Laser treatment of recurrent herpes labialis: a literature review

Recurrent herpes labialis is a worldwide life-long oral health problem that remains unsolved. It affects approximately one third of the world population and causes frequent pain and discomfort episodes, as well as social restriction due to its compromise of esthetic features. In addition, the available antiviral drugs have not been successful in completely eliminating the virus and its recurrence. Currently, different kinds of laser treatment and different protocols have been proposed for the management of recurrent herpes labialis. Therefore, the aim of the present article was to review the literature regarding the effects of laser irradiation on recurrent herpes labialis and to identify the indications and most successful clinical protocols. The literature was searched with the aim of identifying the effects on healing time, pain relief, duration of viral shedding, viral inactivation, and interval of recurrence. According to the literature, none of the laser treatment modalities is able to completely eliminate the virus and its recurrence. However, laser phototherapy appears to strongly decrease pain and the interval of recurrences without causing any side effects. Photodynamic therapy can be helpful in reducing viral titer in the vesicle phase, and high-power lasers may be useful to drain vesicles. The main advantages of the laser treatment appear to be the absence of side effects and drug interactions, which are especially helpful for older and immunocompromised patients. Although these results indicate a potential beneficial use for lasers in the management of recurrent herpes labialis, they are based on limited published clinical trials and case reports. The literature still lacks double-blind controlled clinical trials verifying these effects and such trials should be the focus of future research.     

From coagulation to enucleation: the use of lasers in surgery for benign prostatic hyperplasia

The application of lasers for the treatment of benign prostatic hyperplasia has evolved over the past 15 years. Early-generation neodymium:yttrium aluminum garnet lasers were used to coagulate and ablate prostatic tissue, but significant postoperative irritative symptoms and high reoperation rates meant that this approach did not seriously challenge the status quo for long. Ablative techniques have recently become popular again with the marketing of the newer-generation, higher-power potassium titanyl phosphate and holmium lasers. Although short-term data are encouraging, there are no comparative trials of significant duration, so it is not yet possible to draw conclusions with regard to efficacy and durability. The holmium laser can also be used as an incisional and dissecting tool that allows resection or enucleation of whole lobes of the prostate, mimicking the action of the index finger in open prostatectomy. The safety, efficacy, durability and cost-effectiveness of the holmium laser have been shown in well-designed randomized controlled trials.     

Meta-analysis of pain relief effects by laser irradiation on joint areas

Abstract Background: Laser therapy has been proposed as a physical therapy for musculoskeletal disorders and has attained popularity because no side effects have been reported after treatment. However, its true effectiveness is still controversial because several clinical trials have reported the ineffectiveness of lasers in treating pain. Methods: In this systematic review, we investigate the clinical effectiveness of low-level laser therapy (LLLT) on joint pain. Clinical trials on joint pain satisfying the following conditions are included: the laser is irradiated on the joint area, the PEDro scale score is at least 5, and the effectiveness of the trial is measured using a visual analogue scale (VAS). To estimate the overall effectiveness of all included clinical trials, a mean weighted difference in change of pain on VAS was used. Results: MEDLINE is the main source of the literature search. After the literature search, 22 trials related to joint pain were selected. The average methodological quality score of the 22 trials consisting of 1014 patients was 7.96 on the PEDro scale; 11 trials reported positive effects and 11 trials reported negative effects. The mean weighted difference in change of pain on VAS was 13.96?mm (95% CI, 7.24-20.69) in favor of the active LLLT groups. When we only considered the clinical trials in which the energy dose was within the dose range suggested in the review by Bjordal et al. in 2003 and in World Association for Laser Therapy (WALT) dose recommendation, the mean effect sizes were 19.88 and 21.05?mm in favor of the true LLLT groups, respectively. Conclusions: The review shows that laser therapy on the joint reduces pain in patients. Moreover, when we restrict the energy doses of the laser therapy into the dose window suggested in the previous study, we can expect more reliable pain relief treatments.     

Cost-effectiveness of neonatal surgery: a review

BACKGROUND/PURPOSE: Technological developments have revolutionized both diagnosis and treatment in neonatal surgery. However, it has been increasingly recognized that financial resources might become insufficient to provide all the medical care that is technically feasible or that patients and families might desire. The purpose of this study is to apply the theory of health economics to neonatal surgery and to explore the extent and the kind of economic evaluation done in neonatal surgery. METHODS: To explore the work done so far, the authors undertook a literature search aimed at costs and effects of surgical interventions in newborns with Ravitch' surgical index diagnoses of congenital anomalies. Common keywords in cost-effectiveness analysis were used to search Medline. RESULTS: Evidence about the cost effectiveness of neonatal surgery is largely lacking. This is probably because of difficulties in long-term tracking of the patients and to the problem that most generic quality-of-life measures are not applicable in children yet. CONCLUSIONS: Further cost-effectiveness research in neonatal surgery is warranted to settle priority discussions in health care when neonatal surgery is part of such discussions. Methodology for generic quality-of-life measurement in children is badly needed.     

Evidence-based management of critically ill patients: analysis and implementation

A number of important clinical trials focusing on critically ill patients have been completed in the last few years. These trials have been among the first critical care clinical trials to demonstrate mortality reduction in the critically ill. As in any adaptation of evidence-based medicine, it is essential to closely examine the trials and to determine whether the demonstrated benefits can be translated to the individual patient. In addition to the primary outcome, usually survival benefit, it is also important to examine cost-effectiveness. All of the trials examined in this review were able to demonstrate mortality reduction. Most focused on patients with severe sepsis, because this population has been associated with both frequent mortality and increased hospital costs. Some of the interventions, such as small tidal volume mechanical ventilation in patients with acute lung injury or the administration of low-dose corticosteroids for patients with septic shock, are cost-effective and relatively simple to implement. Others, such as use of activated protein C in patients with severe sepsis or "tight" glycemic control in patients with hyperglycemia, require either significant pharmaceutical expenditure or, possibly, additional health care personnel. Nevertheless, the trials discussed represent significant advances in the field of critical care medicine and should at least be considered for implementation in all intensive care units.     

Laser-assisted prevention of enamel caries: a 10-year review of the literature

Since the invention of lasers in dentistry, investigations in caries prevention by the use of laser radiation have been proposed. There are several mechanisms stated for this purpose such as photothermal and/or photochemical interaction processes with the enamel. Alone or in conjugation with topical fluoride application, this treatment modality may improve enamel acid resistance in high-caries-risk populations. Data collection was done by searching the keywords caries, prevention, and laser in PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar. Lasing protocols of the collected literature and their effectiveness as well as examination methods used to verify treatment outcomes have been evaluated. One hundred eighteen publications were found for the last 10 years. The wavelengths investigated for caries prevention are mainly located in the near and the mid-infrared spectral range. In the evaluated period of time, investigations using CO₂; Er:YAG; Er,Cr:YSGG; Er:YLF; fundamental, second, and third harmonic generations of Nd:YAG; diodes; and argon ion lasers were found in the databases. Accounting for 39% of the literature, CO₂ laser was the most examined system for this purpose. Reviewing the literature in this narrative review showed that all laser systems presented a positive effect in varying degrees. Laser irradiation could be an alternative or synergistic to topical fluoridation for enamel caries prevention with longer lasting effect. Further research should be focused on selecting proper laser settings to avoid damage to enamel and developing effective evidence-based clinical protocols.

     

Cochrane Anaesthesia Review Group and the Cochrane Library. Useful resources for anaesthetists

The Cochrane Collaboration is an international non-profit organisation that aims to help clinicians in making well-informed decisions about health care issues.This is done through preparing, maintaining and disseminating systematic reviews on the effects of health care interventions.To facilitate this task, review groups have been established. These groups cover specific health care areas and form the organisational basis of the collaboration. They provide methodological and logistic help to the authors of the systematic reviews.The Cochrane Anaesthesia Review Group (CARG) covers anaesthesia, perioperative medicine, intensive care,pre-hospital medicine, resuscitation, and emergency medicine.Protocols and completed Cochrane reviews are published in a structured format in the electronic Cochrane Library.Beside this Cochrane database of systematic reviews, the Cochrane library contains a database with summaries of non-Cochrane systematic reviews (database of abstracts of reviews of effectiveness), and a comprehensive database with controlled clinical trials (Cochrane central register of controlled trials). Thus the Cochrane library is a useful source of information on health care interventions for anaesthetists.     

Acceptance and rejection: cost-effectiveness and the working nephrologist

While many nephrologists have developed a sophisticated approach to appraising clinical trials, an equal comfort in critiquing cost-effectiveness literature is often lagging. Readers can wonder how new results compare to those from other cost-effectiveness trials, and whether they should accept a new intervention as cost-effective or reject it as too costly for the benefit it produces. Critical readers should first judge whether the authors have made the correct trade-off between complexity and generalizability when selecting a study perspective, and should examine the method of linkage between costs and effectiveness. The most popular method is the incremental cost-effectiveness ratio (ICER), which has limitations that have led some authors to prefer the net monetary benefit (NMB), where confidence intervals are more easily determined and which can more readily be used in regression analyses. Interpretation of the ICER and NMB require the choice of a cost-effectiveness ceiling, representing the maximum that society would be willing to pay for an incremental health benefit, and the development of a decision rule based on this maximum. Comparing cost-effectiveness studies from different disciplines requires the use of "universal" effectiveness measures, such as the quality-adjusted life-year (QALY). An understanding of study perspective, the relative strengths of different cost-effectiveness measures, the methods for measuring uncertainty in these estimates, and how to select and use cost-effectiveness ceiling ratios will help the critical reader to determine if a new intervention should be accepted or rejected.     

Meta-analysis of hair removal laser trials

Traditional hair-removal techniques have included shaving, waxing, chemical depilation, and electrolysis. All of these methods result in temporary hair removal. The theory of selective photo thermolysis led to the development of a variety of different laser systems. These lasers range from the short end of spectrum, with the 694-nm ruby laser, to the middle, with the 755-nm alexandrite and 810-nm diode lasers, and to the long end with the 1,064-nm Nd:YAG laser. We made a systematic review on the clinical trials with use of various laser sources for hair removal, so all clinical trials related to hair removal lasers in 1998–2003 were considered after elimination of heterogenite sources in data store. Trial results were synthetized on the basis of kind of laser. Our study clarified that hair reduction at least 6 months after the last treatment and hair reductions were 57.5, 42.3, 54.7, and 52.8% after three sessions for diode, Nd:YAG, alexandrite and ruby, respectively. We compared the result with use of analysis of variance method (Scheffes) and double comparison with use of Student’s t test. Our results clarified that diode laser is the most effective, and Nd:YAG has the least effect of hair removal.It seems that diode and alexandrite lasers are proper for hair removal, but as we need high fluence in the darker skin types and this is accompanied with higher complications, diode is advised for lighter skin, and we advised alexandrite laser for darker skin types.     

The light revival: Does phototherapy promote wound healing? A review

BackgroundThroughout history, light has been recognised as a potential source of healing. The introduction of lasers made it possible to modify and control light for optimum therapeutic use.AimThis paper reviews recent clinical trials that test phototherapy on human models in order to assess the value of phototherapy in routine wound care.MethodA literature search was undertaken using a variety of sources including online databases.ResultsThe results of numerous in vitro and animal investigations suggest that phototherapy may stimulate cell activity and promote tissue repair. Reports of human clinical trials are relatively few. There is inconsistency of selected treatment parameters amongst studies testing the effect of phototherapy on wound healing. Clinical trials using human models do not provide sufficient evidence to establish the usefulness of phototherapy as an effective tool in wound care regimes.ConclusionFurther well designed research trials are required to determine the true value of phototherapy in routine wound care.     

Applications of laser surgery in gynecology. Hype or high tech?

Despite the proliferation of the use of lasers in gynecology, physicians in both private practice and the academic setting remain skeptical about the role of these instruments. The laser has not made it possible to perform surgical procedures that have previously been impossible to carry out in the operating theater. Further, as yet, higher pregnancy rates have not been achieved with any reconstructive procedure using the laser rather than conventional or electrocautery surgery. On the other hand, surgeons such as Daniell reported on the impact of laser in decreasing the need for laparotomy in their practices. For instance, prior to the introduction of the laser, Daniell performed laparotomy on 80% of his patients with endometriosis, pelvic adhesive disease, or tubal disease, whereas currently he performs 80% of these procedures through the laparoscope. However, one could argue that this change simply represents the trend of performing more gynecologic procedures through endoscopes whether a laser is involved or not. Convincing evidence exists that pelviscopy results in savings in terms of morbidity and the cost of surgery. Whether endoscopic surgery can be performed more safely using the laser than with a traditional technique has not been addressed in a formal study. Whether laser surgery produces better pregnancy rates is unresolved. Ninety per cent of all clinical trials involving the laser have been uncontrolled. Those studies that have been controlled, reported by Tulandi, for example, have shown results at least equivalent to those achieved with diathermy, and it is of interest that the pregnancies tended to occur sooner in the laser-treated groups. The laser is at least as effective as electrocautery in the treatment of adhesions and distal tubal disease. Therefore, it is the author's recommendation that all types of lasers be used in conjunction with electrocautery and conventional sharp dissection in the treatment of various forms of pelvic pathology. It is important that surgeons become familiar with all types of lasers, as future devices may be vastly different and prove to be clearly superior in treating the various pelvic pathologies.     

Economic analysis of lung volume reduction surgery as part of the National Emphysema Treatment Trial. NETT Research Group

BACKGROUND: In today's cost-conscious health care environment, obtaining timely and accurate economic information regarding new medical technologies has become extremely important. The National Emphysema Treatment Trial, a multicenter, randomized controlled trial of lung volume reduction surgery (LVRS) plus medical therapy, versus medical therapy for patients with severe emphysema, includes a parallel cost-effectiveness analysis. METHODS: The analysis is designed to determine the cost-effectiveness of LVRS versus medical therapy for those who are eligible for the procedure. After describing theoretical foundations of cost-effectiveness analysis as they apply to this study, we describe the economic and quality of life data that are being collected alongside the clinical trial, methods of analysis, and approach to presenting the results. RESULTS: The cost-effectiveness of LVRS relative to medical therapy will be presented as costs per quality-adjusted life years gained. CONCLUSIONS: This analysis will provide timely economic data that can be considered alongside the clinical results of the National Emphysema Treatment Trial. As one of the largest clinical trials to include a parallel, prospective cost-effectiveness analyses, this study will also provide valuable practical information about conducting an economic analysis alongside a multicenter clinical trial.     

Vaporization of the prostate

PURPOSE OF REVIEW: Transurethral resection of the prostate remains the treatment of choice for men with symptomatic benign prostatic enlargement. Concerns regarding the morbidity of this operation have led to the development of alternative surgical procedures. Vaporization of the prostate can be achieved using either laser energy or electrosurgery. The advantage of these approaches is that they allow tissue removal with reduced blood loss. Vaporization techniques have been around for almost a decade and more powerful lasers have recently become available. This has led to a minor resurgence in interest in laser vaporization. We reviewed articles on all forms of vaporization of the prostate published in the 12 months from August 2002. RECENT FINDINGS: Electrovaporization of the prostate is an effective treatment for men who require surgery for benign prostatic enlargement. The results are well maintained at 5 years follow-up with low reoperation rates. Scanty data are available for the Gyrus (Gyrus Medical Ltd, Cardiff, Wales) bipolar electrovaporization system but preliminary results suggest there is no significant advantage over transurethral resection of the prostate. Early forms of laser vaporization of the prostate are not as effective as either transurethral resection of the prostate or transurethral electrovaporization of the prostate and have a higher retreatment rate. Newer, more powerful lasers have been recently introduced with encouraging initial results in small numbers of patients. SUMMARY: Electrovaporization of the prostate is a safe, effective and durable alternative to transurethral resection. Early laser vaporization techniques have high retreatment rates, which limit their cost-effectiveness. Few data are yet available on high-powered lasers for bladder outflow obstruction. Whether any vaporization technique will stand the test of time is unclear.     

Transcutaneous laser treatment of leg veins

Leg telangiectasias and reticular veins are a common complaint affecting more than 80 % of the population to some extent. To date, the gold standard remains sclerotherapy for most patients. However, there may be some specific situations, where sclerotherapy is contraindicated such as needle phobia, allergy to certain sclerosing agents, and the presence of vessels smaller than the diameter of a 30-gauge needle (including telangiectatic matting). In these cases, transcutaneous laser therapy is a valuable alternative. Currently, different laser modalities have been proposed for the management of leg veins. The aim of this article is to present an overview of the basic principles of transcutaneous laser therapy of leg veins and to review the existing literature on this subject, including the most recent developments. The 532-nm potassium titanyl phosphate (KTP) laser, the 585–600-nm pulsed dye laser, the 755-nm alexandrite laser, various 800–983-nm diode lasers, and the 1,064-nm neodymium yttrium–aluminum–garnet (Nd:YAG) laser and various intense pulsed light sources have been investigated for this indication. The KTP and pulsed dye laser are an effective treatment option for small vessels (<1 mm). The side effect profile is usually favorable to that of longer wavelength modalities. For larger veins, the use of a longer wavelength is required. According to the scarce evidence available, the Nd:YAG laser produces better clinical results than the alexandrite and diode laser. Penetration depth is high, whereas absorption by melanin is low, making the Nd:YAG laser suitable for the treatment of larger and deeply located veins and for the treatment of patients with dark skin types. Clinical outcome of Nd:YAG laser therapy approximates that of sclerotherapy, although the latter is associated with less pain. New developments include (1) the use of a nonuniform pulse sequence or a dual-wavelength modality, inducing methemoglobin formation and enhancing the optical absorption properties of the target structure, (2) pulse stacking and multiple pass laser treatment, (3) combination of laser therapy with sclerotherapy or radiofrequency, and (4) indocyanin green enhanced laser therapy. Future studies will have to confirm the role of these developments in the treatment of leg veins. The literature still lacks double-blind controlled clinical trials comparing the different laser modalities with each other and with sclerotherapy. Such trials should be the focus of future research.     

Challenges for Model-Based Economic Evaluations of Postmenopausal Osteoporosis Interventions

Assessing the cost-effectiveness of long-term treatment for osteoporosis requires use of mathematical models to estimate health effects and costs for competing interventions. The primary motivations for model-based analyses include the lack of long-term clinical trial outcome data and the lack of data comparing all relevant treatments within randomized clinical trials. We report on specific modeling challenges that arose in the development of a model of the natural history of postmenopausal osteoporosis that is suitable for assessing the cost-effectiveness of osteoporosis interventions among various population subgroups in diverse countries. These include choice of modeling changes in bone mineral density (BMD) or in fracture rate, definition of health states, modeling mortality and costs of long-term care following fracture, incorporation of health utility, and model validation. This report should facilitate future postmenopausal osteoporosis model development and provide insight for decision-makers who must evaluate model-based economic analyses of postmenopausal osteoporosis interventions. Received: 14 November 2000 / Accepted: 9 April 2001     

Vascular applications of lasers.

There have been major advances in laser technology and in our understanding of the effects of laser energy on blood vessels. This, in turn, has led to the many clinical applications of lasers in patients with vascular disease. The clinical results of laser endarterectomy, laser angioplasty, laser-assisted balloon angioplasty, laser-assisted vascular anastomoses, and the future of lasers in cardiovascular disease are discussed.     

Economic appraisal of laser applications in medicine

Laser applications are developing rapidly in medicine. Virtually every specialty of surgery, and a number of medical specialties, are using the laser for several conditions, and the number of conditions treated seems to grow every day. This fact is of concern to policy-makers in a time of limited resources for health care. Increasingly, health policy decisions are guided by costeffectiveness studies of medical applications. This paper reviews evidence of cost-effectiveness for a number of relatively mature laser applications. In general, although available studies are suggestive of benefit, effectiveness has been demonstrated for relatively few laser applications. Little reliable cost information has been developed, although out-patient therapy and shortened length of stay in hospital seem to be demonstrated for several conditions.     

Review of nonablative laser resurfacing modalities

Because of considerable morbidities and recovery time associated with CO2 laser resurfacing,many efforts are being made to discover a less ablative resurfacing modality. A thorough review of the literature demonstrates promising but less than ideal results for all of the currently used lasers. The clinical efficacy does not appear to be as significant as the histologic results that have been documented. Our review of the literature also demonstrates that not all of the modalities are equal.     

Cost-effectiveness Analysis of Goal-directed Hemodynamic Treatment of Elderly Hip Fracture Patients: Before Clinical Research Starts

BACKGROUND:: Health economic evaluations are increasingly used to make the decision to adopt new medical interventions. Before such decisions, various stakeholders have invested in clinical research. But health economic factors are seldom considered in research funding decisions. Cost-effectiveness analyses could be informative before the launch of clinical research projects, particularly when a targeted intervention is resource-intensive, total cost for the trial is very high, and expected gain of health benefits is uncertain. This study analyzed cost-effectiveness using a decision analytic model before initiating a large clinical research project on goal-directed hemodynamic treatment of elderly patients with hip fracture. METHODS:: A probabilistic decision analytic cost-effectiveness model was developed; the model contains a decision tree for the postoperative short-term outcome and a Markov structure for long-term outcome. Clinical effect estimates, costs, health-related quality-of-life measures, and long-term survival constituted model input that was extracted from clinical trials, national databases, and surveys. Model output consisted of estimated medical care costs related to quality-adjusted life-years. RESULTS:: In the base case analysis, goal-directed hemodynamic treatment reduced average medical care costs by &OV0556;1,882 and gained 0.344 quality-adjusted life-years. In 96.5% of the simulations, goal-directed hemodynamic treatment is less costly and provides more quality-adjusted life-years. The results are sensitive to clinical effect size variations, although goal-directed hemodynamic treatment seems to be cost-effective even with moderate clinical effect. CONCLUSION:: This study demonstrates that cost-effectiveness analysis is feasible, meaningful, and recommendable before launch of costly clinical research projects.