Adrian V Hernandez

Publications

• 2.63

  Impact points

  Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy.

  Fatih Altunrende, Humberto Laydner, Adrian V Hernandez, Riccardo Autorino, Rakesh Khanna, Michael A White, Wahib Isac, Gregory Spana, Shahab Hillyer, Bo Yang, Rachid Yakoubi, Georges-Pascal Haber, Jihad H Kaouk, Robert J Stein

  World journal of urology. 04/2012;

  PURPOSE: The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). METH... [more] PURPOSE: The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). METHODS: In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT. RESULTS: Overall RNS was of low (4-6), moderate (7-9), and high complexity (10-12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p < 0.0001), entirely endophytic properties (E) (p = 0.005), tumor <4 mm from the collecting system/sinus (N) (p < 0.0001), and location between the polar lines (L) (p = 0.004). Total RNS and WIT were highly correlated (Spearman correlation coefficient = 0.54, p < 0.0001). There was a significant trend of higher WIT with increased tumor complexity (p for trend <0.0001). After multivariable analysis, only R (p = 0.0003), E (p = 0.003), and N (p = 0.00002) components of the RNS were significantly associated with WIT. CONCLUSIONS: The A and L subcategories of the RNS have no significant impact on the WIT of patients undergoing RPN. WIT is significantly dependent upon the other subcategories, as well as the overall RNS. These findings can be used to preoperatively predict which tumor characteristics will likely affect WIT and may be useful in preoperative counseling as well as planning of approach.
• 2.50

  Impact points

  Systematic Review of efficacy and safety of Buprenorphine versus Fentanyl or Morphine in patients with chronic moderate to severe pain.

  Robert F Wolff, Dagfinn Aune, Carla Truyers, Adrian V Hernandez, Kate Misso, Rob Riemsma, Jos Kleijnen

  Current medical research and opinion. 03/2012;

  Abstract Objective To systematically assess efficacy and safety of buprenorphine patch versus fentanyl patch in patients with chronic moderate to severe pain. Methods Fifteen databases were searched up to December 2010. Randomised and quasi-randomised trials assessing the efficacy in patients with c... [more] Abstract Objective To systematically assess efficacy and safety of buprenorphine patch versus fentanyl patch in patients with chronic moderate to severe pain. Methods Fifteen databases were searched up to December 2010. Randomised and quasi-randomised trials assessing the efficacy in patients with chronic pain were included. Quantitative methods for data synthesis were used and two network meta-analyses were conducted. Results Fourteen unique trials (17 publications) were included. No head-to-head randomised trials of buprenorphine patch compared with fentanyl patch were identified. Therefore, less robust evidence from indirect comparisons was used. Results from a network meta-analysis of non-enriched designs (8 trials), using trials versus placebo and trials versus morphine for indirect comparisons, indicated that transdermal fentanyl, in comparison with transdermal buprenorphine, showed significantly more nausea (Odds Ratio (OR) 4.66, 95 %-confidence interval (CI) 1.07 to 20.39), a significantly higher number of treatment discontinuations due to adverse events (OR 5.94, 95 %-CI 1.78 to 19.87), and non-significant differences on all other outcomes, including pain measures. In comparison with morphine, transdermal buprenorphine had a significantly higher decrease of pain intensity (MD (Mean difference) -16.20, 95 %-CI -28.92 to -3.48) while morphine caused more cases of constipation (OR 7.50, 95 %-CI 1.45 to 38.85) and a significantly higher number of treatment discontinuations due to adverse events (OR 5.80, 95 %-CI 1.68 to 20.11). All other outcomes showed non-significant differences between transdermal buprenorphine and morphine. The results were similar when also including 6 trials using enriched designs with the exception of more cases of vomiting for fentanyl (OR 17.32, 95 %-CI 4.43 to 67.71) and morphine (OR 15.85, 95 %-CI 3.92 to 64.13) compared to buprenorphine. Conclusions The findings indicate comparability of transdermal buprenorphine and transdermal fentanyl for pain measures with significantly fewer adverse events (nausea and treatment discontinuation due to adverse events) caused by transdermal buprenorphine.
• 5.64

  Impact points

  Association Between Proton Pump Inhibitor Therapy and Clostridium difficile Infection in a Meta-Analysis.

  Abhishek Deshpande, Chaitanya Pant, Vinay Pasupuleti, David D K Rolston, Anil Jain, Narayan Deshpande, Priyaleela Thota, Thomas J Sferra, Adrian V Hernandez

  Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 03/2012; 10(3):225-33.

  In the past decade, there has been a growing epidemic of Clostridium difficile infection (CDI). During this time, use of proton pump inhibitors (PPIs) has increased exponentially. We evaluated the association between PPI therapy and the risk of CDI by performing a meta-analysis. We searched MEDLINE ... [more] In the past decade, there has been a growing epidemic of Clostridium difficile infection (CDI). During this time, use of proton pump inhibitors (PPIs) has increased exponentially. We evaluated the association between PPI therapy and the risk of CDI by performing a meta-analysis. We searched MEDLINE and 4 other databases for subject headings and text words related to CDI and PPI in articles published from 1990 to 2010. All observational studies that investigated the risk of CDI associated with PPI therapy and used CDI as an end point were considered eligible. Two investigators screened articles independently for inclusion criteria, data extraction, and quality assessment; disagreements were resolved based on consensus with a third investigator. Data were combined by means of a random-effects model and odds ratios were calculated. Subgroup and sensitivity analyses were performed based on study design and antibiotic use. Thirty studies (25 case-control and 5 cohort) reported in 29 articles met the inclusion criteria (n = 202,965). PPI therapy increased the risk for CDI (odds ratio, 2.15, 95% confidence interval, 1.81-2.55), but there was significant heterogeneity in results among studies (P < .00001). This association remained after subgroup and sensitivity analyses, although significant heterogeneity persisted among studies. PPI therapy is associated with a 2-fold increase in risk for CDI. Because of the observational nature of the analyzed studies, we were not able to study the causes of this association. Further studies are needed to determine the mechanisms by which PPI therapy might increase risk for CDI.

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• 5.64

  Impact points

  Reply.

  Abhishek Deshpande, Vinay Pasupuleti, Adrian V Hernandez, Chaitanya Pant, Thomas J Sferra

  Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 02/2012;
• 6.71

  Impact points

  Adenoma detection rate is not influenced by full-day blocks, time, or modified queue position.

  Einar Lurix, Adrian V Hernandez, Matthew Thoma, Fernando Castro

  Gastrointestinal endoscopy. 02/2012; 75(4):827-34.

  Recent studies have shown the adenoma detection rate (ADR) to decrease from endoscopist fatigue. Our primary objective was to evaluate the afternoon ADR in half-day versus full-day blocks. Secondary objectives were to determine whether time or complexity of prior procedures (modified queue position)... [more] Recent studies have shown the adenoma detection rate (ADR) to decrease from endoscopist fatigue. Our primary objective was to evaluate the afternoon ADR in half-day versus full-day blocks. Secondary objectives were to determine whether time or complexity of prior procedures (modified queue position) influence ADR. Retrospective chart review on consecutive colonoscopies. Tertiary-care teaching hospital. This study involved all patients in our database who were over age 45 and who underwent screening and surveillance colonoscopies. ADR. A total of 3085 patients were included in the study, with an overall 31% ADR. Of these procedures, 2148 (70%) were done in the morning, and 937 (30%) were done in the afternoon (512 full-day block, 425 half-day block). By multivariate analysis, there was no difference in ADR between full-day blocks compared with afternoon-only blocks (35% vs 32%; odds ratio [OR] 1.1; 95% confidence interval [CI], 0.8-1.5; P = .2). For all afternoon colonoscopies, no decrease in ADR was noted with increasing queue position (P = .9) or time (P = .3). In addition, no difference was found comparing ADR between all afternoon colonoscopies versus morning colonoscopies (33% vs 30%; OR 1.1; CI, 1.0-1.3; P = .1). No difference was found for advanced adenomas and number of adenomas between either afternoon-only blocks versus afternoon colonoscopy in full-day blocks or morning versus all afternoon cases. Retrospective study; not all withdrawal times were recorded; trainees performed some of the procedures. Our data show that colonoscopy can be performed in full-day blocks and 30-minute slots without compromising ADR.
• 3.06

  Impact points

  Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management.

  Akshat C Pujara, Eric E Roselli, Adrian V. Hernandez, et al

  Journal of Thoracic and Cardiovascular Surgery. 02/2012;

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• 9.81

  Impact points

  Dabigatran Association With Higher Risk of Acute Coronary Events: Meta-analysis of Noninferiority Randomized Controlled Trials.

  Ken Uchino, Adrian V Hernandez

  Archives of internal medicine. 01/2012;

  BACKGROUND: The original RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) trial suggested a small increased risk of myocardial infarction (MI) with the use of dabigatran etexilate vs warfarin in patients with atrial fibrillation. We systematically evaluated the risk of MI or acute co... [more] BACKGROUND: The original RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) trial suggested a small increased risk of myocardial infarction (MI) with the use of dabigatran etexilate vs warfarin in patients with atrial fibrillation. We systematically evaluated the risk of MI or acute coronary syndrome (ACS) with the use of dabigatran. METHODS: We searched PubMed, Scopus, and the Web of Science for randomized controlled trials of dabigatran that reported on MI or ACS as secondary outcomes. The fixed-effects Mantel-Haenszel (M-H) test was used to evaluate the effect of dabigatran on MI or ACS. We expressed the associations as odds ratios (ORs) and their 95% CIs. RESULTS: Seven trials were selected (N = 30 514), including 2 studies of stroke prophylaxis in atrial fibrillation, 1 in acute venous thromboembolism, 1 in ACS, and 3 of short-term prophylaxis of deep venous thrombosis. Control arms included warfarin, enoxaparin, or placebo administration. Dabigatran was significantly associated with a higher risk of MI or ACS than that seen with agents used in the control group (dabigatran, 237 of 20 000 [1.19%] vs control, 83 of 10 514 [0.79%]; OR(M-H), 1.33; 95% CI, 1.03-1.71; P = .03). The risk of MI or ACS was similar when using revised RE-LY trial results (OR(M-H), 1.27; 95% CI, 1.00-1.61; P = .05) or after exclusion of short-term trials (OR(M-H), 1.33; 95% CI, 1.03-1.72; P = .03). Risks were not heterogeneous for all analyses (I(2) = 0%; P ≥ .30) and were consistent using different methods and measures of association. CONCLUSIONS: Dabigatran is associated with an increased risk of MI or ACS in a broad spectrum of patients when tested against different controls. Clinicians should consider the potential of these serious harmful cardiovascular effects with use of dabigatran.

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• African american race and prevalence of atrial fibrillation:a meta-analysis.

  Marlow B Hernandez, Craig R Asher, Adrian V Hernandez, Gian M Novaro

  Cardiology research and practice. 01/2012; 2012:275624.

  Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient... [more] Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient populations which reported the presence of AF by race. Methods. A literature search was conducted using electronic databases between January 1999 and January 2011. The search was limited to published studies in English conducted in the United States, which clearly defined the presence of AF in African American and Caucasian subjects. A meta-analysis was performed with prevalence of AF as the primary endpoint. Results. In total, 10 studies involving 1,031,351 subjects were included. According to a random effects analysis, African American race was associated with a protective effect with regard to AF as compared to Caucasian race (odds ratio 0.51, 95% CI 0.44 to 0.59, P < 0.001). In subgroup analyses, African American race was significantly associated with a lower prevalence of AF in the general population, those hospitalized or greater than 60 years old, postcoronary artery bypass surgery patients, and subjects with heart failure. Conclusions. In a broad sweep of subjects in the general population and hospitalized patients, the prevalence of AF in African Americans is consistently lower than in Caucasians.
• 2.96

  Impact points

  Covariate adjustment increased power in randomized controlled trials: an example in traumatic brain injury.

  Elizabeth L Turner, Pablo Perel, Tim Clayton, Phil Edwards, Adrian V Hernández, Ian Roberts, Haleema Shakur, Ewout W Steyerberg

  Journal of clinical epidemiology. 12/2011;

  OBJECTIVE: We aimed to determine to what extent covariate adjustment could affect power in a randomized controlled trial (RCT) of a heterogeneous population with traumatic brain injury (TBI). STUDY DESIGN AND SETTING: We analyzed 14-day mortality in 9,497 participants in the Corticosteroid Randomiza... [more] OBJECTIVE: We aimed to determine to what extent covariate adjustment could affect power in a randomized controlled trial (RCT) of a heterogeneous population with traumatic brain injury (TBI). STUDY DESIGN AND SETTING: We analyzed 14-day mortality in 9,497 participants in the Corticosteroid Randomization After Significant Head Injury (CRASH) RCT of corticosteroid vs. placebo. Adjustment was made using logistic regression for baseline covariates of two validated risk models derived from external data (International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury [IMPACT]) and from the CRASH data. The relative sample size (RESS) measure, defined as the ratio of the sample size required by an adjusted analysis to attain the same power as the unadjusted reference analysis, was used to assess the impact of adjustment. RESULTS: Corticosteroid was associated with higher mortality compared with placebo (odds ratio=1.25, 95% confidence interval=1.13-1.39). RESS of 0.79 and 0.73 were obtained by adjustment using the IMPACT and CRASH models, respectively, which, for example, implies an increase from 80% to 88% and 91% power, respectively. CONCLUSION: Moderate gains in power may be obtained using covariate adjustment from logistic regression in heterogeneous conditions such as TBI. Although analyses of RCTs might consider covariate adjustment to improve power, we caution against this approach in the planning of RCTs.

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• 3.08

  Impact points

  Discrepancy in prostate cancer localization between biopsy and prostatectomy specimens in patients with unilateral positive biopsy: Implications for focal therapy.

  Michael Sinnott, Sara M Falzarano, Adrian V Hernandez, J Stephen Jones, Eric A Klein, Ming Zhou, Cristina Magi-Galluzzi

  The Prostate. 12/2011;

  BACKGROUND: Unilateral ablative strategy success depends on reliable prediction of prostate cancer (PCA) location. We evaluated the discrepancy in PCA localization between unilateral positive biopsy (PBx) and radical prostatectomy (RP). METHODS: Between 2004 and 2008, 431 patients were diagnosed wit... [more] BACKGROUND: Unilateral ablative strategy success depends on reliable prediction of prostate cancer (PCA) location. We evaluated the discrepancy in PCA localization between unilateral positive biopsy (PBx) and radical prostatectomy (RP). METHODS: Between 2004 and 2008, 431 patients were diagnosed with unilateral PCA by 12-core PBx; 179 underwent RP and constituted our study cohort. Specimens were reviewed to map tumor outline and determine number of cancer foci, tumor volume, Gleason score (GS), zone of origin, localization, and pathologic stage. RESULTS: In 50 men, biopsy and prostatectomy findings correlated (unilateral tumor); in 129, PCA was detected in the contralateral side of the prostate. In 52 patients, 54 clinically significant tumors were missed by biopsy. When patients with true unilateral and missed contralateral disease at RP were compared with respect to prognostic parameters no significant differences were detected. Sixty-one of the 88 patients with preoperative low-risk disease had true unilateral (n = 21) or missed insignificant contralateral (n = 40) PCA; 27 had missed significant contralateral PCA at RP. PSA > 4 ng/ml predicted presence of significant bilateral disease in low-risk population (P = 0.004). Twenty-four of 27 patients with significant bilateral cancer had PSA > 4, although 33/61 with unilateral or bilateral insignificant cancer had similar elevated PSA values. CONCLUSIONS: Twelve-core biopsy is inadequate to identify candidates for organ-sparing therapy. Most men with unilateral positive biopsies have bilateral cancer at prostatectomy. Tumors missed by biopsy were clinically significant in 40% of patients, but no prognostic parameters could predict unilateral disease. Hemi-ablative treatment might fail to eradicate significant lesions in the contralateral side. Prostate © 2011 Wiley Periodicals, Inc.
• 8.20

  Impact points

  Diagnostic accuracy of real-time polymerase chain reaction in detection of Clostridium difficile in the stool samples of patients with suspected Clostridium difficile Infection: a meta-analysis.

  Abhishek Deshpande, Vinay Pasupuleti, David D K Rolston, Anil Jain, Narayan Deshpande, Chaitanya Pant, Adrian V Hernandez

  Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 10/2011; 53(7):e81-90.

  Current detection methods for Clostridium difficile infection (CDI) can be time-consuming and have variable sensitivities. Real-time polymerase chain reaction (PCR) may allow earlier and more accurate diagnosis of CDI than other currently available diagnostic tests. A meta-analysis was performed to ... [more] Current detection methods for Clostridium difficile infection (CDI) can be time-consuming and have variable sensitivities. Real-time polymerase chain reaction (PCR) may allow earlier and more accurate diagnosis of CDI than other currently available diagnostic tests. A meta-analysis was performed to determine the diagnostic accuracy of real-time PCR. We searched MEDLINE (Pubmed/Ovid) and 4 other online electronic databases (1995-2010) to identify diagnostic accuracy studies that compared PCR with cell culture cytotoxicity neutralization assay (CCCNA) or anaerobic toxigenic culture (TC) of C. difficile. Screening for inclusion, data extraction, and quality assessment were carried out independently by 2 investigators and disagreements resolved. Data were combined by means of a random-effects model, and summary receiver operating characteristic curves and diagnostic odds ratios were calculated. Nineteen studies (7392 samples) met our inclusion criteria. The overall mean sensitivity of PCR was 90% (95% confidence interval [CI]: 88%-91%), specificity 96% (CI: 96%-97%), positive likelihood ratio 26.89 (CI: 20.81-34.74), negative likelihood ratio 0.11 (CI: .08-.15), diagnostic odds ratio 278.23 (CI: 213.56-362.50), and area under the curve 0.98 (CI: .98-.99). Test accuracy depended on the prevalence of C. difficile but not on the reference test used. At C. difficile prevalence of <10%, 10%-20% and >20% the positive predictive value and the negative predictive value were 71%, 79%, 93% and 99%, 98% and 96%, respectively. Real-time PCR has a high sensitivity and specificity to confirm CDI. Overall diagnostic accuracy is variable and depends on CDI prevalence.

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• 5.39

  Impact points

  Effect of rural-to-urban within-country migration on cardiovascular risk factors in low- and middle-income countries: a systematic review.

  Adrián V Hernández, Vinay Pasupuleti, Abhishek Deshpande, Antonio Bernabé-Ortiz, J Jaime Miranda

  Heart (British Cardiac Society). 09/2011; 98(3):185-94.

  Limited information is available of effects of rural-to-urban within-country migration on cardiovascular (CV) risk factors in low- and middle- income countries (LMIC). A systematic review of studies evaluating these effects was performed with rural and/or urban control groups. Two teams of investiga... [more] Limited information is available of effects of rural-to-urban within-country migration on cardiovascular (CV) risk factors in low- and middle- income countries (LMIC). A systematic review of studies evaluating these effects was performed with rural and/or urban control groups. Two teams of investigators searched observational studies in Medline, Web of Science and Scopus until May 2011. Studies evaluating international migration were excluded. Three investigators extracted the information stratified by gender. Information on 17 known CV risk factors was obtained. Eighteen studies (n=58,536) were included. Studies were highly heterogeneous with respect to study design, migrant sampling frame, migrant urban exposure and reported CV risk factors. In migrants, commonly reported CV risk factors-systolic and diastolic blood pressure, body mass index, obesity, total cholesterol and low-density lipoprotein-were usually higher or more common than in the rural group and usually lower or less common than in the urban group. This gradient was usually present in both genders. Anthropometric (waist-to-hip ratio, hip/waist circumference, triceps skinfolds) and metabolic (fasting glucose/insulin, insulin resistance) risk factors usually followed the same gradient, but conclusions were weak as information was insufficient. Hypertension, high-density lipoprotein, fibrinogen and C-reactive protein did not follow any pattern. In LMIC, most but not all, CV risk factors are higher or more common in migrants than in rural groups but lower or less common than in urban groups. Such gradients may or may not be associated with differential CV events and long-term evaluations are necessary.

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• 2.37

  Impact points

  Robotic versus laparoscopic partial nephrectomy for bilateral synchronous kidney tumors: single-institution comparative analysis.

  Shahab P Hillyer, Riccardo Autorino, Humberto Laydner, Bo Yang, Fatih Altunrende, Michael White, Gregory Spana, Rakesh Khanna, Wahib Isac, Adrian V Hernandez, Matthew Simmons, Robert Stein, Georges-Pascal Haber, Jihad Kaouk

  Urology. 08/2011; 78(4):808-12.

  To compare the intraoperative and early postoperative outcomes of robotic partial nephrectomy (RPN) with those of laparoscopic partial nephrectomy (LPN) outcomes in patients with bilateral synchronous renal tumors. RPN is emerging as an attractive minimally invasive nephron-sparing approach for rena... [more] To compare the intraoperative and early postoperative outcomes of robotic partial nephrectomy (RPN) with those of laparoscopic partial nephrectomy (LPN) outcomes in patients with bilateral synchronous renal tumors. RPN is emerging as an attractive minimally invasive nephron-sparing approach for renal tumors. Our ongoing institutional review board-approved, prospectively maintained, kidney cancer database was used to identify the study population. The medical records of patients who underwent minimally invasive nephron-sparing surgery at our institution from January 2001 to March 2010 were used. A cohort of 9 patients undergoing bilateral RPN was identified and compared with 17 consecutive patients who underwent sequential bilateral LPN. The demographic, intraoperative, postoperative, and short-term renal functional data were retrospectively compared between the 2 groups. A total of 18 procedures were performed in the RPN group and 32 in the LPN group. The median warm ischemia time was shorter in the RPN group than in the LPN group (19 vs 37 minutes, respectively; P = .059). The median tumor size was 2.85 and 2.7 cm in the RPN and LPN group, respectively (P = .03). The final median postoperative glomerular filtration rate was 68.7 mL/min/1.73 m(2) (interquartile range 14-73) and 26.9 mL/min/1.73 m(2) (interquartile range 20-70) in the RPN and LPN groups, respectively (P = .004). No difference was found in the complications in the RPN group (n = 2) compared with the LPN group (n = 4). RPN is a safe and effective minimally invasive nephron-sparing treatment of bilateral synchronous kidney tumors. A trend was seen toward a shorter warm ischemia time and less effects on postoperative renal function compared with the laparoscopic approach.
• 2.37

  Impact points

  Utility of percent free prostate-specific antigen in repeat prostate biopsy.

  Byron H Lee, Adrian V Hernandez, Osama Zaytoun, Ryan K Berglund, Michael C Gong, J Stephen Jones

  Urology. 06/2011; 78(2):386-91.

  To assess the utility of the percent free prostate-specific antigen (%fPSA) for the prediction of prostate cancer in men undergoing repeat biopsy. A retrospective review was performed of 1037 patients in an institutional review board-approved repeat prostate biopsy database. A total of 617 patients ... [more] To assess the utility of the percent free prostate-specific antigen (%fPSA) for the prediction of prostate cancer in men undergoing repeat biopsy. A retrospective review was performed of 1037 patients in an institutional review board-approved repeat prostate biopsy database. A total of 617 patients who underwent 683 biopsies had all their data available for analysis. The patients were categorized as having undergone 1 repeat biopsy or >1 repeat biopsy. The overall cancer detection rate was 27% and 22% in men who underwent 1 and >1 repeat biopsy, respectively. The area under the receiver operating characteristic curve for the %fPSA was 0.65 for men who underwent 1 repeat biopsy. Multivariate analysis demonstrated that a positive family history, decreasing %fPSA, and presence of high-grade intraepithelial neoplasia and/or atypical small acinar proliferation predicted for cancer. The univariate odds ratio for every 5% decrease in the %fPSA was 1.5 (95% confidence interval 1.2-1.7). The performance of %fPSA was further improved in men who underwent >1 repeat biopsy, with an area under the curve of 0.72. In men who underwent >1 repeat biopsy, multivariate analysis showed that a decreasing %fPSA, >20 cores removed, and high-grade intraepithelial neoplasia predicted for cancer. The univariate odds ratio for every 5% decrease in the %fPSA was 1.8 (95% confidence interval 1.4-2.3). A %fPSA cutoff of 10% achieved 90% and 91% specificity in the 1 repeat biopsy and >1 repeat biopsy groups, respectively. %fPSA is useful in predicting for prostate cancer in the repeat biopsy population, particularly for those who have undergone multiple repeat biopsies. A persistently low %fPSA should prompt additional investigation in these men.
• 0.55

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  Prevalence and factors associated with darunavir resistance mutations in multi-experienced HIV-1-infected patients failing other protease inhibitors in a referral teaching center in Brazil.

  Jose E Vidal, Angela C Freitas, Alice Tw Song, Silvia V Campos, Mirian Dalben, Adrian V Hernandez

  The Brazilian journal of infectious diseases : an official publication of the Brazilian Society of Infectious Diseases. 06/2011; 15(3):245-8.

  Information about resistance profile of darunavir (DRV) is scarce in Brazil. Our objectives were to estimate the prevalence of DRV resistance mutations in patients failing protease inhibitors (PI) and to identify factors associated with having more DRV resistance mutations. All HIV-infected patients... [more] Information about resistance profile of darunavir (DRV) is scarce in Brazil. Our objectives were to estimate the prevalence of DRV resistance mutations in patients failing protease inhibitors (PI) and to identify factors associated with having more DRV resistance mutations. All HIV-infected patients failing PI-based regimens with genotyping performed between 2007 and 2008 in a referral teaching center in São Paulo, Brazil, were included. DRV-specific resistance mutations listed by December 2008 IAS-USA panel update were considered. Two Poisson regression models were constructed to assess factors related to the presence of more DRV resistance mutations. A total of 171 HIV-infected patients with available genotyping were included. The number of patients with lopinavir, saquinavir, and amprenavir used in previous regimen were 130 (76%), 83 (49%), and 35 (20%), respectively. The prevalence of major DRV resistance mutations was 50V: 5%; 54M: 1%; 76V: 4%; 84V: 15%. For minor mutations, the rates were 11I: 3%; 32I: 7%; 33F: 23%; 47V: 6%; 54L: 6%; 74P: 3%; 89V: 6%. Only 11 (6%) of the genotypes had > 3 DRV resistance mutations. In the clinical model, time of HIV infection of > 10 years and use of amprenavir were independently associated with having more DRV resistance mutations. In the genotyping-based model, only total number of PI resistance mutations was associated with our outcome. In conclusion, the prevalence of DRV mutations was low. Time of HIV infection, use of amprenavir and total number of PI resistance mutations were associated with having more DRV mutations.
• 3.06

  Impact points

  Endovascular repair of complicated chronic distal aortic dissections: intermediate outcomes and complications.

  Woong Chol Kang, Roy K Greenberg, Tara M Mastracci, Matthew J Eagleton, Adrian V Hernandez, Akshat C Pujara, Eric E Roselli

  The Journal of thoracic and cardiovascular surgery. 05/2011; 142(5):1074-83.

  Patients with chronic distal aortic dissection (CDAD) remain at high risk for late aorta-related events and reinterventions, and the ideal management strategy remains undefined. Open surgical procedures carry morbidity, but scant data for thoracic endovascular aortic repair (TEVAR) of CDAD exist. Th... [more] Patients with chronic distal aortic dissection (CDAD) remain at high risk for late aorta-related events and reinterventions, and the ideal management strategy remains undefined. Open surgical procedures carry morbidity, but scant data for thoracic endovascular aortic repair (TEVAR) of CDAD exist. This study reports our intermediate-term results with TEVAR for complicated CDAD. All cases of TEVAR for complicated (aortic growth, malperfusion, intractable pain) CDAD at our institution between 2000 and 2007 were retrospectively reviewed. Demographic information, indications for repair, complications, and aortic morphologic changes were collected from medical records and imaging studies. Aortic morphology (aneurysm size, false lumen thrombosis) was assessed at multiple levels with 3-dimensional image analysis techniques. Kaplan-Meier analysis was used to estimate survival, freedom from reintervention, and likelihood of false lumen thrombosis, with log-rank tests used to discriminate between Kaplan-Meier curves. In total, 144 stent-grafts were implanted in 76 consecutive patients (49 male) with complicated CDAD. Early (<30 postoperative days) mortality was 5%. There was no paraplegia, and 1 patient died of stroke. At mean follow-up of 34 months, 12 patients had died (1 aorta-related death). Seventeen patients (22%) underwent 19 secondary aortic reinterventions, mainly for enlargement of the untreated aorta remote to stent-graft repair. Three secondary procedures treated retrograde proximal dissections. Estimated survivals were 86%, 82%, and 80% at 12, 24, and 36 months, respectively, and freedoms from both death and reintervention were 72%, 64%, and 59% at similar time points. Of 67 patients (88%) with complete imaging follow-up, TEVAR resulted in significantly decreased aortic diameter through the stent-grafted segment but not untreated segments. Complete thrombosis of the entire false lumen was uncommon in patients with extensive dissections (13% vs 78% P < .001). Management of complicated CDAD remains challenging for clinicians. TEVAR is a reasonable treatment modality for dissections limited to the thoracic aorta and for prevention of focal aortic growth in extensive dissections. Late complications and the need for secondary interventions emphasize the complexity of this patient population and the need for long-term follow-up.

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• 4.02

  Impact points

  Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function.

  Brian R Lane, Paul Russo, Robert G Uzzo, Adrian V Hernandez, Stephen A Boorjian, R Houston Thompson, Amr F Fergany, Thomas E Love, Steven C Campbell

  The Journal of urology. 02/2011; 185(2):421-7.

  Factors that determine renal function after partial nephrectomy are not well-defined, including the impact of cold vs warm ischemia, and the relative importance of modifiable and nonmodifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney und... [more] Factors that determine renal function after partial nephrectomy are not well-defined, including the impact of cold vs warm ischemia, and the relative importance of modifiable and nonmodifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney undergoing partial nephrectomy. From 1980 to 2009, 660 partial nephrectomies were performed at 4 centers for tumor in a solitary functioning kidney under cold (300) or warm (360) ischemia. Data were collected in institutional review board approved registries and followup averaged 4.5 years. Preoperative and postoperative glomerular filtration rates were estimated via the Chronic Kidney Disease-Epidemiology Study equation. At 3 months after partial nephrectomy median glomerular filtration rate decreased by equivalent amounts with cold or warm ischemia (21% vs 22%, respectively, p = 0.7), although median cold ischemic times were much longer (45 vs 22 minutes respectively, p <0.001). On multivariable analyses increasing age, larger tumor size, lower preoperative glomerular filtration rate and longer ischemia time were associated with decreased postoperative glomerular filtration rate (p <0.05). When percentage of parenchyma spared was incorporated into the analysis, this factor and preoperative glomerular filtration rate proved to be the primary determinants of ultimate renal function, and duration of ischemia lost statistical significance. This nonrandomized, comparative study suggests that within the relatively strict parameters of conventional practice, ie predominantly short ischemic intervals and liberal use of hypothermia, ischemia time was not an independent predictor of ultimate renal function after partial nephrectomy. Long-term renal function after partial nephrectomy is determined primarily by the quantity and quality of renal parenchyma preserved, although type and duration of ischemia remain the most important modifiable factors, and warrant further study.
• 4.02

  Impact points

  Single focus prostate cancer: pathological features and ERG fusion status.

  Sara M Falzarano, Ming Zhou, Adrian V Hernandez, Eric A Klein, Mark A Rubin, Cristina Magi-Galluzzi

  The Journal of urology. 02/2011; 185(2):489-94.

  We evaluated the clinicopathological characteristics of single focus prostate cancer in radical prostatectomies, its clinical relevance and the occurrence of TMPRSS2-ERG rearrangement. We reviewed the records of 1,100 radical prostatectomies and determined the tumor outline and number of cancer foci... [more] We evaluated the clinicopathological characteristics of single focus prostate cancer in radical prostatectomies, its clinical relevance and the occurrence of TMPRSS2-ERG rearrangement. We reviewed the records of 1,100 radical prostatectomies and determined the tumor outline and number of cancer foci. When single focus prostate cancer was identified, we recorded pathological characteristics. We assessed ERG fusion status in a subset of cases. Single focus prostate cancer was identified in 106 radical prostatectomies. Median patient age was 59 years. Median prostate specific antigen was 5.1 ng/ml. Single focus cancer was unilateral in 81% of cases and 98% originated from the peripheral zone. Tumor volume was 0.1 to 3.9 cm(3) (median 0.5). Gleason score was 6 in 38% of patients, 7 in 40%, 8 or greater in 21% and undetermined in 2%. Extraprostatic extension and seminal vesicles invasion were detected in 30% and 2% of cases, respectively. Stage was pT2 in 62% of cases, pT2 with positive margin of resection in 7% and pT3 in 30%. ERG fusion was detected in 68% of tumors. Cases rearranged via deletion had significantly higher tumor volume. Three cases showed intratumor heterogeneity. Single focus prostate cancer accounted for 9.6% of tumors. In most cases it involved 1 lobe of the gland and originated from the peripheral zone. Despite a trend toward high grade disease 62% of single focus prostate cancers were organ confined. Only 3 fusion positive cases showed intratumor heterogeneity, suggesting that most single focus cancer may evolve from a single clone of malignant cells.
• 1.96

  Impact points

  Thiazolidinediones and risk of heart failure in patients with or at high risk of type 2 diabetes mellitus: a meta-analysis and meta-regression analysis of placebo-controlled randomized clinical trials.

  Adrian V Hernandez, Ali Usmani, Anitha Rajamanickam, A Moheet

  American journal of cardiovascular drugs : drugs, devices, and other interventions. 02/2011; 11(2):115-28.

  Recent meta-analyses of randomized clinical trials (RCTs) demonstrated a higher risk of heart failure (HF) with the use of thiazolidinediones (TZDs). However, this effect may have been diluted by including active controls. Also, it is uncertain whether the risk of HF is similar with rosiglitazone an... [more] Recent meta-analyses of randomized clinical trials (RCTs) demonstrated a higher risk of heart failure (HF) with the use of thiazolidinediones (TZDs). However, this effect may have been diluted by including active controls. Also, it is uncertain whether the risk of HF is similar with rosiglitazone and pioglitazone. This study quantified the risks of HF with the use of TZDs in patients with or at high risk of developing type 2 diabetes mellitus (DM), and evaluated differential effects by type of TZD. Secondarily, we evaluated risks of peripheral edema. We performed a systematic review and meta-analysis of placebo-controlled RCTs evaluating the effect of rosiglitazone or pioglitazone on investigator-reported HF and edema. Articles published before 31 December 2009 were searched in MEDLINE, The Web of Science, and Scopus, and the data were extracted by three investigators. RCTs with ≥100 patients and ≥3 months of follow-up were included. We quantified the effect of TZDs as odds ratios (ORs) by using the Mantel-Haenzel and alternative models. We further evaluated the risk of serious/severe HF, and the effect of several trial characteristics on HF risk by subgroup analysis and meta-regression analysis. 29 trials (n = 20 254) were evaluated. TZDs were significantly associated with HF (TZD 360/6807 [5.3%] vs placebo 234/6328 [3.7%], OR 1.59; 95% CI 1.34, 1.89; p < 0.00001). The risk of HF was higher with rosiglitazone than with pioglitazone (2.73 [95% CI 1.46, 5.10] vs 1.51 [1.26, 1.81]; p = 0.06). TZDs were associated with a similar risk of serious/severe HF (OR 1.47; 95% CI 1.16, 1.87; p = 0.002). Use of TZDs was also associated with edema (OR 2.04; 95% CI 1.85, 2.26; p < 0.00001). HF and edema risks were consistent using Peto and random effects models. Risks of HF were significantly high for the subgroups of trials including patients with or at high risk for type 2 DM, and for the subgroup of trials with ≥12 months of follow-up. Meta-regression analysis showed that trials with lower overall baseline risk had higher HF risks. In placebo-controlled trials of adult patients with or at high risk for type 2 DM, TZD therapy is significantly and consistently associated with a higher risk of HF. The risk of serious/severe HF is also increased with the use of TZDs. HF risks are similar to those of meta-analyses combining active- and placebo-controlled trials. The benefit/risk profile of TZDs should be considered when treating diabetic patients with or without prior HF.

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• 2.37

  Impact points

  Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of ≥7.

  Michael A White, Georges-Pascal Haber, Riccardo Autorino, Rakesh Khanna, Adrian V Hernandez, Sylvain Forest, Bo Yang, Fatih Altunrende, Robert J Stein, Jihad H Kaouk

  Urology. 02/2011; 77(4):809-13.

  To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients... [more] To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (≥7) (tumor size-[R]adius, location and depth-[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. The median body mass index was 29.6 kg/m(2) (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m(2) (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.