Tratamiento actual de la membrana neovascular miópica / Updated treatment of myopic neovascular membrane

Una de las causas frecuentes de perdida de agudeza visual en la miopía degenerativa es la membrana neovascular coroidea (1-3). Actualmente el único tratamiento aprobado para esta patología es la terapia fotodinámica. La terapia fotodinámica ha demostrado en algunos estudios estabilización de la Agudeza Visual en comparación con grupo placebo (4-6). Actualmente con la aparición de los fármacos anti- factor de crecimiento del endotelio vascular (anti- VEFG) se ha abierto una nueva opción de tratamiento en estos pacientes, se ha visto en pequeñas series de casos que estos fármacos logran no solo estabilización de la agudeza visual sino también mejoría de esta (7-11-12-25). Bevacizumab (Avastin) es uno de estos fármacos sin embargo no esta autorizado para uso intaocular, en cambio Ranibizumab (Lucentis) si esta autorizado para uso intraocular pero fuera de indicación para esta patología. En estudios randomizados, doble ciego a demostrado su eficacia en uso intravitreo para el tratamiento de membranas neovasculares, demostrando mejores resultados que la terapia fotodinamica y consiguiendo mejoras en la agudeza visual en pacientes con degeneración macular asociado a la edad (7-9). Realizamos una revisión bibliográfica para encontrar las diferentes opciones terapéuticas que podemos ofrecer a estos pacientes (AU)

One of the common causes of visual loss in degenerative myopia is the choroidal neovascular membrane (1-3). Currently the only approved treatment for this disease is photodynamic therapy. Photodynamic therapy has been shown in some studies stabilization of visual acuity compared with placebo (4-6). Currently with the appearance of anti-vascular endothelial growth factor (anti-VEGF) has opened a new treatment option for these patients, seen in small series of cases that these drugs not only maintain visual acuity but also they improved (7-11-12- 25). Bevacizumab (Avastin) is not yet approved for use intaocular, instead Ranibizumab (Lucentis) is approved for intraocular use but offlabel for this condition. Randomised, double blind studies proved effective in intravitreal use for the treatment of any type of neovascular membrane, showing better results than photodynamic therapy and achieving improvements in visual acuity in patients with macular degeneration associated with age (7-9). We review the literature to find the options of treatement that we can offer to these patients (AU)

Population-based study of biochemical and survival outcomes after permanent 125I brachytherapy for low- and intermediate-risk prostate cancer.

OBJECTIVES: To analyze the biochemical and survival outcomes after permanent low-dose-rate prostate brachytherapy in a large, consecutive, population-based cohort of patients. METHODS: A total of 1006 consecutive implants were performed from July 20, 1998 to October 23, 2003 for men with low-risk and "low-tier" intermediate-risk prostate cancer. The prescribed minimal peripheral dose was 144 Gy, using 0.33 mCi (125)I sources and a preplan technique with a strong posterior-peripheral dose bias. Most patients (65%) had received 6 months of androgen deprivation therapy. Supplemental external beam radiotherapy was not used. The prognostic features, dose metrics, and follow-up data were prospectively collected. Kaplan-Meier and Cox regression analyses were used to assess the factors associated with freedom from biochemical recurrence and survival. RESULTS: The median patient age at treatment was 66 years. The median follow-up was 54 months for biochemical outcomes and 66 months for survival. The actuarial freedom from biochemical recurrence rate was 95.6% +/- 1.6% at 5 years and 94.0% +/- 2.2% at 7 years. On multivariate analysis, the pretreatment prostate-specific antigen level (P = .03) and androgen deprivation therapy use (P = .04) were predictive of the freedom from biochemical recurrence. The actuarial rates of distant metastasis and disease-specific death at 5 years were both <1%. The overall survival rate at 5 years was 95.2% +/- 1.4% and was 93.4% +/- 1.8% at 7 years. On multivariate analysis, only age was predictive of overall survival (P = .011). CONCLUSIONS: When consistently planned and delivered, low-dose-rate brachytherapy, without supplemental external beam radiotherapy or intraoperative planning, can produce cancer-specific outcomes for men with low- and "low-tier" intermediate-risk prostate cancer at least equal to that produced by dose-escalated external beam radiotherapy or surgical prostatectomy.

Methadone in the management of intractable neuropathic noncancer pain.

OBJECTIVE: To evaluate the role of methadone in the management of intractable neuropathic noncancer pain. METHODS: A case series of 50 consecutive noncancer pain patients who were seen at a tertiary care centre and treated with oral methadone for a variety of intractable neuropathic pain states. RESULTS: The mean age was 52.7 years and the mean duration of follow-up was 13.9 months. Post-discectomy nerve root fibrosis, complex regional pain syndrome, peripheral neuropathy and central spinal cord pain syndromes were the most common diagnoses. Over 90% had been treated with one or more tricyclic antidepressants and anticonvulsants and a similar number had received other adjuvant analgesics. All patients had failed treatment with one or more conventional opioid analgesics (mean 2.8) at a mean maximal morphine dose of 384 mg (or equivalents) per day. Twelve patients had failed spinal cord stimulation. Nineteen patients (38%) did not tolerate initial methadone titration or thought their pain was worse on methadone. Five patients (10%) declared initial benefit but required repetitive dose escalation and eventually became non-responders. Twenty-six patients (52%) reported mild (4), moderate (15), marked (6) or complete (1) pain relief and continued on methadone at a mean maintenance dose of 159.8 mg/day for a mean duration of 21.3 months. Fourteen patients (28%) reported improved function on methadone relative to previous treatments. CONCLUSIONS: Methadone appears to have unique properties including N-methyl-D-aspartate antagonist activity that may make it especially useful in the management of intractable neuropathic pain. This observation needs to be tested in randomized, controlled trials.

Impact of the application of neurolinguistic programming to mothers of children enrolled in a day care center of a shantytown.

CONTEXT: Of the members of a family, the mother is without doubt the most important one, which provides justification for including an evaluation of her mental health as one of the variables to be considered as determining factors in each child's level of development. OBJECTIVE: To assess the impact of the application of Neurolinguistic Programming (NLP) on child development, home environment and maternal mental health. DESIGN: Randomised controlled trial. SETTING: The study included children enrolled in the municipal day care center of a shantytown in the City of São Paulo. PARTICIPANTS: 45 pairs of mothers and respective children between 18 and 36 months of age. MAIN MEASUREMENTS: Children's development (Bayley scales); home environment variation (HOME); and maternal mental health (SRQ). Comparison between before and after the intervention was made in terms of children's psychomotor development, home environment and maternal mental health. INTERVENTION: Application of the NLP technique to the experimental group and comparison with a control group. 1--Experimental (EG), consisting of 23 children submitted to intervention by NLP; and 2--Control (CG), with 22 children with no intervention. Length of intervention: 15 sessions of NLP. RESULTS: 37 children remained in the study (EG = 10, CG = 27). Variations in mental development (OR 1.21, IC 95% 0.0 to 23.08) in their home environment (Wilcoxon): p = 0.96 (before) and p = 0.09 (after); in maternal mental health: p = 0.26, 2 df. CONCLUSIONS: There was a trend that indicated positive effects on the home environment from the intervention.