Wednesday, June 29, 2016

Platelet Rich Plasma Compared to Dry Needling

I have recently seen many young athletes with patellar tendonitis, or jumper's knee.  This type of injury is commonly seen in basketball players, soccer players, or other athletes that do a lot of jumping in their sports.  A common treatment for this injury typically involves physical therapy to strengthen the quads and sometimes rest.  Most of my athletes are not big fans of resting, and prefer some other form of treatment that will serve to return them to play more quickly.



After my last patient complained about wanting to be ready for basketball tryouts at school sooner, I decided to do some further research to see what might help him heal more quickly.  I found a good article on dry needling versus platelet rich plasma for treatment of patellar tendinopathy.

I chose this particular article, as it evaluated pain, activity levels, quality of life, and function.  All of these components are going to help an athlete get back to their sport sooner.  I then put in each variable, separately, into the Treatment Scores Calculator and the STAR™ Blocks.  As you can see below, dry needling actually is rated higher than PRP.



The above scores are based on a combination of the primary and the secondary statistics.  In both the dry needling and in the PRP groups, the patients improved with treatment.  Neither group had significant side effects from the treatment.  The reason the dry needling group ended up with a higher score is that the net treatment benefit was greater with dry needling.  Meaning, the people who underwent dry needling had less pain and improved function as compared to the PRP group.  As you can see, however, neither treatment had a complete resolution of symptoms.  

Treatment Scores enable us to quantify the net treatment benefit of different therapies for a variety of conditions.  Through this new, innovative technology, we will be able to compare the quality of treatments for any condition.


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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Thursday, June 23, 2016

Treatment Scores Tutorial 6: Creating the Calculator (Spina Bifida)

There are several steps to creating a Treatment Score. First, you need to create a diagnosis. Second, you need to create a treatment list. Third, you need to create a Treatment Score Calculator™ for each treatment. Three previous tutorials can be found here:


The Treatment Score Calculator™ is the "heart and soul" of science-based medicine, evidence-based medicine, shared decision-making, and informed consent.

At first, some people cannot think outside the box enough to understand the Treatment Score Calculator™. Most people can only understand the same old thing they have done for years and years. What people have done in the past is write essays instead of digesting a treatment down to its “net treatment benefit” = the Treatment Score.

You are diagnosed with deadly cancer. You are given a list of Western medical treatments that you can undergo such as: surgery, chemotherapy, radiation, cryotherapy, and immune therapy. You also discover a bunch of alternative medical treatments from the Internet. What would you rather have, a list of all these treatments with their Treatment Scores, or 500 medical studies and Internet articles to read? With Treatment Scores you will understand all the treatments within seconds. Doing things the old way could take you months to years. You could be dead before you actually understand the treatment options!

INCOME AS AN EXAMPLE
The concept of the “net treatment benefit for the patient,” which we call the “Treatment Score,” is so new to many people I have been explaining it in terms of gross income and net income.

When you’re trying to figure out your financial health, first you figure out your gross income, and then you figure out your net income.

Imagine a greatly oversimplified situation like this:

Gross Income Expenses
$100,000 $10,000 medical
$10,000 education
$10,000 insurance
$10,000 taxes
$10,000 maintenance

Net Income
$50,000

First you figure out your gross income, and then you subtract all your expenses to get your net income. That’s how you figure out your financial health. Figuring out the Treatment Score is very similar. First, you figure out the gross treatment benefit and then you figure out the net treatment benefit. In other words, we want to get from the “gross treatment benefit” down to the “net treatment benefit,” which equals the Treatment Score.


SCALES
What confuses people are the many different scales for the gross treatment benefit, and the fact that you can have “side effects” from treatments that are negative, but you can also have “side benefits” from treatments that are positive.

How do you determine the scale for the “gross treatment benefit?” The scale you start with is the outcome that is most important to the patient! The scale could be “overall survival” if we are dealing with cancer. The scale could be “resolution of symptoms” if we are dealing with the common cold, pneumonia, autism, incontinence, or some other diagnosis. This is an area of empowerment for patients. Patients need to be involved in setting the scale for the gross treatment benefit. Patients are often astonished to learn that the “outcome scales” used in medical papers are not the “scales” that are important to them!

NET TREATMENT BENEFIT = TREATMENT SCORE
Farther down in this essay I am going to use the scale of “resolution of urinary incontinence.” But before I get to that, I want to point out to you the problem we have in healthcare with figuring out the “net treatment benefit.” Here is the general formula for figuring out the net treatment benefit:


  • net treatment benefit = gross treatment benefit - side effects + side benefits


Remember, how this is similar to your financial health:


  • net income = gross income – expenses


MANY DIFFERENT CURRENCIES
So what’s the big problem? The big problem is that while your gross income is in dollars, and all your expenses are in dollars, it’s not nearly so simple for the net treatment benefit. The gross treatment benefit is in one currency (dollars), all the side effects are in other currencies, and all the side benefits are in other currencies. This means that we are going to need conversion factors to figure out the net treatment benefit. Let’s redo our formula for the net treatment benefit using common currencies such as the US dollar, European euro, and British pound.



  • Net treatment benefit (US dollars) = gross treatment benefit (US dollars) – side effects (European euros) + side benefits (British pounds)



You can see that the net treatment benefit has become complicated. We want our outcome in US dollars. However, we must also work with European euros and British pounds.

It’s even more complicated than that. When dealing with the net treatment benefit we want in US dollars, we actually have to deal with an unlimited number of different currencies. All the negative side effects and positive side benefits of treatments are in different currencies. We essentially have to deal with an infinite number of currencies when calculating the net treatment benefit (although for any one diagnosis there is a limited number of side effects and side benefits, so it can be done)!

REAL-LIFE EXAMPLE
I recently reviewed a treatment for urinary incontinence in patients suffering from spina bifida. I wanted to figure out the net treatment benefit for an operation that has come to be called the Xiao procedure, named after the physician who invented it.

To figure out the Treatment Score, which is the net treatment benefit, I needed to collect several statistics. The main statistic I was interested in was urinary incontinence. This main outcome measure can also be thought of as the gross treatment benefit. This statistic goes in the top left of the Treatment Score Calculator™. Interestingly, I discovered that patients who underwent the Xiao procedure were no better off than those who did not when it came to the main outcome measure. They were 0% better.

Next, on the right I collected statistics for the positive side benefits, and I collected statistics for the negative side effects. The green bar indicates positive items and the red bar indicates negative items.


When I figured out that the main statistic was 0%, I thought perhaps I was done. For the purposes of demonstrating the concept of Treatment Scores, I thought perhaps a Treatment Score = 0 was good enough. But the Xiao procedure kept bothering me. If you really took the time to add up every positive side benefit and negative side effect would the Xiao procedure Treatment Score continue to be zero?

TRANSPARENCY
It’s time to better explain the statistics in the Treatment Score Calculator™. These statistics are pulled from the medical literature. When you click on the statistics, within the programming itself, it takes you to another page where it is completely transparent where the statistics come from and how they are compiled. This kind of transparency that we are providing for Treatment Scores is essential for science-based medicine. The statistics that go in the Treatment Score Calculator™ are the “hardest” numbers that we can obtain. Eventually, the entire process of obtaining the numbers will be transparent, peer-reviewed, and as objective as possible. They will also be continuously reviewed by software algorithms.

REDOING THE NUMBERS
When I reviewed the numbers this time, I decided that I was going to have to use a another feature of the Treatment Score Calculator™, which allows us to decide how certain we are of the numbers based on the quality of the studies.

POSITIVE SIDE BENEFITS
This time I was laser focused on fecal incontinence. If even 1% of the patients became continent of their feces, that would be a major life improvement. I had issues with the numbers because the software was rounding numbers up or down, instead of being as precise as I wanted it to be. This is something we can fix down the line. But also the numbers within the studies were somewhat subject to interpretation and uncertainty. So I emailed authors of two of the studies. This turned out to be a great help (and I thank them).

Doing this quality review caused me to revise many of the numbers. The Treatment Score calculator now looks like this:




POSITIVE SIDE BENEFITS
Notice that all the potential positive side benefits have been reduced to zero. It turns out that the quality of the studies that suggested these positive side benefits were present is very low. This reduced my statistical certainty of these positive side benefits to zero. That takes care of the positive side benefits, and now we need to move on to the negative side effects.

NEGATIVE SIDE EFFECTS
Next, I did the same thing when reviewing the numbers for the potential negative side effects. Many of these numbers dropped to zero because the quality of the studies done was so low that their statistical certainty rounded to zero. One negative side effect, “bed rest x 3.5 days required” was dropped completely, because it was from an uncontrolled study, and detethering surgery with or without the Xiao procedure requires bed rest afterwards.

Two negative side effects remained: 100% of the time the total operation time increased when the Xiao procedure was added to the detethering operation, in fact, the Xiao procedure added about 90 more minutes of operating time. And, in 50% of the patients who got the Xiao procedure, there was a wound infection.

CONVERSION FACTORS
The two negative side effects on the right need to be subtracted from the scale of “incontinence of urine resolved” on the left.

But everything on the right has to be weighted. Where do we get the conversion factors we need? Sometimes they exist in the medical literature. Sometimes, they exist as “quality adjusted life years” or “disability adjusted life years.” Sometimes you can find a “disability weight” for a side effect. However, the overwhelming majority of the conversion factors we need do not exist. I would hazard a guess that 99.9% of the conversion factors we need do not exist. This means that most of the time we have to figure them out as mathematically and logically as we can ourselves. We also have to make our conversion factors transparent so that others can critique them and improve upon them. This becomes part of shared decision-making with the patient.

In this situation, the Xiao procedure adds an average of 90 minutes of operating time to the overall operation. This is a negative, but how much of a negative in the overall scheme of things? This negative is very near to zero. If the operation worked and incontinence was restored for a lifetime, that 90 minutes would not be very important. That 90 minutes would literally be a tiny blip out of the next 10, 20, or 30 years.

Even in this situation, where the operation did not work, that 90 minutes does not change the outcome very much over the course of a lifetime either. It’s basically 90 minutes lost from the patient’s entire lifespan. Although, it is important to note that patients with spina bifida have a decreased average lifespan than patients without spina bifida.

We still have to convert the 50% event rate of wound infection in the Xiao procedure patients as a negative onto the main scale of resolution of urinary incontinence. We need to subtract it from the Treatment Score of zero, which is where we now stand.

According to the study from which the 50% rate of wound infection comes, the patients required oral antibiotics only, and no patients required a surgical revision of the wound. If incontinence were restored to the patients this would be a relatively small price to pay. In the setting of incontinence not being restored in the patients, the wound infections are more troubling, but they are a short term negative, not a long term negative unless there are permanent complications from the antibiotics.

The typical course of oral antibiotics is seven days, 10 days, or 14 days. I looked at the medical literature on wound infections after appendectomies, wound infections after hip surgeries, and in other situations focusing on quality adjusted life years and disability adjusted life years to try to gain perspective.

I did find one hard number to use in my calculations. The disability weight for urinary incontinence is 0.142 according to a World Health Organization paper.
(http://www.who.int/healthinfo/statistics/GlobalDALYmethods_2000_2011.pdf)

I could not however find the disability weight for a postoperative wound infection. I wrote the World Health Organization to see if they could give me a disability weight for a post-operative would infection that requires only oral antibiotics for resolution. (I did not hear back from WHO as of this writing.)

In the meantime, I developed a disability weight myself. After reading many of the World Health Organization documents, I decided that the disability weight for postoperative wound infection that resolves with oral antibiotics is low and close to zero when compared to the scale of “resolution of incontinence” for the rest of one’s life. This negative side effect now rounds to zero.

The bottom line is that the Treatment Score for the Xiao procedure = 0.

To be extremely precise with the estimation, the Treatment Score for the Xiao procedure = -0.001.

That’s a negative 0.001.

TREATMENT GRADES
The Treatment Score being negative is important. The Treatment Score scale goes from 0% to 100%. We use a didecile (20 points) to establish each Treatment Grade like this:


  • Grade A = 81 to 100%
  • Great B = 61 to 80%
  • Great C = 41 to 60%
  • Grade D = 21 to 40%
  • Grade E = 1 to 20%
  • Grade 0 = 0%
  • Grade F = any Treatment Score that is negative.


For the Xiao procedure, the Treatment Grade goes from Treatment Grade = 0 to treatment grade = F. Obviously in medicine we want all Grade A treatments. We don’t want any Grade 0 or Grade F treatments.

In reality, the world is full of grade C, grade D, and grade E treatments. The lower grades of treatments make up the vast majority of all treatments in use today.

TREATMENT SCORES ARE IN THEIR INFANCY
Treatment Scores are in their infancy. The concept is just beginning to gain traction. Like most things in medicine, they may take a long time to catch on in less you help. Treatment Scores will also keep getting better and better over time as we move into the future. You can lead the healthcare revolution. You can lead the movement for treatment transparency. All you have to do is ask, “What’s the Treatment Score for that?”

SNAKE OIL
Recently a prominent physician: James Madera, MD, suggested in an article that most of the modern healthcare digital products and medical devices are nothing more than “snake oil.”
(Source: James Madara, MD, as quoted in “AMA CEO calls digital products modern-day ‘snake oil’” By Greg Slabodkin. Health data management. June 13 2016. Accessed June 20, 2016.)

I share Dr. Madera’s frustration. Ask yourself, what has big data done for you? What has health information technology done for you?

Treatment Scores are the exception to the snake oil. Treatment Scores can use big data and health information technology to help everyone around the world right now. Treatment Scores are the treatment transparency product that everyone around the world needs.

The reason is simple; everyone needs treatment transparency. Your health and your life are at stake. We have problems with over-treatment, under-treatment, mistreatment, and lack of transparency. Treatment Scores are the tool that can actually deliver personalized medicine, science-based medicine, evidence-based medicine, shared decision-making, and informed consent.

NONPROFIT HEALTH ORGANIZATIONS
Recently I called a breast-cancer nonprofit, because someone I know is suffering from highly aggressive metastatic breast cancer. I talked to their patient advocate/counselor and got absolutely nowhere. The person I talked to had no idea about the science of medicine behind the available treatment options. I could not blame this person whatsoever. Studies show that doctors don’t understand medical treatments. Therefore, how can nonprofit organizations understand medical treatments? We have to change this!

Nonprofits are in a very difficult situation. Usually, they are financially strapped. Often they know the research that needs to be done, but they cannot raise enough money to do research themselves.

However, there is something nonprofit organizations can do right now. Nonprofit organizations that are advocating for a disease can do Treatment Scores at TreatmentScores.com with their medical advisory board. The Treatment Scores can be published in a transparent way, so that everyone in the world can peer review the Treatment Scores. This will be educational and highly informative. We can make sure that the science is as objective and unbiased as possible.

For any diagnosis, there are a limited number of high-quality studies. Within those high-quality studies there are a limited number of important statistics. Nonprofit organizations can now collect this information at TreatmentScores.com, and can make this information transparent to all their patients.

The world is about to change for the better. Treatment Scores are coming. Treatment transparency is a train that cannot be stopped. The good that a small disease-related non-profit organization can do is about to increase dramatically.

It will soon become the duty of every nonprofit healthcare organization to create diagnoses, to create treatment lists, and to create Treatment Scores for each and every treatment.

Nonprofits can do the most important thing for their patients; they can provide treatment transparency.

CONCLUSION
By using Treatment Scores, personalized medicine, treatment transparency, shared decision-making, science-based medicine, peer review, evidence-based medicine, and informed consent can all work together for the benefit of patients everywhere.

SOURCES and URLs:
Source of the Randomized Controlled Trial:
Tuite GF, Polsky EG, Homsy Y, Reilly MA, Carey CM, Parrish Winesett S, Rodriguez LF, Storrs BB, Gaskill SJ, Tetreault LL, Martinez DG,Amankwah EK. “Lack of efficacy of an intradural somatic-to-autonomic nerve anastomosis (Xiao procedure) for bladder control in children with myelomeningocele and lipomyelomeningocele: results of a prospective, randomized, double-blind study.” J Neurosurg Pediatr. 2016 May 3:1-14.
http://www.ncbi.nlm.nih.gov/pubmed/27137626
DOI: 10.3171/2015.10.PEDS15271

Additional Sources:
Xiao CG1, Du MX, Li B, Liu Z, Chen M, Chen ZH, Cheng P, Xue XN, Shapiro E, Lepor H. "An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida." J Urol. 2005 Jun;173(6):2112-6.
http://www.ncbi.nlm.nih.gov/pubmed/15879861

“Response: Some lessons learned from negative results of a randomized controlled trial for bladder reinnervation with the Xiao procedure.” Tuite GF, Polsky EG, Homsy Y, Reilly MA, Carey CM, Parrish Winesett S, Rodriguez LF, Storrs BB, Gaskill SJ, Tetreault LL, Martinez DG, Amankwah EK. J Neurosurg Pediatr. 2016 May 3:1-2.
http://www.ncbi.nlm.nih.gov/pubmed/27137925

[An electrophysiological study on the artificial somato-autonomic pathway for inducing voiding]. Liu Z, Liu CJ, Hu XW, Du MX, Xiao CG. Zhonghua Yi Xue Za Zhi. 2005 May 25;85(19):1315-8.
http://www.ncbi.nlm.nih.gov/pubmed/16029629

“Electrophysiological monitoring and identification of neural roots during somatic-autonomic reflex pathway procedure for neurogenic bladder.” Dai CF1, Xiao CG. Chin J Traumatol. 2005 Apr;8(2):74-6. http://www.ncbi.nlm.nih.gov/pubmed/15769303

“An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients.” Xiao CG1, Du MX, Dai C, Li B, Nitti VW, de Groat WC. J Urol. 2003 Oct;170(4 Pt 1):1237-41.
http://www.ncbi.nlm.nih.gov/pubmed/14501733

"Skin-CNS-bladder" reflex pathway for micturition after spinal cord injury and its underlying mechanisms. Xiao CG1, de Groat WC, Godec CJ, Dai C, Xiao Q. J Urol. 1999 Sep;162(3 Pt 1):936-42. http://www.ncbi.nlm.nih.gov/pubmed/10458412

“Xiao Procedure for Neurogenic Bladder in Spinal Cord Injury and Spina Bifida.” Neurogenic Bladder (F Daneshgari, Section Editor). Chuan-Guo Xiao. Current Bladder Dysfunction Reports. June 2012, Volume 7, Issue 2, pp 83-87. First online: 01 April 2012.
http://link.springer.com/article/10.1007%2Fs11884-012-0130-2

“US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience.” Kenneth M. Peters, Holly Gilmer, Kevin Feber, Benjamin J. Girdler, William Nantau, Gary Trock, Kim A. Killinger, and Judith A. Boura1. Advances in Urology. Volume 2014 (2014). Article ID 863209, 7 pages.
http://www.hindawi.com/journals/au/2014/863209/

“Outcomes of lumbar to sacral nerve rerouting for spina bifida.” Peters KM, Girdler B, Turzewski C, Trock G, Feber K, Nantau W, Bush B, Gonzalez J, Kass E, de Benito J, Diokno A. J Urol. 2010 Aug;184(2):702-7. doi: 10.1016/j.juro.2010.03.058. Epub 2010 Jun 19.
http://www.ncbi.nlm.nih.gov/pubmed/20639040

“The artificial somato-autonomic reflex arch does not improve lower urinary tract function in patients with spinal cord lesions.” Rasmussen MM, Rawashdeh YF, Clemmensen D, Tankisi H, Fuglsang-Frederiksen A, Krogh K, Christensen P. J Urol. 2015 Feb;193(2):598-604.
http://www.ncbi.nlm.nih.gov/pubmed/25158270

“Double-blinded randomized controlled trial of the Xiao procedure in children.”
http://www.eurekalert.org/pub_releases/2016-05/jonp-drc042716.php

“Double-blinded randomized controlled trial of the Xiao procedure in children.”
www.sciencedaily.com/releases/2016/05/160503072231.htm

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Website:
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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Wednesday, June 15, 2016

Treatment Scores Tutorial 4: Creating a List of Treatments

After you have created a diagnosis at TreatmentScores.com, you need to create a list of treatments for that diagnosis. We are continuing our tutorial on how to create a Treatment Score. Remember, the Treatment Score equals the net benefit for the patient. Why don’t you already know the Treatment Score for every treatment? What’s wrong with our medical system that it never tells us the net treatment benefit for the patient?


You have already created a diagnosis at TreatmentScores.com and you have clicked on the blue “Tx” button on the left side of your diagnosis as seen here:


You are taken to the Treatment Organizer™. At first glance the Treatment Organizer™ looks complicated, however it is actually simple. The diagnosis is on the left and the area you will be working on to create a treatment list is in the middle:



If you focus on the middle area of the graphic above it looks like this:

All you have to do is put your cursor in the box where it says “New Treatment” and enter in some treatments you want to review. For example, I want to look at: ginger powder, sumatriptan, and botulinum toxin type A as treatments for a “migraine headache, acute.” After I enter the treatments into the box my treatment list looks like this:


Note that “No Treatment” is always at the top of the list and “Clinical Trials” are always at the bottom of the list. The reason “No Treatment” is at the top of the list is, because in some situations, you need to explore the baseline where the patient does not get any treatment at all. This becomes especially important when there are no randomized placebo-controlled trials. Most of the time, at least in the beginning, you will not deal with the “No Treatment” issue. The reason “Clinical Trials” are always at the end of every treatment list is that if you have something deadly, like a deadly cancer, and there are no good treatments, you will need to investigate clinical trials, which have experimental treatments. There are other situations, perhaps not deadly situations, where there are no effective treatments. That's another reason to look at "Clinical Trials."

After you have put at least one treatment into your treatment list, you will move on to the Treatment Score Calculator™, by clicking the icon to the right that says “Calculator.”

The “Calculator” button is will take you to the Treatment Score Calculator™ for that treatment. Eventually, you will create a Treatment Score Calculator™ for each and every treatment. The Treatment Score Calculator™ is the heart and soul of science based medicine, evidence-based medicine, and shared decision-making.

Another tutorial will follow that explains how to use the Treatment Score Calculator™.  There are actually 57 treatments that you can add to your treatment list for a “migraine headache, acute.”

The goal is to get each and every treatment in your treatment list, and to create a Treatment Score for each and every treatment. This means that you will look at the science behind Western medical treatments, Eastern medical treatments, herbal medicines, and all other forms of alternative medicine. All the data from all the medical literature needs to be captured in one place.

Why haven’t you known about Treatment Scores before? Haven’t you always needed to know the net treatment benefit? The Treatment Score puts big data and health information technology to work for you! It's about time!

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Follow this blog by entering your email address in the box at the top right. You MUST CONFIRM your subscription VIA EMAIL. Then, you will automatically receive all new posts. If you have any problems, search for "feedburner" to make sure the confirmation email did not go into your spam folder.

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https://Facebook.com/TreatmentScores
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Blog:
http://TreatmentScoresBlog.com
Website:
http://TreatmentScores.com

DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Tuesday, June 14, 2016

Treatment Scores Tutorial 3: Creating the Diagnosis

Start with the diagnosis! When reviewing the medical literature and doing Journal Club about treatments we begin with the diagnosis. Especially, when producing Treatment Scores we always start with the diagnosis.

First, you go to http://TreatmentScores.com and register. You will receive a registration email (you might have to check your spam folder). Once your registration is complete you can login and see your dashboard.

At the top right of your dashboard will be the icon “Add Diagnosis,” which you want to click on to add your first diagnosis.


This will bring up a page for you to fill out about your diagnosis. Because we want “personalized medicine” you can put in up to 10 categories for your diagnosis. Start with the most general diagnosis, and then add in more specific terms as you go.


For example, you might want to start with the diagnosis “incontinence.” However, there are two kinds of incontinence, urinary and fecal. A person can be incontinent of urine or incontinent of feces. So put incontinence in the 1st cell, and put urinary in the 2nd cell.


In addition, I want to look at incontinence of urine associated with spina bifida. This means that my diagnosis is going to look like this: “incontinence, urinary, spina bifida.” In the graphic below I have used those three terms for my diagnosis.



That takes care of the top half of the diagnosis form. Now we need to look at the bottom half. The bottom half consists of the following items: the follow-up time period, a description of the patients, the main statistic, and the author or authors.




For “incontinence of urine associated with spina bifida,” I want to look at a follow-up time period of three years. The reason I am looking at three years is that there are several medical studies have a duration of three years. If there were a body of literature that went out to 5 years or 10 years, I could use those time periods as the follow-up. One of the big things you learn when doing Treatment Scores, is how shockingly short the follow-up time period is for many treatments that may affect someone’s life forever.

The patients I am interested in are children. So, I enter “children” in that cell.

The outcome I am interested in is “resolution of urinary incontinence.”



When you create a diagnosis, the “main statistic,” or main outcome measure, is the most important entry. The main statistic you’re most interested in is the main statistic that is “most important to the patient.” Patients come first. The main statistic also needs to be the hardest statistic possible. The reason I chose the “resolution of urinary incontinence” as my main outcome measure is because it is a “hard” outcome measure. Either the patient is incontinent of urine and is wearing diapers or pull-ups, or the patient is dry and is not wearing any diapers or pull-ups. It is a very clear-cut outcome measure.

The left half of your diagnosis looks like this:


The right half of your diagnosis looks like this:


To summarize the 6 things we have done to create a diagnosis:

  1. Create a general diagnosis
  2. Create a more specific diagnosis by adding up to 10 items
  3. Enter the follow-up time period
  4. Enter a description of the patients
  5. Enter the main statistic (main outcome measure)
  6. Enter the name of the author or authors

The next step will be to create a list of treatments. To go to the next page on the website, the Treatment Organizer™ page, you will click on the blue icon that says “Tx” which is an abbreviation for treatment.


Another tutorial follows which will explain how to use the Treatment Organizer™ page.

Remember, you are dealing with two websites. This website is the Treatment Scores Blog at:
http://TreatmentScoresBlog.com

The tools for creating Treatment Scores are at:
http://Treatment Scores.com

We are creating Treatment Scores at TreatmentScores.com and then we are blogging about them at TreatmentScoresBlog.com. Eventually, we will combine the two websites into one.

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Saturday, June 11, 2016

Treatment Scores Tutorial 2: The Big Picture

The Treatment Score = the net benefit of the treatment. We need to expand upon our comparison of Treatment Scores being like gross income and net income and add some details. When you do your taxes, you figure out your gross income and net income. Before you undergo a medical treatment, you need to figure out your “gross treatment benefit” and “net treatment benefit.”

Why is this such a big deal? It’s a big deal, because doctors have never provided the “net treatment benefit” before. You may have to demand Treatment Scores!

In fact, in perfect world, physicians would provide you with the “net absolute treatment benefit for the patient as determined by the doctor and you, the patient, working together doing personalized medicine and shared decision-making.” That’s too much to say, so we use the simple phrase, Treatment Score. Let’s start creating that perfect world.

Here is the longer formula:
The Treatment Score = gross treatment benefit + side benefits – side effects.

Treatment Scores have been a secret, a mystery, unable to be calculated, and almost systematically hidden from you until now.

Why don’t you already know Treatment Scores? It’s because the organization of the data is difficult. One diagnosis may have 10 treatments. Each of those treatments may have 10 vital statistics. Each of those statistics may come from 10 different references. Each of those references may have 10 different variables. All of a sudden, you have 10×10×10×10 = 10,000 pieces of information! Some situations have 100,000 pieces of information.

Thankfully, the entire process can be made easy with technology. We simply put a graphical user interface over it. It’s like the early days of the computer. Back in the early days only those who could do machine language could use a computer. Then, Xerox, Apple, and Windows put a graphical user interface over the computer, and suddenly everyone could use one. That’s what we have done for science-based medicine, evidence-based medicine, and medical treatments; we have put a simple graphical user interface over all the organization of information and calculations.

You may be aware of some big problems in medicine: over-treatment, under-treatment, harmful treatment, and lack of treatment transparency. Treatment Scores help to fix all of these things.

Treatment Scores are a revolution, because the very idea of treatment transparency is a revolution. Basically, everyone has always assumed quantified treatment transparency in healthcare was impossible, because it has been too difficult for most people to even comprehend.

When you get sick with a disease, you need to review the medical literature for a list of treatments for that disease. In general, the more treatments that exist for a disease, the less effective the treatments are. For example, there are 130 treatments for insomnia, because most of the treatments for insomnia don’t work very well. There are 57 treatments for an acute migraine headache, because most treatments for an acute migraine headache don’t work very well. There are only a few treatments for stage I testicular cancer, because those treatments do work well in terms of increasing overall survival.

Once you get diagnosed with a disease, any disease, for each and every treatment for that disease, you need to figure out the “gross treatment benefit” for patients that have been treated in the past. Then, you need to figure out the “net treatment benefit” for those same patients that have been treated in the past, which is the Treatment Score.

For example, I just read a medical paper. The diagnosis was migraine headache. The focus was on migraine headache prevention. The treatment was “botulinum toxin A” injected into the outer surface of the skull. Let’s summarize this:

Diagnosis: migraine headache, prevention
Treatment: botulinum A injection
Treatment Score: 0

What if in the future you could get a list of treatments like this:

1. botulinum A injection
2. sumatriptan
3. ginger powder

What if you get a list of all 57 treatments for an acute migraine headache and their Treatment Scores? That would be a great step forward in healthcare!

There are additional details that can be provided, and they will be in other essays on this blog. Right now, we are trying to give you the big picture:
The Treatment Score = the net treatment benefit for the patient.

Treatment Scores will be great for mobile health, because Treatment Scores will download easily onto a smart phone.

There has been lots of talk about “big data” and “health information technology,” but there has been little to show for it. The Treatment Score is the product, which everyone needs, that can actually be produced using big data and health information technology. All healthcare consumers need Treatment Scores and all healthcare distributors need Treatment Scores.

Treatment Scores are the statistics that you need every day:

What is the Treatment Score for Harvoni for hepatitis C?
What is the Treatment Score for Ambien for insomnia?
What is the Treatment Score for ginger powder for an acute migraine headache?
What is the Treatment Score for the radical prostatectomy for prostate cancer?
What is the Treatment Score for the Xiao surgery for incontinence?

Treatment Scores are the statistics that will “ride the wave” every news cycle; for example, what are the Treatment Scores for Zika virus treatments?

If you are a physician, nurse, pharmacist, dentist, or other allied healthcare professional, or are an expert patient, you need to start figuring out the Treatment Score for each and every treatment you know about.

What does all this mean for you? It means for the first time in your life you should ask your physician, “What’s the Treatment Score for that?”

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Sunday, June 5, 2016

Treatment Scores Tutorial 5: Spina Bifida Surgery Treatment Score = 0

When it comes to spina bifida surgery for incontinence the Treatment Score = 0. Specifically, when it comes to the Xiao procedure for incontinence (in patients with spina bifida) the Treatment Score = 0.

What is a Treatment Score? The Treatment Score represents the “net treatment benefit for the patient.” So, for the Xiao procedure for incontinence the Treatment Score = 0, meaning the net treatment benefit for the patient = 0. We want a 100% net benefit for the patient, instead, here we have 0%.

Spina bifida is a problem of the lower spine. It is a birth defect that causes many children to be incontinent of urine and incontinent of feces. Many of those born with spina bifida will wear diapers or “pull-ups” for the rest of their lives because of incontinence.

Spina bifida means “split spine,” and is a defect in which the lower spine is not properly closed. It’s also called a “neural tube” defect. In addition to urinary incontinence and fecal incontinence, many patients suffer paralysis of the lower limbs, weakness of the legs, and other neurologic problems. Spina bifida is a terrible situation and better treatments are desperately needed for the benefit of suffering patients.

Dr. Chuan-Guo Xiao, a urologist in China, invented the procedure that now bears his name, the Xiao procedure, to treat incontinence in spina bifida patients.

The Xiao procedure is an operation where a nerve, usually from the lumbar spine, is rerouted to a nerve in the sacral spine, which is lower down in the spine. The idea is that the “good nerve” from the lumbar spine will restore innervation to the damaged nerve of the sacral spine, which will then return function to the bladder and bowels. Such a procedure is called a nerve to nerve anastomosis. “Anastomosis” means joining together.

Spina bifida patients have a problem in that the spinal cord becomes attached to the surrounding structures, becoming “tethered” to them, which interferes with the normal mobility of the spinal cord. Spina bifida patients, therefore, commonly undergo a “detethering” surgery. The Xiao procedure is added to the detethering operation as an additional procedure in an attempt to treat incontinence.

Summary:
To summarize, the exact situation I did the Treatment Score for is this:

Diagnosis: incontinence of urine, associated with spina bifida
Treatment: detethering + Xiao procedure
Main outcome measure: resolution of urinary incontinence
Follow-up time period: 3 years
Patients: children

Outcome Measure
When you review the medical literature you want to look at the outcome measure that is most important for patients. You also want to look at the “hardest” outcome measure possible. Incontinence of urine is a horrible situation so the outcome I wanted to study was resolution of urinary incontinence. It is a relatively hard outcome measure, because either you are wearing diapers or pull-ups because you are wet all the time, or you are not, because you are dry.

Studies
There have been case series reports of good results with the Xiao procedure. For example, one study reported an 85% success rate, “Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR [ventral root] microanastomosis.”
(Source: http://www.ncbi.nlm.nih.gov/pubmed/15879861)

Another case series of 506 patients reported that 435 of 506 = 86% of patients had “significant” improvements.
(Source: http://link.springer.com/article/10.1007%2Fs11884-012-0130-2)

Other case series studies were encouraging about the Xiao procedure including this article, “US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience” (http://www.hindawi.com/journals/au/2014/863209/), and this article, “Outcomes of lumbar to sacral nerve rerouting for spina bifida” (http://www.ncbi.nlm.nih.gov/pubmed/20639040).

Lessons about Case Series Studies
This may be a cautionary tale about the “incredible unreliability” of case series studies. Case series studies may be full of biases. How can a case series study say something works 85% of the time, and a randomized controlled study say it works 0% of the time? This scenario has happened over and over again in medical history.

Case Series Biases
There are many problems with case series studies. One is not having a “hard enough” outcome measure. Another problem is the placebo effect. It seems like in medicine the more invasive a procedure one undergoes, the more prevalent the placebo effect. For example, the patients may be highly invested in the surgery to cure incontinence and thus may report better outcomes than are actually present. Similarly, the treating physicians may be highly invested in the outcome and may be biased towards reporting good outcomes. This is why randomized controlled studies are “blind.” The physicians collecting the outcomes data are “blinded” as to whether the patients had the treatment or not.

Case Series Studies with Soft Outcome Measures
As noted, the outcome measure for one of the case series studies was rather soft. Here is a quote of the outcome measure used: “17 gained satisfactory bladder control and continence within 8 to 12 months after VR [ventral root] microanastomosis.” Technically, that is an 85% success rate for 17 of the 20 patients studied. However, what is “satisfactory bladder control?” Who is it satisfactory for? Is it satisfactory in the opinion of the physicians? Or satisfactory in the opinion of the patients? Why wasn’t a hard outcome measure used?
(Source: http://www.ncbi.nlm.nih.gov/pubmed/15879861)

Lessons about Randomized Controlled Trials
The purpose of randomized controlled trials is to remove all biases and produce as much certainty as possible. Randomized controlled trials are the heart of science-based medicine and evidence-based medicine. Randomized controlled trials have been recognized as the epitome of clinical evidence since 1948, when the first randomized controlled trial was published in the British Medical Journal about treating tuberculosis with streptomycin. The hero behind that RCT was Sir Austin Bradford Hill.

The Randomized Controlled Trial on the Xiao Procedure
Physicians and researchers got together and performed a randomized controlled trial on the Xiao procedure, which was published in 2016, after several case series studies had been done, and after the procedure had been presented at medical conferences. The group were concerned with the following:

“… high success rates (70% – 85%) were reported…”
“… many of these studies did not use blinded observers…”
“…did not have control groups…”
“…limited follow-up durations.”
“…lack of…detailed follow up.”

(Source: http://www.ncbi.nlm.nih.gov/pubmed/27137626)

The group studied the Xiao procedure in children with a median age of 9 years, that ranged in age from a 1-year-old to an 18-year-old; 13 of the patients were boys, and 7 of the patients were girls. The authors stated in their paper that: “All patients were incontinent of urine, all wore pull-ups or diapers, and none were able to void voluntarily or on command.”

The results were bad. Urinary incontinence did not resolve in any of the patients who underwent the Xiao procedure. The study says, “…all patients required diapers or Pull-Ups throughout the three year period.”

Why Another Randomized Controlled Trial Needs to Be Done
No medical study is ever perfect and the randomized controlled trial by Gerald F. Tuite, M.D., et al. is no exception. The most glaring problem for me was that the issue of fecal incontinence was not reported. I did not find it reported in the randomized controlled study itself, or in the attached appendix. If more of the treated patients regained continence of feces compared to the control group that would be a very important outcome, a beneficial outcome. We are left to assume that since urinary incontinence did not improve that fecal incontinence probably did not improve either.

Dr.  Xiao’s Letter-to-the-Editor
Dr. Xiao wrote a letter to the editor addressing the “Tuite study,” the randomized controlled trial of 20 patients, regarding the Xiao procedure in spina bifida. The letter can be found here:
http://www.jurology.com/article/S0022-5347(15)04294-9/abstract
Dr. Xiao believes "...that there must be something fundamentally wrong in the trial."

There are concerns about whether the patients operated on in the “Tuite study” are similar to the patients that Dr. Xiao typically operates on. For example, all the patients in the “Tuite study” had previously underwent surgeries. In addition, apparently all of the patients in the “Tuite study” had previously had anticholinergic medications and clean intermittent catheterizations as routine treatments. In theory, these things might have prevented nerve regeneration from working. Previous surgeries may have done damage, and anticholinergic medications are thought to make the bladder “floppy.”

For example, one anticholinergic medication commonly used in spina bifida patients is Ditropan (oxybutynin). It reduces bladder spasms in patients with overactive bladders and treats frequent or urgent urination.

Importantly, the “Tuite study” says: “Based on Xiao’s 2012 guidelines, it is clear that the typical patient selected for the procedure by Xiao differs from the type of patients with spinal dysraphism [defective closure of the neural tube] we would typically consider for the procedure in our clinical practice in the US.”

Other issues with the “Tuite study” include these statements from the study which make it sound like the authors might not have known how to replicate the Xiao surgery:

“… The EMG and intraoperative nerve root selection protocol remained ambiguous to us.”
“… Only half of our patients who underwent the Xiao procedure had intact muscle strength at the donor root level before surgery….”

“We routinely sectioned the entire sacral root selected, both the dorsal and ventral roots, because there was no way to reliably differentiate the ventral and dorsal sacral rootlets without electrical stimulation data.”

“Even though Xiao et al. and Peters et al. have reported better results than we obtained, neither group has provided detailed information concerning nerve root selection in their previous publications, making it impossible to know if the lack of efficacy in our patients could be explained by surgical variation.”

There are other differences between the patients that Dr. Xiao operates on and the patients in the “Tuite study.” There are differences in age, the number of previous operations, and although not clear, there are probably differences in the signs and symptoms the patients exhibit. Only a more detailed analysis would tell us for sure.

This is the Future of Treatment Transparency
The graphic below demonstrates what we believe will be the future of treatment transparency. To understand a medical treatment, you need to understand the gross benefit of the treatment. The main statistic, in this case “incontinence of urine resolved” represents the gross benefit of the treatment and it stands at 0%.

Then on the scale to the right are the event rates of the side benefits and side effects. The calculation that needs to be made to get the Treatment Score, or the net treatment benefit, is the Main Statistic – side effects + side benefits.



The problem is that all of these statistics are on different scales. You can think of it like this: the main statistic is in dollars, and all the secondary statistics are in different currencies. Every secondary statistic has to be converted into dollars. Right now, there are apparently very few physicians in the entire world that understand that this needs to be done and how to do it.

Side Effects
There are some possible side benefits that show up on the right next to the green scale. However, each of these side of benefits are actually less than 1% certain. In the future we will display these numbers differently to show that.

Why the Treatment Score May Be Negative
For the purpose of demonstrating Treatment Scores, it is enough to know that the Treatment Score for the Xiao procedure equals zero. However, it may actually be negative.

There are definitely negative side effects to the Xiao procedure. 100% of the patients will be at bed rest for three days after the operation. 100% of the patients will have their operation time increased. In fact, when the Xiao procedure is added on top of the detethering operation, on average it adds 85 minutes to the overall surgery time.

Pudendal nerve damage
90% of the patients had pudendal nerve damage on the side of the surgery according to one study which documented the phenomenon.
(Source: http://www.ncbi.nlm.nih.gov/pubmed/25158270
It makes sense that there would be nerve damage during the Xiao procedure because they are harvesting a good nerve root to try to repair a bad nerve root.

Side Effects: Wound Infections
Why did 50% of the Xiao procedure patients have wound infections that required oral antibiotics? The authors of the Tuite, et al. randomized controlled trial speculate that the additional 90 minutes of operating time to do the Xiao procedure put the patients at risk of increased infection.

Quality Adjusted Life Years
One source says that urinary incontinence like losing 3.5 months per year due to quality-of-life issues. (Source: http://www.hindawi.com/journals/jger/2015/703425/)

Another source says that having a stroke is like losing 8.7 quality adjusted life years.
(http://stroke.ahajournals.org/content/41/4/739.full)

Remember, that a stroke was a side effect in the patients who underwent the Xiao procedure. Other serious side effects were erectile dysfunction, footdrop, pudendal nerve dysfunction, spinal fluid leakage, and wound infection. Because of these things, it would be easy to give the Xiao procedure of Treatment Score of negative 10%. My problem with giving a negative score at this time for the Xiao procedure is the data on fecal incontinence is not complete enough.

Most Important Outcome
The most important outcome from the Tuite, et al. randomized controlled trial is this: “No patient in either group was continent of urine before surgery or at any time during follow-up. All patients wore diapers or pull-ups before and at all points in the three-year follow-up.”

What Might Have Gone Wrong
What are some other things that might have gone wrong with the case series studies that seem to show that the Xiao procedure worked? Why do some physicians believe it works? Here are two ideas:

These children may simply grow out of being incontinent over time. The surgeons doing the Xiao procedure may think it worked when it was simply due to the normal growth of the children and normal growth of their neurologic system.

The detethering operation may be responsible any good outcomes, and the Xiao procedure actually adds no benefit on top of the detethering.

What Needs to be Done Now
Right now the Treatment Score for the Xiao procedure = 0, or is actually negative, based on the best available studies. However, there are enough issues with the one and only randomized controlled trial, that another randomized controlled trial should be done. Ideally, it should be done by Dr. Chuan-Guo Xiao in China on Chinese patients. It should be a double blinded study with all the outcome measures followed up by a group that are independent of Dr. Chuan-Guo Xiao.

If Dr. Xiao did such a study, and the results of the study were good, it would vindicate the Xiao procedure and would be a great lesson about doing medical research.

However, it takes a lot of time and resources to do a randomized controlled trial, especially one that involves independent researchers. It would be great if it were to happen, but I am not sure that it ever will.

Sources and URLs:
Source of the Randomized Controlled Trial:
Tuite GF, Polsky EG, Homsy Y, Reilly MA, Carey CM, Parrish Winesett S, Rodriguez LF, Storrs BB, Gaskill SJ, Tetreault LL, Martinez DG,Amankwah EK. “Lack of efficacy of an intradural somatic-to-autonomic nerve anastomosis (Xiao procedure) for bladder control in children with myelomeningocele and lipomyelomeningocele: results of a prospective, randomized, double-blind study.” J Neurosurg Pediatr. 2016 May 3:1-14.
http://www.ncbi.nlm.nih.gov/pubmed/27137626
DOI: 10.3171/2015.10.PEDS15271

Additional Sources:
Xiao CG1, Du MX, Li B, Liu Z, Chen M, Chen ZH, Cheng P, Xue XN, Shapiro E, Lepor H. "An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida." J Urol. 2005 Jun;173(6):2112-6.
http://www.ncbi.nlm.nih.gov/pubmed/15879861

“Response: Some lessons learned from negative results of a randomized controlled trial for bladder reinnervation with the Xiao procedure.” Tuite GF, Polsky EG, Homsy Y, Reilly MA, Carey CM, Parrish Winesett S, Rodriguez LF, Storrs BB, Gaskill SJ, Tetreault LL, Martinez DG, Amankwah EK. J Neurosurg Pediatr. 2016 May 3:1-2.
http://www.ncbi.nlm.nih.gov/pubmed/27137925

[An electrophysiological study on the artificial somato-autonomic pathway for inducing voiding]. Liu Z, Liu CJ, Hu XW, Du MX, Xiao CG. Zhonghua Yi Xue Za Zhi. 2005 May 25;85(19):1315-8.
http://www.ncbi.nlm.nih.gov/pubmed/16029629

“Electrophysiological monitoring and identification of neural roots during somatic-autonomic reflex pathway procedure for neurogenic bladder.” Dai CF1, Xiao CG. Chin J Traumatol. 2005 Apr;8(2):74-6.
http://www.ncbi.nlm.nih.gov/pubmed/15769303

“An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients.” Xiao CG1, Du MX, Dai C, Li B, Nitti VW, de Groat WC. J Urol. 2003 Oct;170(4 Pt 1):1237-41.
http://www.ncbi.nlm.nih.gov/pubmed/14501733

"Skin-CNS-bladder" reflex pathway for micturition after spinal cord injury and its underlying mechanisms. Xiao CG1, de Groat WC, Godec CJ, Dai C, Xiao Q. J Urol. 1999 Sep;162(3 Pt 1):936-42. http://www.ncbi.nlm.nih.gov/pubmed/10458412

“Xiao Procedure for Neurogenic Bladder in Spinal Cord Injury and Spina Bifida.” Neurogenic Bladder (F Daneshgari, Section Editor). Chuan-Guo Xiao. Current Bladder Dysfunction Reports. June 2012, Volume 7, Issue 2, pp 83-87. First online: 01 April 2012.
http://link.springer.com/article/10.1007%2Fs11884-012-0130-2

“US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience.” Kenneth M. Peters, Holly Gilmer, Kevin Feber, Benjamin J. Girdler, William Nantau, Gary Trock, Kim A. Killinger, and Judith A. Boura1. Advances in Urology. Volume 2014 (2014). Article ID 863209, 7 pages.
http://www.hindawi.com/journals/au/2014/863209/

“Outcomes of lumbar to sacral nerve rerouting for spina bifida.” Peters KM, Girdler B, Turzewski C, Trock G, Feber K, Nantau W, Bush B, Gonzalez J, Kass E, de Benito J, Diokno A. J Urol. 2010 Aug;184(2):702-7. doi: 10.1016/j.juro.2010.03.058. Epub 2010 Jun 19.
http://www.ncbi.nlm.nih.gov/pubmed/20639040

“The artificial somato-autonomic reflex arch does not improve lower urinary tract function in patients with spinal cord lesions.” Rasmussen MM, Rawashdeh YF, Clemmensen D, Tankisi H, Fuglsang-Frederiksen A, Krogh K, Christensen P. J Urol. 2015 Feb;193(2):598-604.
http://www.ncbi.nlm.nih.gov/pubmed/25158270

“Double-blinded randomized controlled trial of the Xiao procedure in children.”
http://www.eurekalert.org/pub_releases/2016-05/jonp-drc042716.php

“Double-blinded randomized controlled trial of the Xiao procedure in children.”
www.sciencedaily.com/releases/2016/05/160503072231.htm

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http://TreatmentScores.com

DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.