3900 Woodland Ave Philadelphia Va Medical Center
Philadelphia PA 19104
Medical School: Other - 1989
Accepts Medicare: Yes
Participates In eRX: No
Participates In PQRS: Yes
Participates In EHR: No
License #: MD420248
Taxonomy Codes:2085R0202X 2085R0204X
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*These referrals represent the top 10 that Dr. Itkin has made to other doctors
Long-Term Outcomes of a Benign Biliary Stricture Protocol. - Journal of vascular and interventional radiology : JVIR
To evaluate long-term outcomes of a structured protocol for percutaneous treatment of benign biliary stricture.Seventy-one patients (37 men, 34 women; mean age, 54 y; age range, 23-84 y) entered the protocol, which consisted of staged upsizing of internal/external biliary catheters, balloon dilation (nominally 8 mm), and prolonged stent treatment (6 mo) at maximal catheter size (nominally 18 F). It concluded with a capping trial and catheter removal if the stricture remained patent. Fifty-three patients completed the protocol and 18 did not (6 died, 6 underwent alternative treatment, 4 were lost to follow-up, and 2 underwent repeat transplantation). Stricture features, treatment parameters, complications, and outcomes were reviewed, and Kaplan-Meier analysis was conducted.Strictures were anastomotic in 45 patients (64%), intrahepatic in 14 (20%), extrahepatic in 7 (10%), and multiple (intra- and extrahepatic) in 5 (7%). A right-sided approach was used in 47 patients (66%) patients, a left-sided approach in 18 (25%), and a bilateral approach in 6 (9%). Forty-six patients who entered the protocol (65%) and 46 patients who completed the protocol (87%) showed stricture patency. Four of 7 patients in whom a capping trial failed underwent surgical revision, 2 required chronic biliary drainage, and 1 received a metal stent. Follow-up (range, 0-12 y; mean, 4.7 y) was obtained for 42 of 53 patients who completed the protocol (79%). Kaplan-Meier analysis showed stricture patency probabilities of 84% at 1 year after treatment, 78% at 2 years, 74% at 5 years, and 67% at 10 years.Use of a structured protocol for the percutaneous treatment of benign biliary strictures yields durable long-term results, suggesting that percutaneous treatment is an effective therapy.Copyright Â© 2015 SIR. Published by Elsevier Inc. All rights reserved.
Recombinant yeast as a functional tool for understanding bitterness and cucurbitacin biosynthesis in watermelon (Citrullus spp.). - Yeast (Chichester, England)
Cucurbitacins are a group of bitter-tasting oxygenated tetracyclic triterpenes that are produced in the family Cucurbitaceae and other plant families. The natural roles of cucurbitacins in plants are probably related to defence against pathogens and pests. Cucurbitadienol, a triterpene synthesized from oxidosqualene, is the first committed precursor to cucurbitacins produced by a specialized oxidosqualene cyclase termed cucurbitadienol synthase. We explored cucurbitacin accumulation in watermelon in relation to bitterness. Our findings show that cucurbitacins are accumulated in bitter-tasting watermelon, Citrullus lanatus var. citroides, as well as in their wild ancestor, C. colocynthis, but not in non-bitter commercial cultivars of sweet watermelon (C. lanatus var. lanatus). Molecular analysis of genes expressed in the roots of several watermelon accessions led to the isolation of three sequences (CcCDS1, CcCDS2 and ClCDS1), all displaying high similarity to the pumpkin CpCPQ, encoding a protein previously shown to possess cucurbitadienol synthase activity. We utilized the Saccharomyces cerevisiae strain BY4743, heterozygous for lanosterol synthase, to probe for possible encoded cucurbitadienol synthase activity of the expressed watermelon sequences. Functional expression of the two sequences isolated from C. colocynthis (CcCDS1 and CcCDS2) in yeast revealed that only CcCDS2 possessed cucurbitadienol synthase activity, while CcCDS1 did not display cucurbitadienol synthase activity in recombinant yeast. ClCDS1 isolated from C. lanatus var. lanatus is almost identical to CcCDS1. Our results imply that CcCDS2 plays a role in imparting bitterness to watermelon. Yeast has been an excellent diagnostic tool to determine the first committed step of cucurbitacin biosynthesis in watermelon.Copyright Â© 2014 John Wiley & Sons, Ltd.
Successful treatment of plastic bronchitis by selective lymphatic embolization in a Fontan patient. - Pediatrics
Plastic bronchitis is a rare and often fatal complication of single-ventricle surgical palliation after total cavopulmonary connection. Although lymphatic abnormalities have been postulated to play a role in the disease process, the etiology and pathophysiology of this complication remain incompletely understood. Here we report on the etiology of plastic bronchitis in a child with total cavopulmonary connection as demonstrated by magnetic resonance (MR) lymphangiography. We also report on a new treatment of this disease. The patient underwent noncontrast T2-weighted MR lymphatic mapping and dynamic contrast MR lymphangiography with bi-inguinal intranodal contrast injection to determine the anatomy and flow pattern of lymph in his central lymphatic system. The MRI scan demonstrated the presence of a dilated right-sided peribronchial lymphatic network supplied by retrograde lymphatic flow through a large collateral lymphatic vessel originating from the thoracic duct. After careful analysis of the MRI scans we performed selective lymphatic embolization of the pathologic lymphatic network and supplying vessel. This provided resolution of plastic bronchitis for this patient. Five months after the procedure, the patient remains asymptomatic off respiratory medications.Copyright Â© 2014 by the American Academy of Pediatrics.
Dynamic contrast-enhanced MR lymphangiography: feasibility study in swine. - Radiology
To demonstrate the feasibility of dynamic four-dimensional ( 4D four-dimensional ) intranodal contrast material-enhanced magnetic resonance (MR) lymphangiography with inguinal lymph node injection of gadopentetate dimeglumine.All procedures were performed in accordance with the guidelines on the use of animals in research and were approved by the animal care and use committee. Five swine underwent nonenhanced MR lymphangiography with a heavily T2-weighted MR sequence, bilateral inguinal lymph node injection of 2 mL of undiluted gadopentetate at a rate of 1 mL/min, and 60 minutes of MR imaging with T1-weighted high-spatial- and high-temporal-resolution MR angiography. Images were reviewed by a radiologist with expertise in lymphatic imaging and a pediatric cardiac MR imaging specialist for visualization of the thoracic duct ( TD thoracic duct ). Categorical variables were compared by using the exact conditional McNemar test. A difference with a P value less than .05 was considered significant.The TD thoracic duct was visualized in three of the five animals (60%) on T2-weighted images. In contrast, the TD thoracic duct was visualized in all five of the animals (100%) after contrast agent injection (P = .25). The median time for flow of the contrast agent through the lymphatic system to the TD thoracic duct outlet was 244 seconds (range, 201-387 seconds). Enhancement was seen in the TD thoracic duct up to 1 hour after injection. All animals survived without any complications.Dynamic 4D four-dimensional contrast-enhanced MR lymphangiography with intranodal injection of gadopentetate dimeglumine is feasible, produces good images of the central lymphatic system, and demonstrates the time course of flow of contrast agent up the central lymphatic ducts. On the basis of the results of this initial animal experiment, it appears that dynamic 4D four-dimensional contrast-enhanced MR lymphangiography is potentially feasible and safe with commercially available contrast agents.
The PH gene determines fruit acidity and contributes to the evolution of sweet melons. - Nature communications
Taste has been the subject of human selection in the evolution of agricultural crops, and acidity is one of the three major components of fleshy fruit taste, together with sugars and volatile flavour compounds. We identify a family of plant-specific genes with a major effect on fruit acidity by map-based cloning of C. melo PH gene (CmPH) from melon, Cucumis melo taking advantage of the novel natural genetic variation for both high and low fruit acidity in this species. Functional silencing of orthologous PH genes in two distantly related plant families, cucumber and tomato, produced low-acid, bland tasting fruit, showing that PH genes control fruit acidity across plant families. A four amino-acid duplication in CmPH distinguishes between primitive acidic varieties and modern dessert melons. This fortuitous mutation served as a preadaptive antecedent to the development of sweet melon cultigens in Central Asia over 1,000 years ago.
MRI of lymphatic abnormalities after functional single-ventricle palliation surgery. - AJR. American journal of roentgenology
Protein-losing enteropathy (PLE) and plastic bronchitis are serious complications that occur after single-ventricle surgery. A lymphatic cause for these conditions has been proposed, but imaging correlation has not been reported. The objective of this study was to evaluate lymphatic abnormalities in patients after functional single-ventricle palliation compared with patients with non-single-ventricle congenital heart conditions using T2-weighted MR lymphangiography.We retrospectively reviewed imaging data from 48 patients who underwent T2-weighted MR lymphangiography in our institution between May 1, 2012, and October 24, 2012. The patients were divided into four groups: patients who underwent superior cavopulmonary connection, patients who underwent total cavopulmonary connection, patients with total cavopulmonary connection and lymphatic complications, and patients with non-single-ventricle cardiac anomalies.There were 38 patients with single ventricles in this study. The lymphatic abnormalities observed in these patients included thoracic duct dilation greater than 3 mm (31%), lymphangiectasia and lymphatic collateralization (78%), and tissue edema (86%). There were five patients with PLE, one patient with plastic bronchitis, and one patient with chronic chylous effusions and superior cavopulmonary connection. The patients with PLE and plastic bronchitis had statistically significant larger thoracic duct maximal diameters (median, 3.9 mm; range, 3-7.2 mm) than did the other patients with total cavopulmonary connection (p < 0.01). In the two-ventricle patient group, there were no abnormal lymphatic findings.Lymphatic abnormalities are found in many patients after functional single-ventricle palliation. T2-weighted unenhanced MRI is capable of anatomic assessment of the lymphatic system in this patient population and has promise for guiding treatment in the future.
Should all inflow stenoses be treated in failing autogenous hemodialysis fistulae? - Journal of vascular and interventional radiology : JVIR
To determine whether angioplasty of inflow stenosis in malfunctioning but patent autogenous hemodialysis fistulae has an impact on postintervention primary patency in patients without a clinical indicator of inflow-related access malfunction.Medical records for 76 procedures in 62 patients with inflow stenoses undergoing fistulography in nonthrombosed mature autogenous fistulae without an inflow-related indication of access malfunction over a 5-year period were reviewed retrospectively. Control and treatment arms were defined as patients with untreated (26 procedures in 23 patients) and treated (50 procedures in 39 patients) inflow stenoses, respectively. All patients in both arms of the study had concurrent intrafistula and/or venous outflow stenosis, which were treated successfully with angioplasty. The clinical endpoint was defined as return for a failing or thrombosed access (ie, primary patency). A two-tailed unpaired Student t test was performed to compare primary patency and percent inflow stenosis in treatment (angioplasty) and control (untreated inflow stenoses) groups, with significance defined at P < .05. Kaplan-Meier analysis was performed.There was no significant difference in percent inflow stenosis between control and treatment arms (P = .95). There was no significant difference in access patency between the two groups (139 and 124 d for control and treated groups, respectively; P = .95). No procedural complications occurred in either arm of the study.Angioplasty of inflow stenosis in failing autogenous fistulae without an appropriate clinical indicator of an inflow pathologic process does not improve postintervention primary patency.Copyright Â© 2014 SIR. Published by Elsevier Inc. All rights reserved.
Embolization of the neck lymphatic varix, causing periodic neck swelling. - Cardiovascular and interventional radiology
We report a case of a 44-year-old female patient, presented to us after years of recurrent intermittent episodes of unilateral left neck swelling. An MR lymphangiogram demonstrated a lymphatic varix at the confluence of the left upper extremity lymphatic ducts, confirmed by intranodal axillary lymphangiography. After successful catheterization of the feeding lymphatic vessels, the varix was successfully embolized with detachable microcoils and an autologous blood patch. The patient has been free from symptoms on subsequent outpatient follow-up.
Peripherally inserted central catheter thrombosis--reverse tapered versus nontapered catheters: a randomized controlled study. - Journal of vascular and interventional radiology : JVIR
To compare the thrombosis rate, ease of insertion, bleeding rate, and complications of a nontapered peripherally inserted central catheter (PICC) versus a reverse tapered PICC.This was a prospective randomized, controlled trial conducted in single center. All patients 18-90 years old requiring PICC insertion were considered for the study. All patients were followed until PICC removal. Ultrasound examination of the arm was performed at PICC removal or at 28 days. There were 332 patients randomly assigned--164 to the nontapered PICC group and 168 to the reverse tapered PICC group.The overall thrombosis rate was 71.9%. The thrombosis rate was 70.4% in the nontapered PICC group and 73.4% in the reverse tapered PICC group (P = .58). The symptomatic thrombosis rate was 4.3% in the nontapered PICC group and 3.6% in the reverse tapered PICC group (P = .75). The complete thrombosis rate was 15.6% in the nontapered PICC group compared with 20.8% in the reverse tapered PICC group (P = .44). There was a statistically significantly higher thrombosis rate in patients with cancer (71.9% vs 66.7%, P = .002).This study showed a high incidence of thrombosis of peripheral veins used for PICC insertion. The implication of this thrombosis is significant in light of the morbidity and potential mortality associated with this condition. A difference in thrombosis rate between devices could not be detected in this study.Published by SIR on behalf of The Society of Interventional Radiology.
Thoracic duct embolization for the management of chylothoraces. - Current opinion in pulmonary medicine
The aim is to inform the reader on the recent advancements in the minimally invasive treatment of chylothorax.Intranodal lymphangiography has been demonstrated to be a superior alternative to traditional pedal lymphangiography for thoracic duct embolization (TDE). TDE is associated with less morbidity and better clinical success than conservative management or surgical intervention in both traumatic and nontraumatic causes of chylothorax. TDE embolization in the pediatric population was found to be feasible.Recent advances in the lymphangiography techniques and the accumulation of experience in treating chylous effusions have significantly broadened the adoption of TDE to treat chylothorax. TDE for traumatic chylothorax has been demonstrated to be less morbid and more effective than surgical and conservative treatment. In cases of nontraumatic chylothorax, the patient has to be evaluated by MRI and lymphangiography to exclude causes of chylothorax which cannot be managed by interruption of the thoracic duct (e.g. lymphatic malformations or chylous ascites). Future advancements in noninvasive imaging of the thoracic duct and imaging guidance during TDE will continue to refine the percutaneous management of chylous effusions.
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