Role of strengthening during nonoperative treatment of lateral epicondyle tendinopathy

IntroductionLateral epicondyle tendinopathy (LET) is the most common cause of lateral elbow pain. The literature on rehabilitation of the condition encompasses a plethora of interventions with most current evidence indicating that stretches and some form of strengthening are vital components. However, patient outcomes are infrequently reported further than 12 weeks from the start of therapy and it is unclear which components of a home exercise program are necessary to alleviate symptoms up to one year from the initiation of a therapy program.Purpose of the StudyThe purpose of the study is to determine if a therapy program with 4 to 6 visits spaced out over 12 weeks focusing on self-management and strengthening is more effective in reducing pain and improving function long term than the same program without strengthening, for individuals with LET.Study DesignThis is a randomized controlled trial.MethodsNinety-four patients were randomly allocated into two groups: both groups received the interventions of education in pertinent pathoanatomy, stretching, pain management through rest and icing, and activity modification. Group 1 (n = 38) was also provided with a strengthening component to the home exercise program, whereas group 2 did not (n = 21). Our primary outcome measure was pain at rest and pain with activity; our secondary measure was the level of functional impairment as measured by the quick disabilities of arm shoulder and hand. Outcome measurements were assessed at baseline, 6, 12, 24, and 52 weeks after initiation of therapy.ResultsBoth groups demonstrated statistically significant improvement with a moderate to large effect size in pain and function scores when compared with previous time point at 6, 12, and 24 weeks. Pain continued to decrease for both groups from 24 weeks to 52 weeks, but interestingly, there was a significant increase with moderate effect size in the quick disabilities of arm shoulder and hand score at 52 weeks when compared with week 24. No statistically significant difference was found between the two groups at any time point up to 52 weeks from the start of therapy.ConclusionsThis study demonstrates that a therapy program consisting of a low number of visits spaced out over 12 weeks based on education, stretches, activity modification, and pain management techniques is effective at reducing pain and increasing function in patients with LET. The addition of strengthening to this program did not improve outcomes. The therapy approach used in this study is consistent with the International Classification of Function guidelines and focuses on engaging patients in self-management of the condition through patient education and self-empowerment.     

Cost-effectiveness of postmastectomy hypofractionated radiation therapy vs conventional fractionated radiation therapy for high-risk breast cancer

BackgroundThe phase 3 NCT00793962 trial demonstrated that postmastectomy hypofractionated radiation therapy (HFRT) was noninferior to conventional fractionated radiation therapy (CFRT) in patients with high-risk breast cancer. This study assessed the cost-effectiveness of postmastectomy HFRT vs CFRT based on the NCT00793962 trial.MethodsA Markov model was adopted to synthesize the medical costs and health benefits of patients with high-risk breast cancer based on data from the NCT00793962 trial. Main outcomes were discounted lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). We employed a time-dependent horizon from Chinese, French and USA payer perspectives. Model robustness was evaluated with one-way and probabilistic sensitivity analyses.ResultsPatients receiving CFRT versus HFRT gained an incremental 0.0163 QALYs, 0.0118 QALYs and 0.0028 QALYs; meanwhile an incremental cost of $2351.92, $4978.34 and $8812.70 from Chinese, French and USA payer perspectives, respectively. Thus CFRT versus HFRT yielded an ICER of $144,281.47, $420,636.10 and $3,187,955.76 per QALY from Chinese, French and USA payer perspectives, respectively. HFRT could maintain a trend of >50% probabilities of cost-effectiveness below a willingness-to-pay (WTP) of $178,882.00 in China, while HFRT was dominant relative to CFRT, regardless of the WTP values in France and the USA. Sensitivity analyses indicated that the ICERs were most sensitive to the parameters of overall survival after radiotherapy.ConclusionsPostmastectomy HFRT could be used as a cost-effective substitute for CFRT in patients with high-risk breast cancer and should be considered in appropriately selected patients.     

The role of CDK4/6 inhibitors in early breast cancer

The use of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) has proven to be a successful strategy in the treatment of advanced hormone receptor-positive (HR⁺) and human epidermal growth factor receptor 2-negative (HER2^-) breast cancer (BC), leading to a strong interest in their possible role in the treatment of early luminal BC. In this review we collect the most relevant and recent information on the use of CDK4/6i for the treatment of early BC in the neoadjuvant and adjuvant settings. Specifically, we evaluate the results of the large phase 3 adjuvant trials recently released, which have yielded apparently divergent results. We also examine the relevance of biomarkers as response predictive factors for CDI4/6i, the combination between radiotherapy and CDK4/6i, and provide a critical discussion on the evidence that we have so far and future directions of the role of these drugs in the treatment of early BC.     

The effect of postmastectomy radiation therapy on high-risk patients with T1-2N0 breast cancer

BackgroundThe prognostic impact of postmastectomy radiation therapy (PMRT) on high-risk patients with T1-2N0 breast cancer is controversial. We aimed to investigate the effect of PMRT on high-risk patients with T1-2N0 breast cancer.MethodsA total of 3439 patients diagnosed with T1-2N0 breast cancer who received mastectomy between 2000 and 2016 in our institute were retrospectively analyzed. Leveraging the Fine and Gray competing risks regression in unirradiated patients, risk factors of locoregional recurrence (LRR) were identified. All patients were stratified into high-risk (3 or 4 risk factors) and low-risk (no more than 2 risk factors) groups. The prognostic effect of PMRT was estimated in two subgroups. This subgroup analysis was also performed in patients with T2N0 breast cancer.ResultsThe median follow-up was 89 months. The 5-year cumulative incidence of LRR was 2.2% in unirradiated patients. Tumor size, estrogen receptor (ER) status, histologic grade and lymphovascular invasion (LVI) were identified as independent risk factors of LRR. In the high-risk group, PMRT was correlated with a 8.3% risk reduction of 5-year LRR, 7.8% risk reduction of 5-year distant recurrence (DR), and 6.4% risk reduction of 5-year breast cancer mortality (BCM), whereas it was not correlated with LRR, DR, or BCM in low-risk group. In patients with T2N0 breast cancer, PMRT was associated with decreased LRR, DR and BCM in high-risk group, other than low-risk group.ConclusionsPMRT presented heterogenous effect on patients with T1-2N0 breast cancer. Patients at high risk of LRR were more likely to benefit from PMRT.     

Change in granulation tissue coverage and bacteriological load using Low Cost Negative Pressure Wound Therapy in acute musculoskeletal wounds

BackgroundLow cost Negative Pressure Wound Therapy (NPWT) dressings have been considered as an alternative to traditional daily dressings. There is scanty literature evaluating the change in the percentage area of wound covered by granulation tissue following application of low-cost NPWT. The change in the bacteriological flora following application of low-cost NPWT devices has also not been evaluated.MethodsPatients above the age of 18 years with acute musculoskeletal injuries of <3 weeks duration which underwent a surgical debridement and required subsequent wound coverage were included in the study. Area of the wound and the area covered by the granulation tissue as well as the bacteriological count were measured before and after application of NPWT. A low cost NPWT using wall mounted vacuum device was put on the patient giving a constant negative pressure of 125 mm of Hg for 2 days. The findings before and after application of NPWT were compared and analyzed using Wilcoxin Signed-rank test.Results21 patients with mean age of 35.52±15.075 were included. The pre-NPWT granulation tissue area ranged from 122 mm² to 8483 mm² with a mean of 1648.38 mm² (SD = 1933.866). The post-NPWT granulation tissue area ranged from 234 mm² to 7847 mm² with a mean of 2364.48 mm² (SD = 1857.716). The mean increase in granulation tissue was 716.1 mm².The pre-NPWT wound area ranged from 422 mm² to 10847 mm² with a mean of 4009.62 mm² (SD = 3026.209). The post-NPWT wound area ranged from 326 mm² to 9143 mm² with a mean of 3410.33 mm² (SD = 2636.206). The mean reduction in wound size was 599.29 mm².The pre-NPWT bacteriological count ranged from 3000/ml to 130000000/ml with a mean of 12616761.90/ml (SD = 29664589.37). The post-NPWT bacteriological count ranged from 1000/ml to 380000000/ml with a mean of 26401523.81/ml. The mean increase in bacteriological count was 13784761.91/ml.ConclusionThere was a statistically significant decrease in wound size (p = 0.001) and statistically significant increase in percentage area of granulation tissue coverage (p = 0.000) following low cost NPWT application. However there was no statistically significant increase in bacteriological clearance in these patients.     

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1. This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.     

中医外治法在慢性萎缩性胃炎中的应用研究进展

慢性萎缩性胃炎（CAG）是消化系统常见的慢性疾病,被认为是胃癌癌前病变,严重危害人类健康。如何有效促进胃黏膜的修复、抑制腺体的萎缩、阻断癌变是临床研究的热点。目前西医尚缺乏特效的治疗手段,近年来,大量研究结果表明,中医外治法在治疗CAG方面取得了显著成果,且具有简、便、效、廉等优势,深受患者青睐。现查阅近年来包括针刺法、灸法及贴敷法等在内的常用中医外治法治疗CAG的相关文献并进行综述,以期为临床治疗该病提供参考。