus underwent successful corrective surgery employing the Rastelli procedure with use of deep hypothermia and total circulatory arrest. Postoperative hemodynamic studies showed complete closure of the septal defect, disappearance of truncal stenosis, but presence of mild porcine valve stenosis. This procedure is possible even in very small subjects and is preferable to palliative pulmonary arterial banding.     

Laser welding of fascial grafts and its potential application in tympanoplasty: an animal model

This study evaluates the welding effect of argon laser on fascial grafts and its potential application in tympanoplasty. An animal model was designed so that surgically induced perforations of the lumbar fascia of the animals were grafted in an underlay fashion. Each graft was "spot welded" around the circumference of the perforation using a hand-held argon laser. Various lasing parameters were used on different grafts. Control perforations were grafted but not welded. A total of 96 perforations was studied. Weld sites were evaluated both histologically and by tensile strength measurement at the end of surgery, and at 7, 14, and 21 days postoperatively. Comparison with controls showed a higher tensile strength for welded grafts, which was most significant in the early postoperative period (p < 0.001). Histologically, it seems that the basic mechanism of fascial welding involves liquification and denaturation of extravasated proteins at the weld sites. Correlation between the extent of thermal damage on the tissues and the various lasing parameters is described. Based on the well-documented safety of argon laser in otologic surgery, and the successful welding of fascial grafts in this study, argon laser may prove beneficial in welding temporalis fascia grafts in tympanoplasty.     

The dystrophinopathies: an alternative to the structural hypothesis

Two studies with college students were conducted to further explore the reliability and construct validity of fear of emotion, as assessed by the Affective Control Scale (ACS), a measure of fear of anxiety, depressed mood, anger, and strong positive emotion. The ACS fared well in tests of internal consistency and of convergent and divergent validity. In an analogue study of panic onset with college students with no history of panic, the predictive and incremental validity of the ACS was demonstrated: the ACS predicted students' fear of induced panic-like bodily sensations even once trait and state anxiety were statistically controlled. A second aspect of the investigation was an analogue test of the hypothesis that stress from interpersonal conflict (induced via remembrance of conflictual interactions with an important person) would moderate the ACS's effects on anxiety and fear of induced bodily sensations. This hypothesis was not confirmed.     

Hemispherical deafferentation: an alternative to functional hemispherectomy

An alternative technique for so-called functional hemispherectomy has been developed to be used for the classical indications of hemispherectomy or the various modifications of functional hemispherectomy. The technique entails a smaller trepanation, less operation time, and less blood loss, and it leaves more brain tissue in place as compared with other functional hemispherectomy techniques. It starts with either hippocampectomy alone or with hippocampectomy and anterior temporal lobectomy. After this, deafferentation of the white matter of the temporal, occipital, parietal, and frontal lobe, using either a transcortical transventricular approach along the outline of the lateral ventricle or a sylvian key hole approach, is performed. The technique includes a transventricular callosotomy, and it leaves in place only a small portion of the suprainsular cortex and the insular cortex. However, as one modification, removal of the insular cortex can easily be performed, if necessary, and, as a second modification, the entire transventricular deafferentation can be performed through a sylvian key hole. In this report, the technique is described and the surgical experience for the first 13 patients is outlined. The immediate seizure relief with an average follow-up of 12 months was similar to that for patients with functional hemispherectomy, but the follow-up period for these 13 patients is not long enough to allow definite conclusions concerning long-term control of seizures and long-term complications.     

Midpalmar approach to the carpal tunnel: an alternative to endoscopic release

OBJECTIVE: To determine whether hysteroscopic adhesiolysis improves reproductive outcome in women with Asherman's syndrome and pregnancy failure. SUBJECTS: Ninety consecutive women who had undergone hysteroscopic adhesiolysis of intrauterine adhesions during a 5-year period. Only women in whom at least two previous pregnancies had ended with either a spontaneous abortion or a premature delivery accompanied by fetal or neonatal mortality and a hysteroscopic diagnosis of intrauterine adhesions were enrolled. RESULTS: Whereas pregnancy outcome prior to the operation was 18.3% term deliveries, 3.3% premature deliveries, 62.4% first-trimester abortions, and 16.0% late abortions, after hysteroscopic adhesiolysis pregnancy outcome was 68.6% term deliveries, 9.3% premature deliveries, 17.4% first-trimester abortions, and 4.7% late abortions. In women with two previous unsuccessful pregnancies, the operative success rate measured by delivering a healthy newborn improved from 18.3% preoperatively to 64% postoperatively. In women with three or more unsuccessful pregnancies the success rate improved from 18.3% to 75%. Successful outcome of adhesiolysis was observed in 61.9% of mild (stage I) and in 70.6% of moderate to severe cases (stages II and III) of intrauterine adhesions. CONCLUSION: Hysteroscopic adhesiolysis in women with Asherman's syndrome and poor reproductive performance contributes significantly to a successful reproductive outcome.     

Outpatient group psychotherapy for the elderly: an alternative to institutionalization

Two case studies illustrate the positive effects of group psychotherapy for elderly outpatients of a municipal hospital in an industrial community of Baltimore. Most of the outpatients were depressed about physical, mental, or social losses. A total of five brief therapy groups were established. Each group had a maximum of 12 members and met in the hospital for an hour and a half once a week for 12 consecutive weeks. Members could continue in subsequent 12-week sessions if they desired. As a result of their participation in groups, many members became involved in volunteer or part-time work, renewed contact with family and friends, and were better able to deal with life's stresses.     

Hysteroscopic resection of the endometrium: an alternative to hysterectomy?

A study carried out on 342 cases of endometrial resection, with a follow up of 3 to 36 months, has allowed us to precise: 1. The indications of this technique: patients more than 40 years, suffering of abnormal uterine bleeding. 2. The endometrial ablation was performed by electrosurgery through an operating channel of the hysteroscopic sheet (9 mm) and with a glycocol distended media (1.5%). The mean time to complete the operation was 35 +/- 10 minutes, the mean length of the hospital stay was 1 day. We had no serious complications. 3. And the rate of success (amenorrhea or hypomenorrhea) was 95% at 3 months but decreased at 90% at 36 months. The rate of secondary hysterectomy was 10%, due to the associated lesions: myoma with adenomyosis in 50% of the cases. There was some evidence of superior health related quality of life among hysterectomy patients. It's the reason why it is necessary to make a serious selection of the patients who are to be treated by this method in order to avoid complications and secondary hysterectomy.     

Best evidence synthesis: an intelligent alternative to meta-analysis

Research review has long been one of the most important scholarly activities in all branches of science. While there is sometimes a single study so well-designed, well carried out, and difficult to replicate that its findings are accepted as conclusive, more often there are many studies on a given topic, no one of which clearly supersedes the others. These studies may be done by different investigators using different methods or different populations. They may arrive at different conclusions. When this is the case, there is a need for reviewers to carefully consider the evidence and to put forth conclusions or hypotheses about where the weight of the evidence lies.     

Sentinel lymphadenectomy: an alternative to axillary lymphadenectomy in breast carcinoma

BACKGROUND: Axillary lymph node status is an important determinant of prognosis in breast cancer. However, lymphadenectomy does not benefit half of the patients in whom axillary nodes are free of disease. Sentinel lymph node biopsy is a new technique which allows accurate staging of breast carcinoma without performing total axillary dissection. We describe our experience with the introduction of sentinel lymphadenectomy. METHODS: Thirty-seven sentinel lymphadenectomies were performed in 35 patients referred to the Department of Obstetrics and Gynaecology of the University of Berne between December 1997 and June 1998. Mapping procedures were performed using a combination of vital blue dye with preoperative lymphscintigraphy with 99mTechnetium-labelled colloidal albumin and intraoperative use of a gamma probe. Complete axillary lymphadenectomy was then performed in 34 patients. RESULTS: One or more lymph nodes were identified in 33 of 37 procedures (89%). With the combination of both localisation techniques the sentinel nodes were identified in all (100%) of the last 19 patients. Sentinel and non-sentinel lymph nodes were always concordant. In this series the negative predictive value is 100% (95% confidence interval: 87.7%-100%). Metastases were found in the sentinel node in 11 of 30 patients (37%). From these 11 patients, 3 (27%) had micrometastases. CONCLUSIONS: Histopathologic examination of the sentinel lymph node accurately predicts the axillary lymph-node status. Patients with sentinel nodes free of metastases could avoid the unnecessary peri- and postoperative complications of complete axillary dissection. Further studies are needed to assess whether the improved diagnosis of micrometastases by sentinel lymphadenectomy influences the long-term prognosis of breast cancer.     

Colposacropexy: an alternative technique

Colposacropexy procedures restore anatomically correct apical vaginal support on the levator plate at the ischial spine level. Venous hemorrhage resulting from laceration of presacral veins during suture fixation is the major hazard of this procedure. Titanium orthopedic bone anchor fixation minimizes this risk through precision placement of the bone anchor-suture unit.     

Pegaspargase: an alternative?

OBJECTIVE: To review the chemistry, pharmacology, pharmacokinetics, clinical activity, adverse effects, dosage, and administration guidelines for pegaspargase. DATA SOURCES: A MEDLINE search (1980-1996), a CANCERLIT search (1983-1996), and a CURRENT CONTENTS search (1980-1996) using the terms pegaspargase, PEG-asparaginase, PEG-L-asparaginase, polyethylene glycol L-asparaginase, polyethylene glycol conjugated L-asparaginase, and Oncaspar were conducted. STUDY SELECTION AND DATA EXTRACTION: All articles were considered for possible inclusion in this review. Abstracts were included only when they were judged to add critical information not otherwise available in the medical literature. DATA SYNTHESIS: L-Asparaginase has been a main component of treatment regimens for acute lymphocytic leukemia. A key limiting factor of L-asparaginase use has been the development of hypersensitivity to the drug. Recently, a polyethylene glycol (PEG) conjugated form of L-asparaginase, pegaspargase, has been made available. PEG modification of L-asparaginase has been shown to alter the tendency of the enzyme to induce an immune response and to extend the half-life of the drug. The majority of patients with hypersensitivity to the native enzyme preparations tolerate pegaspargase without further clinical hypersensitivity. The adverse effect profile of pegaspargase is similar to that of the native forms of L-asparaginase. The recommended dosage of pegaspargase is 2500 IU/m2 administered by intramuscular or intravenous injection every 2 weeks in combination with other chemotherapeutic agents. CONCLUSIONS: Pegaspargase is a safe, effective alternative to L-asparaginase in patients who have had clinical hypersensitivity reactions to both Escherichia coli- and Erwinia carotovora-derived L-asparaginase. However, pegaspargase should not be routinely substituted for L-asparaginase.