Functional electrical stimulation (FES) involves the use of an orthotic device or exercise equipment with microprocessor-controlled electrical muscular stimulation. These devices are being developed to restore function and improve health in patients with damaged or destroyed nerve pathways (eg, spinal cord injury [SCI], stroke, multiple sclerosis, cerebral palsy).

Hippotherapy, also referred to as equine-assisted therapy, describes a treatment strategy that uses equine movement to engage sensory, neuromotor, and cognitive systems to achieve functional outcomes. Hippotherapy has been proposed as a therapy for individuals with impaired walking or balance.

Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. National organizations have specified core components to be included in cardiac rehabilitation programs.

Endobronchial brachytherapy is the delivery of radiotherapy directly to endobronchial lesions, either intraluminally or interstitially, using permanently implanted radioactive seeds or a temporary afterloading implant. The technique permits targeted radiation while minimizing exposure to surrounding radiosensitive structures, such as normal lung, heart, and spinal cord.

Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing, particularly autism spectrum disorder. Sensory integration therapy may be offered by occupational and physical therapists who are certified in sensory integration therapy. Auditory integration therapy uses gradual exposure to certain types of sounds to improve communication in a variety of developmental disorders, particularly autism.

Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem-solving, and executive functions. Cognitive rehabilitation comprises tasks to reinforce or reestablish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist.

Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in individuals with compromised lung function. Pulmonary rehabilitation programs generally include a patient assessment followed by therapeutic interventions including exercise training, education, and behavior change.

Various nonpharmacologic treatments are being evaluated to improve the symptoms of tinnitus. These approaches include psychological coping therapies, sound therapies, combined psychological and sound therapies, repetitive transcranial magnetic stimulation, electrical and electromagnetic stimulation, and transmeatal laser irradiation.

This use of low-density lipoprotein (LDL) apheresis has been proposed to treat various types of familial hypercholesterolemia (FH) and other significant hyperlipidemia and to reduce atherosclerosis in cardiovascular disease. Lipid apheresis discriminately removes LDL particles from plasma while leaving other factors intact, allowing the filtrated plasma to be returned to the patient.

An ultrasonic diathermy device applies ultrasonic energy to specific body parts at a frequency higher than 20 kilohertz in order to generate deep heat within body tissues for the treatment of certain medical conditions, such as the alleviation of pain, muscle spasms, and joint contractures. Newer portable stationary devices can be self-applied and used at home to deliver diathermy via continuous low-intensity therapeutic ultrasound. Electrodes attached to adhesive bandages are applied to the skin over the desired treatment area. The continuous low-intensity ultrasound unit can provide treatment for several hours.

Dry hydrotherapy, also known as hydromassage or aquamassage, is a massage treatment modality that circulates heated, pressurized water in a self-contained device such as a bed or chair. The individual remains clothed and dry as they sit or lie on top of a waterproof barrier containing rotating and pulsating interior jets. Purported benefits of dry hydrotherapy include alleviation of pain, increased blood circulation, improved range of motion, and decreased need for other interventions.

Prostate cancer is the second most common cancer diagnosis men receive in the U.S., and the behavior of localized prostate cancer can prove difficult to predict on a case-by-case basis. Most men with prostate cancer undergo whole-gland treatments, which can often lead to substantial adverse events. To reduce tumor burden and minimize morbidity associated with radical treatment, investigators have developed a therapy known as focal treatment. Focal treatment seeks to ablate either an “index” lesion (defined as the largest cancerous lesion with the highest grade tumor), or alternatively, to ablate nonindex lesions and other areas where cancer has been known to occur. Addressed in this review are several ablative methods used to remove cancerous lesions in localized prostate cancer (eg, focal laser ablation, high-intensity focused ultrasound [HIFU], cryoablation, radiofrequency ablation [RFA], photodynamic therapy, irreversible electroporation).

Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in the carotid arteries using an implanted device. Activation of the baroreflex inhibits the sympathetic nervous system, resulting in various physiologic changes, including slowed heart rate and lower blood pressure.

Intradialytic parenteral nutrition is the infusion of an intravenous hyperalimentation formula, such as amino acids, glucose, and lipids, during dialysis, to treat protein calorie malnutrition in an effort to decrease the morbidity and mortality experienced in patients with renal failure.

Peripheral arterial disease (PAD) is a common atherosclerotic syndrome associated with significant morbidity and mortality. Critical limb ischemia (CLI) is the end stage of lower-extremity PAD in which severe obstruction of blood flow results in ischemic pain at rest, ulcers, and a significant risk for limb loss. Use of autologous stem cells freshly harvested and allogeneic stem cells are reported to have a role in the treatment of PAD.

Chimeric antigen receptor (CAR) T-cells are genetically engineered cells that represent a novel class of cancer immunotherapy. In general, the process of autologous CAR T-cell therapy begins with harvesting white blood cells from the patient via leukapheresis followed by T-cell receptor activation and genetic engineering via retroviral or lentiviral transduction. After the CAR T-cells are generated, they are expanded to clinically relevant numbers, undergo quality control testing, and are cryopreserved. Commercial CAR T-cell products are manufactured at a centralized facility, necessitating transfer of the apheresis product to the manufacturing site, and the final cryopreserved CAR T-cell product back to the treatment facility. Typically, the patient undergoes lymphodepleting chemotherapy to create a favorable immune environment for CAR T-cell activity prior to receiving a single intravenous infusion of the product. Multiple commercial CAR T-cell products have been approved by the U.S. Food and Drug Administration for the treatment of lymphoma and leukemia. Tisagenlecleucel and brexucabtagene autoleucel are approved for treatment of subsets of patients with leukemia and lymphoma and axicabtagene ciloleucel and lisocabtagene maraleucel are approved to treat subsets of patients with lymphoma.

Intraoperative radiotherapy (IORT) is delivered directly to exposed tissues during surgery and may allow higher radiation doses by excluding nearby radiation dose-sensitive tissues. Different IORT modalities are available that impact both the dose distribution and method of application. IORT techniques include electron beam IORT, high-dose rate brachytherapy based IORT, and low-energy x-ray IORT.

Hematopoietic cell transplantation (HCT) refers to the infusion of hematopoietic stem cells to restore bone marrow function in individuals with cancer who receive bone-marrow-toxic doses of drugs with or without whole-body radiotherapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HCT) or from a donor (allogeneic HCT).

Most individuals with autoimmune disorders respond to conventional drug therapies; however, conventional drug therapies are not curative and a proportion of individuals suffer from autoimmune diseases that range from severe to recalcitrant to rapidly progressive. It is in this group of individuals with a severe autoimmune disease that alternative therapies have been sought, including hematopoietic cell transplantation (HCT).

Hematopoietic cell transplantation (HCT) refers to a procedure by which hematopoietic stem cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of cytotoxic drugs, with or without whole-body radiotherapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HCT) or a donor (allogeneic HCT [allo-HCT]). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Although umbilical cord blood is an allogeneic source, the stem cells in it are antigenically “naive” and thus are associated with a lower incidence of rejection or graft-versus-host disease. Umbilical cord blood is discussed in greater detail in evidence review 7.01.50

Risk stratification of patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) guides therapy decisions, which may include hematopoietic cell transplantation (HCT) for those with poor risk features.

Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate radiation to treat nonmelanoma skin cancer (NMSC). This technique focuses a uniform dose of X-ray source radiation to the lesion with the aid of a shielded surface application.

Cranial electrotherapy stimulation (CES), also known as cranial electrical stimulation, transcranial electrical stimulation, or electrical stimulation therapy, delivers weak pulses of electrical current to the earlobes, mastoid processes, or scalp with devices such as the Alpha-Stim. Auricular electrostimulation involves the stimulation of acupuncture points on the ear. Devices, including the P-Stim and e-pulse, provide ambulatory auricular electrical stimulation over a period of several days. Cranial electrotherapy stimulation is being evaluated for a variety of conditions, including pain, insomnia, depression, anxiety, and functional constipation. Auricular electrical stimulation is being evaluated for pain, weight loss, and opioid withdrawal.

Hyperhidrosis, or excessive sweating, can lead to impairments in psychologic and social functioning. Various treatments for hyperhidrosis are available, such as topical antiperspirant agents (eg, aluminum chloride 20% solution), oral medications, botulinum toxin, and surgical procedures.

Acute lymphoblastic leukemia (ALL) is a heterogeneous disease with different genetic variations resulting in distinct biologic subtypes. Patients are stratified to risk-adapted therapy according to certain clinical and genetic risk factors that predict an outcome. Therapy may include hematopoietic cell transplantation (HCT).

Mesenchymal stem cells (MSCs) have the capability to differentiate into a variety of tissue types, including various musculoskeletal tissues. Potential uses of MSCs for orthopedic applications include treatment of damaged bone, cartilage, ligaments, tendons, and intervertebral discs.

Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can be prevented through regular preventive dental care and counseling [1]. Despite the decrease in prevalence of dental caries among school-aged children from approximately 75 percent in the 1970s to 37 percent in 2011 to 2012 [2], caries continues to be one of the most common chronic diseases [3-8]. Data from the Centers for Disease Control and Prevention suggest that tooth decay in primary teeth of children aged two to five years has fluctuated since the 1980s but has not declined overall, increasing from 24 percent in 1988 to 1994 to 28 percent in 1999 to 2004 [9] and then decreasing to 23 percent in 2011 to 2012 [2]. The oral health goals for Healthy People 2020 include [6]: Decrease the proportion of three- to five-year-olds with caries in the primary dentition from 33 percent (1999 to 2004) to 30 percent Decrease the proportion of six- to nine-year-old children with caries in the mixed dentition from 54 percent (1999 to 2004) to 49 percent Decrease the proportion of adolescents with caries in the permanent dentition from 54 percent (1999-2004) to 48 percent The fluoride varnish is a protective medication that is painted over the teeth to help prevent new cavities and helps to stop cavities that have already begun. The application of topical fluoride varnish can be performed by a physician or another qualified health care professional when the insured does not have dental coverage with SSS Salud. <a id="

Chronic cerebrospinal venous insufficiency (CCSVI) may be associated with multiple sclerosis (MS), although this is controversial and an active area of research. Correction of CCSVI in patients with MS has been attempted using percutaneous venoplasty. The intent of this procedure is to relieve MS symptoms by improving venous drainage of the central nervous system. For individuals who have MS who receive ultrasound with or without magnetic resonance imaging to diagnose CCSVI, the evidence includes systematic reviews and controlled observational studies. Relevant outcomes are test accuracy, test validity, and other test performance measures. Systematic reviews have generally found a statistically significant association between CCSVI and MS, but a 2014 meta-analysis that excluded studies by Zamboni (who proposed criteria for defining CCSVI) and associated research groups found no significant association. Moreover, systematic reviews have reported significant heterogeneity among studies. Recent observational studies have not found that Zamboni criteria or updated criteria proposed by the International Society for Neurovascular Disease can discriminate between patients with and without MS. The association between CCSVI and MS, especially as a causative factor, remains unclear. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have MS and CCSVI who receive treatment for CCSVI with percutaneous venoplasty, the evidence includes 1 randomized controlled trial (RCT) and several case series. Relevant outcomes are overall survival, symptoms, quality of life, and treatment-related morbidity. The RCT was double-blind and sham-controlled. It found no statistically significant differences in venous outflow characteristics or improvements in clinical disease scores between groups treated with venoplasty and a sham intervention. The results of this RCT are limited by the potential for underpowering, and we did not identify any other RCTs on the efficacy of percutaneous venoplasty. Data on adverse events are available from the Food and Drug Administration (FDA) as well as larger published case series (ie, with several hundred patients). The case series found that adverse events were uncommon following venoplasty, but serious adverse events have been reported to FDA. FDA issued an alert in May 2012, noting the existence of serious complications, including death, and the need for ongoing monitoring. It is not currently possible from the available literature to estimate with confidence the rate of serious adverse events (eg, death, major bleeding). The evidence is insufficient to determine the effects of the technology on health outcomes. <a id="

Extracorporeal membrane oxygenation (ECMO) provides extracorporeal circulation and physiologic gas exchange for temporary cardiorespiratory support in cases of severe respiratory and cardiorespiratory failure. Generally, ECMO has been used in clinical situations in which there is respiratory or cardiac failure, or both, in which death would be imminent unless medical interventions can immediately reverse the underlying disease process, or physiologic functions can be supported long enough that normal reparative processes or treatment can occur (eg, resolution of acute respiratory distress syndrome, treatment of infection), or other life-saving intervention can be delivered (eg, provision of a lung transplant). Potential indications for ECMO in the adult population include acute, potentially reversible respiratory failure due to a variety of causes; as a bridge to lung transplant; in potentially reversible cardiogenic shock; and as an adjunct to cardiopulmonary resuscitation (ECMO-assisted cardiopulmonary resuscitation [ECPR]).

Approximately 240,000 men in the United States are expected to be diagnosed with prostate cancer in 2016. Although most are diagnosed at an early localized stage, up to 30% of cases will be repeated after surgical therapy or curative radiotherapy. Androgen deprivation therapy, either with surgical or gonadotropin releasing castration analogous to the hormone, is normally initiated to control the disease in people who have developed metastases. Unfortunately, almost all these cases will continue progressing. When patients turn to androgen deprivation therapy in the adjustment of "castration" levels of testosterone, patients receive the name of "castration-resistant". <a id="

Hodgkin lymphoma (HL) results from a clonal expansion of a B-cell lineage, characterized by the presence of Reed-Sternberg cells on pathology. Standard treatment is based on the stage at presentation and may involve chemotherapy with or without radiotherapy. Hematopoietic cell transplantation (HCT) has been used for HL, particularly in the setting of relapse or refractory disease.

Chronic myeloid leukemia (CML) is a hematopoietic stem cell disorder characterized by the presence of a chromosomal abnormality called the Philadelphia chromosome, which results from a reciprocal translocation between the long arms of chromosomes 9 and 22. Chronic myeloid leukemia most often presents in a chronic phase from which it progresses to an accelerated and then a blast phase. Allogeneic hematopoietic cell transplantation (allo-HCT) is a treatment option for CML.

Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in resistance (eg viscosity) and heat. The advantage of flotation is direct: when a person enters the water, there is an immediate reduction in the effect of gravity on the body. The advantage of water viscosity is indirect: when a person moves in the water the resistance is felt. This is known as an accommodation resistance because it matches the strength or effort applied by the patient. Since the resistance of the water equals the force, it applies the likelihood of exacerbating the injury and dramatically reduces it. It has been proposed that water facilitates active movement, stabilizes the trunk, relaxes spastic muscles, improves circulation, strengthens and improves functional activity. Aquatic therapy may be necessary when there is a restriction of movement, function and strength of a joint that has resulted in a specific disease or trauma. The clinical record should be specific as to the degrees of movement lost, as well as the levels of assistance needed. The standard therapy duration treatment should be 3-4 times per week for 2-4 weeks. It is not necessary more than one form of hydrotherapy in the same visit. Other forms of exercises may be necessary in addition to hydrotherapy when the patient can not perform exercises on the ground without first doing the hydrotherapy. In any case, it will not exceed the limits of the policy <a id="

Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of swallowing that have been altered by an illness or injury. The phases of swallowing include oral, pharynx, and/or esophagus (upper third). Dysphagia is a swallowing disorder that can be due to various neurological, structural, and cognitive deficiencies. Dysphagia can be the result of head trauma, stroke, neuromuscular degenerative diseases, head and neck cancer, and encephalopathies. While dysphagia can affect any age group, it appears more frequently in the elderly. Dysphagia is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction. Consequences of dysphagia include malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death. Adults with dysphagia may also experience disinterest, reduced enjoyment, embarrassment, and/or isolation related to eating or drinking. Dysphagia may increase caregiver costs and burden and may require significant lifestyle alterations for the patient and the patient’s family. Dysphagia intervention may concentrate on swallowing exercises, compensatory swallowing strategies (including posture considerations), bolus consistency modification, and caregiver/patient education. <a id="

Multiple myeloma (MM) is a systemic malignancy of plasma cells that represents approximately 10% of all hematologic cancers. POEMS syndrome, characterized by polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes, is a rare, paraneoplastic disorder secondary to a plasma cell dyscrasia. Plasma cell dyscrasias are treatable but rarely curable. In some cases, autologous or allogeneic hematopoietic cell transplantation (HCT) is considered as therapy.

A chemical peel is a controlled removal of various layers of the skin with the use of a chemical agent. The most common use of chemical peeling is the treatment of photoaged skin. Chemical peeling has also been used for other conditions, including actinic keratoses, active acne, and acne scarring.

Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person physically impaired to perform the tasks of daily living or the skills of a particular occupation. Occupational therapy also includes activities specifically designed and tailored to a specific condition. These services emphasize the use of activities to improve neuromuscular and musculoskeletal function and provide training in the activities of daily living. Other aspects of occupational therapy include the design, manufacture and use of the orthosis as well as instructions, assistance and selection of necessary equipment. For activities of daily living we mean those activities and skills necessary on a typical day such as: eating, bathing, dressing, physiological necessities, ambulating and mobility. <a id="

Compression pumps are proposed as a treatment for patients with lymphedema who have failed conservative measures. They are also proposed to supplement standard care for patients with venous ulcers. A variety of pumps are available; they can be single chamber (nonsegmented) or multichamber (segmented) and have varying designs and complexity. Non-pneumatic, programmable, wearable devices, are also available.

Lysis of epidural adhesions involves passing a catheter, either endoscopically or percutaneously, under fluoroscopic guidance into the epidural space to break up adhesions and reduce pain and inflammation. For individuals who have epidural adhesions who receive lysis, the evidence includes randomized controlled trials. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. Several randomized controlled trials have reported benefits for epidural lysis of adhesions compared with placebo treatment. Many of these trials were conducted at the same center. The interpretation of these trials is limited by differences in patients, populations, and treatment protocols. The treatment for lysis of adhesions varied in the use of mechanical disruption, the type of lytic medications used, and the number of injections given. There was also a large effect in the placebo group, raising questions whether some component of the placebo treatment may be therapeutic. Larger trials with standardized treatment protocols would help determine whether specific treatment protocols have beneficial effects in specific patient populations. The evidence is insufficient to determine the effects of the technology on health outcomes.

Sipuleucel-T (Provenge) is a therapeutic agent used to treat asymptomatic or minimally symptomatic, castration-resistant, metastatic prostate cancer. The agent comprises specially treated dendritic cells obtained from the individual through leukapheresis. The cells are then exposed in vitro to proteins that contain prostate antigens and immunologic-stimulating factors and reinfused into the individual. The proposed mechanism of action is that treatment stimulates the individual's own immune system to resist cancer spread.

The spontaneous regression of certain cancers (eg, renal cell carcinoma, melanoma) supports the idea that a patient’s immune system can delay tumor progression and, on rare occasions, can eliminate tumors altogether. These observations have led to research into various immunologic therapies designed to stimulate a patient’s own immune system. Adoptive immunotherapy is a method of activating lymphocytes and/or other types of cells for the treatment of cancer and other diseases. Cells are removed from the patient, processed for some period of time, and then infused back into the patient. Allogeneic cell transplantation following nonmyeloablative conditioning of the recipient (known as reduced-intensity conditioning) also may be referred to as “adoptive immunotherapy” in the literature. However, reduced-intensity conditioning cell transplantation relies on a donor-versus-malignancy effect of donor lymphocytes. In contrast, the adoptive immunotherapy techniques described in this evidence review enhance autoimmune effects primarily. The use of reduced-intensity conditioning in cell transplantation is discussed for specific cancers in individual policies related to cell transplantation. Chimeric antigen receptor T-cell therapies for certain hematologic malignancies (eg, tisagenlecleucel, axicabtagene ciloleucel, brexucabtagene autoleucel) are discussed separately in evidence review 8.01.63. Use of tumor-infiltrating lymphocytes in melanoma is discussed separately in evidence review 5.01.51.

Asparagine is an amino acid essential for cell growth. It occurs in most cells. The neoplastic cells present in acute lymphocytic leukemia lack the enzyme that synthesizes asparagine, therefore these neoplastic cells use circulating asparagine in the blood for their growth. L-asparaginase is an enzyme that reduces levels of circulating asparagine in the blood, thus depriving the asparagine available to the neoplastic cells, thus inhibiting their growth. <a id="

Intracavitary balloon catheter brain brachytherapy is an approach to localized radiotherapy using liquid I-125 delivered with an inflatable balloon catheter to treat malignant brain lesions.

Scintimammography, breast-specific gamma imaging (BSGI), and molecular breast imaging (MBI) use radiotracers with nuclear medicine imaging as a diagnostic tool for abnormalities of the breast. These tests are distinguished by the use of differing gamma camera technology, which may improve diagnostic performance for detecting small lesions. Breast-specific gamma imaging uses a single-head breast-specific gamma camera and a compression device; whereas, MBI uses dual-head breast-specific gamma cameras that also produce breast compression. Preoperative lymphoscintigraphy and/or intraoperative hand-held gamma detection of sentinel lymph nodes is a method of identifying sentinel lymph nodes for a biopsy after radiotracer injection. Surgical removal of 1 or more sentinel lymph nodes is an alternative to full axillary lymph node dissection for staging, evaluation, and management of breast cancer.

Neutron beam therapy is a form of radiotherapy that is used primarily for the treatment of unresectable or recurrent tumors. This policy does not address boron neutron capture therapy for cancer. Radiobiological principles demonstrate that radiation therapy using a neutron beam is associated with a higher linear energy transfer when compared to conventional photon or electron radiation therapy. This increased energy results in greater effectiveness. Some tumors appear to be more susceptible to the cytotoxic effect of neutrons. Studies show that local tumor control over 5 years was 75% in neutron use and 32% when compared to conventional photon and electron therapy. Acute toxicity was similar in all three therapy modalities although late severe toxicity, grade 3 and grade 4 is more prevalent with neutrons when compared to the other modalities. The modality using the neutron beam has also been shown to provide greater local control in salivary gland tumors in cases of advanced, recurrent, incomplete or inoperable resection. <a id="

Evaluation of exhaled nitric oxide (NO) and exhaled breath condensate (EBC) are proposed as techniques to diagnose and monitor asthma and other respiratory conditions. There are commercially available devices for measuring NO in expired breath and various laboratory techniques for evaluating components of EBC.

Radiotherapy is the standard of care for patients with breast cancer undergoing breast-conserving surgery because it reduces recurrences and lengthens survival. A conventional radiotherapy regimen consists of approximately 25 treatments of 2 Gray (a measure of absorbed radiation dose) delivered over 5 to 6 weeks. Nonetheless, not all patients undergo radiotherapy following breast-conserving surgery; the duration and logistics of treatment may be barriers for some women. Accelerated radiotherapy approaches have been proposed to make the regimen less burdensome for patients with early-stage breast cancer at a low-risk of recurrence. Accelerated (also called hypofractionated) whole-breast irradiation (AWBI) reduces the number of fractions and the duration of treatment to about 3 weeks. Accelerated partial-breast irradiation (APBI) targets a limited part of the breast in and close to the tumor cavity. By reducing the area irradiated, fewer treatments are needed, and the total treatment takes about 1 week.

Extracorporeal photopheresis (ECP) is a leukapheresis-based immunomodulatory procedure that involves the following 3 steps: (1) the patient’s blood is collected into a centrifuge system that separates the leukocyte-rich portion (buffy coat) from the rest of the blood; (2) the photosensitizer agent 8-methoxypsoralen is added to the lymphocyte fraction, which is then exposed to ultraviolet-A (320-400 nm wavelength) light at a dose of 1 to 2 J/cm2; and (3) the light-sensitized lymphocytes are reinfused into the patient. The use of ECP has been investigated for patients needing treatment for organ rejection after solid organ transplant, graft-versus-host disease (GVHD), autoimmune diseases, and T-cell lymphoma.

Inhaled nitric oxide (INO) is a natural vasodilator and has been studied for a variety of types of respiratory failure. Most commonly, it is used as an initial treatment for neonates with hypoxic respiratory failure to improve oxygenation and reduce the need for invasive extracorporeal membrane oxygenation (ECMO). It is also proposed as a treatment for premature infants, critically ill children, and adults with respiratory failure, as well as in the postoperative management of children undergoing repair of congenital heart disease and individuals after lung transplantation to prevent or reduce reperfusion injury.

Chelation therapy, an established treatment for heavy metal toxicities and transfusional hemosiderosis, has been investigated for a variety of off-label applications, such as treatment of atherosclerosis, Alzheimer disease, and autism. This evidence review does not address indications for chelation therapy approved by the U.S. Food and Drug Administration. Instead, it addresses off-label indications, including Alzheimer disease, cardiovascular disease, autism spectrum disorder, diabetes, multiple sclerosis, and arthritis.

Interferon is one of about 20 naturally occurring proteins. Three classes of interferons have been identified; alpha, beta and gamma. Each of these classes is chemically unique, distinct, synthesized and released by different groups of cells. Each one has a specific function. Interferons play a very important part in the immune system. Animal and preclinical studies in human tissues suggest that interferons have antiviral, antiproliferative, antiangiogenic, immunomodulatory, and gene regulatory properties. Its application in clinical oncology is based on the following observations: • Evidence suggests that interferons have a direct antiproliferative effect on some cancer cells. • Increase cycle length and deplete essential intracellular metabolites, promoting cell lysis or destruction. • The proposed mechanism of action is the activation of the expression of surface antigens. • Macrophage activity, lymphocyte cytotoxicity, and induction of antibodies to tumor cells are enhanced. <a id="

Charged-particle beams consisting of protons or helium ions are a type of particulate radiotherapy. Treatment with charged-particle radiotherapy is proposed for a large number of tumors that would benefit from the delivery of a high dose of radiation with limited scatter, minimizing the radiation dose to surrounding normal tissues and critical structures.

Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures performed while the individual is sedated (usually with general anesthesia or moderate sedation).

High-dose rate (HDR) temporary prostate brachytherapy is a technique for delivering a high-intensity radiation source directly to the prostate gland to treat cancer. The radiation source is administered through hollow catheters or needles inserted precisely into several areas of the prostate gland using ultrasound guidance and treatment planning computed tomography or ultrasound images. Radiation is applied to target areas until the prescribed dose is reached and is then removed. The goal of treatment is to induce direct tumor necrosis and reduce toxicity and surrounding tissue damage.

Low-level laser therapy (LLLT), also called photobiomodulation, is being evaluated to treat various conditions, including, among others, oral mucositis, myofascial pain, joint pain, lymphedema, and chronic wounds.

Photodynamic therapy (PDT; also called phototherapy, photoradiotherapy, photosensitizing therapy, or photochemotherapy) is an ablative treatment that uses a photosensitizing agent to expose tumor cells to a light source of a specific wavelength for the purpose of damaging the cells. After administration of the photosensitizing agent, the target tissue is exposed to light using a variety of laser techniques. For example, a laser fiber may be placed through the channel of the endoscope, or a specialized modified diffuser may be placed via fluoroscopic guidance. Treatment for tumor cells occurs through selective retention of the photosensitizing agent and the selective delivery of light.

Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain.

Vertebral axial decompression applies traction to the vertebral column to reduce intradiscal pressure and, in doing so, potentially relieves low back pain associated with herniated lumbar discs or degenerative lumbar disc disease.

Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal neovascular tissue. The therapy is a 2-step process, consisting of an injection of the photosensitizer verteporfin, followed 15 minutes later by laser treatment to the targeted sites of retinal neovascularization. The laser treatment selectively damages the vascular endothelium, thereby occluding choroidal neovascularization tissue. Patients may be retreated if leakage from choroidal neovascularization persists.

Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to 10 percent of children. Children learn language in early childhood; later they use language to learn. Children with language disorders are at increased risk for difficulty with reading and written language when they enter school . Early intervention may prevent the more serious consequences of later learning disabilities. <a id="

Physical therapy is the treatment of illness or physical damage through the use of therapeutic exercise, other interventions (active and passive) and techniques based on biomechanical and neurophysiological principles. These focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and the ability of the person to perform the functions of daily living and relieve pain. Physical therapy services include the different modalities and procedures used in the rehabilitation of neuromuscular diseases, muscular dystrophies, myopathy and diseases involving motor neurons. These conditions may require periodic intervention as the disease progresses. PR Law no. 114 of June 29, 1962, as amended, defines Physical Therapy or physiotherapy as a treatment of any disability, injury, illness and other health condition and rehabilitation, through the use of physical, chemical and other properties of heat, cold, light, water, electricity, sound, massage and therapeutic exercises, including posture and procedures derived from rehabilitation. Also, the administration of neuromuscular tests to help in the diagnosis or treatment of any human condition. For the purposes of this Law, "Physical Therapy or Physiotherapy" does not include the use of radiology, nor the use of electricity for surgical purposes, including cauterization. Law no. 114 also defines the physical therapist or physiotherapist as "the professional in the field of health who applies physiotherapy or physical therapy following the diagnosis, prescription or referral of a physician authorized to practice Medicine in Puerto Rico. Physical therapy services are provided in the doctor's office or at home when there are reasonable and medically necessary situations for the treatment of the condition. The type, frequency and duration of these therapies for the patient's condition must be within the standards of physical and occupational therapy directly expressed in a written treatment plan. There must be a certain degree of certainty that the condition or level of function must improve in a reasonable time. The rehabilitation of most musculoskeletal conditions is achieved in a short period of time, usually not exceeding one month, unless accompanied by other comorbidities that interfere with or aggravate the condition treated. In any rehabilitation program, treatment must be based on clear, defined and specific short and long-term goals. These goals must be related to the injury or illness that results in a pain picture or produces functional limitations in mobility and in the performance of daily living activities. The duration of treatment will depend on the progress in achieving those goals. Treatment will end when those goals are achieved or when the patient does not show additional progress in their condition. This must be clearly documented. Definition of modalities: • Any physical agent that is applied on the body to produce therapeutic change in the tissue. • Includes, but is not limited to, thermal, acoustic, light, mechanical or electrical effects. There are two types of modalities: 1. Supervised modalities. These do not require direct contact between the patient and the provider. Such as: Cold or hot cloth tractions electrical stimulation, unsupervised paraffin bath microwave "whirpool" diathermy infrared rays ultraviolet rays 2. Modalities of continued attention. These require direct contact between the patient and the provider. Such as: iontophoresis continuous bathroom ultrasound electrical stimulation (manual) Hubbard tank <a id="

Physical therapy is the treatment of an illness or injury with the use of therapeutic exercises or interventions that are focused on improving posture, locomotion, strength, support, balance, coordination, or movement of articulation. <a id="

Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular conditions characterized by choroidal neovascularization (CNV) and macular edema. Neovascular age related macular degeneration (AMD) is characterized by CNV which is the growth of abnormal choroidal blood vessels beneath the macula. This abnormal vascular growth causes severe loss of vision and is responsible for most of the loss of vision caused by AMD. Angiostatic agents block a stage in the vascular growth pathway leading to new blood vessel formation (angiogenesis) and therefore are disease modifying by inhibiting the development of newly formed vessels. Angiogenesis inhibitors are also being evaluated for the treatment of other disorders of choroidal circulation, including central serous chorioretinopathy pathologic myopia, presumed ocular histoplasmosis syndrome, angioid streaks, idiopathic CNV, uveitis, choroidal rupture or trauma, and chorioretinal scars Examples of angiogenesis inhibiting drugs for treating choroidal vascular conditions are Ranibizumab (Lucentis™), and Bevacizumab (Avastin®) from Genentech. <a id="

Intrastromal corneal ring segments (ICRS) are composed of microthin soft plastic inserts of variable thickness that are placed in the periphery of the cornea. They have been investigated as a means of improving vision in diseases such as keratoconus and pellucid marginal degeneration, and for astigmatism following penetrating keratoplasty. For individuals who have keratoconus who receive ICRS, the evidence includes primarily single-institution case series. Relevant outcomes are change in disease status, functional outcomes, and treatment-related morbidity. A number of single-center case series with sample sizes ranging from 19 to 105 eyes have been published. These series have generally reported that a substantial proportion of patients with keratoconus treated with this device have improved vision at 1 to 2 years of follow-up. More limited data are available on long-term efficacy. ICRS is associated with a number of adverse events and explantation. The net health outcome is uncertain. The evidence is insufficient to determine the effects of the technology on health outcomes. Clinical input obtained in 2009 strongly supported the use of ICRS in a select group of patients with advanced keratoconus whose only other option for restoration of functional vision was the more invasive penetrating keratoplasty. Some clinicians may opt to delay a more invasive procedure, although the success rate of this strategy is as yet unproven. Therefore, use of ICRS may be considered medically necessary in patients with keratoconus who meet the U.S. Food and Drug Administration humanitarian device exemption criteria for use of this device. For individuals who have pellucid marginal degeneration who receive ICRS, the evidence includes a few case series. Relevant outcomes are change in disease status, functional outcomes, and treatment-related morbidity. A small number of case series with fewer than 25 eyes per study have evaluated ICRS in patients with pellucid marginal degeneration. Most reports have assessed devices not available in the United States. In 1 study, which included some patients implanted with Intacs, there was no improvement in uncorrected visual acuity 6 months after surgery. Moreover, explantation occurred in about 20% of eyes due to visual deterioration. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have astigmatism after penetrating keratoplasty who receive ICRS, the evidence includes a few case series. Relevant outcomes are change in disease status, functional outcomes, and treatment-related morbidity. Two case series, with 9 and 54 patients, were identified; both used devices not available in the United States. ICRS was associated with adverse events such as extrusion and Descemet membrane detachment. The evidence is insufficient to determine the effects of the technology on health outcomes. Additional Information 2009 Input Clinical input obtained in 2009 strongly supported the use of intrastromal corneal ring segments in a select group of patients with advanced keratoconus whose only other option for restoration of functional vision was the more invasive penetrating keratoplasty. Some clinicians may opt to delay a more invasive procedure, although the success rate of this strategy is as yet unproven. Therefore, use of intrastromal corneal ring segments may be considered medically necessary in patients with keratoconus who meet the U.S. Food and Drug Administration humanitarian device exemption criteria for use of this device

Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney from a cadaver, living-related donor, or living-unrelated donor and transplantation into the recipient.

Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is defined as transplantation of histologically different tissues. This type of transplantation is being proposed for facial transplants in individuals with severely disfigured faces, and for hand transplants in patients dissatisfied with prosthetic hands. The treatment has potential benefits in terms of improving functional status and psychosocial well-being. It also has potential risks, most notably those associated with a lifelong regimen of immunosuppressive drugs.

Several commercially available forms of human amniotic membrane (HAM) and amniotic fluid can be administered by patches, topical application, or injection. Amniotic membrane and amniotic fluid are being evaluated for the treatment of a variety of conditions, including chronic full-thickness diabetic lower-extremity ulcers, venous ulcers, knee osteoarthritis, plantar fasciitis, and ophthalmic conditions.

Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is proposed to reduce the likelihood of insulin-dependent diabetes. Allogeneic islet cell transplantation with donislecel-jujn is also being investigated as a treatment or cure for patients with type 1 diabetes.

This evidence review addresses transplantation and retransplantation of an intestinal allograft in combination with a liver allograft, either alone or in combination with 1 or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.

Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a donor heart/lung block, excision of the heart and lungs of the recipient, and implantation of the heart and lungs into the recipient. Heart/lung transplantation refers to the transplantation of 1 or both lungs and heart from a single cadaver donor.

A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s) or lobes. Transplantation is an option for individuals with end-stage lung disease.

A heart transplant and a retransplant consist of replacing a diseased heart with a healthy donor heart. Transplantation is used for individuals with refractory end-stage cardiac disease.

Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease. Liver transplantation may be performed with a liver donation after a brain or cardiac death or with a liver segment donation from a living donor. Individuals are prioritized for transplant by mortality risk and severity of illness criteria developed by the Organ Procurement and Transplantation Network and the United Network of Organ Sharing. The severity of illness is determined by the Model for End-stage Liver Disease and Pediatric End-stage Liver Disease scores.

Transplantation of a healthy pancreas is a treatment for individuals with insulin-dependent diabetes. Pancreas transplantation can restore glucose control and prevent, halt, or reverse the secondary complications from diabetes.

A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral organs, including the liver, duodenum, jejunum, ileum, pancreas, or colon. Isolated small bowel transplant is commonly performed in individuals with short bowel syndrome. Small bowel/liver transplants and multivisceral transplants are considered in evidence review 7.03.05.

This evidence review addresses the collection, storage, and transplantation of placental and umbilical cord blood (“cord blood”) as a source of stem cells for allogeneic and autologous stem cell transplantation. Potential indications for the use of cord blood are not addressed herein; they are discussed in the disease-specific evidence reviews. For individuals who have an appropriate indication for allogeneic stem cell transplant who receive cord blood as a source of stem cells, the evidence includes a number of observational studies, a meta-analysis of observational studies, and a randomized controlled trial comparing outcomes after single- or double-cord blood units. Relevant outcomes are overall survival, disease-specific survival, resource utilization, and treatment-related mortality. The meta-analysis of observational studies found similar survival outcomes and lower graft-versus-host disease after cord blood transplantation than bone marrow transplantation. In the randomized controlled trial, survival rates were similar after single- and double-unit cord blood transplantation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who have an unspecified potential future need for stem cell transplant who receive prophylactic collection and storage of cord blood, the evidence includes no published studies. Relevant outcomes are overall survival, disease-specific survival, resource utilization, and treatment-related mortality. No evidence was identified on the safety or effectiveness of autologous cord blood transplantation from prophylactically stored cord blood for the treatment of malignant neoplasms. The evidence is insufficient to determine the effects of the technology on health outcomes. Additional Information Not applicable.

Revascularization (either surgical or percutaneous) is a treatment option for certain individuals with lower extremity peripheral arterial disease. Percutaneous revascularization procedures include balloon angioplasty, stent procedures, and atherectomy. Lithotripsy is proposed as a vessel preparation option to facilitate definitive endovascular treatment in heavily calcified lesions.

Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. Various levels of sedation and analgesia (anesthesia) may be used, depending on the patient’s condition and the procedure being performed. Monitored anesthesia care (MAC) refers to a set of physician services, not a particular level of sedation. The services include the ability to convert a patient to general anesthesia (if needed) and to intervene in the event a patient’s airway becomes compromised.

Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. Several levels of sedation can be used depending on the condition of the patient and the procedure to be performed, namely: • Minimum sedation (anxiolysis) – the patient responds normally to verbal commands, although their cognitive function and coordination may be altered. Your cardiopulmonary function is not affected. • Moderate sedation / analgesia ("conscious sedation") – state slightly depressed the conscious, where the patient responds to verbal commands, alone or accompanied by tactile stimuli, ventilation is spontaneous and cardiovascular function is unchanged. (No interactions are required to maintain a respiratory route). • Deep sedation / analgesia – depressed state of consciousness where the patient does not respond to verbal stimuli but responds to painful stimuli. • General anesthesia – depressed state of consciousness induced by medication where the patient does not respond to painful stimuli, requires maintaining his ventilation, his cardiovascular function can be altered <a id="

Irreversible electroporation produces high-frequency electric pulses to create an electric current that permanently damages cell membranes causing cell death due to the inability to maintain homeostasis. Irreversible electroporation produces no thermal effect and appears to preserve vessels, nerves and the extracellular matrix.

Intramedullary limb-lengthening systems (ILLS) have been introduced as an alternative to the circular external fixation to reduce complications and improve patient comfort. ILLS was designed to control the lengthening process using remote control technology. The electrical (FITBONE) and the magnetic (PRECICE) driven motorized intramedullary bone-lengthening nails were introduced. With these, conflicts with the first mechanically driven intramedullary bone-lengthening nail, which had challenges controlling the lengthening rate, and a relevant point of the treatment, were expected to be resolved.

Peripheral nerve injuries are common traumatic events for which the conventional treatment is the microsurgical repair for gaps <5 mm in length. Autologous grafting is used for repairing nerve gaps of greater length. Because autologous grafts must be harvested from the patient, there is a risk of donor site complications, and the overall success rate of autografting may be limited. Therapies such as processed nerve allografts and synthetic nerve conduits are being investigated to provide improved treatment alternatives.

Hypertrophic scars and keloids are cutaneous lesions resulting from abnormal wound healing. There is no gold standard therapy for hypertrophic scars and keloids, and treatment frequently involves multiple techniques, including pharmacotherapy, compression, surgery, radiation, and light sources. For scars and keloids impairing function, fractional carbon dioxide (CO2) ablative laser treatment is proposed to improve abnormal texture, thickness, and stiffness of scars by ablative destruction and resurfacing. The treatment may be used as monotherapy or in combination with other therapies (e.g., sequential treatment with other lasers, sequential treatment with other therapies, or laser-assisted drug delivery).

In the thumb, the most common site for arthritis to develop is in the joint at the base of the thumb, also known as the carpometacarpal (CMC) joint. Pain and functional limitations associated with symptomatic thumb CMC joint osteoarthritis, especially when pinching or gripping objects, can significantly interfere with quality of life. Surgery is indicated when conservative measures fail to provide sufficient relief and functional improvement. There is currently no consensus on the optimal surgical approach, but the most frequently used procedure is trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Trapeziectomy using suture button suspensionplasty (SBS) is proposed as a less invasive alternative to trapeziectomy with LRTI.

Benign prostatic hyperplasia (BPH) is a common, noncancerous, and benign enlargement of the prostate gland. BPH is the main cause of significant lower urinary tract symptoms (LUTS) in older individuals with a prostate, including urinary frequency, urinary urgency, feelings of incomplete emptying, having to get up to urinate at night, difficulty starting a urinary stream, or a weak stream that starts and stops. There are multiple means of treatment for the condition, medication being the first line of treatment, and then surgery is considered when all other methods have failed. Symptoms recurrence, and/or complications determine if the patient is a candidate for surgery. Holmium laser enucleation of the prostate (HoLEP) is an alternative to the gold standard surgery Transurethral Resection of the Prostate (TURP). It is a minimally invasive treatment that does not require an incision. HoLEP is used during a cystoscopy, which guides the laser to access the enlarged tissue of the prostate near the bladder. The laser is used to cut excess tissue out of the prostate gland. It can vaporize, cut through the prostate, and also help to cauterize / coagulate small to medium-sized blood vessels. A significant amount of prostate tissue can be resected with minimal amounts of bleeding. HoLEP has minimal side effects compared to the TURP procedure. Photo vaporization of the prostate (PVP) is considered an alternative for the Transurethral Resection of the Prostate (TURP). It removes excess prostate tissue by means of vaporization and coagulates the remaining soft tissue using light. PVP has become the reference surgical technique to manage patients who cannot stop anticoagulation/antiplatelet therapy.

The major salivary glands, parotid (front and behind the ear), submandibular (both sides of the jaw), and sublingual glands (beneath the tongue), are located near the mouth and throat. Their function is to secrete saliva into the mouth aiding in digestion, moistening the mouth, and protecting teeth from decay. There are also approximately 600 to 1,000 small glands, called minor salivary glands and they are 1-2mm in diameter. They coat all the mucosa surface around the mouth and throat. Sialolithiasis is the most common cause of ductal obstruction of the major salivary glands. Salivary stones or Sialolithiasis are developed when chemicals, debris, and calcium build-up from a small rock or "stone" and it becomes lodged or stuck on the salivary duct. The shape and size of these stones vary and may be asymptomatic. In some patients, these stones may present the following symptoms: pain, swelling, difficulty eating or swallowing, inflammation, and infection. Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive approach that uses high-energy shock waves generated outside the body to pulverize or crush the stones inside the body. ESWL consists of high-intensity shock waves that are produced electrically, and focused radiographically or ultrasonically on the treatment area. Intra-corporeal lithotripsy exploits the shock waves generated by a lithotripsy probe that is inserted into the salivary duct system under endoscopic guidance and directly reaches the stone's surface. More than one treatment may be required. <a id="

Benign prostatic hyperplasia (BPH) is a common condition in older individuals that can lead to increased urinary frequency, an urgency to urinate, a hesitancy to urinate, nocturia, and a weak stream when urinating. Temporarily implanted nitinol devices have been proposed as a minimally invasive alternative to transurethral resection of the prostate (TURP), considered the traditional standard treatment for symptomatic benign prostatic hyperplasia. The device is temporarily implanted into the obstructed prostatic urethra to facilitate tissue reshaping and improve urine outflow. The implant is typically removed after 5 to 7 days of treatment.

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Stroke associated with AF is primarily embolic, tends to be more severe than the typical ischemic stroke, and causes higher rates of mortality and disability. As a result, stroke prevention is one of the main goals of AF treatment. Treatment with anticoagulant medications is a first-line approach to stroke prevention in individuals with AF, although occlusion of the left atrial appendage (LAA) may offer a non-pharmacological alternative to anticoagulant medications for those with a contraindication or intolerance to long-term anticoagulant use or with poor anticoagulant adherence. Multiple surgical techniques may be used to excise or occlude the LAA. One device, the AtriClip Left Atrial Appendage Exclusion System, has approval from the U.S. Food and Drug Administration for surgical LAA occlusion for stroke prevention in patients with AF.

Migraine attacks due to episodic or chronic migraine require acute management. Some individuals may also require preventive migraine therapy. Current first-line therapy for treatment and prevention of acute migraine involves use of various pharmacologic interventions. Regular use of pharmacologic interventions can result in medication overuse and increased risk of progression from episodic to chronic migraine. Nonpharmacologic remote electrical neuromodulation (REN) may offer an alternative to pharmacologic interventions for patients with migraine.

Absolute uterine factor infertility is a condition in which an individual is unable to achieve pregnancy due to an absent or non-functioning uterus. Uterus transplantation may present a childbearing option that is an alternative to existing family planning pathways, including adoption, foster parenting, and gestational carrier pregnancy. Uterus transplantation is a complex, multi-stage process involving a living or deceased donor, recipient, and genetic partner.

Laser interstitial thermal therapy (LITT) involves the introduction of a laser fiber probe to deliver thermal energy for the targeted ablation of diseased tissue. The goal of therapy is selective thermal injury through the maintenance of a sharp thermal border, as monitored via the parallel use of real-time magnetic resonance (MR) thermography and controlled with the use of actively cooled applicators. In neurological applications, LITT involves the creation of a transcranial burr hole for the placement of the laser probe at the target brain tissue. Probe position, ablation time, and intensity are controlled under magnetic resonance imaging (MRI) guidance. LITT has been proposed as a less invasive treatment option for patients with neurological conditions compared to surgery. Two LITT systems, Visualase and NeuroBlate, have received marketing clearance from the U.S. Food and Drug Administration (FDA).

Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the legs and thighs. The adipose tissue may be painful. In contrast, lymphedema is the accumulation of interstitial fluid due to impaired lymphatic flow. This increase in interstitial fluid may lead to the accumulation and hypertrophy of fat cells. Liposuction, consisting of the removal of fat cells with a cannula and tumescent anesthesia is being investigated as a treatment option for both lipedema and lymphedema.

Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and mixed rhinitis and can severely impact quality of life. The initial treatment for chronic rhinitis often involves medical management with pharmacotherapy that may include steroids, anticholinergics, nasal decongestants, and antihistamines. For individuals who do not attain improvement in chronic rhinitis symptoms after receiving adequate medical therapy (referred to as refractory chronic rhinitis), invasive surgical options to block posterior nasal nerve may be considered. Historically, vidian neurectomy which targets the vidian nerve was offered for refractory rhinitis. Although vidian neurectomy was shown to be effective in reducing symptoms like rhinorrhea, it is associated with side effects of cheek and palate numbness and dry eyes (in nearly 50% of cases, ranging between 35 to 72%). In an effort to improve on complications of vidian neurectomy such as xerophthalmia, interventions that specifically target the posterior nasal nerve branches of the vidian nerve have been developed. These interventions range from surgical ablation of the post-ganglionic posterior nasal nerve to minimally invasive options of cryotherapy, radiofrequency, or laser ablation of the nerve. These minimally invasive procedures can be performed under endoscopy. The efficacy of ablation of posterior nasal nerve is thought to result from the interruption of efferent parasympathetic stimulation of the nasal mucosa, which leads to reduction in submucosal gland secretions and blood flow.

Degeneration of the intervertebral discs is commonly observed in imaging and has been proposed to be a source of back pain. In order to treat the observed changes in the discs, cellular therapies such as mesencyhmal stem cells are being studied. One of these cellular therapies involves the intradiscal injection of a mixture of nucleus pulposus allograft and viable cells into the degenerated disc.