[Show abstract][Hide abstract] ABSTRACT: Bevacizumab (BZM) and temozolomide (TMZ) have been shown to be beneficial in the treatment of patients with glioblastoma. We sought evidence for the benefit of BZM in the general patient population at large. The Surveillance, Epidemiology, and End Results SEER database was queried for patients diagnosed with glioblastoma between 2000 and 2009, divided into a pre-TMZ era (January 2000–June 2003), a transitional era (July 2003–March 2005), a TMZ era (April 2005–October 2007), and a BZM-TMZ era (November 2007–December 2009). Binomial logit regression analyzed odds of death, taking into account age at diagnosis, tumor size, gender, race, marital status, radiotherapy, and extensive surgery. Compared with the pre-TMZ era, odds of death were decreased in the TMZ era by 12% (97.5% CI [confidence interval] 3–20%) 6 months after diagnosis and 36% (30–42%) a year after diagnosis; corresponding values for BZM-TMZ were 31% (24–37%) and 50% (45–55%). For era comparisons, decreases in odds of death were larger at 12 than 6 months; the opposite was true for extensive surgery and radiotherapy (P < 0.025, Wald χ2 test, for each analysis). For both 6 and 12 month comparisons, odds of death in the BZM-TMZ era were lower than in the TMZ era (P < 0.025, Wald χ2 test, for each analysis). The results provide evidence that TMZ positively impacted survival of glioblastoma patients and that the addition of BZM further improved survival, this lends support to the addition of BZM to the chemotherapeutic armamentarium. Evaluation of odds of death is an attractive alternative to Cox regression when proportional hazards assumptions are violated and follow-up is good.
[Show abstract][Hide abstract] ABSTRACT: The present study sought to determine the survival outcomes for women diagnosed with breast and endometrial cancer. Using SEER data, a population-based cohort study of women diagnosed with breast and endometrial cancer was conducted. Kaplan-Meier survival curves were created for disease-specific survival rates. A total of 2,027 women diagnosed with breast and endometrial cancer were identified. Of these, 1,296 (63.9%) developed breast cancer first and 731 (36.1%) developed endometrial cancer first. Regional lymph node involvement was significantly more common with a breast cancer diagnosis [522 (25.8%) women] compared with an endometrial cancer diagnosis [87 (4.3%) women] (P<0.05). Factors associated with decreased survival included a high tumor grade in endometrial cancer, nodal positivity and estrogen receptor-negative breast cancer (P<0.05 for each). There were 83 (4.1%) mortalities due to breast cancer, 63 (3.1%) mortalities due to endometrial cancer and 178 (8.8%) mortalities due to other causes (P<0.05). In conclusion, for women diagnosed with breast and endometrial cancer, the cumulative risk of mortality at five years following the second cancer diagnosis is nearly four times more likely to be due to breast cancer than endometrial cancer.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND/OBJECTIVES: Sildenafil decreases pulmonary vascular resistance index (PVRI), in patients with pulmonary hypertension (PH). We investigated sildenafils' effects on central hemodynamics of mechanically ventilated patients with WHO group-III PH and RV failure necessitating dobutamine administration. METHODS: Prospective non-controlled study involving 12 (9 males, 59±4years old), patients with the above characteristics. All patients in phase-1 (days 1-2) received dobutamine (5μg/kg/min IV). During phase-2 (days 3-6), sildenafil was started via nasogastric tube (80mg/day) and dobutamine discontinuation was attempted. Patients were designated responders or non-responders based on whether dobutamine could be stopped or not. Phase-3 lasted from day 7 to day of weaning from mechanical ventilation; or if weaning failed, until day 20 following admission (end-of-study). Invasive and echocardiographic parameters were repeatedly recorded throughout the study. RESULTS: Significantly changed parameters (P<0.025) from baseline to phase-1, -2 and -3 (%change of mean ratios), in responders (n=7) included among others PVRI (-40%, -51%, -42%), RV stroke work index (RVSWI: 43%, 79%, 41%) and cardiac index (49%, 54%, 48%), which also differed significantly from non-responders (N=5). In phases-1 and -3 non-responders had not significant changes, in phase-2 PVRI (27%) and RVSWI (-22%) changed significantly. In contrast to non-responders, all responders were weaned from mechanical ventilation until the end-of-study (P<0.025). CONCLUSIONS: Sildenafil may improve central hemodynamics and RV function indices in ventilated patients with WHO group-III PH and RV failure requiring dobutamine infusion, when they respond favorably to the latter. Accordingly, an adequate RV systolic reserve may be mandatory for sildenafil to exert its actions.
International journal of cardiology 03/2012; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction. Fast and accurate diagnosis of alveolar-interstitial syndrome is of major importance in the critically ill. We evaluated the utility of lung ultrasound (US) in detecting and localizing alveolar-interstitial syndrome in respective pulmonary lobes as compared to computed tomography scans (CT). Methods. One hundred and seven critically ill patients participated in the study. The presence of diffuse comet-tail artifacts was considered a sign of alveolar-interstitial syndrome. We designated lobar reflections along intercostal spaces and surface lines by means of sonoanatomy in an effort to accurately localize lung pathology. Each sonographic finding was thereafter grouped into the respective lobe. Results. From 107 patients, 77 were finally included in the analysis (42 males with mean age = 61 ± 17 years, APACHE II score = 17.6 ± 6.4, and lung injury score = 1.0 ± 0.7). US exhibited high sensitivity and specificity values (ranging from over 80% for the lower lung fields up to over 90% for the upper lung fields) and considerable consistency in the diagnosis and localization of alveolar-interstitial syndrome. Conclusions. US is a reliable, bedside method for accurate detection and localization of alveolar-interstitial syndrome in the critically ill.
Critical care research and practice 01/2012; 2012:179719.
[Show abstract][Hide abstract] ABSTRACT: Background-Aim. Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting. Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC) were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers. Results. Thirty-six (11.25%) patients had UEDVT and a complete scan was performed. One (2.7%) of these patients died, and 2 had pulmonary embolism (5.5%). Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR) 2.716, P = 0.007)], malignancy (OR 1.483, P = 0.036), total parenteral nutrition (OR 1.399, P = 0.035), hypercoagulable state (OR 1.284, P = 0.045), and obesity (OR 1.191, P = 0.049). Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined. Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.
Critical care research and practice 01/2012; 2012:489135.
[Show abstract][Hide abstract] ABSTRACT: Pseudomonas aeruginosa, which causes serious infections in immunocompromised patients, produces numerous virulence factors, including exotoxin A and the siderophore pyoverdine. As production of these virulence factors is influenced by the host environment, we examined the effect serum has on global transcription within P. aeruginosa strain PAO1 at different phases of growth in an iron-deficient medium. At early exponential phase, serum significantly enhanced expression of 138 genes, most of which are repressed by iron, including pvdS, regA and the pyoverdine synthesis genes. However, serum did not interfere with the repression of these genes by iron. Serum enhanced regA expression in a fur mutant of PAO1 but not in a pvdS mutant. The serum iron-binding protein apotransferrin, but not ferritin, enhanced regA and pvdS expression. However, in PAO1 grown in a chemically defined medium that contains no iron, serum but not apotransferrin enhanced pvdS and regA expression. While complement inactivation failed to eliminate this effect, albumin absorption reduced the effect of serum on pvdS and regA expression in the iron-deficient medium chelexed tryptic soy broth dialysate. Additionally, albumin absorption eliminated the effect of serum on pvdS and regA expression in the chemically defined medium. These results suggest that serum enhances the expression of P. aeruginosa iron-controlled genes by two mechanisms: one through apotransferrin and another one through albumin.
[Show abstract][Hide abstract] ABSTRACT: Endoscopic thyroidectomy (ET) precludes the long cervical incision of the open procedure. Although endoscopy is an essential tool taught to almost every surgeon, its effective use with regard to thyroidectomy requires understanding its limitations pertaining to trauma and cancer, as well as an understanding of the advantages and disadvantages of the different endoscopic approaches. The development of an ET center in China is discussed here.
Overall, 235 patients who had undergone attempted ET in Qilu Hospital of Shandong University in China from August 2001 to September 2010 were evaluated.
Of the 11 men and 224 women on whom the procedure had been attempted, all but seven successfully underwent ET, 145 (63.6%) via a modified anterior chest approach, and 83 (36.4%) via a breast approach. Age ranged from 17 to 52 years, with a mean of 34.5 years. Surgery was limited, in the case of masses, to lesions smaller than 6 cm ultrasonographically. All patients were followed for at least 3 months. The 24 and 48 hours Visual Analog Scale postoperative measurements were low. Complications included four cases of cutaneous emphysema, five seromas, four episodes of anterior chest discomfort, three transient laryngeal nerve palsies, and four episodes of hypocalcemia. The seven procedures that had been converted to an open procedure comprised two patients discovered at frozen section to have poorly differentiated thyroid carcinoma, two with tumors larger than 5 cm, and three with thyroiditis.
ET is readily learned, provided the surgeon is competent at both laparoscopic technique and open thyroidectomy. Procedural advantages of an endoscopic approach include superior cosmesis and decreased invasiveness.
[Show abstract][Hide abstract] ABSTRACT: We evaluated whether the use of an intraoperative algorithm based on cerebral oximetry with near-infrared refracted spectroscopy (NIRS) monitoring, could aid in the intraoperative decision for shunt placement, in patients undergoing carotid endarterectomy (CEA).
In this prospective, randomized, controlled study were included 253 patients who underwent CEA under general anesthesia. They were randomly allocated in Group A (n=83) using NIRS monitoring and the suggested algorithm, Group B (n=84) using NIRS monitoring without the algorithm and Group C (n=86) who served as controls. Shunt placement criterion for Group A and B was 20% drop in ipsilateral regional saturation from the baseline value recorded before surgery. Primary endpoint of the study was to evaluate the use of the intraoperative algorithm based on NIRS monitoring, in the intraoperative decision for shunt placement, in patients undergoing carotid endarterectomy. Additionally, we examined whether this might affect the rate of postoperative neurologic deficits.
When compared with Group A, Group B and Group C had 3.7 times (99% c.i. 1.5-9.5) and 70.6 times (99% c.i. 15-724.3) respectively, greater likelihood of having a shunt placed. When compared with Group B, Group C had 19.4 times (99% c.i. 4.3-191.2) greater likelihood of having a shunt placed. Regarding the rate of postoperative neurologic deficits no significant difference was found between the three groups.
The use of a specific algorithm based on NIRS monitoring, in patients undergoing CEA, may aid in the intraoperative decision for shunt placement.
Middle East journal of anaesthesiology 10/2011; 21(3):367-73.
[Show abstract][Hide abstract] ABSTRACT: In October 2006, bevacizumab was approved for treatment for patients with metastatic non-small-cell lung cancer other than squamous carcinoma. Our hypothesis was that the change in survival after approval of bevacizumab for metastatic adenocarcinoma would show differences from that of small-cell carcinoma and squamous carcinoma.
Data was obtained from the National Cancer Institute Surveillance Epidemiology and End Results (SEER) registry for patients with lung cancer diagnosed between January 2004 and November 2007. In addition to known characteristics predicting survival differences (histotype, age, gender, and race) we compared 1-year survival experience in those diagnosed before (January 2004-September 2006) and after (October 2006-November 2007) introduction of bevacizumab.
Of 24,575 patients meeting criteria, 16,081 (65.4%) died within 1 y. Adjusted for age, gender, and race, patients with squamous carcinoma showed a 13% decline (95% CI 7%-20%) in survival times. By contrast, the 1% increment for adenocarcinoma and the 1% decrement for small cell carcinoma might well have been due to chance (P > 0.05 for each analysis).
Life expectancy for metastatic adenocarcinoma (for which bevacizumab is approved) and metastatic small-cell carcinoma (bevacizumab not approved) did not change statistically. On the other hand, life expectancy for patients with metastatic squamous carcinoma (bevacizumab not approved) of the lung has declined since the approval of bevacizumab. This likely reflects increased classification of tumors previously diagnosed as poorly differentiated non-small-cell carcinoma as poorly differentiated squamous carcinoma. Hence, life expectancy of metastatic adeno, squamous, and small-cell-lung cancer has not improved after introduction of bevacizumab.
Journal of Surgical Research 07/2011; 174(1):20-3. · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients diagnosed with both breast and colorectal cancer are not uncommon and will likely be seen more often as the population ages and treatment modalities improve. Survival outcomes for such patients have not been previously reported.
The 1988-2007 Surveillance, Epidemiology, and End Results data were used to identify women diagnosed with both breast and colorectal cancer. Disease-specific survival rates were compared.
We identified 4,835 women who were diagnosed with both breast and colorectal cancer. Of these, 2,844 (58.8%) were diagnosed with breast cancer first and 1,807 (37.4%) were diagnosed with colorectal cancer first; 184 (3.8%) had synchronous cancers. At 5 years following the second cancer diagnosis, 163 (3.4%) died of breast cancer and 477 (9.9%) died of colorectal cancer (P < 0.05). Comparing primary site groups between years 1 and 5 after the second cancer diagnosis showed that the relative risk of death from breast cancer declined by 46%, though it did not reach statistical significance (P = 0.24), while it significantly increased by 46% for colorectal cancer death (P = 0.0004). These findings persisted regardless of patient age, stage at diagnosis, or breast tumor histology.
For women diagnosed with both breast and colorectal cancer, the cumulative risk of death at 5 years following the second cancer diagnosis is 3 times more likely to be due to colorectal cancer than to breast cancer. Colorectal cancer specific mortality increases with time, while breast cancer specific mortality decreases with time. Consideration should be given to these findings when discussing prognosis and making treatment decisions.
Annals of Surgical Oncology 06/2011; 19(1):242-8. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The regional economic burdens of obesity have not been fully quantified. This study incorporated bariatric surgery demographics collected from a large university hospital with regional economic and employment data to evaluate the cost of obesity for the South Plains region of Texas. Data were collected from patients who underwent laparoscopic gastric bypass and laparoscopic banding between September 2003 and September 2005 at Texas Tech University Health Sciences Center. A regional economic model estimated the economic impact of lost productivity due to obesity. Comparisons of lost work days in the year before and after surgery were used to estimate the potential benefit of bariatric surgery to the South Plains economy. Total output impacts of obesity, over $364 million, were 3.3% of total personal income; total labor income impacts neared $60 million: the losses corresponded to $2,389 lost output and $390 lost labor income per household. Obesity cost the South Plains over 1,977 jobs and decreased indirect business tax revenues by over $13 million. The net benefit of bariatric surgery was estimated at $9.9 billion for a discount rate of 3%, $5.0 billion for a discount rate of 5%, and $1.3 billion for a discount rate of 10%. Potential benefits to the South Plains economy of performing bariatric surgery more than outweigh its costs.
Obesity Surgery 05/2011; 21(5):644-9. · 3.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Invasive lobular cancer (L) differs clinically and morphologically from invasive ductal cancer (D); differences notwithstanding, Nottingham grades are provided in both. This study compared 22,719 lobular carcinomas with 201,517 ductal carcinomas, dividing them into the grades: well differentiated (W), moderately differentiated (M), poorly differentiated (P), and ungraded to see if differences between comparable grades of lobular and ductal cancer were uniform, consistent with the notion the grading system provides similar information for both cancer subtypes.
The Surveillance, Epidemiology and End Results (SEER) database was used to limn relationships among grades, as respects proportions of patients with T3 tumors and nodal metastases, as well as cancer-specific survival. Taken into account were age, estrogen and progesterone receptor status, and the administration of radiotherapy.
More lobular than ductal carcinomas were T3; grades were not homogenous, with the incidence rate ratio (IRR) comparing lobular and ductal carcinomas being 8.2 for well differentiated, 4.1 for moderately differentiated, and 2.48 for poorly differentiated. With respect to nodal metastases, the 1.16 W L:W D IRR (P < 0.05) was not explicable by chance, but both the 0.97 M L:M D IRR (P > 0.05) and the 0.96 P L:P D IRR (P > 0.05) could have been due to chance. As respects survival, neither the 1.4 P L:P D time ratio (TR) (P < 0.05) nor the 1.23 M L:M D TR (P < 0.05) could have been explained by chance; the 1.05 W L: W D (P > 0.05) might have been due to chance.
Grades of lobular carcinoma imply different meanings than do grades of ductal carcinoma. Studies of breast cancer should not assume commonality with respect to grade.
Journal of Surgical Research 03/2011; 166(1):19-27. · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: That obesity in the USA has reached epidemic proportions is undeniable: one in three American adults is obese. High levels of obesity yield adverse microeconomic and macroeconomic effects, but assessing the viability of bariatric surgery in this respect requires careful consideration of its efficacy, its economic costs, and the benefits of the surgery. Metabolic syndrome is a microcosm of multiple disease states; the diseases that fall under the umbrella of the metabolic syndrome are, like obesity, becoming more prevalent. Epidemic obesity in part reflects inadequate utilization of bariatric surgery and inadequate coordination of efforts by the healthcare system. An integrated delivery network (IDN) is the best current model to achieve healthcare goals for patient subsets that are deemed important. Our overweight population, both with and without the metabolic syndrome, constitutes such a group because of the fraction of the general population they compose, the inherent costs to the healthcare system that their comorbid conditions generate, and the lost productivity to our economy that the treatment of these conditions entail. In this paper, we show a metabolic syndrome service line that will benefit both the individual hospital and the healthcare system. Pathways accepted for bariatric practices can be used, with modification, for the creation of a metabolic syndrome IDN. Implementation of such a system would benefit patients, caregivers, and society.
Obesity Surgery 03/2011; 21(3):379-85. · 3.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Haemorrhoids are the most common surgically-treated gastrointestinal disorder. Complications of this surgery are generally non-neoplastic. Because rectal tumours usually present demonstratively during endoscopic examination, it is perhaps tempting to omit histopathologic examination after haemorrhoidectomy, especially in younger patients.
The AA present a case of an early rectal carcinoid discovered after surgical treatment of haemorrhoids in a 27 years old man as an example of why it is essential to send all such specimens in the pathologist.
The detection of early lesions permits the adequate follow-up necessary to preclude more extensive surgery and eventually to prevent recurrence of tumour.
All tissue resected by haemorrhoidopexy must be sent to the pathology laboratory to protect the life and health of the patient .
Annali italiani di chirurgia 01/2011; 82(2):155-7. · 0.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Studies with limited sample sizes have found colorectal signet ring carcinoma (SRC), to be prognostically similar to high grade adenocarcinoma (HGA); the relationship of these tumors to undifferentiated adenocarcinoma (UND) has not yet been fully elucidated. This study of Surveillance, Epidemiology, and End Results (SEER) program data compared the histotypes.
Registered as having been diagnosed between 1988 and 2003 were 2,246 SRC, 32,999 HGA, and 920 UND. Analyses were performed to determine the presence or absence of differences in survival and extent at presentation.
SRC, compared with HGA, was more likely to (1) be confined to an in situ stage or within a polyp, (2) have invaded visceral peritoneum, (3) have spread to contiguous organs, and (4) have metastasized. No differences between SRC and UND were seen, although this may have been due to small UND sample size. SRC was associated with a worse prognosis than HGA for patients with (1) T3 tumors, (2) contiguous organ spread, and (3) visceral peritoneal invasion. UND was associated with a worse prognosis than SRC among patients with metastases.
These three histotypes of aggressive colorectal cancer are separate entities that should be regarded as such. Future study with respect to SRC should include further evaluation of T1 and T2 patients with appropriate sample size populations and the potential utility of peritoneal sampling and frozen section evaluation of non-mucosal margins.
Journal of Surgical Research 10/2010; 163(2):250-6. · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Transcranial Doppler sonography (TCD) provides accurate confirmation of cerebral circulatory arrest (CCA) in brain death (BD), but is not feasible in patients with absent temporal bone windows. We added the transorbital approach in the TCD protocol for the diagnosis of CCA and compared findings with angiography. Furthermore, we evaluated whether reporting the angiographic and sonographic confirmation of CCA to relatives of brain-dead patients improves their comprehension and satisfaction with the medical information.
Eighty-two clinically brain-dead patients underwent 4-vessel angiography, TCD of the basilar and middle cerebral arteries, and transorbital Doppler sonography (TOD) of the internal carotid arteries. Relatives were randomly allocated to 41 in whom BD was presented as a clinical diagnosis (group A) and to 41 in whom BD was presented as a clinical diagnosis confirmed by TCD and angiography (group B). Comprehension and satisfaction of the relatives were assessed using an interview and a questionnaire.
Both angiography and TCD verified CCA in all cases (k = 1). In 11 patients with failure of the transtemporal approach, CCA was confirmed by the transorbital recordings. The addition of TOD enabled 15.5% more cases of CCA to be diagnosed by TCD. Group B exhibited improved comprehension and satisfaction rates (P < .05).
The addition of TOD increases the efficacy of TCD in confirming CCA in BD. Reporting confirmation of CCA to families of brain-dead patients may improve their comprehension and satisfaction with the provided medical information.