2540 Huntingdon Pike
Huntingdon Valley PA 19006
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Accuracy and Internal Consistency of Cardiac Magnetic Resonance Imaging in Measuring Branch Pulmonary Artery Flows in Patients With Conotruncal Anomalies and Branch Pulmonary Artery Stents. - The American journal of cardiology
Clinicians use branch pulmonary artery (BPA) blood flow distribution to help determine the need for intervention. Although phase-contrast magnetic resonance (PCMR) flow measurements are accurate, this has never been shown in the vicinity of a BPA ferromagnetic stent (FS) which produces significant susceptibility artifact. We retrospectively reviewed 49 consecutive PCMR studies performed from 2005 to 2012 on patients with repaired conotruncal anomalies and either left (nÂ = 29) or right PA (nÂ = 20) stents. Three methods of measuring the stented BPA flow were compared: (1) main PA (MPA) minus nonstented BPA, (2) direct PCMR of stented BPA away from the artifact, and (3) pulmonary venous flows (ipsilateral to stented BPA and derived pulmonary blood flow ratio from bilateral pulmonary venous flows). Internal consistency was tested with the Student t test, linear regression, Bland-Altman analysis, and intraclass correlation (ICC). The mean age was 11.7 Â± 6.9Â years with 5.8 Â± 4.2Â years between stent placement and CMR. There was good agreement without significant difference between MPA-derived stented BPA flow (method 1) and direct PCMR of stented BPA (method 2; 41 Â± 19% vs 39 Â± 19%, pÂ = 0.59; R(2)Â = 0.84, p <0.001; ICCÂ = 0.96). There was also good agreement between methods 1 and 2 compared to pulmonary venous flows, with the highest correlation occurring between method 2 and ipsilateral pulmonary venous flow (R(2)Â = 0.90, p <0.001; ICCÂ = 0.97 for MPA-derived-stented BPA flow; R(2)Â = 0.94, p <0.001; ICCÂ = 0.98 for direct PCMR of stented BPA). Eleven of the 49 patients (22%) underwent interventional catheterization after PCMR. In conclusion, in the vicinity of a BPA FS, accurate measurement of the net fractional pulmonary blood flow ratio is feasible. PCMR adjacent to the stent and ipsilateral pulmonary venous flows provide the most internally consistent data. These data underscore PCMR's utility in managing patients with implanted FS.Copyright Â© 2016 Elsevier Inc. All rights reserved.
Cardiac magnetic resonance imaging characterizes stenosis, perfusion, and fibrosis preoperatively and postoperatively in children with anomalous coronary arteries. - The Journal of thoracic and cardiovascular surgery
Using cardiac magnetic resonance imaging (MRI) with virtual angioscopy, we sought to evaluate coronary anatomy, myocardial injury, and left ventricular function in children with interarterial anomalous aortic origin of coronary artery before and after surgery.We prospectively enrolled children 5 to 19Â years old with interarterial anomalous coronary artery. Cardiac MRI was performed with respiratory-navigated steady-state free-precession 3-dimensional data set acquisition. Virtual angioscopy was used to evaluate the coronary ostia directly. Surgery consisted of the modified unroofing procedure.We enrolled 9 subjects between February 2009 and May 2015. Subjects were male, with an average age at surgery of 14.1Â years. Anomalous coronary was right in 7 patients (77%) and left in 2. In all subjects, the proximal anomalous coronary arose tangential to the aorta with an elliptical, slitlike ostium. Before the operation, the proximal coronary artery was significantly smaller proximally than distally (2 vs 3.1Â mm; PÂ <Â .0001. After the operation, neo-orifices were round and patent in 7 subjects; however, 2 subjects still had narrowed neo-orifices. New postoperative MRI findings included flattened septal wall motion (NÂ =Â 1), small region of midmyocardial partial-thickness scar (NÂ =Â 1), and dyskinetic septal wall motion with mild aortic insufficiency (NÂ =Â 1). Left ventricular function was normal both before and after surgery (PÂ =Â .85).Cardiac MRI with virtual angioscopy is an important tool for evaluating anomalous coronary anatomy, myocardial function, and ischemia and should be considered for initial and postoperative assessment of children with anomalous coronary arteries.Copyright Â© 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
Effect of utilization of veno-venous bypass vs. cardiopulmonary bypass on complications for high level inferior vena cava tumor thrombectomy and concomitant radical nephrectomy. - International braz j urol : official journal of the Brazilian Society of Urology
To determine if patients with renal cell carcinoma (RCC) with levels III and IV tumor thrombi are receive any reduction in complication rate utilizing veno-venous bypass (VVB) over cardiopulmonary bypass (CPB) for high level (III/IV) inferior vena cava (IVC) tumor thrombectomy and concomitant radical nephrectomy.From May 1990 to August 2011, we reviewed 21 patients that had been treated for RCC with radical nephrectomy and concomitant IVC thrombectomy employing either CPB (n =16) or VVB (n=5). We retrospectively reviewed our study population for complication rates and perioperative characteristics.Our results are reported using the validated Dindo-Clavien Classification system comparing the VVB and CPB cohorts. No significant difference was noted in minor complication rate (60.0% versus 68.7%, P=1.0), major complication rate (40.0% versus 31.3%, P=1.0), or overall complication rate (60.0% versus 62.5%, P=1.0) comparing VVB versus CPB. We also demonstrated a trend towards decreased time on bypass (P=0.09) in the VVB cohort.The use of VVB over CPB provides no decrease in minor, major, or overall complication rate. The use of VVB however, can be employed on an individualized basis with final decision on vascular bypass selection left to the discretion of the surgeon based on specifics of the individual case.
Surveillance Following Nephron-Sparing Surgery: An Assessment of Recurrence Patterns and Surveillance Costs. - Urology
To assess the pattern of renal cell carcinoma (RCC) recurrences in nephron-sparing surgery (NSS) patients, and to determine whether current guidelines for surveillance could be modified based on such patterns.Retrospective review of a single-institution NSS database. Pattern of RCC recurrences and factors associated with recurrence were analyzed using univariate and multivariable competing risk regression analyses. Cost of surveillance was estimated based on Medicare charges.A total of 505 patients underwent elective NSS for RCC. Pathologic T stage included 394 pT1a and 79 pT1b lesions. Median follow-up was 38.3 (6-88) months. Recurrence was detected in 26 patients (5.1%) at a median of 18.9Â months (2.7% pT1a and 12.7% pT1b). The estimated 5-year cumulative incidence of recurrence for unifocal pT1a lesions was 2.7%. On multivariable analysis, stage higher than pT1a (HR, 5.56 [CI. 2.57-12.0]) and the presence of multifocal or bilateral tumors (HR, 3.32 [CI, 1.45-7.61]) were independent predictors of disease recurrence. For the entire cohort, recurrence was observed in only 10 patients beyond 24Â months including only 2Â cases with pT1a.Current guidelines adequately capture most clinically significant recurrences, and with longer follow-up, it may be possible to confirm that routine surveillance beyond 2Â years may have little clinical significance for patients with asymptomatic unifocal pT1a.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Repaired tetralogy of Fallot with coexisting unrepaired partial anomalous pulmonary venous connection is associated with diminished right ventricular ejection fraction and more severe right ventricular dilation. - Pediatric radiology
There is an established association between tetralogy of Fallot and partial anomalous pulmonary venous connections. This association is important because surgically repaired tetralogy patients have increased risk of right heart failure. We hypothesize that partial anomalous venous connections increase right ventricular volumes and worsen right ventricular failure.We reviewed cardiac MRI exams performed at a tertiary pediatric hospital from January 2005 to January 2014. We identified patients with repaired tetralogy and unrepaired partial anomalous pulmonary venous connection. We used age- and gender-matched repaired tetralogy patients without partial anomalous pulmonary venous connection as controls. We analyzed the MRI results and surgical course and performed comparative statistics to identify group differences.There were eight patients with repaired tetralogy and unrepaired partial anomalous pulmonary venous connection and 16 controls. In all cases, the partial anomalous pulmonary venous connection was not detected on preoperative echocardiography. There were no significant differences in surgical course and body surface area between the two groups. Repaired tetralogy patients with unrepaired partial anomalous pulmonary venous connection showed significantly higher indexed right ventricular end diastolic volume (149â€‰Â±â€‰33Â mL/m(2) vs. 118â€‰Â±â€‰30Â mL/m(2)), right ventricle to left ventricle size ratios (3.1â€‰Â±â€‰1.3 vs. 1.9â€‰Â±â€‰0.5) and a higher incidence of reduced right ventricular ejection fraction compared to controls (3/8 vs. 0/16).Repaired tetralogy of Fallot with unrepaired partial anomalous pulmonary venous connection is associated with reduced right ventricular ejection fraction and more significant right ventricular dilation.
Predicting postoperative complications of inguinal lymph node dissection for penile cancer in an international multicentre cohort. - BJU international
To assess the potential complications associated with inguinal lymph node dissection (ILND) across international tertiary care referral centres, and to determine the prognostic factors that best predict the development of these complications.A retrospective chart review was conducted across four international cancer centres. The study population of 327 patients underwent diagnostic/therapeutic ILND. The endpoint was the overall incidence of complications and their respective severity (major/minor). The Clavien-Dindo classification system was used to standardize the reporting of complications.A total of 181 patients (55.4%) had a postoperative complication, with minor complications in 119 cases (65.7%) and major in 62 (34.3%). The total number of lymph nodes removed was an independent predictor of experiencing any complication, while the median number of lymph nodes removed was an independent predictor of major complications. The American Joint Committee on Cancer stage was an independent predictor of all wound infections, while the patient's age, ILND with Sartorius flap transposition, and surgery performed before the year 2008 were independent predictors of major wound infections.This is the largest report of complication rates after ILND for squamous cell carcinoma of the penis and it shows that the majority of complications associated with ILND are minor and resolve without prolonged morbidity. Variables pertaining to the extent of disease burden have been found to be prognostic of increased postoperative morbidity.Â© 2014 The Authors BJU International Â© 2014 BJU International Published by John Wiley & Sons Ltd.
Using percentage of sarcomatoid differentiation as a prognostic factor in renal cell carcinoma. - Clinical genitourinary cancer
The objective of this study was to determine if the percentage of sarcomatoid differentiation (%Sarc) in renal cell carcinoma (RCC) can be used for prognostic risk stratification, because sarcomatoid RCC (sRCC) is an aggressive variant of kidney cancer.We performed a retrospective analysis of patients who underwent surgery for RCC at our institution between 1999 and 2012. Pathology slides for all sRCC cases were reexamined by a single pathologist and %Sarc was calculated. %Sarc was analyzed as a continuous variable and as a categorical variable at cut points of 5%, 10%, and 25%. Potential prognostic factors associated with overall survival (OS) were determined using the Cox regression model. OS curves were generated using Kaplan-Meier methods and survival differences compared using the log-rank test.One thousand three hundred seven consecutive cases of RCC were identified, of which 59 patients had sRCC (4.5%). As a continuous variable %Sarc was inversely associated with OS (PÂ = .023). Predictors of survival on multivariable analysis included pathologic (p) T status, tumor size, clinical (c) M status and %Sarc at the 25% level. OS was most dependent on the presence of metastatic disease (4 months vs. 21.2 months; PÂ = .001). In cM0 patients with locally advanced (â‰¥ pT3) tumors, OS was significantly diminished in patients with > 25 %Sarc (PÂ = .045). However, %Sarc did not influence OS in patients with cM1 disease.Patients with sRCC have a poor overall outcome as evidenced by high rates of recurrence and death, indicating the need for more effective systemic therapies. In nonmetastatic patients, the incorporation of %Sarc in predictive nomograms might further improve risk stratification.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus. - Journal of vascular surgery. Venous and lymphatic disorders
This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus.A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (nÂ = 40) and stage IV (nÂ = 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30Â days) complications and mortality was recorded, including a review of secondary surgical interventions.According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (nÂ = 10), venovenous bypass (nÂ = 4), or infrahepatic IVC control (nÂ = 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23Â months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (nÂ = 3), II (nÂ = 6), IIIa (nÂ = 2), IIIb (nÂ = 3), and V (nÂ = 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8Â months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5Â years. Early mortality was 3.6% (nÂ = 2), with 27 patients (49%) dying within 24Â months, resulting in an overall mortality for the cohort of 80% (nÂ = 44) as established on routine regular postoperative surveillance.A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.Copyright Â© 2014. Published by Elsevier Inc.
An abundant dysfunctional apolipoprotein A1 in human atheroma. - Nature medicine
Recent studies have indicated that high-density lipoproteins (HDLs) and their major structural protein, apolipoprotein A1 (apoA1), recovered from human atheroma are dysfunctional and are extensively oxidized by myeloperoxidase (MPO). In vitro oxidation of either apoA1 or HDL particles by MPO impairs their cholesterol acceptor function. Here, using phage display affinity maturation, we developed a high-affinity monoclonal antibody that specifically recognizes both apoA1 and HDL that have been modified by the MPO-H2O2-Cl(-) system. An oxindolyl alanine (2-OH-Trp) moiety at Trp72 of apoA1 is the immunogenic epitope. Mutagenesis studies confirmed a critical role for apoA1 Trp72 in MPO-mediated inhibition of the ATP-binding cassette transporter A1 (ABCA1)-dependent cholesterol acceptor activity of apoA1 in vitro and in vivo. ApoA1 containing a 2-OH-Trp72 group (oxTrp72-apoA1) is in low abundance within the circulation but accounts for 20% of the apoA1 in atherosclerosis-laden arteries. OxTrp72-apoA1 recovered from human atheroma or plasma is lipid poor, virtually devoid of cholesterol acceptor activity and demonstrated both a potent proinflammatory activity on endothelial cells and an impaired HDL biogenesis activity in vivo. Elevated oxTrp72-apoA1 levels in subjects presenting to a cardiology clinic (n = 627) were associated with increased cardiovascular disease risk. Circulating oxTrp72-apoA1 levels may serve as a way to monitor a proatherogenic process in the artery wall.
Implications for human papillomavirus in penile cancer. - Urologic oncology
Human papillomavirus infection (HPV) has been implicated in penile cancer, and although the annual incidence is estimated to be 1,570 in the United States, there are areas of the world in which the incidence is as much as 20-fold higher. Ample data in the literature support testing and vaccination against HPV-related cervical cancer, but for men and penile cancer, these data are lacking. However, some preliminary data would suggest that HPV not only plays an important role in a significant subset of patients with penile cancer but also may be a target for penile cancer prevention as well via initiation of a vaccination program in high-risk male populations.Copyright Â© 2014 Elsevier Inc. All rights reserved.
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2540 Huntingdon Pike Huntingdon Valley, PA 19006
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